What's Gold Standard in breast cancer management:
The patient centred multidisciplinary team approach

Stood the test of time : Triple assessment
The gold standard today is the triple assessment and while not new is still not used by certain clinicians. All patients should have an ultrasound and mammogram depending on their age and wherever possible a needle biopsy; preferably a core needle biopsy. Incision and excision biopsies of breast masses for diagnostic purposes should not be done unless a failed needle biopsy in terms of pathological information is obtained.

Team approach
A multidisciplinary team approach is considered the standard of care in all patients. All patients after being diagnosed with a breast cancer should be presented to a multi-disciplinary team consisting of a cancer surgeon; radiologist; pathologist; reconstructive surgeon; oncologist; radiation oncologist and psychologist. Discussions around whether to start with surgery or primary chemotherapy; reconstructive options particularly taking into account potential needs for radiation therapy should all be discussed.

Margins in breast cancer surgery
This year will start the era of the clear margin in breast cancer surgery. All the studies agree that young age and positive margins are the most important risk factor for recurrence after breast conservation therapy. It is accepted that insufficient margins are related to local recurrence. The question as to what the required margin should be macroscopically and microscopically finally has consensus. 10 mm is the standard now accepted for both DCIS and invasive breast cancer. From this point of view the creation of free margins in conjunction with a good cosmetic result should be a decisive factor in breast conserving surgery.

Chemotherapy
The role of systemic chemotherapy has been confirmed in a recent meta-analysis of most subsets of patients with breast cancer with anthracycline-containing regemins are superior to non-anthracycline containing regimens.

The addition of the taxanes seems to improve overall survival in node positive disease and in ER/PR negative breast cancers. Primary chemotherapy is the gold standard for all patients with locally advanced breast cancer and  can be used to facilitate cosmesis and make breast conservation feasible in some patients.

Amplification of the Her2/neu is associated with increased aggressiveness of breast cancers. Trastuzumab should be utilised in these patients.

Radiation
All patients with invasive carcinoma should receive radiation therapy as part of breast conservation therapy. Patients undergoing intra-operative radiation should be part of a trial. Patients with implants, collagen vascular disease, very large breasts, locally advanced breast cancers or who have had primary chemotherapy. should all see the radiation oncologist as part of the multi-disciplinary team prior to having surgery.

Post–operative radiation to the nodal basins and chest wall is appropriate in all stage 3, stage 2 with 4 or more positive nodes  (1-3 nodes positive conflicting data).

Endicrine therapy
All patients with hormone receptor – positive tumours are candidates for endocrine therapy which  reduces the risk of recurrence and improves overall survival.

Patients with ER/PR negative tumours should not get hormonal therapy. Hormonal therapy should be started once chemotherapy is completed.

Concurrent use of Tamoxifen and radiation therapy is not recommended due to potential risk of lung toxicity.

Aromatase inhibitors can be used in post menopausal patients either alone or in sequence with tamoxifen.

Certain subgroups (ER+/PR-; HER2+) seem to have a more marked benefit with aromatase inhibitors.

Reconstruction
Breast reconstruction is considered vital to the patients rehabilitation and an intrinsic part of breast cancer treatment (if this is the patients desire).

Immediate reconstruction is and should be available to most patients with breast reconstruction.

Skin sparing mastectomy has proven to be a safe and effective surgical approach  (leaving less than 1% of breast tissue) and facilitating most reconstructive surgical options.

Patients receiving adjuvant radiation therapy or primary chemotherapy should have multidisciplinary discussions so as to ensure the safest reconstructive options are offered to the patient.

Oncology surgery reigns supreme and should not be compromised for the sake of reconstruction.

Implants and expanders are generally not compatible with radiation (should not be placed in a patient who is going to receive radiation therapy.

In Conclusion

The psychological management of the patient is imperative to good outcome. Onco-reconstruction principles should be used in all patients undergoing breast cancer surgery (tried and tested now for over 20years) and immediate reconstruction is the procedure of choice should this be the women’s wish. Strict adherence to margins (greater than 1 cm) for both DCIS and invasive cancer surgery and sentinel lymph node biopsy in node negative tumours are essential for good cancer surgery. Greater use of primary chemotherapy and understanding oncological and radiation therapy principles should now be part of the breast surgeons armamentarium.

New management principles revolve around patient centred, multidisciplinary team approach to breast cancer.