Teaching medical students how to break bad news with standardized patients

One of the biggest challenges that a physician will face is conveying difficult news (CDN) to a patient.The ability to provide this information may either strengthen or destroy the patient–physician relationship. Despite the importance of this skill, formal education for medical students has been limited. To improve upon skill building in the medical student experience, fourth year medical students(on their oncology clerkship) spent 3 hours partaking ina CDN session. During this session, each student had a videotaped encounter with a standardized patient, followed by a small group discussion and review of the tape with other students and a clinician. We evaluated the experience with pre- and post-questionnaires assessing overall knowledge,satisfaction, and specific components of the curriculum. The objective of this study was to review our institution’s educational program focused on teaching techniques for CDN.

P5-11-14: Flat Epithelial Atypia of the Breast: A Single Institution Experience

Background: Flat epithelial atypia of the breast is a relatively new entity of unknown significance. Our objective is to evaluate our surgical experience with this diagnosis.

Methods: A single institution database of breast patients from 2005–2010 was used to identify women who were diagnosed with flat epithelial atypia on core biopsy and subsequently underwent surgical excision. Patient data regarding history, type and reason for biopsy, and associated pathology was collected. Individuals diagnosed with flat epithelia atypia and cancer on core biopsies in the same breast were excluded.

Results: There were 52 patients who underwent surgical excision for the primary diagnosis of flat epithelial atypia. There were 3 (6%) patients with a personal history of breast cancer, 14 (27%) patients with a family history of breast cancer, and 11 (21%) patients with a concurrent new diagnosis of breast cancer in the contralateral breast. Core biopsy was recommended in most (81%) cases because of suspicious calcifications on mammography. Twenty-eight (54%) patients were found to have flat epithelial atypia associated with other atypical breast hyperplasia and 24 (46%) had flat epithelial atypia as the most significant lesion on core biopsy. In 8 (15%) patients, there was a sonographic correlate that was biopsied; 5 had only flat epithelial atypia and 3 had flat epithelial atypia associated with other atypical hyperplasia. Of the 52 patients there were 4 (8%) patients who upstaged to ductal carcinoma in-situ on surgical excision. There were no cases of invasive carcinoma. All ductal carcinoma in-situ cases were associated with other atypical breast hyperplasia, not flat epithelial atypia alone.

Conclusion: Though flat epithelial atypia may be associated with an increased risk of breast cancer, surgical excision of pure flat epithelial atypia may not be necessary. Larger studies are needed to corroborate these findings.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-11-14.

The effect of Oncotype DX recurrence score on treatment recommendations for patients with estrogen receptor-positive early stage breast cancer and correlation with estimation of recurrence risk by breast cancer specialists

PURPOSE

The Oncotype DX assay predicts likelihood of distant recurrence and improves patient selection for adjuvant chemotherapy in estrogen receptor-positive (ER-positive) early stage breast cancer. This study has two primary endpoints: to evaluate the impact of Oncotype DX recurrence scores (RS) on chemotherapy recommendations and to compare the estimated recurrence risk predicted by breast oncology specialists to RS.

METHODS

One hundred fifty-four patients with ER-positive early stage breast cancer and available RS results were selected. Clinicopathologic data were provided to four surgeons, four medical oncologists, and four pathologists. Participants were asked to estimate recurrence risk category and offer their chemotherapy recommendations initially without and later with knowledge of RS results. The three most important clinicopathologic features guiding their recommendations were requested.

RESULTS

Ninety-five (61.7%), 45 (29.2%), and 14 (9.1%) tumors were low, intermediate, and high risk by RS, respectively. RS significantly correlated with tumor grade, mitotic activity, lymphovascular invasion, hormone receptor, and HER2/neu status. Estimated recurrence risk by participants agreed with RS in 54.2% ± 2.3% of cases. Without and with knowledge of RS, 82.3% ± 1.3% and 69.0% ± 6.9% of patients may be overtreated, respectively (p = 0.0322). Inclusion of RS data resulted in a 24.9% change in treatment recommendations. There was no significant difference in recommendations between groups of participants.

CONCLUSIONS

Breast oncology specialists tended to overestimate the risk of tumor recurrence compared with RS. RS provides useful information that improves patient selection for chemotherapy and changes treatment recommendations in approximately 25% of cases.

Male breast cancer: management and follow-up recommendations

National Comprehensive Cancer Network (NCCN) guidelines for female breast cancer treatment and surveillance are well established, but similar guidelines on male breast cancers are less recognized. As an NCCN institution, our objective was to examine practice patterns and follow-up for male breast cancer compared to established guidelines for female patients. After Institutional Review Board approval, a prospective breast database from 1990 to 2009 was queried for male patients. Medical records were examined for clinico-pathological factors and follow-up. The 5-year survival rates with 95% confidence intervals were estimated using Kaplan-Meier method and Greenwood formula. Of the 19,084 patients in the database, 73 (0.4%) were male patients; 62 had complete data. One patient had bilateral synchronous breast cancer. The median age was 68.8 years (range 29-85 years). The mean/median invasive tumor size was 2.2/1.6 cm (range 0.0-10.0 cm). All cases had mastectomy (29 with axillary node dissection, 23 with sentinel lymph node biopsy only, 11 with sentinel node biopsy followed by completion axillary dissection). Lymph node involvement occurred in 25/63 (39.7%). Based on NCCN guidelines, chemotherapy, hormonal therapy, and radiation are indicated in 34 cases, 62 cases, and 14 cases, respectively. Only 20/34 (59%) received chemotherapy, 51/62 (82%) received hormonal therapy, and 10/14 (71%) received post-mastectomy radiation. Median follow-up was 26.2 months (range: 1.6-230.9 months). The 5-year survival estimates for node positive and negative diseases were 68.5% and 87.5%, respectively (p = 0.3). Despite the rarity of male breast cancer, treatment options based on current female breast tumors produce comparable results to female breast cancer. Increased awareness and a national registry for patients could help improve outcomes and tailor treatment recommendations to the male variant.

Role of axillary staging in women diagnosed with ductal carcinoma in situ with microinvasion

BACKGROUND

Axillary staging via sentinel node biopsy (SLNB) in patients with ductal carcinoma in situ with microinvasion (DCISM) is routinely performed but remains controversial with regard to the risk-benefit ratio.

METHODS

Retrospective single-institution review of patients with diagnosis of DCISM (invasive tumor ≤ 0.1 cm). Age, clinicopathologic data, and follow-up were recorded.

RESULTS

Of 90 patients, 33% were diagnosed by core needle biopsy (CNB), 37% by excisional biopsy, and 29% were upstaged from DCIS on CNB to DCISM at final operation. Three (10%) of 30 patients with DCISM on CNB were upstaged to invasive cancer on final pathology. Median age at diagnosis was 58.9 years (range: 30-89). Lumpectomy was performed in 45% of patients and mastectomy in 55%. Mean number of sentinel nodes was 2.59 (SE 0.17). Six (6.9%) of 87 patients with DCISM as final diagnosis had a positive SLNB (four lumpectomies, two mastectomies). There was no correlation with any clinicopathologic features, including palpable DCIS, DCIS grade/necrosis, or age at diagnosis. All six SLNB-positive patients had a complete axillary dissection; two had additional disease. Median follow-up time was 74.2 months (range: 2-169). In-breast recurrence was seen in three patients (5%), regardless of SLN status, DCIS grade, or necrosis. Two patients developed distant metastasis. Overall survival was 94.19% at 5 years for DCISM and 100% for DCISM with nodal disease.

CONCLUSION

DCISM comprises 0.6% of breast cancer diagnoses at our institution. There is a low likelihood of nodal spread; however, a lack of identifiable clinicopathologic features associated with a positive SLNB limits selective SLNB use.

Selective application of routine preoperative axillary ultrasonography reduces costs for invasive breast cancers

PURPOSE

Preoperative axillary sonography with fine needle aspiration (FNA) in patients with invasive breast cancer identifies patients with nodal metastasis who can be spared further surgery. Indiscriminate use of the diagnostic modality can increase costs and yield inaccurate results. We evaluate the costs associated with the use of highly sensitive axillary ultrasonography in patients with stage ≥T2 tumors.

PATIENTS AND METHODS

We constructed a decision analysis tree using TreeAge Pro 2009 software comparing direct hospital charges between patients with and without routine use of axillary ultrasound. Base case estimates were derived from our institutional data and compared with those derived from the literature. One- and two-way sensitivity analyses were performed to check the validity of our inferences.

RESULTS

We found that, for the base case estimate with 35% lymph node positivity in stage ≥T2 tumors and sensitivity of the axillary ultrasound set at 86% with a specificity of 40%, the strategy to perform preoperative axillary ultrasound yielded rollback costs of $15,215, compared with $15,940 for surgery plus sentinel lymph node biopsy (cost difference, $725 per patient favoring axillary ultrasound). On two-way sensitivity analysis, the cost benefit for axillary ultrasound was not seen in patients with a low risk for nodal metastasis.

CONCLUSION

The adoption of routine preoperative axillary sonography with FNA is a lower-cost strategy than conventional strategies in patients with stage ≥T2 invasive breast cancer.

Consequences of axillary ultrasound in patients with T2 or greater invasive breast cancers

BACKGROUND

Axillary ultrasound (AUS) with needle biopsy is used to detect metastasis in patients with invasive breast cancers. Our hypothesis is that preoperative AUS significantly reduces sentinel node biopsy (SLNB) use in patients with invasive breast tumors >2 cm upon clinical examination.

METHODS

A single-institution database of patients with breast cancer and AUS was reviewed. Patients with incomplete records, clinical tumor <2 cm, or postoperative AUS were excluded. A control cohort of non-AUS patients with clinical T2 (cT2) or greater disease was identified. Clinicopathologic data were collected. Simple Kappa coefficient and chi-square statistical analyses were performed.

RESULTS

AUS was performed in 153 patients vs. 370 controls. Of AUS patients, 112 (73.2%) had cT2 disease vs. 272 (73.5%) controls. Median AUS patient age was 53.7 (range, 22.8-85.8) years vs. 53.8 (range, 26.7-91.6) years; median pathologic tumor was 3.8 (range, 1.0-20.0) cm in AUS patients vs. 2.5 (range, 0.1-11.0) cm. Among AUS patients, 78% had needle biopsy; 85 of 120 (70.8%) were positive. Sixty-eight patients had SLNB: 33 after negative AUS and 35 after negative needle biopsy. Twenty-three SLNB (37.3%) were positive; 15 of 33 after negative AUS and 8 of 35 after a negative needle biopsy. Axillary dissection was performed in 102 of 153 vs. 225 of 370 controls. Sensitivity and specificity of AUS was 86.2% and 40.5%. Sensitivity of AUS plus needle biopsy was 89.3% with 100% specificity. Neoadjuvant chemotherapy was given to 49.7% of AUS patients. AUS reduced costs by more than $4,000 per patient.

CONCLUSIONS

AUS reduces SLNB use and affects treatment in patients with cT2 or greater breast cancer. Routine AUS should be considered in this population.

Erratum to: Axillary recurrence rate following negative sentinel node biopsy for invasive breast cancer: long-term follow-up

OBJECTIVE

Sentinel lymph node (SLN) biopsy has replaced axillary lymph node dissection (ALND) as the staging procedure for breast cancer. SLN biopsy causes less morbidity and is more cost effective than complete ALND. Lymphatic mapping and SLN biopsy have a low false-negative rate, but long-term outcomes in large consecutive series of patients are unavailable.

METHODS

Retrospective review of a prospectively accrued institutional breast cancer database was performed. The initial mapping of 1,528 patients with invasive breast cancer that demonstrated negative sentinel node biopsy and no axillary dissection in 1,530 cases between January 1995 and June 2003 were collated and reviewed to achieve a long-term follow-up. These 1,528 patients were reviewed for follow-up time, local recurrences, distant metastases, and survival.

RESULTS

A total of 1,530 consecutively mapped invasive breast cancer cases had negative SLN biopsy and no ALND. The mean invasive tumor size of was 1.40 cm. Of patients, 1,212 (79.2%) underwent lumpectomy and 318 (20.8%) underwent mastectomy. Median follow-up was 63 months (range 0.1-144 months). There have been 4 (0.26%) cases presenting with local axillary recurrences, 54 (3.53%) cases presenting with local recurrences in the ipsilateral breast/chest wall, and 24 (1.57%) cases presenting with distant metastases.

CONCLUSION

These data confirm that SLN biopsy is an effective and safe alternative to ALND for detection of nodal metastases in patients with invasive breast cancer and validates its use as the standard tool for nodal staging.

Axillary recurrence rate following negative sentinel node biopsy for invasive breast cancer: long-term follow-up

OBJECTIVE

Sentinel lymph node (SLN) biopsy has replaced axillary lymph node dissection (ALND) as the definitive nodal staging procedure for breast cancer. SLN biopsy has been proven to cause less morbidity and be more cost effective than complete ALND. Short-term follow-up has shown that lymphatic mapping and SLN have a low false-negative rate, but there is limited data demonstrating long-term outcomes within a large consecutive series of patients.

METHODS

Retrospective review of a prospective database of breast cancer patients at our institution was performed. The initial mapping of 1,530 patients with invasive breast cancer who demonstrated a negative sentinel node biopsy and no axillary dissection between January 1995 and June 2003 were collated and reviewed to achieve a long-term follow-up. These 1,530 patients were reviewed for follow-up time, local recurrences, distant metastases, and survival.

RESULTS

1,530 consecutively mapped invasive breast cancer patients had a negative SLN biopsy and no ALND. The mean invasive tumor size was 1.40 cm. Of 1,530 patients, 73% (1,121) underwent lumpectomy and 27% (409) underwent mastectomy. Mean follow-up was 4.92 years (range 0-12.0 years). There have been 4 (0.26%) patients presenting with local axillary recurrences, 54 (3.53%) patients presenting with local recurrences in the ipsilateral breast/chest wall, and 24 (1.57%) presenting with distant metastases.

CONCLUSION

These data confirm that SLN biopsy is an effective and safe alternative to ALND for detection of nodal metastases in patients with invasive breast cancer and should be used as the standard tool for nodal staging.

Feasibility of sentinel lymph node biopsy through an inframammary incision for a nipple-sparing mastectomy

BACKGROUND

Nipple-sparing mastectomy (NSM) via an inframammary (IM) incision has been described for selected patients with breast cancer. However, the application of sentinel lymph node (SLN) mapping via an IM incision for NSM has yet to be reported. The objective of this study is to determine the technical feasibility of performing SLN through an IM incision without making an axillary counterincision.

METHODS

We retrospectively reviewed our single-institutional experience with SLN biopsy and NSM through IM incisions between January 2006 and March 2008. Clinicopathologic factors were analyzed regarding indications, technical details, postoperative morbidity, and follow-up.

RESULTS

Fifty-two patients underwent 87 NSM through an IM incision (17 unilateral, 35 bilateral) with immediate reconstruction and SLN biopsy. Indications for surgery included invasive breast cancer (n = 21), ductal carcinoma in situ (DCIS) (n = 18), and prophylactic (n = 48). Mean tumor size of invasive carcinoma was 2.1 cm. The mean mastectomy specimen weight was 437 g. Subareolar injection consisted of blue dye (n = 43), technetium sulfur colloid (n = 2), or combination injection (n = 42). SLN biopsy through an IM incision was successfully performed in 84 of 87 cases (96.6%). A mean of 2.8 SLN were removed with a positive sentinel node encountered in 8 of 21 patients (38%) with invasive cancer. No complications were observed regarding the SLN portion of the operation. With a median follow-up of 6.5 months (range, 0.4-23 months), there have been no axillary local recurrences.

CONCLUSION

SLN biopsy can be performed through an IM incision during a NSM, avoiding a secondary axillary incision.

High-risk benign breast lesions: current strategies in management

BACKGROUND

High-risk benign breast lesions can create confusion for both the patient and the clinician. This paper reviews the characteristics of these lesions to help direct appropriate management.

METHODS

The authors reviewed the literature regarding high-risk breast lesions and include management guidelines that we employ at our institute.

RESULTS

High-risk breast lesions offer varying degrees of increased risk for the future development of breast cancer. Chemoprevention may be used to help decrease the risks from some lesions.

CONCLUSIONS

The management of high-risk benign breast lesions can be confusing. Clinicians should assess the risk of future breast cancer and develop a proper screening and prevention strategy for each individual patient.