Tracks 1-12

Track 1 Introduction Track 2 Patients’ misperceptions about the benefits of mastectomy versus breast-conserving surgery Track 3 Improvements in local recurrence rates for patients undergoing breast-conserving surgery Track 4 Potential benefits and preliminary experience with partial breast irradiation Track 5 Differences between surgeons’ and patients’ views on breast-conserving surgery Track 6 False-negative rate of sentinel lymph node biopsy (SLNB) Track 7 Factors influencing the false-negative rate of SLNB Track 8 Clinical use of the Oncotype DXTM assay Track 9 Case discussion: A 48-year old perimenopausal woman with node-negative, ER-positive disease whose tumor was assayed by Oncotype DX Track 10 Counseling patients about the role of Oncotype DX Track 11 Selection of adjuvant systemic therapy Track 12 Tolerability and efficacy of aromatase inhibitors versus tamoxifen

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Track 2

DR MORROW: The adoption of breast conservation has been relatively slow, and people have made the assumption that surgeons either are not in favor of breast conservation or are inappropriately advising patients.

We used the SEER registries from Detroit and Los Angeles to identify women within an average of six months after diagnosis, which is a time when they would have fairly active memory of decisions made during the treatment process (Hawley 2006). In that patient sample, we saw that approximately 70 percent of women were treated with breast-conserving therapy, so those numbers have increased when compared to historical studies.

When we asked patients, “Did you, your surgeon or you and your surgeon in collaboration make the decision about surgery?” we saw a highly statistically significant correlation between greater patient involvement in the decision making process and higher mastectomy rates. Yet in response to the question, “Did your surgeon recommend a treatment to you?” patients overwhelmingly said their surgeons recommended breast-conserving therapy.

We asked patients what was driving their decision and discovered two big issues. One concern was recurrence, and since it’s always been clear that the rate of distant recurrence with mastectomy and breast conservation is the same, this is a local recurrence issue. The second issue was concern about the use of radiation therapy.

To me, probably the most alarming outcome of this study was that when we asked patients a series of true-false questions to assess the knowledge they would need to make an informed decision, only 50 percent of them correctly answered that their chances of surviving after breast-conserving therapy or mastectomy were equal.

I believe this tells us that we are not clearly getting this information to patients, and they are choosing what they perceive to be a safer or more aggressive cancer treatment.

Shared decision-making is certainly a good idea and one I endorse, but patients need to have an appropriate understanding of the key facts, and our study suggests that’s still a problem.

Track 8

DR MORROW: The Oncotype DX assay is an examination of a selected panel of 21 genes. A great advantage is that it can be performed on paraffin specimens, so it’s widely applicable and clinically available in practice.

The initial important validation of this assay was seen in patients on the NSABP-B-14 trial, which randomly assigned patients with ER-positive, node-negative disease to tamoxifen or a placebo (Paik 2004). This study showed that you could look at a recurrence score, which was designated as low, medium or high based on numeric cutoffs, and identify outcomes of patients. Most importantly, it showed that you could identify which patients who had received tamoxifen would not benefit from the addition of chemotherapy.

Subsequently, this was examined again in other NSABP data sets and some non-NSABP data sets, and the initial findings were basically confirmed. The studies confirmed that patients with low recurrence scores who received chemotherapy did not experience any additional benefit.

This is useful information, because when you use the traditional prognostic measures — tumor size, histologic grade — you end up treating many women with receptor-positive disease who already have a good prognosis and will mostly gain only the toxicity of chemotherapy.

In addition, the assay can identify a subset of women who traditionally would not be considered candidates for chemotherapy — tumors less than a centimeter in size, node-negative — who, in fact, fall into a high-risk group.

DR LOVE: Do you use the Oncotype DX clinically?

DR MORROW: We apply this in our practice after we ask ourselves the question, “Would we change how we’re going to treat this patient based on the results of this assay?”

Tracks 11

DR MORROW: It is important for women who have been treated in the past or who are coming to the end of five years of tamoxifen to know that adding an aromatase inhibitor prolongs disease-free survival and, in node-positive subsets, overall survival.

The only group for which I would question the use of an aromatase inhibitor after five years of tamoxifen is patients with very low-risk tumors. For that group, I don’t know the risk-benefit balance of administering an aromatase inhibitor for another five years, but for the vast majority of women with breast cancer, this strategy makes perfect sense.

DR LOVE: If you see a postmenopausal woman who has completed adjuvant tamoxifen, do you prescribe an aromatase inhibitor or send her to an oncologist?

DR MORROW: I definitely believe it’s something that needs to be addressed with patients in this day and age, and I advise them to discuss it with their oncologist.

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Editor:
Neil Love, MD

Interviews
Monica Morrow, MD
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Kevin R Fox, MD
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Thomas B Julian, MD
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Robert W Carlson, MD
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Richard M Elledge, MD
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