Several Opinions Better Than One for Breast Cancer Surgery

ANN ARBOR, Mich., Dec. 1 -- A tumor board's thorough reassessment of recommendations for breast cancer surgery led to changes in treatment planning for more than half of the patients in a year, according to researchers here.

In a retrospective study of 149 consecutive patients seen at a multidisciplinary breast cancer clinic for a second opinion over a year, 52% emerged with a new treatment plan, reported Michael S. Sabel, M.D., of the University of Michigan Comprehensive Cancer Center here, and colleagues.

Each patient's imaging studies and diagnosis were reviewed by specialists from surgery, radiation oncology, medical oncology, radiology and pathology, they reported in the Nov. 15 issue of Cancer.

Re-examining imaging studies changed interpretation for 67 patients (45%) and altered surgical management for 11% of patients.

Pathology review changed interpretation for 43 patients (29%) with resulting changes in surgical management for 13 (9%).

The team recommended different surgical management in another 51 patients (34%) based on discussion rather than reinterpretation of the radiologic or pathologic findings.

The results reinforce the importance of comprehensive care by a multidisciplinary board of specialists, Dr. Sabel and colleagues wrote.

"Although many centers have long utilized tumor boards for other cancers, there are several clear factors supporting the treatment of breast cancer by a multidisciplinary tumor board," they wrote. "The most obvious advantage is the opportunity to review the results of radiology and pathology."

To quantify the advantage, the investigators searched their institution's records for alterations in radiologic, pathologic, surgical, and medical interpretations in patients who were referred or presented for second opinion, and the effect that these alterations had on surgical management recommendations.

Patients without a breast cancer diagnosis prior to presenting at the center were excluded. All patients had already undergone initial evaluation, breast imaging and interpretation, biopsy, and recommendations for treatment at outside facilities.

Evaluation by the tumor board started with a thorough history and physical examination and submission of imaging studies to the breast radiologists and of specimen slides to the pathologists. Then, the entire team consulted to discuss treatment using the National Comprehensive Cancer Network's current clinical guidelines. Additional imaging studies, not including breast magnetic resonance imaging, and histologic staining were often done.

On the basis of imaging review, the most common change was identification of additional lesions. The findings were:

• Nearly 30% (43 patients) needed an additional biopsy or had an alteration in follow-up imaging.
• A small percentage was found to have residual tumor at the site of a previous surgical excision (4%).
• The level of suspicion changed for known lesions among 12% of patients.
• Eight (33%) of the 24 patients who underwent biopsy of second lesions or excision of residual lesions had additional or residual cancer.
• Half the changes in surgical management based on imaging review were a result of additional biopsies and half as a result of radiographic review alone.

On the basis of review of the histologic slides by dedicated breast pathologists, the results were:

• Six patients (4%) had diagnoses changed from ductal carcinoma in situ (DCIS) to lobular carcinoma in situ or atypical ductal hyperplasia or both.
• One patient was discovered to have cancer rather than benign disease.
• Two patients had their diagnoses changed from DCIS to invasive cancer.
• Overall, 17% of patients had changes in tumor grade or subtype and 5% had changes to the surgical margin status.

Changes on the basis of clinical review by the tumor board alone were typically to the management approach. The researchers reported:

• Five patients with mastectomy initially planned had no contraindications to breast conservation.
• Two patients initially recommended for breast conservation were not candidates for adjuvant radiation.
• An additional 19 patients were recommended to undergo a sentinel lymph node biopsy, typically because the outside surgeon recommended axillary lymph node dissection for staging.

Some changes were made on the basis of the board's approach to breast cancer treatment. For example:

• Eleven patients had their plan changed from mastectomy to neoadjuvant chemotherapy with a possible attempt at breast conservation therapy, and
• Three patients were recommended to undergo a reexcision lumpectomy due to less than 2 mm margins, reflecting a more aggressive approach to surgical margins.

Several limitations were noted by the authors. The study was retrospective. The final recommendations from the tumor board were based on the best judgment of the

involved physicians for each patient but there were no "internal controls to determine whether the final radiology, pathology, or surgical decisions were, in fact, the correct conclusions for each case."

Also, the risk-to-benefit ratio for tumor board evaluation is unknown.

"This is particularly significant when one considers the cost-effectiveness of this approach," the authors wrote, "which was not evaluated in the current study and may be prohibitive in some hospital settings."

However, they concluded that multidisciplinary review "can provide patients with useful additional information when making difficult treatment decisions."