AGO Recommendations for the surgical therapy of breast cancer: update 2022

The recommendations of the AGO Breast Committee on the surgical therapy of breast cancer were last updated in March 2022 (www.ago-online.de). Since surgical therapy is one of several partial steps in the treatment of breast cancer, extensive diagnostic and oncological expertise of a breast surgeon and good interdisciplinary cooperation with diagnostic radiologists is of great importance. The most important changes concern localization techniques, resection margins, axillary management in the neoadjuvant setting and the evaluation of the meshes in reconstructive surgery. Based on meta-analyses of randomized studies, the level of recommendation of an intraoperative breast ultrasound for the localization of non-palpable lesions was elevated to “++”. Thus, the technique is considered to be equivalent to wire localization, provided that it is a lesion which can be well represented by sonography, the surgeon has extensive experience in breast ultrasound and has access to a suitable ultrasound device during the operation. In invasive breast cancer, the aim is to reach negative resection margins (“no tumor on ink”), regardless of whether an extensive intraductal component is present or not. Oncoplastic operations can also replace a mastectomy in selected cases due to the large number of existing techniques, and are equivalent to segmental resection in terms of oncological safety at comparable rates of complications. Sentinel node excision is recommended for patients with cN0 status receiving neoadjuvant chemotherapy after completion of chemotherapy. Minimally invasive biopsy is recommended for initially suspect lymph nodes. After neoadjuvant chemotherapy, patients with initially 1 – 3 suspicious lymph nodes and a good response (ycN0) can receive the targeted axillary dissection and the axillary dissection as equivalent options

AGO recommendations for the surgical therapy of the axilla after neoadjuvant chemotherapy: 2021 Update

For many decades, the standard procedure to treat breast cancer included complete dissection of the axillary lymph nodes. The aim was to determine histological node status, which was then used as the basis for adjuvant therapy, and to ensure locoregional tumour control. In addition to the debate on how to optimise the therapeutic strategies of systemic treatment and radiotherapy, the current discussion focuses on improving surgical procedures to treat breast cancer. As neoadjuvant chemotherapy is becoming increasingly important, the surgical procedures used to treat breast cancer, whether they are breast surgery or axillary dissection, are changing. Based on the currently available data, carrying out SLNE prior to neoadjuvant chemotherapy is not recommended. In contrast, surgical axillary management after neoadjuvant chemotherapy is considered the procedure of choice for axillary staging and can range from SLNE to TAD and ALND. To reduce the rate of false negatives during surgical staging of the axilla in pN+(CNB) stage before NACT and ycN0 after NACT, targeted axillary dissection (TAD), the removal of > 2 SLNs (SLNE, no untargeted axillary sampling), immunohistochemistry to detect isolated tumour cells and micro-metastases, and marking positive lymph nodes before NACT should be the standard approach. This most recent update on surgical axillary management describes the significance of isolated tumour cells and micro-metastasis after neoadjuvant chemotherapy and the clinical consequences of low volume residual disease diagnosed using SLNE and TAD and provides an overview of this year's AGO recommendations for surgical management of the axilla during primary surgery and in relation to neoadjuvant chemotherapy

Breast Centers in Germany

A decrease in medical practice variations in national breast cancer care has been shown to improve survival and the negative impact of the disease on affected women and their families. The following report describes the concert of efforts undertaken by the medical societies to optimize national breast cancer care by organizational centralization of multidisciplinary medical competence in certified breast centers (CBC), aiming to attain continual quality of health care by implementation of evidence-and consensus-based guidelines. Centralization and the systematic pursuit of organizational development by tracking guideline adherence using performance quality indicators over time demonstrate the feasibility and practicability of the implementation concept to bridge the gap between determined scientific best evidence and applied best practice. However, the proof of concept will remain pending until the data of the population-based cancer registries are analyzed for survival estimates

Diagnostische Wertigkeit von Untersuchungen zur Diagnostik des sekundären Armlymphödems bei Patientinnen mit Brustkrebs unter besonderer Berücksichtigung der ultrasonographischen Hautschichtendickemessung : Ergebnisse einer Multicenterstudie

Das sekundäre Lymphödem ist eine der häufigsten Komplikationen nach Therapie des Mammakarzinoms. Die wissenschaftliche Lage zur Diagnostik des Lymphödems ist schlecht. Die Erkrankung an einem Lymphödem bringt regelmässig erhebliche Langzeitfolgen, wie die Einschränkung der Lebens-qualität in nahezu allen Lebensbereichen, mit sich. Daher sind frühzeitige Diagnosestellung und Therapiebeginn unabdingbar. Die primäre Fragestellung war, ob das Verfahren der ultrasonographischen Subcutisdifferenzmessung ausreichend diagnostische Güte besitzt und gegebenenfalls zur Stadieneinteilung des Lymphödems anhand eines ermittelten Schwellenwertes dienen kann. Als sekundäre Fragestellung wurde der Einfluss weiterer klinischer und anamnestischer Faktoren auf die Entwicklung eines Armlymphödems untersucht. In unserer prospektiven Multicenterstudie wurden ultrasonographische Untersuchungen an beiden Unterarmen bei 274 Patientinnen im Zeitraum von 02.05.2006 bis zum 17.01.2007 vergleichend durchgeführt. Die Subcutisdicke wurde als primärer Endpunkt mittels Mann-Whitney-U-Test, ROC-Kurven und Korrelationskoeffizient nach Pearson bei einem Signifikanzniveau von 5% analysiert. Zusätzlich aufgenommene Variablen wurden per Mann-Whitney-Test analysiert und deskriptiv ausgewertet. Es konnte kein signifikanter Zusammenhang zwischen der Subcutisdifferenz und dem Armlymphödem festgestellt werden: Für die Alternativhypothese bezüglich der Subcutisdifferenz als trennender Faktor wurde ein p-Wert von 0,135 ermittelt. Die ROC-Kurven, mit einer geschätzten Fläche unter der Kurve von 0,556 mit einem 95%-Konfidenzintervall (0,481; 0,631), weisen auf einen Mangel an diagnostischer Güte hinsichtlich Sensitivität und Spezifität hin. Der Korrelationskoeffizient nach Pearson für den Zusammenhang zwischen Subcutisdifferenz und Unter- bzw. Oberarm-umfangsdifferenz betrug r=0.059 bzw. r=0,133. Für den Zusammenhang zwischen Lymphödem und Umfangmessung wurde sowohl bezüglich der Oberarm- als auch der Unterarmmessungen ein p-Wert von p= 0,000 nach Mann-Whitney-Test bestimmt. Für den Zusammen-hang zwischen Lymphödem und BMI wurde ein p-Wert von p<0,001 errechnet. Die von den Patientinnen per Fragebogen ermittelte selbstberichtete Armsymptomatik wiesen einen signifikanten Zusammenhang zum Lymph-ödem auf (p-Wert von p<0,000 für den Arm-Score und p<0,001 für den Brust-Score). Anamnese und klinische Untersuchung zeigten, dass Patientinnen bereits mit Armlymphödem im Stadium I eine niedrigere Lebensqualität haben als Patientinnen ohne Ödem. Auch das Arbeitsleben und das gesellschaftliche Leben sind häufiger eingeschränkt. Die Differenz der Subcutisdicke ist unseren Ergebnissen zufolge kein günstiger Faktor zur diagnostischen Trennung. Somit konnten die vielversprechenden Ergebnisse von Balzarini et al12, Mellor et al52 und Van der Veen et al86 in unserer Studie nicht bestätigt werden. Der BMI hingegen konnte als Risikofaktor für die Entwicklung eines sekundären Armlymphödems identifiziert werden. Die Armumfangmessungen und die von den Patientinnen selbstberichtete Symptomatik weisen jeweils einen signifikanten Zusammenhang zum Lymphödem auf und es wird empfohlen beides zukünftig zur Früherkennung des Lymphödems in die Nachsorge der Brustkrebspatientinnen zu integrieren

Microcalcification-associated breast cancer: presentation, successful first excision, long-term recurrence and survival rate

INTRODUCTION: In this study we evaluated mammographic, histological and immunohistochemical findings for microcalcification-associated breast cancer with regards to breast-conserving therapy, recurrence and survival rate. PATIENTS AND METHODS: We retrospectively analyzed 99 consecutive, non-palpable and microcalcification-associated breast cancers (94 women) that were treated surgically between January 2002 and December 2003 at a national academic breast cancer center. Calcifications were classified according to the Breast Imaging Reporting and Data System (BI-RADS). Descriptors, surgical outcome and histological findings were assessed. Recurrences and survival rates were evaluated based on medical records, standardized patient questionnaires and/or contacting the physician. RESULTS: 42 of the 99 lesions (42.4%) were invasive carcinomas, 57 (57.6%) were pure ductal carcinoma in situ (DCIS). 6 out of 99 (6.1%) lesions were triple negative, and 29 (29.3%) were HER2/neu positive. Successful first excision rate was 76/99 lesions (76.8%). Breast conservation was achieved in 73.7% (73/99). 10 women showed local recurrences without negatively impacting survival. The recurrences included round/punctate, amorphous, fine pleomorphic, and fine linear or fine-linear branching descriptors. The breast cancer-specific long-term survival rate was 91/94 (96.8%) for a mean follow-up of 81.4 months. The 3 patients who died due to breast carcinoma showed fine pleomorphic calcifications, and had nodal-positive invasive carcinoma at diagnosis. CONCLUSION: Microcalcification-associated breast cancers are frequently treated with breast-conserving therapy. Continuous clinical and mammographic follow-up is recommended for all descriptors

The adherence paradox : guideline deviations contribute to the increased 5-year survival of breast cancer patients

Background: In German breast cancer care, the S1-guidelines of the 1990s were substituted by national S3-guidelines in 2003. The application of guidelines became mandatory for certified breast cancer centers. The aim of the study was to assess guideline adherence according to time intervals and its impact on survival. Methods: Women with primary breast cancer treated in three rural hospitals of one German geographical district were included. A cohort study design encompassed women from 1996–97 (N = 389) and from 2003–04 (N = 488). Quality indicators were defined along inpatient therapy sequences for each time interval and distinguished as guideline-adherent and guideline-divergent medical decisions. Based on all of the quality indicators, a binary overall adherence index was defined and served as a group indicator in multivariate Cox-regression models. A corrected group analysis estimated adjusted 5-year survival curves. Results: From a total of 877 patients, 743 (85 %) and 504 (58 %) were included to assess 104 developed quality indicators and the resuming binary overall adherence index. The latter significantly increased from 13–15 % (1996–97) up to 33–35 % (2003–04). Within each time interval, no significant survival differences of guideline-adherent and -divergent treated patients were detected. Across time intervals and within the group of guideline-adherent treated patients only, survival increased but did not significantly differ between time intervals. Across time intervals and within the group of guideline-divergent treated patients only, survival increased and significantly differed between time intervals. Conclusions: Infrastructural efforts contributed to the increase of process quality of the examined certified breast cancer center. Paradoxically, a systematic impact on 5-year survival has been observed for patients treated divergently from the guideline recommendations. This is an indicator for the appropriate application of guidelines. A maximization of guideline-based decisions instead of the ubiquitous demand of guideline adherence maximization is advocated

Valid comparisons and decisions based on clinical registers and population based cohort studies: assessing the accuracy, completeness and epidemiological relevance of a breast cancer query database

Abstract Background Data accuracy and completeness are crucial for ensuring both the correctness and epidemiological relevance of a given data set. In this study we evaluated a clinical register in the administrative district of Marburg-Biedenkopf, Germany, for these criteria. Methods The register contained data gathered from a comprehensive integrated breast-cancer network from three hospitals that treated all included incident cases of malignant breast cancer in two distinct time periods from 1996–97 (N=389) and 2003–04 (N=488). To assess the accuracy of this data, we compared distributions of risk, prognostic, and predictive factors with distributions from established secondary databases to detect any deviations from these “true” population parameters. To evaluate data completeness, we calculated epidemiological standard measures as well as incidence-mortality-ratios (IMRs). Results In total, 12% (13 of 109) of the variables exhibited inaccuracies: 9% (5 out of 56) in 1996–97 and 15% (8 out of 53) in 2003–04. In contrast to raw, unstandardized incidence rates, (in-) directly age-standardized incidence rates showed no systematic deviations. Our final completeness estimates were IMR=36% (1996–97) and IMR=43% (2003–04). Conclusion Overall, the register contained accurate, complete, and correct data. Regional differences accounted for detected inaccuracies. Demographic shifts occurred. Age-standardized measures indicate an acceptable degree of completeness. The IMR method of measuring completeness was inappropriate for incidence-based data registers. For the rising number of population-based health-care networks, further methodological advancements are necessary. Correct and epidemiologically relevant data are crucial for clinical and health-policy decision-making.</p

Breast Cancer in Countries of Limited Resources.

For 2010, the annual incidence of breast cancer is estimated to increase from now 1.15 Mio to 1.5 Mio new cases per year. The increase is mainly seen in low and middle income countries. Resource limitations in means of finance, personnel, infrastructure, and by political instability are tremendous. Currently, little attention is paid to breast care in low-resource settings due to other health priorities. However, with increasing life expectancy and reduction of mortality due to infectious diseases, more people are confronted with non-communicable diseases, and the topic of cancer in developing countries will emerge more and more. Specific guidelines for breast cancer were given by the Global Breast Health Initiative differentiating according to available resources in different settings. From awareness in public and health care facilities to obtaining the diagnosis, deciding on strategies of treatment, and putting strategies into practice - all these obstacles differ substantially in developed and developing countries. Further research is essential to meet the challenge of breast cancer worldwide in the coming years

Valid comparisons and decisions based on clinical registers and population based cohort studies: assessing the accuracy, completeness and epidemiological relevance of a breast cancer query database

BACKGROUND: Data accuracy and completeness are crucial for ensuring both the correctness and epidemiological relevance of a given data set. In this study we evaluated a clinical register in the administrative district of Marburg-Biedenkopf, Germany, for these criteria. METHODS: The register contained data gathered from a comprehensive integrated breast-cancer network from three hospitals that treated all included incident cases of malignant breast cancer in two distinct time periods from 1996–97 (N=389) and 2003–04 (N=488). To assess the accuracy of this data, we compared distributions of risk, prognostic, and predictive factors with distributions from established secondary databases to detect any deviations from these “true” population parameters. To evaluate data completeness, we calculated epidemiological standard measures as well as incidence-mortality-ratios (IMRs). RESULTS: In total, 12% (13 of 109) of the variables exhibited inaccuracies: 9% (5 out of 56) in 1996–97 and 15% (8 out of 53) in 2003–04. In contrast to raw, unstandardized incidence rates, (in-) directly age-standardized incidence rates showed no systematic deviations. Our final completeness estimates were IMR=36% (1996–97) and IMR=43% (2003–04). CONCLUSION: Overall, the register contained accurate, complete, and correct data. Regional differences accounted for detected inaccuracies. Demographic shifts occurred. Age-standardized measures indicate an acceptable degree of completeness. The IMR method of measuring completeness was inappropriate for incidence-based data registers. For the rising number of population-based health-care networks, further methodological advancements are necessary. Correct and epidemiologically relevant data are crucial for clinical and health-policy decision-making

Are There Disparities in Surgical Treatment for Breast Cancer Patients with Prior Physical Disability A Path Analysis

Introduction:Cancer care for patients with prior physical disability has hardly been researched in clinical research, health services research, or special education. This article aims to compare the severity of disease and the surgical treatment of diagnosed breast cancer patients with and without prior physical disability.Methods:A total of 4,194 patients with primary breast cancer who underwent surgery in a breast cancer center in North Rhine-Westphalia, Germany, participated in an annual postoperative postal survey, which was complemented by clinical data. Latent class analysis and logit path models were applied to study (1) differences in terms of UICC staging and local cancer treatment between patients with and without prior physical disability and (2) respective differences by disability severity.Results:Patients with physical disability (n= 780; 18.7%) had a higher chance of receiving mastectomy compared to breast-conserving therapy, even after controlling for socioeconomic status and UICC staging. Disability severity is directly and indirectly associated with receiving a mastectomy.Conclusion:In light of the research gap on disability and cancer, this work indicates disparities in care for breast cancer patients with prior physical disability. Inequalities might be attributable to (1) unequal access to care, (2) individual preferences and difficulties, or (3) medical difficulties