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Surgeons play crucial role in treating cancer

Natalya Brown writes that surgeons must keep up-to-date with breast cancer treatments as they become more integrated with their colleagues in medicine and radiation oncology.

Breast surgeons should continue to ensure they have up-to-date and in-depth understanding of the advantages and limitations of adjuvant treatment in the management of patients with breast cancer, and should support a multidisciplinary role in the treatment of breast cancer, according to research presented at the 2007 Dublin International Breast Meeting held in the Conrad Hotel, Dublin.

Meeting Chair Prof Thomas Gorey, Professor of Surgery at UCD and Consultant Surgeon at the Mater University Hospital, stressed the importance of surgeons keeping their knowledge of these treatments as current as possible. He explained that the surgeon is the primary contact for patients at presentation and diagnosis. They should remain involved throughout the progression of breast cancer treatment.
Their knowledge of the various specialist treatments informs and influences a patient’s choice. He suggested that the surgeon is responsible for navigating the patient through a variety of treatment courses and must maintain close contact with other specialists in medical and radiation oncology.

Detected on screening

“The surgeon traditionally was first to see a woman with a lump and made the diagnosis and initiated treatment,” said Prof Gorey. “Now many cancers are detected on screening but the surgeon is still the first contact clinician and it is logical to maintain that role.”

Over 75 surgeons from 17 countries were in attendance at the meeting, where previous studies presented established that surgeons are among the most influential figures for patients. Data from studies conducted throughout the past decade indicated that surgeons are almost twice as influential as spouses in the area of deciding whether or not to have surgery. This data further suggested that the role of the surgeon has become more integrated with colleagues in medicine and radiation oncology with the introduction and ongoing development of new cancer therapies.

Integral part

Prof Gorey described the process as a rapidly shifting landscape through which each patient management team member plays an integral part in the assessment and treatment protocol. Prof Gorey also explained that obstacles currently presenting in the area of breast cancer treatment in Ireland are not unique in an international setting. Prof Gorey said that it has become apparent globally that specialised breast units based on triple assessment and multidisciplinary involvement are essential with at least two surgeons per unit ensuring an adequate throughput for maintenance. He suggested that this is essential, not just in the area of clinical and therapeutic skills, but also in the area of quality assurance.

“In addition to carrying out initial surgery,” explained Prof Gorey, “the surgeon’s multidisciplinary approach implies an overview of follow-up adjuvant treatments so that the patient can be navigated through appropriate consultant specialties. The surgeon must therefore keep up-dated with ongoing developments in these areas and at the end, maintain overall responsibility for long-term follow-up.”

Hormonal-endocrine therapy

Focus was placed on the history of adjuvant treatments for breast cancer, such as hormonal-endocrine therapy as well as chemotherapy and evolving techniques of radiotherapy. International approaches to treatment were discussed, with surgeons from five different countries outlining their roles in the area of breast cancer therapy. Practice ranged from the United States, where the surgeon is often exclusively involved in operative procedures, on to Japan, where surgeons are responsible for the whole range of management, including chemo-radiotherapy.

Prof Gorey said that surgeons in Ireland are faring well in this role, staying involved in the follow-up of patients long-term after breast cancer surgery.

“[Ireland] is somewhat mid-way between the approach in many centres in the US – where the surgeon performs the surgery and never sees the patient again – and other countries such as Japan, where surgeons still largely have responsibility, not just for surgery but for follow-up treatments. [These include] chemotherapy and radiotherapy,” said Prof Gorey.

Data from a series of recent studies on the effects of aromatase inhibitors (AIs) for extended adjuvant hormonal therapy in patients with breast cancer was presented by Ms Julie Doughty, Consultant Surgeon, Western Infirmary, Glasgow, with a focus on comparisons between tamoxifen and letrozole. It was reported that there are limitations to a five-year span of treatment with adjuvant tamoxifen. Researchers have indicated that a substantial risk of recurrence of breast cancer during and after treatment with tamoxifen did exist, and that there may be no additional benefit to administering the drug after five years of treatment. Some of the adverse effects presented included occurrence of uterine cancer or thromboembolism.
It was reported that AIs may be more effective than tamoxifen as first-line treatment of advanced breast cancer (ABC), and letrozole was presented as an effective first-line and second-line treatment for ABC following tamoxifen. Dr Doughty reported that letrozole may be more effective than tamoxifen in the neoadjuvant setting.

One of the most recent examples of this kind of research was conducted by Dr Paul E. Goss, Director of Breast Cancer Research at Massachusetts General Hospital. In their updated MA-17 breast cancer clinical trial study, Dr Goss and his team of researchers found that letrozole was extremely well-tolerated relative to their placebo.

The team recommends that letrozole be considered for all women completing tamoxifen. New data from their research, in a post-unblinding analysis, suggests that letrozole treatment should also be considered for all disease-free women for periods up to five years following completion of adjuvant tamoxifen.

A breakthrough

The team reported that third-generation AIs such as letrozole are now providing new options for extended adjuvant hormonal therapy after five years of tamoxifen. This is a breakthrough for women with hormone-responsive breast cancer, who often face relapse after completing adjuvant tamoxifen therapy. In order to determine whether letrozole improves outcome after discontinuation of tamoxifen, Dr Goss and colleagues conducted a randomised trial of 5,187 postmenopausal women with hormone receptor-positive breast cancer. For a period of five years, the group was randomised to letrozole 2.5 mg or placebo once daily. Average follow-up time was 30 months, where the team found letrozole to have significantly improved disease-free survival (DFS; P < 0.001), the primary end point, compared with placebo (hazard ratio [HR] for recurrence or contralateral breast cancer 0.58; 95 per cent confidence interval [CI] 0.45, 0.76] P < 0.001).

Dr Goss and his team further noted that letrozole significantly improved distant DFS (HR = 0.60; 95% CI 0.43, 0.84; P = 0.002). Significant improvement in overall survival was also noted in women with node-positive tumours, (HR = 0.61; 95 per cent CI 0.38, 0.98; P = 0.04). After unblinding, women who switched from placebo to letrozole demonstrated clinical benefits, including an overall survival advantage.

Tumours remain sensitive

The team reported that this indicated that tumours remain sensitive to hormone therapy even after a prolonged period since discontinuation of tamoxifen. At the time of follow-up publication, the team had noted that the efficacy and safety of letrozole therapy beyond five years is being assessed in a re-randomisation study. This was reportedly following new data that Dr Goss’s team had found, which suggests that clinical benefits may correlate with the duration of letrozole.

“The anti-oestrogen hormonal agent tamoxifen has in many ways been the wonder drug in adjuvant treatment of breast cancer for 25 years and was a very well tolerated and effective agent,” commented Prof Gorey. “In recent years, a whole range of new hormonals have become available. Some have more effective anti-cancer activity and a range of different side-effect profiles, some having less thrombo-embolic effects and others being more bone protective. This may support a more selective and focused use of these agents in different patients who may have, for example, a history of deep vein thrombosis/pulmonary embolism or suffer from osteoporosis.”

During the second day of the conference, speakers incorporated the application of adjuvant therapies in presentations, as well as new techniques in surgery. Oncoplastic techniques and sentinel node technology supporting minimally invasive breast surgery were discussed. Through oncoplastic techniques, screen-detected cancers are excised locally within the breast with the aid of radiological guidance and minimal tissue is removed, consistent with a surrounding margin of normal tissue.

Breast can be reconfigured

This is confirmed by x-ray imaging carried out while the patient is still under anaesthetic in the operating theatre. The breast can then be reconfigured by various techniques involving tissue transfer within the breast and optimal scar placement.
“Oncoplastic techniques represent the application of minimally invasive surgery in breast cancer,” said Prof Gorey. “These techniques fortuitively paralleled the detection of early and small cancers found on screening mammography in the BreastCheck programme, which allows a high degree of cure with retention of the breast and a good cosmetic appearance.

“Furthermore, removal of auxiliary glands represented a major morbidity in traditional breast cancer surgery and now in many cases only a single gland or sentinel node is examined through a small incision usually hidden behind the pectoral muscle,” he said. “This is not just better cosmetically, but usually obviates the need for a drain and is much more comfortable for patients and unlikely to result in post-operative arm swelling or lymphoedema.”

Posted in on 12 April 2008
Tags:

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abortion, accupuncture, ACE inhibitors, acne, actinic keratoses, ADHD, ageing, AIDS, alcohol, allergies, Alzheimer's, anaemia, anaethesia, anti-retroviral drugs, antibiotics, antidepressants, antihistamine, anxiety, appetite control, arthritis, ASCOT, aspirin, asthma, atherosclerosis, autism, autoantibodies, back pain, balloon kyphoplasty, beta carotene, beta-blockers, bipolar disorder, birth, birth defects, bleeding, blindness, blood pressure, body dysmorphic disorder, breast cancer, breast feeding, bronchitis, Caesarean section, calcium, cancer, carcinogens, carcinoma, cardiac syncope, cardiolgy, cervical cancer, chemotherapy, child psychiatry, children, chocolate, cholecystectomy, cholesterol, clinical meetings, clopidogrel, Clostridium difficile, coenzyme Q10, coffee, cognitive behavioural therapy, colectomy, colic, colorectal cancer, common cold, complementary and alternative therapies, contraception, COPD, coronary care, coronary stents, cystic fibrosis, defibrillator, dementia, depression, dermatology, diabetes management, diet, disability, diuretics, DNA, Down's syndrome, dyslexia, eating disorders, echinacea, eczema, elderly people, endoscopy, epilepsy, erectile dysfunction, Eurordis, euthanasia, exercise, fertility, fibre optics, fibromyalgia, fitness, flu pandemic, fluoxetine, folic acid, food labelling, fracture, fragile X syndrome, gastric bypass surgery, general surgery, genetics, gerontology, GIK infusion therapy, GORD, gout, gum disease, haemodialysis, hearing aids, hearing loss, heart attack, heart disease, heart failure, heart health, hepatitis, HIV, hospital care, HPV, HRT, hyperglycaemia, hypertension, hypoglycaemia, ICU, incontinence, infant, infant mortality, infection, inflammatory bowel disease, influenza, information technology, interleukin inhibitors, IQ, Irish Heart Foundation, irritable bowel syndrome, keyhole surgery, kidney disease, laser, learning difficulties, leukaemia, life expectancy, liver disease, lumbar disk herniation, lung cancer, lung disease, lymph nodes, macular degeneration, macular oedema, magnetic resonance imaging (MRI), malaria, malnutrition, manual handling, Marfan syndrome, medical ethics, medical research, medication, meningioma, meningitis, mental illness, metabolic syndrome, metformin, migraine, miscarriage, mononucleosis, mortality rate, MRSA, multiple sclerosis (MS), myalgic encephalitis (ME), nephrology, neural tube defects, neurology, Nutrition, OAB, obesity, obstetrics, occupational therapy, ocular medicine, omega-3, opthalmology, oral cancer, organ transplantation, orthopaedics, osteoporosis, otolaryngology, ovarian cancer, paediatrics, pain management, pancreatic cancer, panic, Parkinson’s disease, patient safety, patient-physician communication, personality disorders, physiotherapy, plastic surgery, polio, polycystic ovary syndrome (PCOS), pre-eclampsia, pregnancy, prehypertension, preventative health care, probiotics, prostate cancer, psoriasis, psychiatric admission, psychiatry, psychotherapy, PTSD, public health, quality of life, radiology, reproductive health, resuscitation, rhinitis, salt, SARS, schizophrenia, seizures, sexual abuse, sexual health, sexually transmitted infections, SGA, shiftwork, Sick leave, sinusitis, skin cancer, sleep disorders, Smoking, smoking, smoking ban, spinal injury, sports injuries, sports medicine, statins, streptococcus pneumoniae, stroke, substance abuse, sugar, suicide, supplement, surgery, syncope, teenagers, testosterone, thoracic surgery, thrombosis, thyroid cancer, tonsillectomy, tonsillitis, Tourette's syndrome, toxicology, travel medicine, tuberculosis, tumour angiogenesis, type 1 diabetes, type 2 diabetes, ulcer, ulcerative colitis, urinary incontinence, vaccine, vitamin A, vitamin B12, vitamin C, vitamin D, vitamins, weight, wheeze, WHO, women's health, World Health Assembly, wound

«Previous article | Next article»

Surgeons play crucial role in treating cancer

Natalya Brown writes that surgeons must keep up-to-date with breast cancer treatments as they become more integrated with their colleagues in medicine and radiation oncology.

Breast surgeons should continue to ensure they have up-to-date and in-depth understanding of the advantages and limitations of adjuvant treatment in the management of patients with breast cancer, and should support a multidisciplinary role in the treatment of breast cancer, according to research presented at the 2007 Dublin International Breast Meeting held in the Conrad Hotel, Dublin.

Meeting Chair Prof Thomas Gorey, Professor of Surgery at UCD and Consultant Surgeon at the Mater University Hospital, stressed the importance of surgeons keeping their knowledge of these treatments as current as possible. He explained that the surgeon is the primary contact for patients at presentation and diagnosis. They should remain involved throughout the progression of breast cancer treatment.
Their knowledge of the various specialist treatments informs and influences a patient’s choice. He suggested that the surgeon is responsible for navigating the patient through a variety of treatment courses and must maintain close contact with other specialists in medical and radiation oncology.

Detected on screening

“The surgeon traditionally was first to see a woman with a lump and made the diagnosis and initiated treatment,” said Prof Gorey. “Now many cancers are detected on screening but the surgeon is still the first contact clinician and it is logical to maintain that role.”

Over 75 surgeons from 17 countries were in attendance at the meeting, where previous studies presented established that surgeons are among the most influential figures for patients. Data from studies conducted throughout the past decade indicated that surgeons are almost twice as influential as spouses in the area of deciding whether or not to have surgery. This data further suggested that the role of the surgeon has become more integrated with colleagues in medicine and radiation oncology with the introduction and ongoing development of new cancer therapies.

Integral part

Prof Gorey described the process as a rapidly shifting landscape through which each patient management team member plays an integral part in the assessment and treatment protocol. Prof Gorey also explained that obstacles currently presenting in the area of breast cancer treatment in Ireland are not unique in an international setting. Prof Gorey said that it has become apparent globally that specialised breast units based on triple assessment and multidisciplinary involvement are essential with at least two surgeons per unit ensuring an adequate throughput for maintenance. He suggested that this is essential, not just in the area of clinical and therapeutic skills, but also in the area of quality assurance.

“In addition to carrying out initial surgery,” explained Prof Gorey, “the surgeon’s multidisciplinary approach implies an overview of follow-up adjuvant treatments so that the patient can be navigated through appropriate consultant specialties. The surgeon must therefore keep up-dated with ongoing developments in these areas and at the end, maintain overall responsibility for long-term follow-up.”

Hormonal-endocrine therapy

Focus was placed on the history of adjuvant treatments for breast cancer, such as hormonal-endocrine therapy as well as chemotherapy and evolving techniques of radiotherapy. International approaches to treatment were discussed, with surgeons from five different countries outlining their roles in the area of breast cancer therapy. Practice ranged from the United States, where the surgeon is often exclusively involved in operative procedures, on to Japan, where surgeons are responsible for the whole range of management, including chemo-radiotherapy.

Prof Gorey said that surgeons in Ireland are faring well in this role, staying involved in the follow-up of patients long-term after breast cancer surgery.

“[Ireland] is somewhat mid-way between the approach in many centres in the US – where the surgeon performs the surgery and never sees the patient again – and other countries such as Japan, where surgeons still largely have responsibility, not just for surgery but for follow-up treatments. [These include] chemotherapy and radiotherapy,” said Prof Gorey.

Data from a series of recent studies on the effects of aromatase inhibitors (AIs) for extended adjuvant hormonal therapy in patients with breast cancer was presented by Ms Julie Doughty, Consultant Surgeon, Western Infirmary, Glasgow, with a focus on comparisons between tamoxifen and letrozole. It was reported that there are limitations to a five-year span of treatment with adjuvant tamoxifen. Researchers have indicated that a substantial risk of recurrence of breast cancer during and after treatment with tamoxifen did exist, and that there may be no additional benefit to administering the drug after five years of treatment. Some of the adverse effects presented included occurrence of uterine cancer or thromboembolism.
It was reported that AIs may be more effective than tamoxifen as first-line treatment of advanced breast cancer (ABC), and letrozole was presented as an effective first-line and second-line treatment for ABC following tamoxifen. Dr Doughty reported that letrozole may be more effective than tamoxifen in the neoadjuvant setting.

One of the most recent examples of this kind of research was conducted by Dr Paul E. Goss, Director of Breast Cancer Research at Massachusetts General Hospital. In their updated MA-17 breast cancer clinical trial study, Dr Goss and his team of researchers found that letrozole was extremely well-tolerated relative to their placebo.

The team recommends that letrozole be considered for all women completing tamoxifen. New data from their research, in a post-unblinding analysis, suggests that letrozole treatment should also be considered for all disease-free women for periods up to five years following completion of adjuvant tamoxifen.

A breakthrough

The team reported that third-generation AIs such as letrozole are now providing new options for extended adjuvant hormonal therapy after five years of tamoxifen. This is a breakthrough for women with hormone-responsive breast cancer, who often face relapse after completing adjuvant tamoxifen therapy. In order to determine whether letrozole improves outcome after discontinuation of tamoxifen, Dr Goss and colleagues conducted a randomised trial of 5,187 postmenopausal women with hormone receptor-positive breast cancer. For a period of five years, the group was randomised to letrozole 2.5 mg or placebo once daily. Average follow-up time was 30 months, where the team found letrozole to have significantly improved disease-free survival (DFS; P < 0.001), the primary end point, compared with placebo (hazard ratio [HR] for recurrence or contralateral breast cancer 0.58; 95 per cent confidence interval [CI] 0.45, 0.76] P < 0.001).

Dr Goss and his team further noted that letrozole significantly improved distant DFS (HR = 0.60; 95% CI 0.43, 0.84; P = 0.002). Significant improvement in overall survival was also noted in women with node-positive tumours, (HR = 0.61; 95 per cent CI 0.38, 0.98; P = 0.04). After unblinding, women who switched from placebo to letrozole demonstrated clinical benefits, including an overall survival advantage.

Tumours remain sensitive

The team reported that this indicated that tumours remain sensitive to hormone therapy even after a prolonged period since discontinuation of tamoxifen. At the time of follow-up publication, the team had noted that the efficacy and safety of letrozole therapy beyond five years is being assessed in a re-randomisation study. This was reportedly following new data that Dr Goss’s team had found, which suggests that clinical benefits may correlate with the duration of letrozole.

“The anti-oestrogen hormonal agent tamoxifen has in many ways been the wonder drug in adjuvant treatment of breast cancer for 25 years and was a very well tolerated and effective agent,” commented Prof Gorey. “In recent years, a whole range of new hormonals have become available. Some have more effective anti-cancer activity and a range of different side-effect profiles, some having less thrombo-embolic effects and others being more bone protective. This may support a more selective and focused use of these agents in different patients who may have, for example, a history of deep vein thrombosis/pulmonary embolism or suffer from osteoporosis.”

During the second day of the conference, speakers incorporated the application of adjuvant therapies in presentations, as well as new techniques in surgery. Oncoplastic techniques and sentinel node technology supporting minimally invasive breast surgery were discussed. Through oncoplastic techniques, screen-detected cancers are excised locally within the breast with the aid of radiological guidance and minimal tissue is removed, consistent with a surrounding margin of normal tissue.

Breast can be reconfigured

This is confirmed by x-ray imaging carried out while the patient is still under anaesthetic in the operating theatre. The breast can then be reconfigured by various techniques involving tissue transfer within the breast and optimal scar placement.
“Oncoplastic techniques represent the application of minimally invasive surgery in breast cancer,” said Prof Gorey. “These techniques fortuitively paralleled the detection of early and small cancers found on screening mammography in the BreastCheck programme, which allows a high degree of cure with retention of the breast and a good cosmetic appearance.

“Furthermore, removal of auxiliary glands represented a major morbidity in traditional breast cancer surgery and now in many cases only a single gland or sentinel node is examined through a small incision usually hidden behind the pectoral muscle,” he said. “This is not just better cosmetically, but usually obviates the need for a drain and is much more comfortable for patients and unlikely to result in post-operative arm swelling or lymphoedema.”

Posted in on 12 April 2008
Tags: