Outcomes stand to be optimized when breast care is delivered in a multidisciplinary milieu—as long as such care incorporates screening, diagnosis of borderline and high-risk lesions, and management of the breast cancer patient.
In light of this observation, Savitri Krishnamurthy, MD, and colleagues at the University of Texas’s MD Anderson Cancer Center in Houston suggest that the “current paradigm” for screening is ripe for replacement. They’re referring to the model by which women schedule their own screening mammograms without a clinician order.
While this system simplifies the process of getting screened, and thus helps motivate a wide swath of the population to regularly get screened, it generally precludes adjustments for women at increased risk of breast cancer, the authors point out in a paper published online Dec. 8 in the American Journal of Roentgenology.
But the paradigm is shifting, they note, and it’s for the better.
“Many breast imaging facilities are now routinely assessing breast cancer risk when women are seen for their annual mammography examination,” write Krishnamurthy, senior author Wei Yang, MBBS, and co-authors. “This information provides the opportunity for collaborative care between the breast imager and the cancer prevention specialist (CPS), who may be a primary care physician or a medical oncologist, in the management of women at increased or high risk.”
Communication of this risk to the CPS, along with awareness-raising around the availability of—and guidelines on—supplemental screening modalities such as breast MRI can help make sure high-risk women are appropriately screened, the authors state.
They add that breast imagers are likely to have the greatest knowledge and understanding of current supplemental high-risk screening recommendations.
“On the basis of the outcome of the breast cancer risk assessment performed in the screening mammography setting,” the authors write, “additional opportunities exist to inform the CPS of the need for possible genetic counseling and risk-reduction therapy (e.g., selective estrogen receptor modulators [tamoxifen, raloxifene] and aromatase inhibitors [exemestane, anastrozole]).”
An MD Anderson example
Krishnamurthy and team describe their firsthand experience at the Anderson Cancer Center, where they use a multidisciplinary approach to provide management recommendations for patients with discordant, indeterminate or high-risk proliferative breast lesions.
A weekly multidisciplinary conference includes breast specialists from the departments of radiology, pathology, cancer chemoprevention and surgery; this meeting enables the integration of clinical, radiologic, and pathologic data.
“The patients’ clinical history and radiologic and pathologic findings are reviewed in depth,” the authors write. “Review and discussion of each case takes into consideration [numerous] variables and leads to personalized management recommendations.”
The authors point to a recent study conducted at their facility to look at the utility of regional lymph node ultrasound evaluation in 865 patients presenting with clinical stage III breast cancer.
They found that ultrasound identified extraaxillary nodal metastases in 325 of these patients (37 percent), and these detections led to changes in radiation treatment plans.
Of the patients with extraaxillary disease, approximately 85 percent had infraclavicular involvement, 40 percent had supraclavicular involvement, and 30 percent had internal mammary involvement.
“Most of these nodal metastases were pathologically confirmed by ultrasound-guided fine-needle aspiration biopsy before radiation therapy,” the authors write. “Thoughtful radiation including appropriate targeting and dosing of these involved nodal basins is highly effective, with recent series from our group documenting durable control of the involved nodal basin in greater than 90 percent of treated patients.”
Krishnamurthy et al. conclude that the multidisciplinary delivery of breast care for women that incorporates screening, diagnosis of borderline and high-risk lesions, and management in patients with breast cancer “adds considerable value to outcomes in health care.”
They add that breast imaging “significantly impacts multidisciplinary considerations in breast cancer screening and early detection, discussion around histopathologic findings in the diagnostic evaluation and management of breast abnormalities, and the surgical and radiation therapy planning for patients with breast cancer.”