Ductal Lavage for Breast Cancer Risk Assessment

Lisa A. Newman, MD, MPH, FACS, Cassann Blake, MD

Disclosures

Cancer Control. 2002;9(6) 

In This Article

Evaluation of Lavage Fluid

When the lavage fluid yields frankly malignant cells, it is prudent to confirm the assessment with a second opinion cytopathology evaluation. Repeat breast imaging with mammography and ultrasound followed by a ductography and/or ductoscopy might also be useful, and repeat lavage to determine whether the abnormality is reproducible should also be considered. Breast MRI[36] can also be highly sensitive for detecting an otherwise occult breast tumor. If the entire workup is negative, a terminal duct excision would intuitively seem to be a rational diagnostic approach, but the yield for this strategy is unknown. In summary, the optimal and most definitive means of managing the patient found to have malignant cells on ductal lavage and localizing the site of breast pathology is unclear at present. Fortunately, this condition is unusual, occurring in less than 1% of high-risk women who undergo ductal lavage as a risk assessment procedure.[5]

Many high-risk women are seeking some measure of individualized evidence to determine the appropriate timing for risk reduction intervention. The decision to commit to 5 years of tamoxifen use or to undergo prophylactic mastectomy is a difficult one for the individual patient. Ductal lavage offers a promising opportunity to clarify risk for these women at any given point in time. However, ductal lavage has not yet been fully integrated into the healthcare third-party payor system. Insurance companies are not universally cognizant of the value and indications for ductal lavage as a risk assessment tool. Reimbursement policies have not been standardized, which limits the availability of the procedure. A patient who wishes to undergo the procedure must be counseled that prior approval with her health insurance carrier will be necessary to minimize out-of-pocket expenses.

As ductal lavage is evaluated further by the oncology research community, we may develop other applications for its use. For example, ductal lavage may be incorporated into neoadjuvant chemotherapy protocols to monitor response. Also, ductal lavage findings may be analyzed in long-term tamoxifen users to study molecular changes and perhaps to identify patients developing tamoxifen resistance. The procedure may even become useful in assessing candidates for breast conservation therapy. At present, these possibilities are speculative and will require investigation in the context of carefully designed clinical trials.

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