Tracks 1-15

Track 1 Introduction Track 2 Questions commonly asked by surgical oncologists about the treatment of breast cancer Track 3 Skin-sparing mastectomy Track 4 Incorporating the Oncotype DX assay in clinical practice Track 5 Utilizing the Oncotype DX assay to select which patients to treat with adjuvant chemotherapy Track 6 Chemotherapy with trastuzumab for patients with node-negative, HER2-positive disease Track 7 Benefit of adjuvant chemotherapy in patients with hormone receptor-positive disease Track 8 Assessment of HER2 and hormone receptor status with the Oncotype DX assay Track 9 Duration of use and long-term side effects of aromatase inhibitors Track 10 Long-term risk of relapse for patients with hormone receptor-positive tumors Track 11 Declines in breast cancer incidence in the United States Track 12 Advantages of neoadjuvant chemotherapy Track 13 Use of nanoparticles for tumor imaging Track 14 Use of neoadjuvant chemotherapy versus endocrine therapy Track 15 A physician’s perspective on undergoing surgery

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Track 3

DR LOVE: Are there any new developments in skin-sparing mastectomy?

DR WOOD: We just reported a large series at the Southern Surgical meeting, and skin-sparing mastectomy appears to produce superb results cosmetically, and it does not have a higher failure rate.

We learned two things from that study. We only had about 13 patients with a close superficial margin, but we had five failures in that group. These are usually young women who have generous breasts and almost no subcutaneous tissue. Today, I radiate tumors if there is a margin that is positive superficially.

DR LOVE: Can you discuss your technique and any caveats about the procedure?

DR WOOD: My technique is a circumareolar incision and then a full mastectomy with or without an axillary dissection through that incision. If the breast is stiff, you sometimes need to tee that out with approximately a two-centimeter “racket handle” to deliver the specimen. However, you can usually deliver the specimen through a circumareolar incision that’s dilatable enough after you make the incision. A little white superficial fascia is present as a guide. If you follow that fascia, you’ll have subcutaneous tissue above and the breast is nicely contained within.

Tracks 4-5

DR LOVE: How do you incorporate the Oncotype DX assay into your practice?

DR WOOD: If a woman has an ER-positive, node-negative tumor that is higher than Grade I and larger than a centimeter, she should seriously consider chemotherapy. That is a patient population who should receive an Oncotype DX assay because three quarters of them will not be in the group with the high recurrence score that benefited from chemotherapy in the NSABP-B-20 series.

I’m happy not treating those patients with a clearly low recurrence score with chemotherapy, which is approximately half of these patients. For the patients with intermediate recurrence scores, we are excited to be participating in the TAILORx study (3.1) so that we might find out exactly where that borderline lies between the high-risk group, all of whom should be treated, and the low-risk group, who don’t need treatment.

Track 8

DR LOVE: As we move toward more targeted therapy, it will be increasingly important to accurately measure the targets, and a lot of concern has arisen about measuring HER2 and ER. Where are we right now in terms of testing, and how can a surgeon in practice feel comfortable that the patient will have an accurate assay?

DR WOOD: If you are fortunate enough to practice in a quaternary center that runs controls all week, you can be confident. Otherwise, you’ll find a 20 percent central lab correction rate on assays. Due to central controls, the Oncotype DX assay appears promising in being able to give us these data precisely. They may soon begin reporting ER and PR values, and probably HER2. That would be helpful if that reinforced the local value or called it into question.

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Editor:
Neil Love, MD

Interviews
J Michael Dixon, MD
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Maura N Dickler, MD
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William C Wood, MD
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John Mackey, MD
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