Sentinel lymph node biopsy, aromatase inhibitors, and partial breast irradiation are among the most important topics breast surgeons should be informed about, one expert says. Not only are these issues of great interest to patients, they could affect the way surgeons plan and conduct treatment, Helen Pass, MD, told a group of physicians attending the 5th Annual Meeting of the American Society of Breast Surgeons.

Pass, who is director of the Breast Care Center at William Beaumont Hospital in Royal Oak, Michigan, gave a presentation today on the most clinically relevant studies published last year.

"It's one person's view of the papers I think surgeons really need to know about that will affect the way they do things, or are the most common things patients ask about," Pass said, acknowledging that she couldn't include every important study in the presentation.

Although mainly intended for doctors, the information also has relevance for breast cancer patients.

"We are making progress," Pass said. "It's a very hopeful time to be a patient or family member because treatments are becoming less radical."

But women must seek out the information they need to help make treatment decisions.

"Be your own best advocate and avail yourself of the latest information," Pass advised. "Even after you're 5 years out [from treatment], staying in contact with one of your oncologists is beneficial. But you can even ask your primary care provider, 'What's new?' 'What should I be doing differently?' "

Sentinel lymph node biopsy is one area where women and their surgeons must be sure they understand what is and is not known about the procedure, Pass said.

The operation involves removing only one or two lymph nodes under the arm -- the so-called sentinel nodes, where cancer is likely to spread first -- to determine if a woman's breast cancer has invaded the lymph nodes. If the sentinel node is clear, a woman may not need axillary lymph node dissection, an operation to remove all the lymph nodes under the arm. This more extensive procedure can leave a woman with pain, difficulty of movement, and chronic swelling of the arm, called lymphedema.

Because sentinel node biopsy is a less extensive operation, the incidence of side effects is typically lower, making it an appealing option. But not all women are good candidates, and not all surgeons have the necessary experience to perform the procedure properly. Moreover, Pass said, researchers are still gathering data about its efficacy and safety -- how it compares to axillary dissection in terms of recurrence, for instance -- and the best way to use this procedure.

"We're still awaiting results of US trials," she noted, "but the Italian trials do show that in properly selected patients, it's a safe operation."

Women must choose a surgeon carefully, though, said Pass, who is on the board of governors of the American Society of Breast Surgeons and a member of its education committee. Patients must consider how many such operations a surgeon has performed, what his rate of false-negative diagnoses is, and how many recurrences his patients have experienced. It's also important that the surgeon work in a center that has experience with the procedure, both for selecting appropriate patients and monitoring their outcomes.

For doctors, other questions that still exist about sentinel node biopsy include how large a tumor must be before a woman is no longer a good candidate, whether or not sentinel node biopsy should be done in women who have received chemotherapy, and how to be sure a patient is truly a good candidate for the procedure.

"There are some straightforward patients who would be perfect candidates, there's the other extreme of women who have involved lymph nodes [and so are not good candidates], and then there's this grey area where you have to decide how [sentinel node biopsy] would influence the rest of your treatment," Pass said.

Partial breast irradiation is a newer treatment option, one that comes with various unknowns, Pass said. This therapy is attractive to many women who have had a lumpectomy because it takes less time than conventional breast radiation and limits the treatment area to the tumor site, rather than the whole breast.

But there is little data on the long-term effectiveness or safety of this alternative. One US study, included in Pass's presentation, found that 5 years after treatment, women who chose partial breast radiation did just as well as those who had whole-breast radiation. But the risk of breast cancer recurrence is known to remain for 10 years or even more, so it's not known how women who get partial breast radiation might fare in the long run.

Until there are more answers, women and their doctors should tread carefully, Pass said, although "in a well-controlled clinical trial, it's perfectly reasonable for women to consider it."

In other situations, though, women must be sure that the doctor and center performing the procedure have experience with it and will continue to track their progress long after the treatments have ended.

The breast surgeons' group is conducting follow-up on women who have used a newer type of partial radiation therapy, called MammoSite, in an effort to get more answers about which patients might be good candidates and what their long-term outcomes might be.

Although surgeons deal with different treatment issues than medical oncologists, Pass said breast surgeons should also be aware of recent studies that suggest a new class of drugs called aromatase inhibitors (anastrozole, letrozole, and exemestane) may be better than tamoxifen for preventing recurrences of breast cancer.

"They influence the care we give our patients, so they need to be mentioned," she said.

Although guidelines from the American Society of Clinical Oncology still favor tamoxifen as the first-choice drug, the new findings give doctors good reasons to tailor their drug choice to individual patients, Pass said.

"If you have a patient who is at high risk for [blood clots], you can put them on [an aromatase inhibitor] and have a good reason for it," she said. "Or if you have a woman who is at high risk for osteoporosis, you can choose tamoxifen." (Tamoxifen has a higher risk of blood clots and certain gynecological side effects, while aromatase inhibitors carry a greater risk of osteoporosis.)

"The more selective we can get with these medications, the better," Pass added.