Primary and secondary care management of women with early breast cancer from affluent and deprived areas: retrospective review of hospital and general practice records

OBJECTIVES

To investigate whether poorer survival of breast cancer among deprived women compared with affluent women is related to their NHS care.

DESIGN

Retrospective review of hospital and general practice case records.

SETTING

Greater Glasgow Health Board area.

SUBJECTS

Women diagnosed with breast cancer in 1992-3 who lived in the most affluent (deprivation categories 1 and 2) and the most deprived areas (deprivation categories 6 and 7) of Glasgow (Carstairs and Morris deprivation index).

MAIN OUTCOME MEASURES

Breast cancer treatment, time from general practice consultation to clinic visit and surgery, and details of hospital admissions and follow up in primary and secondary care.

RESULTS

The access to care and surgical and oncological treatment of women from affluent and deprived areas were similar. Admissions to hospital for problems not related to breast cancer were more common in those living in deprived areas (number admitted once or more: 51 (24%) v 13 (10%), P=0.001). Consultation patterns in general practice by the second year after diagnosis showed women in deprived areas consulting more frequently than women in affluent areas (median (interquartile range) number of consultations (5 (2-10) v 7 (4-13), P=0.01).

CONCLUSION

Women living in affluent areas did not receive better NHS care for breast cancer than women in deprived areas. However, women from deprived areas seem to have greater comorbidity, and poorer outcomes from breast cancer among these women is probably due to factors which result in deprived communities having poorer health outcomes rather than to management of their breast cancer.

Margin assessment by cavity shaving after breast-conserving surgery: analysis and follow-up of 543 patients

AIMS

To analyse cavity shaving as a method of assessing completeness of surgical excision after breast-conserving surgery.

METHODS

Shavings were taken from the wall of the cavity remaining in the breast after breast-conserving surgery in 543 women. Each shaving was extensively sectioned and the presence and type of microscopic disease recorded. Disease in cavity shavings (tumour bed positivity) was correlated with clinicopathological factors as well as overall survival.

RESULTS

Tumour bed positivity (TBP) was found in 37% of patients (16% with invasive disease). Patients were selected for further surgery according to the extent of positivity, which varied widely. A total of 15% of patients underwent re-excision or mastectomy. TBP was significantly associated with high tumour grade, presence of an extensive intraduct component, young age and large tumour diameter. It was also associated with a significantly shorter overall survival when compared to patients who were tumour bed negative.

CONCLUSIONS

Cavity shaving is a practical and sensitive method of assessing completeness of excision after breast-conserving surgery. In addition it may provide useful prognostic information.

Influence of tumour bed assessment on local recurrence following breast-conserving surgery for breast cancer

AIMS

To assess the impact of adopting a policy of tumour bed assessment with selective re-excision in patients undergoing breast-conserving surgery for breast cancer.

METHODS

Tumour bed assessment was introduced in our institution in 1988. Patients treated prior to 1988 (125 patients) were compared with patients treated post-1988 (239 patients) for clinico-pathological factors, surgical and adjuvant therapy. Outcome measures were examined at a fixed 5-year follow-up period for each patient.

RESULTS

There were a greater number of small, node-negative, oestrogen receptor tumours post-1988, probably due to the influence of the National Breast Screening Programme. There was also a difference in the prescription of adjuvant systemic therapy between the two cohorts. The incidence of tumour bed positivity was 30.5%. The re-excision rate was 16.4%. There was a significant fall in the incidence of local recurrence from pre-1988 (15.7%) to post-1988 (2.5%).

CONCLUSION

By adopting a policy of tumour bed assessment with selective re-excision, a low local recurrence rate has been achieved. The improvement in systemic recurrence and breast cancer-related death rate are mainly secondary to other factors.

Surgical treatment of oesophageal obstruction after ingestion of a granular laxative

A case of oesophageal obstruction after ingestion of a granular laxative in a 91-year-old man is presented. There was no predisposing oesophageal disease. The severity of obstruction prevented endoscopic clearance and the patient required gastrotomy and manual disimpaction of the lower oesophagus.

Expression of gap junction proteins connexin 26 and connexin 43 in normal human breast and in breast tumours

Gap junctional intercellular communication (GJIC) has been proposed as a cellular mechanism for tumour suppression and there is experimental evidence in support of this. If aberrant GJIC contributes to the formation of human breast tumours, one might expect that the connexins (gap junction proteins) expressed by epithelial cells in normal human breast would be down-regulated in tumour epithelial cells, or that tumour cells might show aberrant expression of other connexin family members. This study examines the immunocytochemical expression of connexins 26 (Cx26) and 43 (Cx43) in normal human breast, 11 benign breast lesions, two special-type carcinomas, and 27 invasive carcinomas of no special histological type (NST). Cx26 generally was not expressed at detectable level in normal human breast, but punctate Cx43 immunostaining of the myoepithelial cells was found. Cx43 staining of the myoepithelium was also a feature of the benign lesions and ductal carcinoma in situ (DCIS). In general, the epithelial cells of benign lesions failed to stain for either connexin. Similarly, a lobular carcinoma did not express Cx26 or Cx43, but there was punctate Cx43 in the epithelial cells of a mucoid carcinoma. Cx26 was up-regulated in the carcinoma cells of 15 of the 27 invasive NST carcinomas, although the staining was usually cytoplasmic and heterogeneous. Cx43 was expressed by stromal cells, possibly myofibroblasts, in all NST carcinomas. Furthermore, there was heterogeneous Cx43 expression in the carcinoma cells of 14 of the 27 NST carcinomas and the staining was often intercellular and punctate, characteristic of functional connexins. Up-regulated of Cx26 and/or Cx43 in the carcinoma cells of over two-thirds of invasive lesions of NST is not necessarily inconsistent with a tumour suppressor role for GJIC. However, the role of gap junctions in the formation and progression of solid human tumours is likely to be more complex than indicated from experimental systems.

Increased proliferative activity and p53 expression in normal glandular breast tissue after radiation therapy

Radiation used in breast-conserving therapy (BCT) for early breast cancer, to eradicate residual malignant cells after tumour resection, induces DNA damage and cell death. Little is known about the effect of the commonly used doses of radiation therapy on normal breast tissue. Under physiological conditions, p53 plays a role in maintaining genomic stability and regulating progression through the cell cycle. In normal glandular breast tissue, p53 expression is very low, as is proliferative activity. The purpose of this study was to investigate the levels of p53 expression and proliferative activity in non-malignant glandular epithelium of the breast after BCT. The immunohistochemical expression of p53 and Ki-67 was semiquantitatively correlated in non-malignant glandular epithelium in biopsies before and after BCT in 24 women with breast cancer. In 18 cases, a recurrence was diagnosed and in the remaining cases, the clinical suspicion was not histologically confirmed. In addition, in six cases with contralateral breast cancer, the same immunohistochemical evaluation was performed in tissue from both breasts. The mean interval between the two surgical interventions was 50 months. The percentage of p53 immunoreactive epithelial cells in normal breast tissue was significantly (P < 0.01) higher after radiation therapy than before in the ipsilateral side (0.2 per cent +/- 0.3 and 4.6 per cent +/- 4.5, respectively). Ki-67 immunoreactivity was also significantly increased (P < 0.001) after radiation therapy, from 0.6 per cent to an average of 4.8 per cent in epithelial cells. In contrast, in the patients with contralateral breast cancer, the levels of p53 and Ki-67 immunoreactivity in the normal glandular breast tissue were comparable to the ipsilateral side (P = 0.7 and P = 0.1, respectively). In conclusion, increased expression of p53 and Ki-67 is present in normal glandular breast tissue, even 2-5 years after radiation therapy.

Putative markers for the detection of breast carcinoma cells in blood

The aim of this study was to investigate certain genes for their suitability as molecular markers for detection of breast carcinoma cells using the reverse transcriptase-polymerase chain reaction (RT-PCR). RNA was prepared from MCF-7 breast carcinoma cells and peripheral blood leucocytes of healthy female volunteers. This RNA was screened for mRNA of MUC1, cytokeratin 19 (CK19) and CD44 (exons 8-11) by RT-PCR and the results validated by Southern blots. Variable degrees of expression of MUC1 and CD44 (exons 8-11) were detected in normal peripheral blood, rendering these genes non-specific for epithelial cells and therefore unsuitable for use as markers to detect breast carcinoma cells. Although CK19 mRNA was apparently specific, it was deemed unsuitable for use as a marker of breast cancer cells in light of its limited sensitivity. Furthermore, an attempt at using nested primers to increase sensitivity resulted in CK19 mRNA being detected after two amplification rounds in blood from healthy volunteers.

Expression of gap junction proteins connexin 26 and connexin 43 in normal human breast and in breast tumours

Gap junctional intercellular communication (GJIC) has been proposed as a cellular mechanism for tumour suppression and there is experimental evidence in support of this. If aberrant GJIC contributes to the formation of human breast tumours, one might expect that the connexins (gap junction proteins) expressed by epithelial cells in normal human breast would be down-regulated in tumour epithelial cells, or that tumour cells might show aberrant expression of other connexin family members. This study examines the immunocytochemical expression of connexins 26 (Cx26) and 43 (Cx43) in normal human breast, 11 benign breast lesions, two special-type carcinomas, and 27 invasive carcinomas of no special histological type (NST). Cx26 generally was not expressed at detectable level in normal human breast, but punctate Cx43 immunostaining of the myoepithelial cells was found. Cx43 staining of the myoepithelium was also a feature of the benign lesions and ductal carcinoma in situ (DCIS). In general, the epithelial cells of benign lesions failed to stain for either connexin. Similarly, a lobular carcinoma did not express Cx26 or Cx43, but there was punctate Cx43 in the epithelial cells of a mucoid carcinoma. Cx26 was up-regulated in the carcinoma cells of 15 of the 27 invasive NST carcinomas, although the staining was usually cytoplasmic and heterogeneous. Cx43 was expressed by stromal cells, possibly myofibroblasts, in all NST carcinomas. Furthermore, there was heterogeneous Cx43 expression in the carcinoma cells of 14 of the 27 NST carcinomas and the staining was often intercellular and punctate, characteristic of functional connexins. Up-regulated of Cx26 and/or Cx43 in the carcinoma cells of over two-thirds of invasive lesions of NST is not necessarily inconsistent with a tumour suppressor role for GJIC. However, the role of gap junctions in the formation and progression of solid human tumours is likely to be more complex than indicated from experimental systems.

Tumour bed positivity predicts outcome after breast-conserving surgery

BACKGROUND

Local recurrence after breast-conserving surgery is associated with a short distant disease-free survival, particularly if it occurs early. Early recurrence is caused by residual disease left at the time of surgery. Previous studies have demonstrated that disease in the tumour bed is a common finding after breast-conserving surgery.

METHODS

The follow-up (mean 4.4 years) of 300 patients who had tumour bed analysis performed by the cavity shaving technique following breast-conserving surgery is presented. Postoperative radiotherapy was administered to all patients.

RESULTS

The incidence of tumour bed positivity was 39.3 per cent. With a selective re-excision policy the local recurrence rate was 2.0 per cent and distant recurrence rate 10.4 per cent. Multivariate analysis identified lymphovascular invasion, oestrogen receptor status and tumour bed status as independent predictors of time to distant recurrence.

CONCLUSION

A low rate of local recurrence can be achieved using this technique of margin assessment. Tumour bed status may be a useful prognostic factor following breast-conserving surgery.

Randomised controlled trial of conservation therapy for breast cancer: 6-year analysis of the Scottish trial. Scottish Cancer Trials Breast Group

BACKGROUND

To determine whether, when primary breast cancer is treated by local excision supported by systemic therapy appropriate to the oestrogen receptor status (ER) of the tumour, local radiotherapy can be avoided.

METHODS

We carried out a randomised controlled trial in 585 patients aged less than 70 years with primary breast cancers of 4 cm or less in size in four specialist units and seven other hospitals in Scotland. After local excision of the tumour (1 cm margin) and an axillary lymph-node clearance or sample, all patients received systemic therapy with oral tamoxifen 20 mg daily or six 3-weekly intravenous bolus injections of cyclophosphamide 600 mg, methotrexate 50 mg, and fluorouracil 600 mg per m2, depending upon the ER concentration in the primary tumour. Patients were then randomly allocated to postoperative radical radiotherapy (50 Gy to breast with boost to the tumour bed) or to no further local treatment. The median follow-up of living patients was 5.7 years. The primary analysis was by intention to treat but since some patients did not receive systemic therapy appropriate to their ER status, a subsidiary analysis was restricted to 464 patients in whom all details of the protocol had been observed.

FINDINGS

In the primary analysis survival was equal in the radiotherapy and non-radiotherapy groups (hazard ratio [HR] 0.98, 95% CI 0.67-1.44). Event-free survival showed an advantage in the irradiated patients (HR 0.54, 95% CI 0.39-0.74), largely due to fewer loco-regional relapses (HR 0.20, 95% CI 0.12-0.33). The relapse rate in the ipsilateral breast was 24.5% in the non-irradiated group and 5.8% following breast irradiation. The subsidiary analysis confirmed these findings and indicated the advantage of radiotherapy irrespective of ER concentration. There was a non-significant trend towards fewer distant metastases in the irradiated group.

INTERPRETATION

After local excision of a primary breast cancer, we conclude that radiotherapy to the residual breast tissue is advisable even when selective adjuvant systemic therapy is given.

Cystosarcoma phylloides: heterogeneity in a rare tumour type

Mammary cystosarcoma phylloides is a rare tumour, and clear guidelines for its clinical management are lacking. We present three cases from the Western Infirmary which illustrate the range of behaviour that these tumours can manifest, and discuss some of the clinical problems that they present.

Randomised comparison of 5 years of adjuvant tamoxifen with continuous therapy for operable breast cancer. The Scottish Cancer Trials Breast Group

In 1985 a second randomisation was initiated for women in the treatment arm of the Scottish Tamoxifen Trial either to stop tamoxifen at 5 years or to continue indefinitely. A preliminary analysis of outcome in 342 patients at a median follow-up of 6 years suggests that a worthwhile gain in disease control from continuing adjuvant tamoxifen beyond 5 years is unlikely. [Hazard ratio for events (relapse or death without relapse) is 1.27, 95% CI = 0.87 - 1.85.] There is a suggestion that therapy for longer than 5 years may increase the risk of endometrial carcinoma (P = 0.064).

Psychological support for patients undergoing breast cancer surgery: a randomised study

OBJECTIVE

To evaluate the effect of support from a nurse specialising in breast care and a voluntary support organisation on prevalence of psychological morbidity after surgery for breast cancer.

DESIGN

Prospective randomised study.

SETTING

Three teaching hospitals in Glasgow with established breast clinics.

SUBJECTS

272 women aged less than 70 years undergoing surgery for breast cancer.

INTERVENTIONS

Patients were randomly allocated to receive routine care from ward staff, routine care plus support from breast care nurse, routine care plus support from voluntary organisation, or routine care plus support from nurse and organisation.

MAIN OUTCOME MEASURES

Prevalence of psychological morbidity as assessed by self rating scales: 28 item general health questionnaire and its subscales, and hospital anxiety and depression scale. Measurements were made at first postoperative clinic visit and at three, six, and 12 months after surgery.

RESULTS

On each self rating scale, psychological morbidity tended to fall over the 12 month period. For each scale, scores were consistently lower in patients offered support from breast care nurse alone compared with the other groups, which were similar to each other. Differences were significant or nearly so: P values were 0.015 (28 item general health questionnaire), 0.027 (anxiety and insomnia), 0.072 (severe depression), 0.053 (somatic symptoms), 0.031 (social dysfunction), 0.093 (hospital anxiety), and 0.003 (hospital depression).

CONCLUSION

Support from breast care nurse can significantly reduce psychological morbidity, as measured by self rating scales, in women undergoing breast cancer surgery.

Hepatocyte growth factor/scatter factor expression and c-met in primary breast cancer

Hepatocyte growth factor/scatter factor (HGF/SF) is a fibroblast-derived cytokine whose receptor is encoded by c-met. Activation of c-met promotes tumour cell proliferation, dissociation, invasiveness and angiogenesis. Aberrant expression of HGF/SF or c-met may play a role in tumour progression. HGF/SF and c-met were determined in 73 breast cancers (median follow up: 61 months) and 10 samples of tumour-free breast tissue. HGF/SF was detected at significantly higher concentrations in breast cancers (median 350, range 58-1604 ng per 100 mg total protein) when compared with normal breast tissue (median 108, range 66-213 ng per 100 mg total protein) (P < 0.001). C-met was detected in all 10 samples of tumour-free breast tissue and in 26 breast cancers. HGF/SF concentrations correlated with disease relapse (P < 0.001) and reduced overall survival (P < 0.001). Tumours with detectable c-met correlated significantly with disease-relapse (P = 0.012). Multivariate analysis demonstrated a significant interaction between HGF/SF and c-met in relation to disease-relapse (P = 0.014). These results suggest a biological interaction involving HGF/SF and c-met in promoting tumour progression in breast cancer.

Local recurrence after breast-conserving surgery for breast cancer

Local recurrence following breast-conserving surgery for breast cancer is a significant failure of local treatment. This article reviews the mechanisms, risk factors and overall significance of such local recurrence. The presence of disease at excision margins, an extensive intraduct component, lymphatic vessel invasion, tumour grade and tumour size are currently the best predictors of risk for local recurrence. Early local recurrence is due to residual disease and is associated with both decreased distant disease-free survival and overall survival; it appears to reflect aggressive biological characteristics of the primary tumour. The importance of adequate local treatment for breast cancer is discussed.

Characterization of extensive genetic alterations in ductal carcinoma in situ by fluorescence in situ hybridization and molecular analysis

BACKGROUND

The molecular genetic analysis of invasive breast cancer has identified breast cancer as a genetically complex disease. Ductal carcinoma in situ (DCIS) is thought to represent a preinvasive step in breast cancer progression, yet we know little about its biologic behavior or the genetic alterations present. Because of the increasing diagnosis of DCIS by mammography screening and the debate over how DCIS should be managed, there is a clear need to define the molecular events underlying the development of DCIS.

PURPOSE

Our purpose was to identify patterns of genetic alterations in DCIS.

METHODS

A group of 30 formalin-fixed, paraffin-embedded blocks of tissue collected from 1987 through 1989 from 21 patients with DCIS was studied. Chromosomal imbalances were determined by interphase cytogenetic analysis using the fluorescence in situ hybridization (FISH) technique. DNA probes were used that recognize chromosome-specific repetitive sequence loci at the centromeres of chromosomes 1, 3, 4, 6, 7, 8, 9, 10, 11, 16, 17, and 18. FISH was also used to detect ERBB2 gene amplification in DCIS. To complement the FISH studies, microsatellite analysis of markers near the BRCA1 region of chromosome 17 was done on tissue microdissected from multiple areas of DCIS. Chromosomal imbalances were determined by comparisons of chromosomal indices (total number of hybridization spots per total number of nuclei counted) of normal and DCIS tissue, using the two-sided Mann-Whitney test.

RESULTS

Using FISH, we have identified patterns of DNA loss and gain of certain chromosome-specific centromeric markers in DCIS. We observed frequent gains of markers on chromosomes 3, 10, and 17 as well as loss of chromosome 18-specific centromeric sequences. ERBB2 gene amplification was detected in tumors from four of 15 patients studied and was clearly limited to the tumor cells within the ducts. Because of the availability of topologically distinct regions of tumors from individuals, we were able to show that paired tumor specimens from individuals share genetic alterations and also have unique ones, suggesting clonal diversity within tumors. The combination of FISH and microsatellite analyses suggested that alterations in chromosome 17 may be quite complex; three of five patients whose samples were analyzed had allelic imbalance at markers on the long arm of chromosome 17.

CONCLUSIONS

FISH and microsatellite analyses are useful in detecting extensive genetic alterations in DCIS. Examinations of DCIS tissue using these techniques have identified chromosomes 1, 3, 10, 16, 17, and 18 as candidate sites worthy of immediate study.

IMPLICATIONS

This approach may give direction to future research aimed at precisely mapping loci altered in DCIS and help in understanding the biologic events associated with tumor progression or recurrence.

Expression and loss of heterozygosity of c-met proto-oncogene in primary breast cancer

The c-met proto-oncogene encodes the receptor to hepatocyte growth factor-scatter factor (HGF-SF), a mesenchyme-derived cytokine with cell-dissociating, invasion, and angiogenic properties. The expression of c-met in breast cancer is the subject of controversy; 111 primary breast cancers were examined for LOH of c-met by Southern blot electrophoresis. c-met expression was measured in a further 40 patients with breast cancer and in 8 patients with benign breast disease by flow cytometry. LOH of c-met was detected in only 4% of informative breast cancers. Expression of c-met was significantly greater in patients with breast cancer than in those with benign breast disease (P < 0.01, Mann-Whitney). There was no correlation however between increased c-met expression and clinicopathological prognostic variables. These results do not support the role of c-met as a tumour suppressor gene in breast cancer but suggest increased receptor expression in malignant breast disease. The significance of this increased expression in breast cancer is the subject of further investigation.

Predicting local recurrence by correlating pre-operative mammographic findings with pathological risk factors in patients with breast cancer

The pre-operative mammograms for 231 patients undergoing conservation surgery for breast cancer between March 1988 and September 1992 were analysed for features that may predict the presence of pathological risk factors of local recurrence (residual microscopic disease, extensive intraduct carcinoma (EIC) and lymphatic/vascular invasion). Residual microscopic disease was detected in 40% of patients and was associated with a DY mammographic pattern (p = 0.03), casting calcification (p = 0.0002) and absence of mammographic nidus (p = 0.0006). Residual microscopic disease was found in 75-88.9% of patients when two of these preoperative mammographic features were present in combination. The mean lumpectomy diameter was significantly smaller for patients with DY compared to N1 mammographic pattern on Wolfe grade (p = 0.039). Both residual disease and Wolfe grade were related to age (p = 0.0032 and p < 0.0001). EIC was found in 22% of patients and was associated with casting (p < 0.0001) and non-casting (p = 0.04) calcification, absence of mammographic nidus (p < 0.0001) and stellate mammographic nidus (p = 0.02). No significant association was found between mammographic features and lymphatic/vascular invasion. Pre-operative mammographic features can predict patients likely to have residual microscopic disease or EIC following conservation surgery for breast cancer. These patients should be selected for wider primary excision.