Contextual factors in shared decision making: a randomised controlled trial in women with a strong suspicion of breast cancer

Decision aids in North American breast cancer outpatients have been shown to assist with treatment decision making and reduce decisional conflict. To date, appropriate delivery formats to effectively increase patient participation in newly diagnosed breast cancer inpatients have not been investigated in the context of German health care provision. The impact of a decision aid intervention was studied in patients (n=111) with a strong suspicion of breast cancer in a randomised controlled trial. The primary outcome variable was decisional conflict. Participants were followed up 1 week post-intervention with a retention rate of 92%. Analyses revealed that the intervention group felt better informed (eta(p)(2)=0.06) but did not experience an overall reduction in decisional conflict as compared with the control group. The intervention had no effect on uptake rates of treatment options, length of consultation with the surgeon, time point of treatment decision making, perceived involvement in decision making, neither decision related nor general patient satisfaction. Patients who received the decision aid intervention experienced a small benefit with regards to how informed they felt about advantages and disadvantages of relevant treatment options. Results are discussed in terms of contextual factors and individual differences as moderators of treatment decision aid effectiveness.

Impact of BRCA mutation status on the clinical phenotype and survival of hereditary breast cancer

Abstract #3091

Background : In a multidisciplinary program supported by the German Cancer Aid in 1996-2006 a total of 3.408 women with a family history for breast and/or ovarian cancer were genetically counselled and tested for BRCA-1 and BRCA-2 mutations.
 Methods: The mutations were detected using DHPLC and direct sequencing. The family history of breast and/or ovarian cancer was proven by collecting medical reports of family members. The statistical analysis was done using standard procedures (Kaplan-Meier-analysis, t-test, chi-square-test).
 Results: Among the women with breast cancer 566 showed a deleterious BRCA1 and 313 a BRCA2 mutation. Four women were found to have mutations in both genes and 2.525 were BRCA-1/2 negative. In accordance with the literature we found the phenotype “hormone receptor negative and grade 3” as well as the medullary subtype significantly more often in BRCA1 associated breast cancers (74% vs. 24%, 63% vs. 42% and 10% vs. 5%). The median age of onset was significantly lower in BRCA1 mutation carriers (38 yrs) compared to BRCA2 mutation carriers (45 yrs) and women tested negative for BRCA1 and BRCA2 mutations (46 yrs) as well as sporadic breast cancer cases within these families (52 yrs). The median age of the 4 women with mutations in both genes was even lower (median age 33.5 yrs). Although BRCA2 associated breast carcinomas presented in more advanced stages (N+ in 44%[118/257] compared to BRCA-1 positive in 31%[166/519], p<0.01) there was no difference in overall survival between BRCA1 and BRCA2 mutation carriers. However, BRCA1 and BRCA2 negative cases showed a significantly better survival rate compared to the women with mutations (p<0.0001). Women from families with early onset breast cancer (<35 yrs) or bilateral breast cancer (<40 yrs) had a significantly better survival (p<0.0001) than women from families with a later age of onset.
 Conclusions: The BRCA mutation status has a significant impact on the clinical phenotype of hereditary breast cancer which is important for the clinical management, counselling and prevention.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 3091.

A clinical review of 33 cases of breast phyllodes tumor over the last 20 years

10629

Background: The “Cystosarcoma phyllodes” of the breast is a rare entity which accounts for 0.5 % of all breast neoplasms. The diagnosis should be considered in all rapidly growing breast nodules. We reviewed all cases of this rare disease that presented at our hospital in the last 20 years. Methods: The data of 5270 patients with primary breast neoplasms treated in our department between 1984 and 2005 were retrospectively analyzed for the histopathologic diagnosis of a cystosarcoma phyllodes. Results: 33 patients with cystosarcoma phyllodes of the breast could be identified. The median age at diagnosis was 47 years. Median follow up was 86 months. The tumors were classified histologically into benign (40%), borderline (27%) and malignant tumors (33%) based on standardized criteria; 3 tumors were unclassified. Surgery was conducted as a breast conserving (58%) or radical operation (mastectomy) (42%). Median tumor size was 7.1 cm, and no lymph node infiltration was found in the 8 patients who received axillary lymph node dissection. Local recurrence occured in 8 patients (26%). 75% (6/8) of the patients with a local recurrence had been treated with a breast conserving surgery. In patients with the diagnosis of a malignant phyllodes tumor we observed a recurrence rate of 40% (4/10), in those with borderline tumors of 25% (2/8) whereas those with benign phylloides tumor had a local relapse rate of 8% (1/12). Distant metastases were seen in 4 patients (12%) with a malignant phyllodes tumor. All patients with distant metastases in the follow up had been treated radically at primary diagnosis. Neither regarding age at primary diagnosis nor in tumor size there was a significant difference between patients with local recurrence or metastasic spread and those without (p = 0.284 tumor size, p = 0.739 for age, Wilcoxon-W). Conclusions: We recommend local excision with appropiate surgical margins in all patients if the tumor-to-breast ratio is sufficient for good cosmesis. Based on our data, routine axillary lymph node dissection is not recommended. Patients with a malignant tumor are at higher risk for local recurrence and metastasic spread. Therefore, the histopathologic classification seems to be the strongest prognostic factor in this disease.

No significant financial relationships to disclose.

The high-grade endometrial sarcoma: a rare entity

INTRODUCTION

With an estimated incidence of one to two per one million women, the endometrial stromal sarcoma (ESS) is a rare disease. It is subclassified into a high-grade and a prognostically better low-grade type. Evidence-based data for a standardized therapy is lacking.

CASE REPORT

A 32-year-old obese nulligravida presented with persistent vaginal bleeding after the operation of an acute adnextorsion at another hospital. The repeat gynecological ultrasound examination showed a 5.3x5.3x3.6 cm vascularized, partially inhomogeneous mass in the uterus. A fractioned curettage yielded a differential diagnosis of malignant muellerian mixed tumor or a non-differentiated endometrial sarcoma. For completion of the operative treatment, laparotomy with hysterectomy, adnexectomy, and pelvine lymphonodectomy were performed. The final histological report described a 7 cm non-differentiated endometrial sarcoma with infiltration of the left ovary and 25 tumor-free lymph nodes.

DISCUSSION

Standard therapy for resectable sarcoma is abdominal hysterectomy and bilateral adnexectomy. So far, there is little data from studies reporting radio- or chemotherapy treatment of small patient numbers in an adjuvant setting.

CONCLUSION

The ESS is a very rare disease of the uterus. Due to missing clinical data, it remains a multidisciplinary therapeutic challenge requiring individual decisions. To receive more information on this rare disease, treatment should be performed according to international protocols.

Reduction mammaplasty in granular cell tumour of the breast

Granular cell tumour of the breast is a rare peripheral nerve tumour. A case in a 34-year-old woman is reported. The clinical and histological differentiation from invasive malignant neoplasm and the surgical management are discussed. Core needle biopsy preoperatively is able to establish the definite diagnosis and help to avoid surgical overtreatment.

Adjuvante Therapie des Mammakarzinoms 2004

The emerging evidence gained from randomized controlled trials accelerated the widespread use of adjuvant endocrine and cytotoxic regimens and their combinations for most breast cancer patients. Even for the earliest cancer stages with low-risk tumour profiles, endocrine treatment can be recommended as adjuvant therapy if the tumour is endocrine responsive. The 8th consensus conference on early breast cancer in St. Gallen in 2003 opened a plethora of treatment options to nearly all breast cancer patients. Key issues were the introduction of adjuvant therapy with anastrozole for those postmenopausal patients with contra-indications or intolerability of tamoxifen and the definition of a group of 'more potent' regimens like the FEC- and the taxane-based regimens for high-risk patients. Unfortunately the expert panel did not clearly define any recommendations either for choosing optimal candidates for purely endocrine treatments (which are a valid option for all patients with optimal endocrine responsive disease or arguments against chemotherapy) or for the proper high-risk patients scheduled for more aggressive regimens. In the meantime, new or updated studies have provided additional information helpful for the shared decision-making with our patients. The Canadian MA.17 study revealed a significant benefit from adding a sequential therapy with letrozole after 5 years of tamoxifen compared to tamoxifen alone. Together with the updated evaluation from the ATAC trial and the Italian ITA study, the role of adjuvant treatment with aromatase inhibitors is steadily strengthened. Several studies comparing taxane-based and taxane-free regimens showed significant survival and/or recurrence benefits for the former. These data should be communicated to the patients. In the complex process of decision-making, a profound knowledge of the study results and the early and complete involvement of the woman and her personal beliefs are mandatory.

Chemosensitivity testing in gynecologic oncology--dream or reality?

Cell culture and animal models have played an essential role in the research of new principles of therapy. Many methods for the individualized testing of therapy sensitivity and resistance have been developed, for example, the clonogenic assay. Presently, the ATP-TCA is commercially available as a testing kit. This review gives an overview of the tumor samples that were tested in the oncologic laboratory in the Department of Obstetrics and Gynecology, Munich Grosshadern between 1993 and 2001. All target parameters show a clear trend in favor of sequential, dose-intensified Epirubicin/Paclitaxel therapy. If this trend remains valid for the total number of patients, a significant impact of this new principle of therapy can be expected. By individualized planning of therapy with ATP-TCA testing, therapy in the individual patient could already be performed by the examination of sensitivity in the preoperative biopsy specimen.

[Detection of disseminated tumor cells in bone marrow--currently of no practical therapeutic value]

Development of metastases in cancer patients is usually due to tumour cells seeding from the primary. These disseminated cells can be detected in blood or bone marrow with the aid of immunocytochemical methods. The clinical significance of this is, however, still controversial. With the aim of determining the prognostic value of disseminated tumour cells, a meta-analysis of 20 publications reporting results based on data collected from a total of 2494 breast cancer patients, was carried out. The outcome of the meta-analysis was that 14 of the 20 studies provided evidence suggesting positive bone marrow findings to be an unfavorable prognostic factor. Five out of twelve studies provided multivariate analytic evidence of an impact of bone marrow status on recurrence-free survival. In five out of twelve studies, a univariate analysis showed a positive bone marrow finding to correlate significantly with overall survival, while a multivariate analysis found such a correlation in only two out of six studies. Owing to a lack of standardization, the results of the individual studies are not directly comparable. Against this background it is too early to say whether the detection of disseminated tumour cells in the bone marrow can be used as a prognostic factor with an impact on therapeutic strategies.