Chest Wall Margin 0.1mm after Mastectomy - radiation decision

Hi Lisa,

I'm 35 and had a 1cm margin.  My RO told me I should have 28 Rads no question, because of grade 3 and my age.  The risks are all % here and % there, but it came down to will I regret this if I don't?   I have 6 more Rads to go and it's not as bad as I thought it would be.  I'm very burnt and my armpit is raw, but this is nothing compared to chemo.  I think the grade 3 scares even the best doctors.  What is your Her2 status?   My Mx was of the rt breast so my heart isn't getting Rads, but I'm on herceptin and that is killer on the heart.  Like I said it % here and % there.  I just want to be around for my 3 kids so I'll do whatever it takes.  I wish you the best of luck with your decision and hang in there  Tracy

Lisa,

Here's a link to the thread that mom3band1g mentioned.  You'll see that there are a few others who've gone through this.  I didn't - but then I was diagnosed 6 years ago and back then it was virtually unheard of for someone who had a mastectomy for DCIS to be recommended radiation. Today's it's changing.

DCIS, BMX/MX, and radiation ladies http://community.breastcancer.org/forum/68/topic/774625

Have you talked to a medical oncologist?  I'd recommend both a 2nd opinion from a radiation oncologist and a discussion with a medical oncologist.  To make this decision you need to have some information from them about your estimated risk of recurrence if you don't have radiation, and how much that risk would be reduced if you do have radiation.  Then you can decide if the reduction in risk is worth it to you or not.  

Oh, also, the authors of the Rashtian study talked about the Carlson study.  They said 2 of 19 patients with surgical margins < 1 mm (10.5%, as you said), recurred.  However, the difference was not statistically significant.  "Given this lack of statistical evidence plus that all patients in that study were treated with SSM, it is rather difficult to draw any firm conclusions regarding the predictions of local recurrence."  I don't have an actual copy of the Carlson study, and its pub med abstract doesn't say this, so I found that quite interesting! 

I agree that the sample sizes are small and the margin of error is large with these studies.  I'm a research junkie and I often highlight these types of concerns with other studies (HER2+ and DCIS, for example, where there are a bunch of conflicting studies and all are small with large margins of error).

What's different for me with this one is that the result is so intuitive.  Dozens of studies have confirmed that after a mastectomy for DCIS, the recurrence rate is 1% - 2%.  And what causes a recurrence?  A recurrence is caused when some cancer cells are left in the breast after surgery and are not in some other way killed off (radiation and/or hormone therapy). At some point in the future - maybe in 3 months or maybe in 3 years or maybe in 13 years, these remaining cancer cells start to multiply and spread.  In order to have a recurrence, some cancer cells must be left alive in the breast after treatment.  (This is of course different than the development of a new primary breast cancer, which is a different and separate risk.) 

Doesn't it make sense then that for those who have a mastectomy for DCIS, since there's no breast mass left where cancer cells might have wandered off into and might be hiding, the only way that a recurrence can happen is if cancer cells are left in the tiny amounts of breast tissue scrapings that inevitably remain against the chest wall and the skin? And aren't close margins the most likely sign that there might be cancer cells left in these areas? 

It just seems so logical to me that the 1% - 2% of women who have a recurrence after a mastectomy for DCIS will be the same women who had close margins after their mastectomy. 100 women have mastectomies for DCIS. 15 women have close or positive margins.  2 women have a recurrence.  If both of those women were in the group that had close margins, it means that the recurrence rate for those with close margins will be 13%.

As someone who focuses on the research rather than on opinions and anecdotes, it's not like me to suggest that something might be true just because it is logical.  But in this case I can't help myself.  Having close margins after a mastectomy seems to be the most likely way that someone could end up with a recurrence.   

I'm reminded of a very old Saturday Night Live skit in which Chevy Chase portrayed President Ford during the Presidential debates. He's asked a complicated question, and Chase (as Ford) looks very confused and doesn't speak for a moment. Eventually he says, "I understood there would be no math in the debates."

cycle path - ha, you made me laugh!  thank you!

dancetrancer - if you find one would you please let me look?  thanks.

Hi Lisa,

I could have written your OP, as we have nearly identical diagnoses. I was 36 at diagnosis; my tumor was 9.5cm, all DCIS but grade 3 (downgraded to 2/3 in the final pathology) with comedonecrosis. I also had <1mm margins at the chest wall, though my breast surgeon removed the fascia.

I also faced the question of radiation, and got the input of two tumor boards -- first, the board at the hospital where I was treated. That group had a split opinion about radiation, with their radiation oncologist strongly recommending it. I consulted with her but didn't feel confident about proceeding... so I got a 2nd opinion from a radiation oncologist at Dana Farber. When she reviewed my case, she wanted to take it to the DF tumor board. Which she did, and they came back with a unanimous opinion that I did NOT need radiation.

Their decision comported with where my husband and I were at....much more at peace with the "no rads" decision than anything else. And that surprised me because when I was first diagnosed, I assumed I would want to throw everything at this stupid tumor especially given my age. But I have wound up feeling much more comfortable with foregoing rx and tamoxifen -- the latter decision mostly because my husband and I wanted to start a family (and, lo and behold, I am today 19 weeks pregnant).

I have had a couple of twinges of "gosh, did I make the right decision?" particularly when I've run across studies like what you mention above. I also read a study about the Van Nuys prognostic index suggests a higher recurrence rate for mastectomies with small margins and no rx. I took that article to my breast surgeon, who found it academically interesting but it didn't change his point of view that I am very unlikely to have a recurrence, partly because he removed the fascia.

Sometimes I wish I could lay my hands on research that discusses the impact of removing the fascia on recurrence rates. Anecdotally it seems like it's a really good thing to do, but I've never seen any research or writing on the issue. (Anyone know of any relevant studies?)

So - all that to say, Lisa, I have been where you are. I totally understand the weighing you are doing. I am still overall happy with my decision to forego rads. I feel confident that I had a great surgeon who knew what he was doing. If I'm unfortunate enough to have a recurrence, I hope I don't second guess my decision on rx, but now there's nothing I can do about it so for the most part I don't sweat it. Good luck to you!!!

Sunshine gal and red64, thank you for sharing your stories. 

Sunshinegal, I looked and found this study:  Eleven Year Follow-up of a Randomized Study of Pectoral Fascia Preservation After Mastectomy for Early Breast Cancer.  

Method The trial included 247 patients with breast cancer
who underwent modified radical mastectomy in five
Swedish hospitals between 1993 and 1997. The median
follow-up time was 11 years. The patients were randomized
between removal (n = 122) versus preservation
(n = 125) of the pectoral fascia.
Results The breast-cancer-specific survival at 10 years
was 73%. Removal or preservation of the pectoral fascia
had no significant impact on chest-wall recurrence rate or
breast-cancer-specific survival. A total of 18 patients with
chest-wall recurrence were seen in the group allocated to
pectoral fascia preservation versus a total of 10 in patients
allocated to pectoral fascia removal (hazard ratio = 1.8,
95% confidence interval = 0.8-4.0). The majority of the
chest-wall recurrences were detected 0-5 years postoperatively.
The cumulative chest-wall recurrence rates at 5 and
at 10 years were 13 and 15%, respectively, in patients
allocated to pectoral fascia preservation and 8 and 9% in
patients allocated to pectoral fascia removal.
Conclusions With long-term follow-up neither the chest
wall recurrence rate nor the breast-cancer-specific survival
was significantly influenced by the preservation of the
pectoral fascia. A trend toward an increased risk for chest
wall recurrence was observed in patients with preserved
pectoral fascia. A hazard ratio of 1.8 for a chest-wall
recurrence in patients with preserved fascia indicates that
fascia-sparing mastectomy may negatively affect
prognosis. 

I find this article confusing.  It says there was no significant influence on fascia preservation, but then it goes on to say there was a trend in increase risk of chest wall recurrence if fascia is preserved.  To me it sounds like they are saying they didn't have statistical significance but the numbers were strong enough to suggest preserving the fascia may not be a good idea.  Is that how others interpret this? 

P.S. This study is on early bc patients - it doesn't say what stage, but it definitely wasn't DCIS only.  Oh and 100 of the pts had post-op radiotherapy (3+ nodes) and around 100 had chemo before or after.  133 took tamoxifen after MX.  However the pts were randomized into the two fascia/no fascia groups, so that helps to reduce the impact of all of these other factors.  I think.  LOL 

Here are some more interesting things they write in the conclusion:

To conclude: in patients with a tumor not involving the
pectoral fascia either clinically or at breast imaging, the
preservation of the pectoral fascia did not significantly
influence the chest-wall recurrence rate or the breast-cancer-
specific survival. However, a trend toward a lower
recurrence rate among patients with removed pectoral
fascia was observed.

...

An increased risk for a chest-wall recurrence of 1.8
among patients with preserved fascia indicates that fasciasparing
mastectomy can endanger patients without any
benefit provided beyond facilitation of primary breast
reconstruction. However, to prove this statement much
larger studies are required.

 

Hey Nerdy Nat, LOL,  - THANK YOU for chiming in!  Love the info and educational review.  It's been about 14 years since I had to critically review articles in grad school, so I really appreciate the help - the old brain is rusty!  

I would love to take a pass on rads, too - for the same concerns as you have about the long-term heart and lung damage.  I am still on the fence, still reading, still waiting for my 3rd RO appt. 

P.S. I've gotta a tabby kitty, too.  She's got spunk!  

Hi everyone,my situation is this-0.1 cm to deep margin located against my chest wall on the left side. The clean margin was so small before it hit the chest. My GS said they don't dig into chests and remove ribs to get wider clean margins so that's the best i'll get. My MO said the studies they have done on this show no real benefit to me doing rads. The close margin is the only reason it was brought up but there's no data to support it's usefullness on me. Well having little to no data really shows their disinterest in the early stagers. I guess they all think it's pointless to study us more because we're going to be fine. The RO was no better,he finally got the correct stats together and stated the same thing. But he upped my recur risk because of my age as well as the close margin. That being said they still didn't feel it would help me. And with the risk of lung cancer after rads I agreed. The main problem is the stats are so small on us as they've researched so little. They both told me the BEST thing I did to prevent recur was having my bmx. They both stated that the bmx was the most important thing I could have done,more than rads or Tamox. My next questions will be to my second RO on friday which will include:What are the stats on lung cancer after 28 rads? What's the mortality rate for it? As well as stats on early stage,close margin girls and their mortality rate after recur? Especially since 50% of recur cases will be invasive they say. And finally how many recur after having rads? If there's no difference then why put yourself thru it? My MO said there are no answers to my other questions. He said it boils down to which decision I can live with. They really need to focus on early stagers more than they have. We're in danger too,as much as they'd have us believe we're not.

I just found this: 

Rates of Second Malignancies after Definitive Local Treatment for DCIS of the Breast

This compared surgery vs surgery plus rads in breast conservation patients.  I think we can still apply this to us being post-MX; although there may be some variability in the amount of rads our organs get due to no recon/recon vs having a breast, I wouldn't think it would be too much (IMO).

Looks like they are saying no significant difference in long-term effects (malignancies) between the two groups.  I'd like to know what years they are looking at, since newer rads techniques are supposed to have less effect on the internal organs.  This study doesn't appear to look at heart damage effects, just malignancies.    I can't find the entire study for free online, though.  I'd like to read it - if anyone can find the whole study please share a link.  Thanks!

-----------------------------------------------------------

Purpose
We analyzed the risk of second malignancies developing in patients with ductal carcinoma in situ (DCIS) undergoing surgery and radiotherapy (S+RT) vs. surgery alone.

Methods and Materials
The S+RT cohort consisted of 256 women treated with breast-conserving therapy at William Beaumont Hospital. The surgery alone cohort consisted of 2,788 women with DCIS in the regional Surveillance, Epidemiology, and End Results database treated during the same time period. A matched-pair analysis was performed in which each S+RT patient was randomly matched with 8 surgery alone patients (total of 2,048 patients). Matching criteria included age ± 2 years. The rates of second malignancies were analyzed overall and as contralateral breast vs. non-breast cancers and by organ system.

Results
Median follow-up was 13.7 years for the S+RT cohort and 13.3 years for the surgery alone cohort. The overall 10-/15-year rates of second malignancies among the S+RT and surgery alone cohorts were 14.2%/24.2% and 16.4%/22.6%, respectively (p = 0.668). The 15-year second contralateral breast cancer rate was 14.2% in the S+RT cohort and 10.3% in the surgery alone cohort (p = 0.439). The 15-year risk of a second non-breast malignancy was 14.2% for the S+RT cohort and 13.4% for the surgery alone cohort (p = 0.660). When analyzed by organ system, the 10- and 15-year rates of second malignancies did not differ between the S+RT and surgery alone cohorts for pulmonary, gastrointestinal, central nervous system, gynecologic, genitourinary, lymphoid, sarcomatoid, head and neck, or unknown primary tumors.

Conclusions
Compared with surgery alone, S+RT is not associated with an overall increased risk of second malignancies in women with DCIS.

Wow Zteam, thank you for sharing.  I finally was able to get my 3rd appt set up for late next week, so I will know more by then.  Right now I'm leaning towards rads, due to having kind of an emotional breakdown last night.  I had to go to that place of imagining myself dying of bc vs of heart attack (was hard to put my mind there for real).  Since bc tends to recur statistically in the first 5 years, and heart damage shows up in 10 to 15, rads would give me a longer time frame for life.   Looking at the worst case scenario possible, and, of course, hoping neither happens.  Just wish I had more concrete numbers to base this on, but I know that data just doesn't exist.