After surgery for invasive breast cancer, how often will patients need biopsies during follow-up? Remarkably, the medical literature has been unclear about the answer to this basic question.
Now, a first-of-its-kind study reveals that the 5- and 10-year overall incidence of breast biopsy was under 15% after a lumpectomy and 24% after unilateral mastectomy, with even lower percentages for older women.
A “key message” for patients from the findings is that having a biopsy is the exception, not the rule, said study senior author, Henry Kuerer, MD, PhD, executive director of breast programs, MD Anderson Cancer Network, Houston, Texas.
“Patients may believe they are going to be getting biopsies regularly,” he told Medscape Medical News.
The study is published online January 31 in JAMA Surgery.
The investigators, who are all from the University of Texas MD Anderson Cancer Center in Houston, reviewed records on 80,369 older patients by using the Surveillance, Epidemiology, and End Results–Medicare database (age ≥ 66 years) and on 41,510 younger patients in MarketScan, a private insurance database, (age ≤ 64 years).
The study is the first comprehensive nationwide population-based study of breast biopsies in women with breast cancer, the researchers note.
The 5- and 10-year overall incidence of breast biopsy was 11.8% after lumpectomy and 14.9% after unilateral mastectomy in the cohort of older women and 14.7% and 23.4%, respectively, in the cohort of younger women.
Adjuvant chemotherapy use, patient age, and endocrine therapy were independently associated with biopsy in both cohorts.
The 160,000-plus patients had stage I to III disease and were diagnosed between 2000 and 2011. Patients had breast-conserving surgery (with or without radiation) or unilateral mastectomy; diagnosis and procedural codes were used to identify biopsies during follow-up.
Breast-conserving surgery and mastectomy are the two main options for surgical management of breast cancer, points out Cheng-Har Yip, MD, a surgeon at the University of Malaysia in Kuala Lumpur, writing in an accompanying editorial.
Overall survival does not differ between these two approaches after 20 years, as shown in a major randomized clinical trial (N Engl J Med. 2002;347:1233-1241), Dr Yip comments.
Follow-up is different for patients based on their initial treatment, he points out: “Women who have received a unilateral mastectomy need an annual mammography on the intact breast, and those who have undergone BCS [breast-conserving surgery] require bilateral mammography.”
Until now, there has been “little” information about the rate of biopsies for suspected malignancies that inevitably arise from these mammograms, Dr Yip adds.
Subsequent biopsy rates are seldom discussed with women at the time of surgical decision making.
“Subsequent biopsy rates are seldom discussed with women at the time of surgical decision making but may affect the women’s decision and lead to an increasing number of women who opt for bilateral mastectomy,” he adds.
How Will New Data Be Used in Clinic?
Dr Kuerer says the new data on biopsy rates can be added into patients’ decision-making process about treatment for early-stage, invasive breast cancer..
“Many feel very anxious over the future need for biopsies and the potential of another diagnosis,” he said in a press statement. “Women will often choose a mastectomy rather than have the fear and stress associated with future biopsies or another cancer diagnosis.”
In the new study, having a unilateral mastectomy in one breast did, in fact, result in a lower rate of subsequent biopsy. The estimated 5-year breast biopsy rates for the remaining breast were 7.8% and 10.4% and in the SEER-Medicare and MarketScan and cohorts, respectively.
Whether you remove both breasts, one breast or have a lumpectomy, we are going to need to follow you forever.
However, Dr Kuerer explained that, regardless of what type of treatment a patient chooses — including double mastectomy — both distant and local recurrences are a possibility. Long-term monitoring is needed for all patients.
“Whether you remove both breasts, one breast or have a lumpectomy, we are going to need to follow you forever. You have to get comfortable with this as part of your life,” he said.
Furthermore, the new study also shows that only 23.2% of the women in the SEER-Medicare cohort and 29.8% of the women in the MarketScan cohort eventually underwent subsequent cancer treatment after a biopsy. Hence, most biopsies produced benign results, he added.
But clinicians who encourage lumpectomy are swimming against a tide, Dr Kuerer also suggested.
He commented that in almost all breast surgery settings, patients “increasingly” want a mastectomy or double mastectomy in the event of any breast cancer diagnosis. Unfortunately, the decisions are being made soon after the “trauma” of a breast cancer diagnosis, he said.
The study was funded by the Dutch Cancer Society Clinical KWF Fellowship, the PH and Fay Etta Robinson Distinguished Professorship in Cancer Research Endowment, the National Institutes of Health, and the MD Anderson Clinical Research Funding Award Program. Dr Kuerer reports publishing patents, royalties, and other intellectual property from the New England Journal of Medicine Group and McGraw-Hill Publishing, serving on the speaker’s bureau for PER, and former research funding from Genomic Health. Dr Yip has disclosed no relevant financial relationships.
JAMA Surg. Published online January 31, 2018. Abstract, Editorial
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