Penetrance of Colorectal Cancer Among Mismatch Repair Gene Mutation Carriers: A Meta-Analysis

Background

Lynch syndrome, the most common colorectal cancer (CRC) syndrome, is caused by germline mismatch repair (MMR) genes. Precise estimates of age-specific risks are crucial for sound counseling of individuals managing a genetic predisposition to cancer, but published risk estimates vary. The objective of this work is to provide gene-, sex-, and age-specific risk estimates of CRC for MMR mutation carriers that comprehensively reflect the best available data.

Methods

We conducted a meta-analysis to combine risk information from multiple studies on Lynch syndrome-associated CRC. We used a likelihood-based approach to integrate reported measures of CRC risk and deconvolved aggregated information to estimate gene- and sex-specific risk.

Results

Our comprehensive search identified 10 studies (8 on MLH1, 9 on MSH2, and 3 on MSH6). We estimated the cumulative risk of CRC by age and sex in heterozygous mutation carriers. At age 70 years, for male and female carriers, respectively, risks for MLH1 were 43.9% (95% confidence interval [CI] = 39.6% to 46.6%) and 37.3% (95% CI = 32.2% to 40.2%), for MSH2 were 53.9% (95% CI = 49.0% to 56.3%) and 38.6% (95% CI = 34.1% to 42.0%), and for MSH6 were 12.0% (95% CI = 2.4% to 24.6%) and 12.3% (95% CI = 3.5% to 23.2%).

Conclusions

Our results provide up-to-date and comprehensive age-specific CRC risk estimates for counseling and risk prediction tools. These will have a direct clinical impact by improving prevention and management strategies for both individuals who are MMR mutation carriers and those considering testing.

Breast imaging, breast surgery, and cancer genetics in the age of COVID-19

Background

The objective of the current study was to provide insight into the effect of coronavirus disease 2019 (COVID‐19) on breast cancer screening, breast surgery, and genetics consultations.

Methods

User data from a risk assessment company were collected from February 2 to April 11, 2020. The use of risk assessment was used as a proxy for the use of 3 breast cancer services, namely, breast imaging, breast surgery, and genetics consultation. Changes in the use of these services during the study period were analyzed.

Results

All 3 services experienced significant declines after the COVID‐19 outbreak. The decline in breast surgery began during the week of March 8, followed by breast imaging and genetics consultation (both of which began during the week of March 15). Breast imaging experienced the most significant reduction, with an average weekly decline of 61.7% and a maximum decline of 94.6%. Breast surgery demonstrated an average weekly decline of 20.5%. When surgical consultation was stratified as breast cancer versus no breast cancer, the decrease among in non–breast cancer patients was more significant than that of patients with breast cancer (a decline of 66.8% vs 11.5% from the pre‐COVID average weekly volume for non–breast cancer patients and patients with breast cancer, respectively). During the week of April 5, use of genetics consultations dropped to 39.9% of the average weekly volumes before COVID‐19.

Conclusions

COVID‐19 has had a significant impact on the number of patients undergoing breast cancer prevention, screening, diagnosis, and treatment.

Coronavirus disease 2019 (COVID‐19) has had a significant impact on the number of patients undergoing breast cancer prevention, screening, diagnosis, and treatment in the United States. In the current study, user data from a risk assessment company were collected from February 2 to April 11, 2020, with the use of risk assessment used as a proxy to analyze changes in the use of 3 breast cancer services: breast imaging, breast surgery, and genetics consultation.

Node-Positive Patients Treated with Neoadjuvant Chemotherapy Can Be Spared Axillary Lymph Node Dissection with Wireless Non-Radioactive Localizers

BACKGROUND

Targeted axillary dissection (TAD) involves sentinel lymph node biopsy (SLNB) and excision of a biopsy-proven node marked by a clip. This study evaluates the feasibility of non-radioactive wireless localizers for targeted excision of clipped axillary lymph nodes.

METHODS

We identified biopsy-proven, node-positive breast cancer patients treated with neoadjuvant therapy (NAT) and TAD from 2016 to 2020, and included those with a clipped node localized using SAVI SCOUT, Magseed, or RFID Tag. Primary outcome measures were (1) successful localization (ultrasound or mammographic-guided placement < 10 mm from target), and (2) retrieval of the clipped node during TAD, documented by specimen radiography or gross visualization. Secondary outcomes included rates of completion axillary lymph node dissection (cALND) and complications.

RESULTS

Overall, 57 patients were included; 1 (1.8%) patient had no clip visible at the time of localization, and no radiographic confirmation of clip placement at the time of biopsy, and was therefore excluded. In the remaining 56 patients, localization was successful in 53 (94.6%) patients and the clipped node was retrieved during TAD in 51 (91.1%) patients. Twenty-three of 27 (85.2%) ypN0 patients were spared cALND; 3 (11.1%) patients had cALND for failed clipped node retrieval during TAD, and 1 (3.7%) for false-positive frozen section. In patients with TAD alone, the rates of axillary seroma and infection were 20.0% and 8.6%, respectively.

CONCLUSIONS

Wireless non-radioactive localizers are feasible for axillary localization after NAT, with high success rates of retrieving clipped nodes. The lack of signal decay is an advantage of these devices, allowing flexibility in timing of placement.

Validation of a Semiautomated Natural Language Processing-Based Procedure for Meta-Analysis of Cancer Susceptibility Gene Penetrance

PURPOSE

Quantifying the risk of cancer associated with pathogenic mutations in germline cancer susceptibility genes-that is, penetrance-enables the personalization of preventive management strategies. Conducting a meta-analysis is the best way to obtain robust risk estimates. We have previously developed a natural language processing (NLP) -based abstract classifier which classifies abstracts as relevant to penetrance, prevalence of mutations, both, or neither. In this work, we evaluate the performance of this NLP-based procedure.

MATERIALS AND METHODS

We compared the semiautomated NLP-based procedure, which involves automated abstract classification and text mining, followed by human review of identified studies, with the traditional procedure that requires human review of all studies. Ten high-quality gene-cancer penetrance meta-analyses spanning 16 gene-cancer associations were used as the gold standard by which to evaluate the performance of our procedure. For each meta-analysis, we evaluated the number of abstracts that required human review (workload) and the ability to identify the studies that were included by the authors in their quantitative analysis (coverage).

RESULTS

Compared with the traditional procedure, the semiautomated NLP-based procedure led to a lower workload across all 10 meta-analyses, with an overall 84% reduction (2,774 abstracts v 16,941 abstracts) in the amount of human review required. Overall coverage was 93%-we are able to identify 132 of 142 studies-before reviewing references of identified studies. Reasons for the 10 missed studies included blank and poorly written abstracts. After reviewing references, nine of the previously missed studies were identified and coverage improved to 99% (141 of 142 studies).

CONCLUSION

We demonstrated that an NLP-based procedure can significantly reduce the review workload without compromising the ability to identify relevant studies. NLP algorithms have promising potential for reducing human efforts in the literature review process.

Using Machine Learning and Natural Language Processing to Review and Classify the Medical Literature on Cancer Susceptibility Genes

PURPOSE

The medical literature relevant to germline genetics is growing exponentially. Clinicians need tools that help to monitor and prioritize the literature to understand the clinical implications of pathogenic genetic variants. We developed and evaluated two machine learning models to classify abstracts as relevant to the penetrance-risk of cancer for germline mutation carriers-or prevalence of germline genetic mutations.

MATERIALS AND METHODS

We conducted literature searches in PubMed and retrieved paper titles and abstracts to create an annotated data set for training and evaluating the two machine learning classification models. Our first model is a support vector machine (SVM) which learns a linear decision rule on the basis of the bag-of-ngrams representation of each title and abstract. Our second model is a convolutional neural network (CNN) which learns a complex nonlinear decision rule on the basis of the raw title and abstract. We evaluated the performance of the two models on the classification of papers as relevant to penetrance or prevalence.

RESULTS

For penetrance classification, we annotated 3,740 paper titles and abstracts and evaluated the two models using 10-fold cross-validation. The SVM model achieved 88.93% accuracy-percentage of papers that were correctly classified-whereas the CNN model achieved 88.53% accuracy. For prevalence classification, we annotated 3,753 paper titles and abstracts. The SVM model achieved 88.92% accuracy and the CNN model achieved 88.52% accuracy.

CONCLUSION

Our models achieve high accuracy in classifying abstracts as relevant to penetrance or prevalence. By facilitating literature review, this tool could help clinicians and researchers keep abreast of the burgeoning knowledge of gene-cancer associations and keep the knowledge bases for clinical decision support tools up to date.

Comparing and assessing the reported penetrance of cancer susceptibility genes for breast cancer

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Background: It is critical for oncologists to be aware of unbiased and interpretable cancer risks (i.e., penetrance) in carriers with germline pathogenic variants in cancer susceptibility genes. However, relevant literature is large and varies significantly in study design, patient ascertainment, and types of risk estimates reported. This heterogeneity can cause inconsistent conclusions between studies and create barriers for clinicians to understand and apply them in practice. To further understand the current literature, we assessed penetrance studies associated with non-BRCA breast cancer susceptibility genes based on study design and ascertainment adjustment. Methods: We used a validated natural language processing-based abstract classifier to identify all penetrance studies regarding eleven genes: ATM, BARD1, CDH1, CHEK2, NBN, NF1, PALB2, PTEN, RECQL, STK11, and TP53. Relevant studies were then manually annotated as “with ascertainment adjustment” if a study was based on: (1) a general population; (2) a pedigree analysis or a family-based study with appropriate ascertainment adjustment; or (3) a hospital-based study or a panel testing analysis with well-matched cases and controls. Results: A total of 49 penetrance studies were identified, with a median of nine studies for each gene (range: 4-16). The case-control study was the dominant study type, accounting for over 80% in five genes, 50% in two genes, and 18% to 43% in the other four genes. The proportion of studies with ascertainment adjustment was generally low (mean: 33%) and varied widely between different genes (7% to 80%). Contradictory breast cancer risks (no increased risk vs. significantly increased risk) were found in eight genes (73%) (Table). The most common ascertainment bias identified was a case-control study with cases (patients) who had a strong family history but using general population controls. Conclusions: Ascertainment bias is common in penetrance studies, but few studies adjust for it appropriately. Clinicians should be aware of this issue, and new methods are warranted to select unbiased risk estimates, synthesize them, and provide the accurate general-population penetrance. [Table: see text]

Legacy Genetic Testing Results for Cancer Susceptibility: How Common are Conflicting Classifications in a Large Variant Dataset from Multiple Practices?

PURPOSE

The classification of germline variants may differ between labs and change over time. We apply a variant harmonization tool, Ask2Me VarHarmonizer, to map variants to ClinVar and identify discordant variant classifications in a large multipractice variant dataset.

METHODS

A total of 7496 variants sequenced between 1996 and 2019 were collected from 11 clinical practices. Variants were mapped to ClinVar, and lab-reported and ClinVar variant classifications were analyzed and compared.

RESULTS

Of the 4798 unique variants identified, 3699 (77%) were mappable to ClinVar. Among mappable variants, variants of unknown significance (VUS) accounted for 74% of lab-reported classifications and 60% of ClinVar classifications. Lab-reported and ClinVar discordances were present in 783 unique variants (21.2% of all mappable variants); 121 variants (2.5% of all unique variants) had within-practice lab-reported discordances; and 56 variants (1.2% of all unique variants) had lab-reported discordances across practices. The unmappable variants were associated with a higher proportion of lab-reported pathogenic classifications (50% vs. 21%, p < 0.0001) and a lower proportion of lab-reported VUS classifications (46% vs. 74%, p < 0.0001).

CONCLUSIONS

Our study shows that discordant variant classification occurs frequently, which may lead to inappropriate recommendations for prophylactic treatments or clinical management.

Abstract P1-21-07: The Patient-reported Outcomes after Routine Treatment of Atypical Lesions (PORTAL) study: Pain, psychosocial wellbeing, and quality of life among women undergoing guideline concordant care for DCIS vs. active surveillance for in situ and atypical lesions

Background: Guideline-concordant care (GCC) for DCIS includes surgery, radiation, and endocrine treatment. Active surveillance (AS) is a strategy under study for management of low risk DCIS. The PORTAL Study was designed to evaluate patient reported outcomes (PROs) after GCC for DCIS compared to women who received AS for DCIS combined with women with a history of other atypical lesions (atypical ductal hyperplasia (ADH), or atypical lobular hyperplasia/lobular carcinoma in situ (LN), as proxies for AS-managed DCIS. Methods: The PORTAL Study invited women age≥ 18, diagnosed with DCIS, ADH, or LN between 2012-2017 from 4 academic centers to complete a one-time, cross-sectional survey. Clinical, pathological, and treatment information was obtained from medical record review. The primary outcome was breast/chest wall pain assessed with the Breast Cancer Pain Questionnaire (BCPQ) including severity (10-point scale, ≥3=clinically relevant), a Pain Burden Index (PBI), which is a composite of severity, frequency, and location (breast, arm, side, axilla) and assessments of sensory disturbances, and impact of pain on emotional and physical functioning. Additional PROs included measures of generalized pain (Brief Pain Inventory), anxiety (STAI-Short Form), depression (CES-D), and QOL (Quality of Life in Adult Cancer Survivors). Pain, psychosocial, and QOL outcomes were compared between the GCC vs. AS groups using Wilcoxon Rank Sum and Chi-Square tests. Results: Of 1565 patients invited and sent a survey, 927 (59%) responded to the survey with evaluable pain outcome data. Median time from diagnosis was 3.8 years. Median age at survey completion was 58 (range: 26-94) years; 13% identified as non-White; 4% Hispanic. Among those with DCIS (n=554), 97% had GCC (62%, lumpectomy, 38%, mastectomy; 48%, radiation), representing 58% of participants vs 42% representing AS. The prevalence of clinically relevant pain was higher in the GCC vs. AS group (16.5% vs 9%, p=.0009). Median BCPQ-PBI, sensory disturbance, physical, and emotional impact scores were all higher (p&lt;.0001) in the GCC vs. AS group (Table); BPI scores for pain severity and interference were similar between groups. QOL, anxiety and depressive symptoms were similar among women who had GCC compared to the AS group. Conclusion: Women with DCIS who have undergone GCC experience more breast/chest wall pain and report greater impact of pain on physical and emotional functioning in long term follow-up, compared to women who have undergone AS for DCIS or are managed for other atypical lesions. Given that many women with low risk DCIS may be unlikely to develop invasive cancer, improved understanding of the potential trade-offs of GCC vs AS can help support informed decision making in women with DCIS who are considering their treatment options. Ongoing prospective trials will provide further information regarding risks and benefits of AS vs GCC for women with low risk DCIS.

BCPQ Scores, GCC vs. ASGCCASMean (range)Median (IQR)Mean (range)Median (IQR)p*PBI6.4 (0-80)0 (0-9)2.9 (0-64)0 (0-0)&lt;.0001Sensory disturbance1.4 (0-9)0 (0-2)0.6 (0-9)0 (0-0)&lt;.0001Physical impact9.6 (0-67)0 (0-19)4.4 (0-56)0 (0-0)&lt;.0001Emotional impact1.4 (0-33)0 (0-1)0.6 (0-38)0 (0-0)&lt;.0001*Wilcoxon rank sum test comparing median scores

Citation Format: Shoshana M Rosenberg, Laura H Hendrix, Kristin L Schreiber, Alastair M Thompson, Isabelle Bedrosian, Kevin S Hughes, Thomas Lynch, Desiree Basila, Deborah E Collyar, Elizabeth S Frank, Sonja Darai, Conor Lanahan, Jeffrey R Marks, Jennifer K Plichta, Terry Hyslop, Ann H Partridge, E. Shelley Hwang. The Patient-reported Outcomes after Routine Treatment of Atypical Lesions (PORTAL) study: Pain, psychosocial wellbeing, and quality of life among women undergoing guideline concordant care for DCIS vs. active surveillance for in situ and atypical lesions [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P1-21-07.

Natural language processing to facilitate breast cancer research and management

The medical literature has been growing exponentially, and its size has become a barrier for physicians to locate and extract clinically useful information. As a promising solution, natural language processing (NLP), especially machine learning (ML)-based NLP is a technology that potentially provides a promising solution. ML-based NLP is based on training a computational algorithm with a large number of annotated examples to allow the computer to "learn" and "predict" the meaning of human language. Although NLP has been widely applied in industry and business, most physicians still are not aware of the huge potential of this technology in medicine, and the implementation of NLP in breast cancer research and management is fairly limited. With a real-world successful project of identifying penetrance papers for breast and other cancer susceptibility genes, this review illustrates how to train and evaluate an NLP-based medical abstract classifier, incorporate it into a semiautomatic meta-analysis procedure, and validate the effectiveness of this procedure. Other implementations of NLP technology in breast cancer research, such as parsing pathology reports and mining electronic healthcare records, are also discussed. We hope this review will help breast cancer physicians and researchers to recognize, understand, and apply this technology to meet their own clinical or research needs.

Long-Term Outcomes of Multiple-Wire Localizations for More Extensive Breast Cancer: Multiple-Wire Excision Does Not Increase Recurrence, Unplanned Imaging, or Biopsies

BACKGROUND

We previously reported that breast conservation was feasible for women with large or irregularly shaped breast cancers when tumor resection was guided by multiple localizing wires. We now report long-term outcomes of multiple-wire versus single-wire localized lumpectomies for breast cancer.

PATIENTS AND METHODS

We retrospectively reviewed wire-localized lumpectomies at our institution from May 2000 to November 2006. Rates of ipsilateral in-breast tumor recurrence, metastasis, and subsequent unplanned diagnostic imaging and biopsy were compared between multiple-wire and single-wire cohorts.

RESULTS

We identified 112 multiple-wire and 160 single-wire breast cancer lumpectomies that achieved clear margins. Median age was 64 years in the multiple-wire cohort and 57 years in the single-wire cohort. Mean lumpectomy volume was 75 mL in multiple-wire patients and 49 mL in single-wire patients (P = .003). Invasive tumor size, axillary node status, and use of radiation and systemic therapy were similar, but the multiple-wire group had more patients with ductal carcinoma-in-situ only (38% vs. 28%). At 108 months' median follow-up, there was no significant difference in local or distant recurrence rates between multiple-wire and single-wire cohorts. Six (5%) multiple-wire patients and 6 (4%) single-wire patients had local recurrences and 3 (3%) multiple-wire and 5 (3%) single-wire patients developed metastatic disease. Unplanned diagnostic imaging was required for 53 (47%) multiple-wire and 65 (41%) single-wire patients. Subsequent ipsilateral biopsy occurred in 15 (13%) multiple-wire and 19 (12%) single-wire patients.

CONCLUSION

Breast-conserving surgery with multiple localizing wires is a safe alternative to mastectomy for breast cancer patients with large mammographic lesions.

Consensus Guidelines on Genetic` Testing for Hereditary Breast Cancer from the American Society of Breast Surgeons

BACKGROUND

The purpose of this consensus guideline is to outline recommendations for genetic testing that medical professionals can use to assess hereditary risk for breast cancer.

METHODS

Literature review included large datasets, basic and clinical science publications, and recent updated national guidelines. Genetic testing to assess hereditary risk of cancer is a complex, broad, and dynamic area of medical research. The dominant focus of this guideline is limited in scope to breast cancer.

RESULTS

There is a lack of consensus among experts regarding which genes among many should be tested in different clinical scenarios. There is also variation in the degree of consensus regarding the understanding of risk and appropriate clinical management of mutations in many genes.

CONCLUSIONS

Genetic testing should be made available to all patients with a personal history of breast cancer. Recent data are reviewed that support genetic testing being offered to each patient with breast cancer (newly diagnosed or with a personal history). If genetic testing is performed, such testing should include BRCA1/BRCA2 and PALB2, with other genes as appropriate for the clinical scenario and family history. For patients with newly diagnosed breast cancer, identification of a mutation may impact local treatment recommendations. Patients who had genetic testing previously may benefit from updated testing. Genetic testing should be made available to patients without a history of breast cancer who meet National Comprehensive Cancer Network guidelines. Finally, variants of uncertain significance are not clinically actionable and these patients should be managed based on their individual risk factors.

Trends in Unilateral and Contralateral Prophylactic Mastectomy Use in Ductal Carcinoma In Situ of the Breast: Patterns and Predictors

BACKGROUND

Increased use of contralateral prophylactic mastectomy (CPM) as treatment for ductal carcinoma in situ (DCIS) in the US was first noted in the early 2000s. Optimization of treatment guidelines for DCIS requires an understanding of current surgical treatment trends, particularly as they may differ by patient sociodemographic and community resource factors.

OBJECTIVE

The aim of this study was to evaluate surgical treatment trends among US women with DCIS and to assess the impact of sociodemographic and community resource factors on surgical treatment choice.

METHODS

The Surveillance, Epidemiology, and End Results dataset was queried for women aged 40 years and older who were diagnosed with unilateral DCIS between 2000 and 2014. Annual mastectomy rates were compared over time by age and race/ethnicity. Multivariable logistic regressions were performed to identify predictors of mastectomy use, with patient sociodemographics, tumor characteristics, and community resource factors (i.e. plastic surgeon density) as covariates.

RESULTS

A total of 130,731 women with DCIS met the inclusion criteria. Overall mastectomy rates remained relatively unchanged over the study period (25-30%). CPM use increased for all age and race/ethnic groups, with the greatest increase exhibited by women aged 40-49 years [relative to 2000; 2014 odds ratio (OR) 10.6]. With respect to community resource factors, CPM use, as opposed to unilateral mastectomy, was associated with counties of higher education level (OR 1.52), higher income level (OR 1.22), and lower plastic surgeon density (OR 1.26).

CONCLUSION AND RELEVANCE

While the popularity of mastectomy in the management of DCIS has remained relatively unchanged since the turn of the century, the use of CPM has risen substantially. Younger women with DCIS have seen the greatest increase in CPM use, a choice that remains influenced by race/ethnicity as well as income, education, and health resource availability. Until clinical risk stratifiers of DCIS are identified, the surgical decision-making paradigm must be improved so that treatment choice remains sensitive to cultural differences but becomes independent of income, education, and health resource availability.

Incidental breast carcinoma: incidence, management, and outcomes in 4804 bilateral reduction mammoplasties

INTRODUCTION

Bilateral reduction mammoplasty is one of the most common plastic surgery procedures performed in the U.S. This study examines the incidence, management, and prognosis of incidental breast cancer identified in reduction specimens from a large cohort of reduction mammoplasty patients.

METHODS

Breast pathology reports were retrospectively reviewed for evidence of incidental cancers in bilateral reduction mammoplasty specimens from five institutions between 1990 and 2017.

RESULTS

A total of 4804 women met the inclusion criteria of this study; incidental cancer was identified in 45 breasts of 39 (0.8%) patients. Six patients (15%) had bilateral cancer. Overall, the maximum diagnosis by breast was 16 invasive cancers and 29 ductal carcinomas in situs. Thirty-three patients had unilateral cancer, 15 (45.5%) of which had high-risk lesions in the contralateral breast. Twenty-one patients underwent mastectomy (12 bilateral and nine unilateral), residual cancer was found in 10 in 25 (40%) therapeutic mastectomies. Seven patients did not undergo mastectomy received breast radiation. The median follow-up was 92 months. No local recurrences were observed in the patients undergoing mastectomy or radiation. Three of 11 (27%) patients who did not undergo mastectomy or radiation developed a local recurrence. The overall survival rate was 87.2% and disease-free survival was 82.1%.

CONCLUSIONS

Patients undergoing reduction mammoplasty for macromastia have a small but definite risk of incidental breast cancer. The high rate of bilateral cancer, contralateral high-risk lesions, and residual disease at mastectomy mandates thorough pathologic evaluation and careful follow-up of these patients. Mastectomy or breast radiation is recommended for local control given the high likelihood of local recurrence without either.

Incidental atypical hyperplasia/LCIS in mammoplasty specimens and subsequent risk of breast cancer

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Background: Proliferative breast lesions with atypia (atypical hyperplasia and lobular carcinoma in-situ (LCIS)) increase the risk of breast cancer (BC). Most cases are diagnosed in the context of an abnormal mammogram. Little is known about BC risk for patients with these lesions who are asymptomatic. Mammoplasty specimens allow us to study breast tissue in asymptomatic healthy women. We previously published the rate of atypia in the largest reported mammoplasty cohort. The aim of this study is to examine the risk of BC in the atypia cohort. Methods: Breast pathology reports were retrospectively reviewed for evidence of atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH) or LCIS in bilateral reduction mammoplasty specimens from five institutions within a single healthcare system between 1990 to 2017. Patients with prior or concurrent BC or prior atypia were excluded. Data was extracted from electronic medical records using natural language processing and manual review to assess subsequent risk of BC. Results: From our mammoplasty cohort of 4771 patients, 295 patients were found to have atypia (6.2%) at baseline. 40 of these patients were lost to follow-up and excluded from the study. For the remaining 255 patients, 13 had severe ADH bordering on ductal carcinoma in situ, 52 had LCIS, 119 had ALH, and 71 had ADH at baseline. The median age at baseline was 52.1 (range 17.9 – 74.3). With a median follow-up of 7.7 years, of the 255 patients 9 patients developed BC (8 invasive carcinomas, 1 ductal carcinoma in situ). 81.3% of the cohort did not receive chemoprevention. Only one patient out of the nine who developed BC received chemoprevention. The risk of developing BC among women with atypia at baseline was 0.5%, 2.9% and 4.1%, at 3, 5 and 10 years respectively. Conclusions: Patients with asymptomatic atypias found in reduction mammoplasty specimens appear to be at lower risk of developing BC than those diagnosed with atypia in the context of an abnormal mammogram. These results may provide guidance on how to manage this group of patients related to future screening and/or chemoprevention.

Comprehensive germline multigene panel testing changes clinical care for patients with breast cancer: Untapped clinical utility and PARP inhibitor trial eligibility

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Background: HBOC testing guidelines were established to identify patients with clinically actionable variants and limit economic burden. We report the impact of germline results on health outcome based on clinical decision making and treatment interventions, regardless of guidelines, in a multi-center registry. Methods: 20 community-based and academic participated in an IRB approved registry. Patients with breast cancer were tested with an 80-gene panel; clinical information was collected. Results: Data on 912 patients has been analyzed to date. 50.5% met NCCN criteria; 49.5% did not. Pathogenic/likely pathogenic (P/LP) germline mutations were found in 8.65% of patients. Of all patients with P/LP findings, 85% had variants in cancer-risk genes with established management recommendations and 80% had germline variants conferring eligibility for clinical trials and precision medicine-based cancer treatments, such as PARP inhibitors. For 62% of patients with P/LP germline mutations, clinicians reported results impacted patients’ health outcome. And for 69%, results impacted the health outcome of patients’ relatives. There was no significant association between BRCAPRO scores and patients having a P/LP finding, whether in BRCA1/2 alone (p = 0.42) or for any cancer gene (p = 0.57). Physician reported impact on patient outcome associated significantly with the presence of P/LP germline findings (p < 0.00001). There was no significant difference in the clinician reported clinical utility of variants of uncertain significance (VUS) compared to negative results (p = 0.467). Conclusions: Comprehensive panel testing of breast cancer patients impacts physician assessed patient outcomes and informs changes in surgical treatment strategy, medical therapies and proactive screening. The data suggest that BRCAPRO calculators are poor predictors of germline presence of P/LP findings. Physicians in this study demonstrate the ability to discern the clinically actionable value of P/LP mutations from non-actionable VUS. Multigene panels impact breast cancer patient care by identifying precision medicine treatment interventions, and guiding long-term medical management and preventive surveillance for patients and family members.

Germline Genetic Testing: What the Breast Surgeon Needs to Know

PURPOSE

The American Society of Breast Surgeons (ASBrS) sought to provide educational guidelines for breast surgeons on how to incorporate genetic information and genomics into their practice.

METHODS

A comprehensive nonsystematic review was performed of selected peer-reviewed literature. The Genetics Working Group of the ASBrS convened to develop guideline recommendations.

RESULTS

Clinical and educational guidelines were prepared to outline the essential knowledge for breast surgeons to perform germline genetic testing and to incorporate the findings into their practice, which have been approved by the ASBrS Board of Directors.

RECOMMENDATIONS

Thousands of women in the USA would potentially benefit from genetic testing for BRCA1, BRCA2, and other breast cancer genes that markedly increase their risk of developing breast cancer. As genetic testing is now becoming more widely available, women should be made aware of these tests and consider testing. Breast surgeons are well positioned to help facilitate this process. The areas where surgeons need to be knowledgeable include: (1) identification of patients for initial breast cancer-related genetic testing, (2) identification of patients who tested negative in the past but now need updated testing, (3) initial cancer genetic testing, (4) retesting of patients who need their genetic testing updated, (5) cancer genetic test interpretation, posttest counseling and management, (6) management of variants of uncertain significance, (7) cascade genetic testing, (8) interpretation of genetic tests other than clinical cancer panels and the counseling and management required, and (9) interpretation of somatic genetic tests and the counseling and management required.

Diagnostic Value of Fine-Needle Aspiration in Male Breast Lesions

OBJECTIVE

Differentiation between gynecomastia, a common cause of male breast enlargement, and breast cancer is crucial for appropriate management. Fine-needle aspiration biopsy has been shown to be sensitive and specific in assessing female breast lesions, comparable to core needle biopsy. Few such studies have been conducted in men. We assessed its diagnostic value in a male patient cohort.

STUDY DESIGN

Men who underwent fine-needle aspiration (FNA) for palpable breast lesions at Massachusetts General Hospital from January 2007 to December 2016 were evaluated. Clinical data, radiographic findings, and cytologic diagnoses of 74 breast FNA from 71 men were reviewed. Breast aspirates were classified as nondiagnostic, benign, atypical, suspicious for malignancy, or malignant. Histology was obtained in 37 cases, and clinical and radiological data were used as follow-up in 37 patients.

RESULTS

Most FNA biopsies (73%) were performed by cytopathologists, and 93.2% of the breast FNA in men were adequate; 58% showed benign processes, mostly gynecomastia (n = 22), and 28.4% (n = 21) were malignant, most often ductal carcinoma. No false-positive cytologies were obtained, and there was 1 false-negative cytology. In our study, FNA of palpable male breast lesions was 95.8% sensitive and 100% specific.

CONCLUSIONS

FNA allows sensitive, specific, and safe evaluation and diagnosis of palpable male breast lesions.

Nipple Discharge After Nipple-Sparing Mastectomy With and Without Associated Pregnancy

BACKGROUND

Nipple-sparing mastectomies (NSMs) preserve the intact nipple, including nipple duct orifices. Retained orifices might remain patent and communicate with the underlying reconstruction. We report the incidence and outcomes of nipple discharge after NSM in pregnant and nonpregnant women.

PATIENTS AND METHODS

Retrospective review of all NSMs at our institution from June 2007 to June 2018 was performed. Subsequent pregnancies and nipple discharge were documented. Patient demographic, operative, histopathology, and cancer treatment data were collected. Descriptive analysis was performed for patients who developed nipple discharge.

RESULTS

From June 2007 to June 2018, 2778 NSM procedures were performed in 1620 patients, with a mean age of 48 (range, 20-80) years. Fifteen hundred sixty-eight NSMs were therapeutic and 1210 were for risk reduction. Thirty-three subsequent pregnancies were observed in 27 patients, with a mean age of 33 (range, 26-42) years at NSM. Bilateral or unilateral discharge occurred in 6 of 27 (22%) postpartum patients and resolved spontaneously. At 54 months mean follow-up after NSM (range, 16-98 months) and 23 (range, 1-61) months after delivery, no local-regional recurrences were observed. In 1593 patients without subsequent pregnancy, there were 4 patients (0.25%) treated with bilateral NSM with subsequent unilateral watery nipple discharge. There was no evidence of associated malignancy on physical exam, imaging, or cytology, and with 55 to 110 months follow-up, no new or recurrent cancers have been observed.

CONCLUSION

Despite extensive removal of nipple and subareolar duct tissue during NSM, milky nipple discharge is possible postpartum. Watery, acellular discharge occurs rarely in nonpregnant patients. To date, no patient with discharge has developed a local recurrence or new breast cancer.

Twenty-Five Year Trends in the Incidence of Ductal Carcinoma in Situ in US Women

BACKGROUND

The rising incidence of ductal carcinoma in situ (DCIS) since the widespread enactment of mammography screening has been well documented. Patterns in DCIS incidence among women of various ages and across different racial and ethnic groups have not been well described.

STUDY DESIGN

The Surveillance, Epidemiology, and End Results public-use data set was queried for all women aged 40 years and older diagnosed with DCIS between 1990 and 2014. Annual age-adjusted incidence rates were compared among white, black, Hispanic, and Asian-Pacific Islander women. Additionally, using mammography screening data obtained from the CDC, patterns in mammography screening over time and as they relate to DCIS incidence rates by race and ethnicity were evaluated.

RESULTS

We identified 200,400 women aged 40 years or older with DCIS. Between 1998 and 2014, a period that saw flux in national breast screening guidelines, DCIS incidence rates increased in blacks, Hispanics, and Asian-Pacific Islanders, but remained relatively unchanged in whites (increase in number of DCIS diagnoses per 100,000 individuals in the population per year among blacks +0.66/p < 0.01, Hispanics +3.0/p < 0.01, Asian-Pacific Islanders +0.53/p < 0.01, and whites +0.07/p = 0.21). After accounting for age, year of diagnosis, and mammography screening rates, DCIS incidence was found to be similar between white and black women (0.8 fewer diagnoses per 100,000 individuals compared with whites; p = 0.36) but lower for Hispanic women (9.7 fewer diagnoses per 100,000 individuals compared with whites; p < 0.01).

CONCLUSIONS

The DCIS incidence rates are influenced substantially by breast cancer mammography screening patterns. However, differences exist by race and ethnicity and are not fully explained by screening mammography trends alone. Consideration should be given to including race and ethnicity in determining optimal breast screening guidelines.

Abstract P2-14-19: Surgical and long-term outcomes of patients receiving neoadjuvant pertuzumab-containing regimens for HER2-positive localized breast cancer

Background: The addition of pertuzumab to trastuzumab and chemotherapy significantly improves the pathologic complete response (pCR) rate in HER2+ localized breast cancer in the preoperative setting. Although many patients are converted to breast conserving therapy (BCT) candidates by neoadjuvant HER2-directed therapy, a significant proportion opt for a mastectomy for various reasons. Among mastectomy procedures, nipple sparing mastectomy (NSM) is frequently chosen instead of non-nipple sparing mastectomy (NNSM). In this study, we evaluated the surgical and long-term outcomes of HER2+ patients receiving neoadjuvant pertuzumab-containing regimens.

Methods: We performed a retrospective review of localized breast cancer patients treated with neoadjuvant pertuzumab-containing regimens from 2011 to 2016, who underwent BCT or mastectomy at an academic institution and two community-based practices. Disease characteristics, treatment regimens, surgical outcomes, and recurrence data were extracted from the electronic medical records.

Results: Among 90 patients with stage II-III HER2+ breast cancer, 45 received AC-THP (50.0%), 26 received THP (with adjuvant AC) (29.0%), and 19 received TCHP (21.0%). The majority of patients had grade 3 tumors (61.1%), clinical stage II disease (80.0%), invasive ductal carcinoma (86.7%), and ER+ disease (65.6%). Thirty-seven (41.0%) patients underwent BCT and 53 (59.0%) patients underwent mastectomy. Among the mastectomy patients, 38 (71.7%) patients underwent bilateral mastectomies, specifically 33 (62.0%) patients underwent a NSM and 20 (38.0%) patients underwent a NNSM. The type of surgery that patients underwent stratified by type of neoadjuvant regimen is outlined in the Table 1 below. Most patients who underwent BCT and mastectomy received radiation, including 36 (97.3%) BCT, 24 (72.7%) NSM, and 18 (95.0%) NNSM. Over a median follow-up period of 33 months, 6 patients (6.7%) had recurrences with 2 (2.2%) local recurrences and 4 (4.4%) distant recurrences. The 2 local recurrences occurred in one patient who underwent BCT and one patient who underwent NNSM followed by post-mastectomy radiation.

Conclusions: Among mastectomy patients, NSM was more commonly pursued than NNSM. Rates of local recurrence following pertuzumab-containing regimens for HER2-positive localized breast cancer were low overall, regardless of the type of surgery. Data on plastic surgery approaches and complication rates will be presented at the meeting.

Table 1.Type of surgery in patients receiving neoadjuvant HER2-directed therapy. AC-THP (N = 45)TCHP (N = 19)THP (N = 26)BCT46.7%47.4%26.9%NNSM26.7%10.5%23.1%NSM26.7%42.1%50.0%

Citation Format: Haddad SA, Spring LM, Jimenez RB, Vidula N, Comander A, Shin JA, Coopey SB, Gadd MA, Hughes KS, Taghian A, Smith BL, Isakoff SJ, Moy B, Bardia A, Specht MC. Surgical and long-term outcomes of patients receiving neoadjuvant pertuzumab-containing regimens for HER2-positive localized breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-14-19.