Repeat breast-conserving treatment of ipsilateral breast cancer recurrence: a nationwide survey amongst breast surgeons and radiation oncologists in the Netherlands

Abstract

Background In line with the paradigm to minimize surgical morbidity in patients with primary breast cancer, there is increasing evidence for the safety of a repeat breast-conserving treatment (BCT) of an ipsilateral breast tumour recurrence (IBTR) in selected patients. The conditions for the feasibility of a repeat BCT vary widely in literature. In clinical practice, many physicians have ongoing concerns about the oncological safety and possible toxicity of repeat BCT. Aim To investigate the attitude of Dutch breast surgeons and radiation oncologists towards repeat BCT and to report on their experiences with, objections against and perceived requirements to consider a repeat BCT in case of IBTR. Patients and methods An online survey consisting of a maximum of 26 open and multiple-choice questions about repeat BCT for IBTR was distributed amongst Dutch breast surgeons and radiation oncologists. Results Forty-nine surgeons representing 49% of Dutch hospitals and 20 radiation oncologists representing 70% of Dutch radiation oncology centres responded. A repeat BCT was considered feasible in selected cases by 28.7% of breast surgeons and 55% of radiation oncologists. The most important factors to consider a repeat BCT for both groups were the patient’s preference to preserve the breast and surgical feasibility of a second lumpectomy. Arguments against a repeat BCT were based on the perceived unacceptable toxicity and cosmesis of a second course of radiotherapy. The technique of preference for re-irradiation would be partial breast irradiation (PBI) according to all radiation oncologists. Differentiating between new primary tumours (NPT) and true recurrences (TR) was reported to be done by 57.1% of breast surgeons and 60% of radiation oncologists. The most important reason to differentiate between NPT and TR was to establish prognosis and to consider whether a repeat BCT would be feasible. Conclusion An increasing number of Dutch breast cancer specialists is considering a repeat BCT feasible in selected cases, at the patient’s preference and with partial breast re-irradiation.

Is repeat breast conservation possible for small ipsilateral breast cancer recurrence?

“…The second full‐dose course of whole breast radiation could result in severe radiotherapy‐related complications and toxicities. A survey found that 70% of breast surgeons and radiation oncologists were against re‐BCS for IBTR because of the need for reirradiation 16 . Recently, accelerated partial breast irradiation has provided the same efficacy with reduced toxicity because of the existence of modalities, such as targeted intraoperative radiotherapy and three‐dimensional conformal radiotherapy 25–27 .…”

“…Salvage mastectomy has been regarded as the first‐choice treatment for IBTR after BCS 8,9 . However, other studies have indicated that repeat BCS (re‐BCS) is a safe option for IBTR, 10–15 and a considerable number of patients are willing to undergo re‐BCS after recurrence 16 . Approximately 20% of patients with IBTR in the Surveillance, Epidemiology, and End Results (SEER) database opted for re‐BCS as opposed to mastectomy 8,17 .…”

“…8,9 However, other studies have indicated that repeat BCS (re-BCS) is a safe option for IBTR, [10][11][12][13][14][15] and a considerable number of patients are willing to undergo re-BCS after recurrence. 16 Approximately 20% of patients with IBTR in the Surveillance, Epidemiology, and End Results (SEER) database opted for re-BCS as opposed to mastectomy. 8,17 Furthermore, more than 70% of recurrent tumors after BCS are <2 cm in size, 4,[8][9][10][11][12][13][14][15][16][17][18][19][20] and few studies have recommended that patients with small recurrent tumors are suitable candidates for re-BCS.…”

The MARECA (national study of management of breast cancer locoregional recurrence and oncological outcomes) study: National practice questionnaire of United Kingdom multi-disciplinary decision making

“…This is in direct contravention to the NCCN guidelines which clearly state that patient who have undergone previous BCS with WBRT should be managed surgically with mastectomy in the event of an in-breast recurrence [7]. A Dutch national survey, with responses from breast surgeons and radiation oncologists, have also shown considerable variation in the decision to offer BCS [19]. Furthermore, studies have shown that repeat BCS in the setting of in-breast recurrence is oncologically safe when compared to salvage mastectomy in selected women [20].…”

“…She had post-operative WBRT plus boost, chemotherapy, and 5 years of tamoxifen. 19. She now presents with an in-breast invasive local recurrence close to the primary scar measuring 10 mm.…”