COST-EFFECTIVE PREOPERATIVE EVALUATION, OPERATIVE TREATMENT, AND POSTOPERATIVE FOLLOW-UP IN THE BREAST CANCER PATIENT

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Breast cancer is an extremely common disease in our country, with about 182,000 American women expected to develop the disease in 1995.23 It has been calculated that more than 10% of American women born in 1990 eventually will develop breast cancer during a 90-year life span, assuming that the precipitous rise of breast cancer incidence that occurred in the 1980s continues into the future.19 Furthermore, country-wide data beginning in 1930 through 1992 have revealed that there has been absolutely no difference in age-adjusted mortality from breast cancer during those 63 years.23 These discouraging data emphasize that breast cancer behavior seems to have defied the expected improvement in survival by the effect of the increasing multimodality treatments. The many changes and advances in the treatment of breast cancer during these years have ranged from the wide adaptation of radical mastectomy in the 1930s, the subsequent sequential simplification of surgery from modified mastectomy to breast conservation, to the development of supervoltage radiation therapy, to the practical application of hormonal therapy and the wide usage of adjuvant multidrug chemotherapy. All these therapeutic advances and changes, however, have not led to fewer deaths from breast cancer in population statistics that are age adjusted.23

These disturbing facts, however, may well be changing under the effect of mammographic screening. The rapid rise of breast cancer incidence most recently has been shown to be artifactual,8, 16, 25 the result of mammographic detection of nonpalpable cancers earlier than expected, by a few years or many months, as the incidence has been rapidly declining more recently.15 These data indicate that there is no breast cancer epidemic. A sharp downward revision of the overall risk of American women will have to be made in the near future to acknowledge these new facts.

Most recently, also, reports of population screening programs with mammography have displayed a dramatic and progressive decline in the size of primary invasive breast cancer and the incidence of axillary nodal metastases and an increase in the incidence of noninvasive cancers.6, 12, 22 Furthermore, many small mammographically discovered breast cancers are of low grade.22 Larger, palpable, or clinically discovered breast cancer has a preponderance of poorly differentiated lesions and thus may represent a clonal overgrowth of less differentiated cells from previously more quiescent well-differentiated breast cancers now being detected in a preclinical stage by mammography.10 In any event, dramatic changes are occurring with wide public mammographic screening programs, with the resultant progressive decline in breast cancer size and the incidence of lymph node metastases. In the next few years, the higher proportion of extremely small-sized, better differentiated, and noninvasive primary breast cancer may finally begin to favorably affect the previously unchanging age-adjusted mortality curve.3 Suggestive new data seem to illustrate this.6, 12, 15, 22 Thus, it is now appropriate to rethink many preoperative, operative, and postoperative management strategies to accommodate to these new realities as well as the changing economic aspects of medical care. In addition, recent articles outlining dramatic changes in the treatment of advanced primary breast cancer warrant changing our basic strategies in that aspect of the disease also.18

Section snippets

PREOPERATIVE STRATEGIES

Previously, patients proven to have breast cancer were extensively worked up by routine blood tests and scans of bones, liver, lung, and even brain at the time of disease presentation in order to detect occult metastatic disease. Occasionally, some patients still may need such extensive pretreatment diagnostic efforts if they have an advanced primary breast cancer or suggestive symptoms. A summary of numerous studies26 indicates, however, that liver scans, bone scans, or extensive diagnostic

OPERATIVE STRATEGIES

The role of stereotactic biopsy of mammographically discovered lesions suspicious of cancer is as yet unclear, both from a surgical management as well as a cost point of view. Whether overall it merely adds another expensive step in the diagnostic process or truly saves resources is yet to be defined.

The initial therapeutic operative approach in breast cancer patients in the United States today should be a local anesthesia excision of a palpable mass that fulfills the requirements of a

ADJUVANT THERAPY STRATEGIES

The avoidance of radiation therapy after adequate local excision of selective small or well-differentiated invasive breast cancer detected mammographically can yield significant gains in reduced patient morbidity, increased patient comfort and satisfaction, and reduced cost at no sacrifice of effectiveness in cancer treatment and cure.5, 17 This is particularly to be appreciated when it is realized that the charges for a course of radiation therapy range from $12,000 to $18,000 or more in the

POSTOPERATIVE STRATEGIES

Postoperative management of patients with invasive and noninvasive breast cancer has undergone numerous re-evaluations during the past decade. It has been shown repeatedly that minimal testing following appropriate primary therapy is the most efficient management system.7 In the past, many patients were followed with routine bone scans, blood tests, chest radiographs, and CT scans. These tests are completely ineffective in changing ultimate survival and, therefore, should be abandoned.

SUMMARY

Although medical criteria based on retrospective and prospective studies form the basic foundation for the strategies enunciated in this article, efficiency in management and cost effectiveness follow because of the simplification that has been found to be appropriate by analyzing reports over the past decade and using common sense. In addition, the realization of the effectiveness of mammographic screening programs should encourage all surgeons to promote and practice yearly mammographic

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  • Cited by (0)

    Address reprint requests to Blake Cady, MD, New England Deaconess Hospital, 110 Francis Street, Boston, MA 02215

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    From New England Deaconess Hospital, Boston, Massachusetts

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