Although it was added to the guidelines, the recommendation is not as strong as the unanimous category 1 recommendation for use of trastuzumab in combination with adjuvant endocrine therapy and adjuvant chemotherapy for women with tumors larger than 1 cm or who have node-positive disease with one or more axillary node metastases larger than 2 mm.
Genetic counseling of women with DCIS “if they are at high risk for hereditary breast cancer or early invasive disease” is a new recommendation. “In high-risk women, genetic testing can often lead to a decision that leads to treatment of both the affected breast and the unaffected breast,” Dr. McCormick said, citing a study that notes the increase in prophylactic bilateral mastectomy rates from 4% in 1998 to 11% in 2003 (J. Clin. Oncol. 2007;25:5203–9). “And I suspect if we look again, it would be even higher.”
For the first time, the guidelines also feature a section on principles of breast reconstruction after surgery. Breast implants, autologous tissue, or a combination are identified as options.
These principles say that skin-sparing mastectomy is “probably equivalent” to standard mastectomy, and “should be performed by an experienced breast surgery team that works in a coordinated, multidisciplinary fashion.” Dr. McCormick said at the meeting that reconstruction “most importantly” should be “performed by an experienced team of breast surgeons and plastic surgeons.”
Reconstruction can be done at the same time or after completion of cancer treatment. When postmastectomy radiation is required, however, the general preference is to delay autologous-tissue reconstruction until after the completion of radiation therapy, Dr. McCormick said. This is a category 2B recommendation, which means it was not unanimous, she noted. “We have had great experience [with delayed reconstruction] at Memorial Sloan-Kettering, but other colleagues on the panel, especially at [the University of Texas M.D. Anderson Cancer Center in Houston], have not, so it remains 2B,” she said.
A postexcision mammogram should be performed when there is uncertainty about margins. DR. MCCORMICK