Screening Mammography: Recommendations and Controversies 667

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1 Management of Breast Cancer Foreword Ronald F. Martin xiii Preface: Management of Breast Cancer Catherine C. Parker xvii Screening Mammography: Recommendations and Controversies 667 Meredith Witten and Catherine C. Parker Over the past several years, there have been numerous changes in the guidelines for screening mammography. In addition, different societies have released guidelines with variance in the recommendations of age to initiate and frequency of imaging. The current recommendations as well as the importance of screening mammography for early detection and survival are discussed. Breast Cancer Genetics and Indications for Prophylactic Mastectomy 677 Helen Krontiras, Meagan Farmer, and Julie Whatley As more genetic information becomes available to inform breast cancer treatment, screening, and risk-reduction approaches, clinicians must become more knowledgeable about possible genetic testing and prevention strategies, including outcomes, benefits, risks, and limitations. This article defines and distinguishes high- and moderate-risk breast cancer predisposition genes and summarizes the clinical recommendations that may be considered based on the identification of pathogenic variants (mutations) in these genes and indications for risk-reducing and contralateral prophylactic mastectomy. Incorporating Biologic Factors into the American Joint Committee on Cancer Breast Cancer Staging System: Review of the Supporting Evidence 687 Anna Weiss, Tari A. King, Kelly K. Hunt, and Elizabeth A. Mittendorf The American Joint Committee on Cancer staging system has evolved in response to improved imaging, refined surgical techniques, enhanced pathologic evaluation, and greater understanding of tumor biology. The eighth edition has introduced clinical and pathologic prognostic stages for breast cancer that incorporate biologic variables (grade, estrogen/progesterone receptor status, HER2 status, multigene panels) with TNM categories that define the anatomic stage. The prognostic staging system facilitates more refined stratification than the anatomic stage with respect to survival and is an important advance that maintains the clinical relevance of the staging system by taking into account tumor biology and current treatment algorithms.

2 viii Impact of Advancing Technology on Diagnosis and Treatment of Breast Cancer 703 Heather I. Greenwood, Katerina Dodelzon, and Janine T. Katzen New emerging breast imaging techniques have shown great promise in breast cancer screening, evaluation of the extent of disease, and response to neoadjuvant therapy. Tomosynthesis allows 3-dimensional imaging of the breast and increases breast cancer detection. Fast abbreviated MRI has reduced time and costs associated with traditional breast MRI while maintaining cancer detection. Diffusion-weighted imaging is a functional MRI technique that does not require contrast and has shown potential in screening, lesion characterization, and also evaluation of treatment response. New image-guided preoperative localizations are available that have increased patient satisfaction and decreased operating room delays. Ductal Carcinoma In Situ 725 FangMeng Fu, Richard C. Gilmore, and Lisa K. Jacobs Ductal carcinoma in situ has been stable in incidence for a decade and has an excellent prognosis. Breast conservation therapy is safe and effective for most patients. Adjuvant whole breast radiation therapy is recommended to reduce the risk of local recurrence. Accelerated partial breast irradiation is a promising alternative to decrease toxicity and improve cosmetic results. Adjuvant hormonal therapy can reduce local recurrence but should be used cautiously. Future directions in management include developing predictive tools for guidance for use of adjuvant therapy and selecting low-risk patients with ductal carcinoma in situ in whom surgery may be safely omitted. Management of the Axilla in the Patient with Breast Cancer 747 Ko Un Park and Abigail Caudle Evaluation of the axillary lymph nodes is critical in the management of breast cancer because it is a key predictor of survival outcome. Surgeons must not only be able to perform sentinel lymph node dissection with high accuracy but also understand the implications of the results. Management of clinically node-negative and node-positive cases can vary significantly, as described in this article. With emerging data, management of the axilla in breast cancer will continue to evolve. Definition and Management of Positive Margins for Invasive Breast Cancer 761 Apoorve Nayyar, Kristalyn K. Gallagher, and Kandace P. McGuire Breast-conserving surgery (BCS) followed by radiation therapy is the current standard of care for early-stage breast cancer. Successful BCS necessitates complete tumor resection with clear margins at the pathologic assessment of the specimen ( no ink on tumor ). The presence of positive margins warrants additional surgery to obtain negative final margins, which has significant physical, psychological, and financial implications for the patient. The challenge lies in developing accurate real-time intraoperative margin assessment techniques to minimize the presence of ink on tumor and the subsequent need for additional surgery.

3 ix Future Developments in Neoadjuvant Therapy for Triple-Negative Breast Cancer 773 Lakisha Moore-Smith, Andres Forero-Torres, and Erica Stringer-Reasor Breast cancer is the second leading cause of cancer-related death in women in the United States. In general, advances in targeted treatment for breast cancer have improved over the last 20 years, except in the triple-negative breast cancer (TNBC) subtype. TNBC is an aggressive breast cancer subtype with limited treatment options as compared with hormone-positive breast cancers. Genomic profiling of TNBC has shown promise in aiding clinicians to develop personalized targeted agents. Prioritizing novel molecular-based therapies in the neoadjuvant setting may help investigators understand mechanisms of resistance and ultimately improve patient outcomes in TNBC. Inflammatory Breast Cancer: What to Know About This Unique, Aggressive Breast Cancer 787 Arjun Menta, Tamer M. Fouad, Anthony Lucci, Huong Le-Petross, Michael C. Stauder, Wendy A. Woodward, Naoto T. Ueno, and Bora Lim Inflammatory breast cancer (IBC) is a rare form of breast cancer that accounts for only 2% to 4% of all breast cancer cases. Despite its low incidence, IBC contributes to 7% to 10% of breast cancer caused mortality. Despite ongoing international efforts to formulate better diagnosis, treatment, and research, the survival of patients with IBC has not been significantly improved, and there are no therapeutic agents that specifically target IBC to date. The authors present a comprehensive overview that aims to assess the present and new management strategies of IBC. The Evolving Role of Postmastectomy Radiation Therapy 801 Ashlyn S. Everett, Jennifer F. De Los Santos, and Drexell Hunter Boggs Throughout various eras of breast cancer therapy, postmastectomy radiation therapy (PMRT) has played an important role in the treatment of locally advanced breast cancer. PMRT decreases locoregional recurrence and may improve overall survival in patients with tumors over 5 cm or positive lymph nodes. As novel cancer therapies improve survival in breast cancer, the role of radiation therapy is evolving. Individualized recommendations for PMRT dependent on pathologic response after neoadjuvant systemic therapy are under investigation. This article summarizes the role of PMRT during breast cancer therapy and discusses open questions that may change the landscape of future breast cancer treatment. Breast Cancer in the Elderly 819 Flora Varghese and Jasmine Wong With increasing life expectancy and growth of the elderly US population, it becomes paramount that breast cancer research focuses more on the prevention, screening, and treatment of these patients. Age is no longer a cutoff for managing breast cancer in the elderly. Studies have shown the current undertreatment of cancer undermines survival, but the tide is turning to provide evidence-based medicine for the elderly. More often, clinicians and surgeons look not only at tumor-specific characteristics of

4 x breast cancer but also at the functionality, tolerance, comorbidities, and life expectancy of patients to determine the best treatment. Evolution of Operative Technique for Mastectomy 835 Caroline Jones and Rachael Lancaster The radical mastectomy was the mainstay of breast cancer treatment through the majority of the twentieth century. However, as the understanding of breast cancer increased, the indications for more extensive surgical intervention decreased. The mastectomy has evolved so that skin-sparing or nipple-sparing mastectomy can be performed in the majority of women who undergo mastectomy currently. Today, nearly 40% of all women undergo mastectomy for breast cancer. The improved cosmetic appearance associated with skin- or nipple-sparing mastectomies does not compromise oncologic outcomes. Breast Reconstruction 845 Hani Sbitany Video content accompanies this article at theclinics.com. Breast reconstruction is offered to women undergoing mastectomy or breast conservation, given its safe nature and highly aesthetic reconstructive outcomes. Breast implants are safe, offer flexibility of sizes and projections, and have shorter recovery. Autologous flaps allow women to avoid prosthetic devices, using skin and fat to replace breast tissue. The increasing frequency of nipple-sparing mastectomy, autologous fat grafting, use of acellular dermal matrices, and prepectoral prosthetic reconstruction has enhanced aesthetic outcomes. Breast conservation outcomes have been enhanced by immediate oncoplastic breast reconstruction to reduce the risks of contour deformities and breast asymmetry and maintain excellent, oncologically safe, aesthetic outcomes. Role of Operative Management in Stage IV Breast Cancer 859 Mediget Teshome The role of operative therapy in stage IV breast cancer continues to evolve with advances in therapy and improvements in survival among this population. Traditionally surgery was performed with palliative intent to alleviate symptoms related to the intact breast primary. Several retrospective studies have challenged this paradigm, demonstrating survival advantage with surgery in de novo metastatic disease. Prospective studies are ongoing and maturing data. A comprehensive approach to local therapy following systemic therapy may be beneficial to achieve improved survival outcome associated with stage IV no evidence of disease and to decrease local failure in inflammatory breast cancer. Sarcomas of the Breast 869 Mallory A. Duncan and Meeghan A. Lautner Sarcoma of the breast is extremely rare and differs from epithelial breast carcinomas in staging and treatment. The diagnostic workup includes

5 xi breast imaging and core biopsy as in breast epithelial carcinoma. Surgical management is often wide local excision in the form of breast conservation if possible for primary breast sarcoma or total mastectomy. Radiationassociated breast angiosarcomas often require total mastectomy with radical excision of skin. Breast sarcomas have a hematogenous spread, so lymph node evaluation is not a part of treatment or staging. Local recurrence rates are high; prognosis remains poor despite ongoing advances in the treatment of epithelial breast carcinoma.