11. Planning surgical treatment
11.1 Should clip-marking vs. no clip-marking after needle core biopsy/vacuum assisted needle core biopsy be used for surgical therapy planning in patients with breast cancer lesions?
Recommendation
The ECIBC's Guidelines Development Group (GDG) suggests using clip-marking after needle core biopsy (NCB)/vacuum assisted needle core biopsy (VANCB) for surgical therapy planning in patients with breast cancer lesions.
Issued in November 2017.
Justification
The GDG agreed by consensus to support a conditional recommendation for the intervention.
Subgroup considerations
Palpable lesions possibly candidate for neoadjuvant therapy and non-palpable lesions: the GDG considered both types of lesion and agreed that the evidence did not support distinguishing these subgroups in this recommendation or in any of the Evidence to Decision considerations. The GDG noted that lesions that are initially palpable may later become non-palpable following neoadjuvant chemotherapy.
Considerations for implementation and policy making
- The GDG noted that effective communication at the time of clip insertion is essential to ensure that women understand the implications of clip insertion on future management.
- The GDG noted that the timing of clip insertion is critical and whether it is feasible to insert clips during initial biopsies instead of a follow-up procedure may change the harm/benefit ratio because of the additional stress, complications and costs associated with placing the clip in a second time.
Monitoring and evaluation
The GDG noted that monitoring for whether clips are inserted in the correct position in relation to a lesion is important. The GDG suggests further consideration of assessment mechanisms for the appropriateness of clip position either by radiology follow-up imaging or pathology. The GDG refers this to the ECIBC's Quality Assurance Scheme Development Group for consideration.
Research priorities
- The GDG suggested improved research with higher quality of evidence from observational studies or where clip-marking is not routinely used considering the use of randomised studies for high quality evidence.
- The GDG noted that improved evidence on the effectiveness is very important. Some members suggested that in the context of clinical equipoise randomised trials would provide higher quality evidence.
- The GDG suggested further research on the local effects of clips and impacts on the psychological well-being for women and whether there is an impact of clips on breast cancer progression or recurrence.
- The GDG suggested improved cost-effectiveness evidence on the use of clip-marking and comparing the economic impact of clip-marking on the need for additional procedures such as biopsies and surgeries.
- The GDG suggested research on the use of clip-marking for palpable vs. non-palpable lesions.
Supporting material
11.2 Should additional magnetic resonance imaging vs. no additional magnetic resonance imaging be used in women with histologically confirmed ductal carcinoma in situ for preoperative planning?
Recommendation
In women with histologically confirmed ductal carcinoma in situ (DCIS), the ECIBC's Guidelines Development Group (GDG) suggests not using additional magnetic resonance imaging (MRI) for preoperative planning.
Issued in June 2018.
Justification
The judgment was based mainly on the evidence on desirable and undesirable effects, the moderate costs, and the fact that the intervention is probably no cost-effective and would probably reduce equity.
Subgroup considerations
Utility in very extended, suspect multifocal, or multiple disease could not be investigated, but the rationale for better morphological has been considered stronger in these cases.
Low, intermediate and high-grade DCIS.
Monitoring and evaluation
The overuse of MRI should be monitored, especially when there is a very small DCIS mammographically, as it is unlikely that MRI will find a very big one.
Research priorities
The GDG recommends research on other MRI techniques, especially abbreviated protocols. The ideal design would be randomised control trials (RCT) but there are problems with feasibility because of numbers and long term outcomes; alternatively observational studies could be carried out.
The possible utility in specific subgroups (extremely extended, suspect multifocal or multiple lesions) should be investigated.
Supporting material
11.3 Should contrast-enhanced mammography vs. magnetic resonance imaging be used as additional imaging method to assist in surgical treatment planning in women with histologically confirmed invasive breast cancer?
Recommendation
In women with histologically confirmed invasive breast cancer, who require further evaluation, the ECIBC's Guidelines Development Group (GDG) suggests using contrast-enhanced mammography (CEM) over magnetic resonance imaging (MRI) as additional imaging method to assist in surgical treatment planning.
Issued in October 2021.
Justification
The decision on this recommendation takes into account the balance between desirable and undesirable effects that was judged as not favouring either CEM or MRI in the context of low certainty of the evidence. The GDG considered that costs, acceptability and feasibility are probably in favour of CEM.
Subgroup considerations
Women with medical devices that are not compatible with MRI can have a CEM.
Considerations for implementation and policy making
The GDG discussed that MRI is currently the test of choice for certain women and settings. The use of CEM will reduce the bottle neck of MRI availability for these patients (it would be urgent MRIs given that they have to be done before surgery).
As for any conditional recommendation, values and preferences and shared decision making (possibly decision aids) should be taken into account. For more information, refer to What the strength of the recommendation implies.
Research priorities
- Additional, credible research on accuracy and patient impact.
- Subtypes of breast cancer with CESM especially regarding the likelihood of multicentricity or multifocality.
- Identification of subgroups of women who might benefit from this examination.
Supporting material