Lumpectomy for Multiple Ipsilateral Breast Tumors Yields Satisfying Cosmetic Results: Survey

By Megan Brooks

June 08, 2020

NEW YORK (Reuters Health) - Most women with multiple tumors in a single breast are pleased with the cosmetic results of lumpectomy, despite loss of significant breast volume and often multiple incisions, according to new research.

"Patient-reported outcomes confirm that breast-conserving therapy for multiple ipsilateral breast cancer is an acceptable surgical option from a cosmetic perspective," with patients reporting "high rates of satisfaction with breasts and physical wellbeing," Dr. Kari Rosenkranz of Dartmouth-Hitchcock Medical Center, in Lebanon, New Hampshire, said in a presentation of the findings May 23 at the American Society of Breast Surgeons (ASBrS) 2020 virtual scientific meeting.

Based on improvements in breast imaging, the diagnosis of multiple ipsilateral breast cancer (MIBC) is increasing. Today, this patient population comprises about 15% of women with breast cancer, she explained.

"Yet surgeons remain reluctant to perform breast-conserving surgery in this patient population based on historical, retrospective studies showing high rates of local recurrence as well as concerns about the potential for poor cosmetic outcomes in women who may require large-volume excision and multiple incisions," Dr. Rosenkranz said.

No prospective trial has assessed the oncologic safety or cosmetic success of breast-conserving therapy (BCT) for MIBC despite more recent retrospective data supporting this practice, she noted.

With this in mind, the Alliance Z11102 trial was designed as a single arm prospective study enrolling women with two or three malignant lesions in the same breast separated by more than two centimeters and confirmed on biopsy. Individually, each tumor met criteria for lumpectomy.

Of the 270 women enrolled, 54 were excluded due to ineligibility or conversion to mastectomy, leaving 216 participants. Data for the primary objective of the study - local recurrence rate - are not yet mature, Dr. Rosenkranz said.

She reported data on cosmetic outcomes, a secondary objective of the study. The women rated their perceptions of cosmetic results on a four-point Likert scale on eight separate occasions, beginning at 30 days after surgery and ending at 60 months. They also completed the BREAST-Q, a validated self-rating tool that quantifies patient quality-of-life and satisfaction related to breast surgeries.

At both two and three years, 70% of women reported good or excellent cosmetic outcomes. However, at three years, nearly a third of patients had been lost to follow-up, Dr. Rosenkranz reported.

The BREAST-Q scores showed that the majority of women were satisfied with the appearance of the breast, with the expected slight drop during the time when radiation impact is most severe, she noted.

The satisfaction ratings in this study of women with MIBC undergoing BCT are similar to those treated with lumpectomy for single-site disease in other studies, Dr. Rosenkranz said.

There was no significant predictor of better or worse cosmesis score. Cosmetic outcomes were not associated with patient age, tumor sizes, stage of disease, number of incisions, number of surgeries or radiation dosage.

Dr. Rosenkranz noted several limitations of the study, including the single-arm design, which may have led to accrual of patients with an underlying bias toward BCT who may have had an artificially inflated sense of satisfaction when they were able to retain the breast. Another limitation is the diminishing compliance with cosmesis surveys over time. A third is the lack of a control arm of women with either unifocal disease or MIBC who underwent mastectomy, which compelled the researchers to compare cosmetic outcome to prior studies.

Dr. Stephanie Bernik, chief of Breast Service at Mount Sinai West and associate professor of Surgery at the Icahn School of Medicine at Mount Sinai, in New York City, who was not involved in the study, urges caution in interpreting the results.

"Although it is encouraging that cosmetic results following removal of more than one cancer from a breast appear to be satisfactory, one must not lose sight of the fact that the most important end result is long-term disease-free survival," she told Reuters Health by email.

"It has long been thought that when a cancer is multicentric (occurring in more than one area of the breast) breast conservation might be contraindicated. Perhaps radiation would not be as efficient if the cancer was more widespread. This trial is an attempt to try and sort out the issue of whether or not multifocal cancer can adequately be treated by breast conservation," Dr. Bernik said.

"The study will be flawed by selection bias, as women who do not want to take any risks will opt not to participate in a trial that offers treatment that is not currently standard of care. Furthermore, the definition of what constitutes multiple breast cancers needs to be clarified, as breast surgeons currently often offer breast conservation to women with more than one tumor if they are all within a few centimeters of each other. The ultimate answer to the question as to whether or not breast conservation can be offered to women with more than one cancer will be based on long-term risk of recurrence of disease," Dr. Bernik added.

The study was supported by the National Cancer Institute.

SOURCE: American Society of Breast Surgeons (ASBrS) 2020 scientific meeting, presented May 23, 2020.