MDC is not being implemented in line with best practice or applied consistently across Australia. This audit has highlighted gaps in care delivery, despite national recommendations about MDC. Areas being neglected can affect the quality of care provided and may put clinicians at medico-legal risk. Recommendations to improve uptake and effectiveness of MDC are provided.

No abstract

Neoadjuvant therapy is given before surgery to improve resectability, local control and/or survival. Post-operative radiation therapy for locally advanced rectal cancer has been long accepted, and since 1990 adding fluorouracil (5FU) chemotherapy became the NIH standard. However, trials then showed that pre-operative radiotherapy followed by surgery improved local control over surgery alone, but had a less consistent effect on overall survival. The German trial (Sauer, NEJM, 2004, 351:1731) showed a 5 year local relapse rate of 6% for pre-operative chemo-radiotherapy and 13% for post-operative chemo-radiotherapy for T3 or T4 or node-positive rectal cancer treated by TME. The EORTC 22921 trial (37% had TME) showed a similar reduction in local recurrence whether 5FU/leucovorin chemotherapy was given with pre-operative radiotherapy, after pre-operative radiotherapy plus surgery, or both (Bosset, NEJM, 2006, 355:1114. Trials show increased rates of complete pathological remission, increased acute toxicity, but no consistent effects on sphincter preservation rates or overall survival when chemotherapy is combined with pre-operative radiation.Many questions remain. The TROG/AGITG trial compares pre-operative radiotherapy as a short course (5 Gy X 5#) or long course with chemotherapy (50.4 Gy plus 5 FU infusion), with accrual just completed. Ongoing phase III trials explore capecitabine, adding other drugs to 5 FU, and post-operative adjuvant chemotherapy.Neo-adjuvant pre-operative radiation with concurrent chemotherapy, unless contra-indicated by comorbidity, has become widely accepted for T3 or T4 or node-positive rectal cancer based on MRI staging. Individual patient care is best planned by a multidisciplinary team.

In 1994 and 1995 the BRCA1 and BRCA2 genes were first discovered. These breakthroughs quickly lead to the clinical testing of these genes in families with multiple cases of breast and ovarian cancer. Whilst different centres apply different criteria for clinical testing, only approximately 20% of high risk families are found to harbour a mutation in one or other of these genes. Despite intense efforts by the research community, there has been no BRCA3 gene uncovered, nor is there likely to be any other high penetrant breast cancer to be found. More recent research efforts have uncovered more moderate and low risk breast cancer susceptibility genes. It remains to be seen if there is any clinical utility in testing for these low penetrant genes in years to come.More promising are the trials of new drugs called PARP inhibitors that may offer specific advantages in treating breast and ovarian cancer in women who are germline carriers of BRCA gene mutations. Molecular genetics will no doubt continue to shed light on the biology of breast cancer in productive ways in years to come.Purpose: Sentinel node biopsy (SNB) is standard of care for node negative, early breast cancer. There is debate as to the role of SNB in cases presenting with locally recurrent cancer or new ipsilateral cancer after breast conservation surgery or mastectomy in patients who have had a prior axillary dissection or prior SNB. The role of re-operative SNB is evolving as is its place in staging and management. Methodology: Illustrative case histories and English language literature review. Results: High rates of ipsilateral axillary lymphatic drainage still occur in patients where only prior SNB has been performed in the axilla. When prior axillary dissection has been performed there is approximately 33-38% chance of demonstrating axillary sentinel nodes and a 28-58% chance of demonstrating non-ipsilateral axillary / extra-axillary drainage. The more extensive the axillary intervention the greater the chance of extra-axillary lymphatic drainage. Common sites of non-ipsilateral axillary lymphatic drainage includeinternal mammary nodes and the contralateral axilla. Less common sites include intramammary lymph nodes both in the ipsilateral and the contralateral breast, interpectoral nodes and supraclavicular nodes. Information from the redo SNB alters management in the majority of cases. Re-operative SNB has been reported after prior mastectomy but there is very little data available. Conclusions: Lymphatic mapping is possible in the majority of ipsilateral local recurrent and new primary breast cancer patients. Re-operative SNB is technically feasible in the majority of cases where lymphatic drainage is demonstrated. When performed the results change management in the majority of cases.

In 1994 and 1995 the BRCA1 and BRCA2 genes were first discovered. These breakthroughs quickly lead to the clinical testing of these genes in families with multiple cases of breast and ovarian cancer. Whilst different centres apply different criteria for clinical testing, only approximately 20% of high risk families are found to harbour a mutation in one or other of these genes. Despite intense efforts by the research community, there has been no BRCA3 gene uncovered, nor is there likely to be any other high penetrant breast cancer to be found. More recent research efforts have uncovered more moderate and low risk breast cancer susceptibility genes. It remains to be seen if there is any clinical utility in testing for these low penetrant genes in years to come.More promising are the trials of new drugs called PARP inhibitors that may offer specific advantages in treating breast and ovarian cancer in women who are germline carriers of BRCA gene mutations. Molecular genetics will no doubt continue to shed light on the biology of breast cancer in productive ways in years to come.Purpose: Sentinel node biopsy (SNB) is standard of care for node negative, early breast cancer. There is debate as to the role of SNB in cases presenting with locally recurrent cancer or new ipsilateral cancer after breast conservation surgery or mastectomy in patients who have had a prior axillary dissection or prior SNB. The role of re-operative SNB is evolving as is its place in staging and management. Methodology: Illustrative case histories and English language literature review. Results: High rates of ipsilateral axillary lymphatic drainage still occur in patients where only prior SNB has been performed in the axilla. When prior axillary dissection has been performed there is approximately 33-38% chance of demonstrating axillary sentinel nodes and a 28-58% chance of demonstrating non-ipsilateral axillary / extra-axillary drainage. The more extensive the axillary intervention the greater the chance of extra-axillary lymphatic drainage. Common sites of non-ipsilateral axillary lymphatic drainage includeinternal mammary nodes and the contralateral axilla. Less common sites include intramammary lymph nodes both in the ipsilateral and the contralateral breast, interpectoral nodes and supraclavicular nodes. Information from the redo SNB alters management in the majority of cases. Re-operative SNB has been reported after prior mastectomy but there is very little data available. Conclusions: Lymphatic mapping is possible in the majority of ipsilateral local recurrent and new primary breast cancer patients. Re-operative SNB is technically feasible in the majority of cases where lymphatic drainage is demonstrated. When performed the results change management in the majority of cases.