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Oct 18, 2020 04:37PM
Since ADH is common, and since it's not checked for in surgical margins, I suspect it's not all that unusual for some ADH to remain in surgical margins. A lot of pathology reports read like LivinLife's and mine, with lots of 'incidental' findings of fibrocystic and high risk conditions. Any of those conditions could be in the margins - pathologists only look for and report on DCIS and IDC.
For those who have an excisional biopsy for ADH, margins usually don't come into play unless either DCIS or IDC is found. So although some ADH may remain in the breast (and often does), a re-excision isn't usually recommended and rads is never recommended. Those diagnosed with ADH may choose to take endocrine therapy, but it's considered optional - some take it, some don't.
After a MX with clear margins, whether the diagnosis is DCIS or invasive cancer, the risk of a localized recurrence is 1%-2%. The risk of a new primary, in the small amount of breast tissue that remains, is also about 1%-2%. For those who have pure DCIS and clear margins, these risk levels are not considered high enough to warrant either rads or endocrine therapy. So if ADH is in the margins, how much would that increase the risk and would it warrant a change in treatment?
Well, if rads isn't recommended even for those who have an excisional biopsy for ADH and who may have ADH in their remaining breast tissue, it wouldn't seem to make sense to recommend rads after a MX, even if a small amount of ADH remains. (I seem to recall reading that rads isn't particularly effective on ADH, but I'm not sure about that - maybe someone else reading this will know.)
What about endocrine therapy? It can reduce the risk of breast cancer developing from ADH by 50%. But if endocrine therapy isn't definitively recommended for those who have ADH and have two breasts with all their breast tissue, is it warranted when the patient has only a small amount of breast tissue left? Even if the risk of recurrence is doubled to 2%-4% because of the presence of ADH, a 50% risk reduction is at most 2%. Endocrine therapy presents, in the best case (healthy patient with no other health conditions) approx. a 1% risk of serious side effects and a 50%-60% (or maybe much higher than that) risk of quality-of-life effects.
And that may be the answer as to why our doctors don't consider whether we have ADH in the surgical margins. Because the additional risk isn't high enough to warrant a change in the treatment plan and the inclusion of any additional treatment.
“No power so effectually robs the mind of all its powers of acting and reasoning as fear.” Edmund Burke