Breast reconstruction improves quality of life, but providers must be aware of the risks and benefits of each reconstruction approach in the setting of postmastectomy radiotherapy.
William C. Wood, MD
A chest wall recurrence of breast cancer following mastectomy is a complex clinical problem that can push centers to the limits of their resources.
COUNTERPOINT: Should Radiation Therapy After Surgery for Ductal Carcinoma In Situ Be Standard Practice?
To universally recommend breast irradiation for all women after excision of DCIS lesions ignores information now available to us that can spare the majority of women with DCIS the downsides of RT, but be applied in the treatment of DCIS patients at greater risk for invasive disease.
The DCIS Score provides clinically relevant information about personal risk that can guide patient discussions and facilitate shared decision making.
Kinder, gentler cancer therapy is neither of those things if it fails to be as effective in controlling the cancer. When an area of completely clinically regressed cancer is excised, there is commonly residual cancer present.
To make the punishment fit the crime, you would want the decision of whether or not to use adjuvants to be informed by the degree of risk that the DCIS would recur. What factors can predict for an increased risk of recurrence, or more importantly, the risk of an invasive breast cancer occurring?
Since 1990, death rates from breast cancer have decreased, mainly in women younger than 50 years of age (3.3% per year) vs women aged 50 years or older (2% per year), reflecting the benefit of widespread use of systemic treatment added to early detection.
The past twenty-five years have seen a drop in deaths from cancer, particularly in the last half of that period.
Women with any family history of breast cancer assume a high probability
of risk. Counseling women involves ascertainment of an accurate
family history and use of the best predictive models to assess both
the risk of a known mutation and the risk of breast cancer. This risk
must then be considered in the contexts of both the woman’s lifetime
and the next decade, in each instance carefully separating the risk of
developing cancer from the risk of mortality. These two risks are often
emotionally melded in women who have watched a loved one die of
cancer. The options for a woman at significantly increased risk of breast
cancer include optimal surveillance, chemoprevention, and prophylactic
surgery. This entire field is in continuing evolution as better methods
of diagnosis, screening, and chemoprevention continue to enter clinical