Use of patient-reported outcome measures after breast reconstruction in low- and middle-income countries: a scoping review

BACKGROUND

Patient-reported outcome measures (PROMs) are increasingly administered in high-income countries to monitor health-related quality of life of breast cancer patients undergoing breast reconstruction. Although low- and middle-income countries (LMICs) face a disproportionate burden of breast cancer, little is known about the use of PROMs in LMICs. This scoping review aims to examine the use of PROMs after post-mastectomy breast reconstruction among patients with breast cancer in LMICs.

METHODS

MEDLINE, Embase, Web of Science, CINAHL, and PsycINFO were searched in August 2022 for English-language studies using PROMs after breast reconstruction among patients with breast cancer in LMICs. Study screening and data extraction were completed. Data were analyzed descriptively.

RESULTS

The search produced 1024 unique studies, 33 of which met inclusion criteria. Most were observational (48.5%) or retrospective (33.3%) studies. Studies were conducted in only 10 LMICs, with 60.5% in China and Brazil and none in low-income countries. Most were conducted in urban settings (84.8%) and outpatient clinics (57.6%), with 63.6% incorporating breast-specific PROMs and 33.3% including breast reconstruction-specific PROMs. Less than half (45.5%) used PROMs explicitly validated for their populations of interest. Only 21.2% reported PROM response rates, ranging from 43.1 to 96.9%. Barriers and facilitators of PROM use were infrequently noted.

CONCLUSIONS

Despite the importance of PROM collection and use in providing patient-centered care, it continues to be limited in middle-income countries and is not evident in low-income countries after breast reconstruction. Further research is necessary to determine effective methods to address the challenges of PROM use in LMICs.

Virtual Reality-Based Exercise Rehabilitation in Cancer-Related Dysfunctions: Scoping Review

BACKGROUND

Virtual reality-based exercise rehabilitation (VRER) is a promising intervention for patients with cancer-related dysfunctions (CRDs). However, studies focusing on VRER for CRDs are lacking, and the results are inconsistent.

OBJECTIVE

We aimed to review the application of VRER in patients with CRDs.

METHODS

This scoping review was conducted following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist framework. Publications were included from the time of database establishment to October 14, 2023. The databases were PubMed, Embase, Scopus, Cochrane, Web of Science, ProQuest, arXiv, IEEE Xplore, MedRxiv, CNKI, Wanfang Data, VIP, and SinoMed. The population included patients with cancer. A virtual reality (VR) system or device was required to be provided in exercise rehabilitation as an intervention. Eligible studies focused on VRER used for CRDs. Study selection and data extraction were performed by 2 reviewers independently. Extracted data included authors, year, country, study type, groups, sample size, participant age, cancer type, existing or potential CRDs, VR models and devices, intervention programs and durations, effectiveness, compliance, satisfaction, and safety.

RESULTS

We identified 25 articles, and among these, 12 (48%) were randomized clinical trials, 11 (44%) were other experimental studies, and 2 (8%) were observational studies. The total sample size was 1174 (range 6-136). Among the 25 studies, 22 (88%), 2 (8%), and 1 (4%) included nonimmersive VR, immersive VR, and augmented reality, respectively, which are models of VRER. Commercial game programs (17/25, 68%) were the most popular interventions of VRER, and their duration ranged from 3 to 12 weeks. Using these models and devices, VRER was mostly applied in patients with breast cancer (14/25, 56%), leukemia (8/25, 32%), and lung cancer (3/25, 12%). Furthermore, 6 CRDs were intervened by VRER, and among these, postmastectomy syndromes were the most common (10/25, 40%). Overall, 74% (17/23) of studies reported positive results, including significant improvements in limb function, joint range of motion, edema rates, cognition, respiratory disturbance index, apnea, activities of daily living, and quality of life. The compliance rate ranged from 56% to 100%. Overall, 32% (8/25) of studies reported on patient satisfaction, and of these, 88% (7/8) reported satisfaction with VRER. Moreover, 13% (1/8) reported mild sickness as an adverse event.

CONCLUSIONS

We found that around half of the studies reported using VRER in patients with breast cancer and postmastectomy dysfunctions through nonimmersive models and commercial game programs having durations of 3-12 weeks. In addition, most studies showed that VRER was effective owing to virtualization and interaction. Therefore, VRER may be an alternate intervention for patients with CRDs. However, as the conclusions were drawn from data with acknowledged inconsistencies and limited satisfaction reports, studies with larger sample sizes and more outcome indictors are required.

A high-grade breast mucoepidermoid carcinoma without MAML2 rearrangement: A case report and literature review

INTRODUCTION

Mucoepidermoid carcinoma (MEC) of the breast is an extremely rare primary breast tumor. Between 1979 and June 2022, only 50 cases were reported. The pathological morphology and biological behavior of breast MEC remain poorly understood.

PATIENT CONCERNS

A 47-year-old female was presented with a 10-day-old left breast mass detected by physical examination.

DIAGNOSES

Ultrasonography could not distinguish whether the breast tumor was benign or malignant. After a biopsy of a breast tumor excision specimen, combined with immunohistochemical results, the patient was diagnosed with high-grade mucoepidermoid breast carcinoma.

INTERVENTIONS

The patient underwent a modified radical mastectomy for her left breast.

OUTCOMES

The patient was still free from local recurrence or metastases at 1-year follow-up.

CONCLUSION

A high-grade MEC case without MAML2 rearrangement shows good recovery without complications. The diagnosis was confirmed by histomorphology and immunohistochemical markers. It is sometimes necessary to distinguish it from adenosquamous, adenoid cystic, or mucinous carcinoma. The primary treatment is surgical resection, and the prognosis is closely related to the pathological grade.

Surgical Management and System Therapy of the Most Giant Known Malignant Metastatic Breast Phyllodes Tumor: A Case Report and Review of the Literature

INTRODUCTION

Phyllodes tumors belong to uncommon fibroepithelial breast tumors with a range of biological behaviors. Phyllodes tumors are responsible for less than 1 percent of all neoplasms of the breast.

CASE PRESENTATION

A 66-year-old woman presented to our Breastcancer Unit in March 2021 because of a huge mass of her left breast with bleeding out of a tumor necrosis. Five years ago in 2016, a benign phyllodes tumor was diagnosed externally. When we started the treatment, the tumor had a weight of 18.6 kg.

CONCLUSION

We describe the surgical management and the systemic treatment of metastatic disease.

Translation and psychometric assessment of the mastectomy module of the BREAST-Q questionnaire for use in Nigeria

BACKGROUND

The majority of non-metastatic breast cancer patients in sub-Saharan Africa are recommended to have mastectomy. The impact of mastectomy on a predominantly young African patient population requires evaluation. The BREAST-Q is a validated patient-reported outcome measure of quality-of-life following breast surgery that has been translated into 30 languages-none in Africa. This study aimed to translate and assess the psychometric properties of the mastectomy module of the BREAST-Q for use in Nigeria.

METHODS

The BREAST-Q mastectomy module was translated from English to Yoruba and its psychometric properties assessed using best practice guidelines. Translation was performed in 4 steps: forward translation (x2), back translation, back translation review, and cognitive interviews with post-mastectomy patients. The translated BREAST-Q instrument was administered to post-mastectomy patients (n = 21) alongside the EORTC-QLQ BR23 to evaluate construct validity. Test-retest reliability was evaluated using intraclass correlation coefficients (ICC); surveys were re-administered 4 weeks apart.

RESULTS

The translation process identified English phrases not amenable to direct translation, including "emotionally healthy" and descriptions of pain ("nagging," "throbbing," "sharp"). Translations were amended to reflect local context and question intent. During cognitive interviews, patients provided suggestions to simplify complex phrases, e.g. "discomfort in your breast area.". Internal consistency within scales was over 0.70 for psychosocial wellbeing (α = 0.84-0.87), sexual wellbeing (α = 0.98-0.99), physical wellbeing in chest (α = 0.84-0.86), and satisfaction with care (α = 0.89-0.93). ICC for test-retest reliability was moderate (0.46-0.63).

CONCLUSIONS

The Yoruba version of the BREAST-Q mastectomy module presents a unique opportunity to adequately capture the experiences of Nigerian women post mastectomy. This instrument is being used in a pilot study of Nigerian patients to identify targets for intervention to improve the patient experience and compliance with breast cancer surgery.

Inflammatory breast cancer: Epidemiologic data and therapeutic results

Since the early description more than a century ago, inflammatory breast cancer (IBC) remains an aggressive disease, with a different geographic repartition, with the highest ones incidence reported in the North of Africa (Tunisia, Algeria, Morocco, and Egypt), and the lowest incidence in Western countries (USA, Europe…). In this study, we reviewed the literature using the Surveillance, Epidemiology, and End Results (SEER) database compared to other published series. We observed that in the high incidence areas (North of Africa) when compared to "classical" breast cancer, IBC was associated to younger age (less than 50 years) with rapid evolution of signs and symptoms (in less than 3 up to 6 months), and more aggressive clinical and histopathological-molecular parameters, due to the predominance of triple-negative and HER2+ subtypes in around 60% of cases. An epidemiologic trend was observed in both high and low incidence areas since the eighties are towards reduction of IBC prevalence. Concerning Tunisia, in comparison with the historical series of the 1980s, the incidence decreased in part by applying more stringent diagnostic criteria but also probably due to a slight improvement of the socio-economic level (SEL). This trend was also observed in the US, due to the efforts of collaborative IBC groups from MD Anderson Cancer Center (MDACC), Duke and IBC patient advocacy groups. Therapeutic results are slightly better due to the standardization of a multidisciplinary approach and the use of combined primary chemotherapy and/or targeted therapies (especially in HER2 positive patients), followed by mastectomy plus radiotherapy. The 5-year overall and disease-free survival is at more than 60%, related to an IBC mortality decrease observed in the cohorts of patients treated in the last decade.

Cost-Effectiveness of Gene-Specific Prevention Strategies for Ovarian and Breast Cancer

Importance

Pathogenic variants (PVs) in BRCA1, BRCA2, PALB2, RAD51C, RAD51D, and BRIP1 cancer susceptibility genes (CSGs) confer an increased ovarian cancer (OC) risk, with BRCA1, BRCA2, PALB2, RAD51C, and RAD51D PVs also conferring an elevated breast cancer (BC) risk. Risk-reducing surgery, medical prevention, and BC surveillance offer the opportunity to prevent cancers and deaths, but their cost-effectiveness for individual CSGs remains poorly addressed.

Objective

To estimate the cost-effectiveness of prevention strategies for OC and BC among individuals carrying PVs in the previously listed CSGs.

Design, Setting, and Participants

In this economic evaluation, a decision-analytic Markov model evaluated the cost-effectiveness of risk-reducing salpingo-oophorectomy (RRSO) and, where relevant, risk-reducing mastectomy (RRM) compared with nonsurgical interventions (including BC surveillance and medical prevention for increased BC risk) from December 1, 2022, to August 31, 2023. The analysis took a UK payer perspective with a lifetime horizon. The simulated cohort consisted of women aged 30 years who carried BRCA1, BRCA2, PALB2, RAD51C, RAD51D, or BRIP1 PVs. Appropriate sensitivity and scenario analyses were performed.

Exposures

CSG-specific interventions, including RRSO at age 35 to 50 years with or without BC surveillance and medical prevention (ie, tamoxifen or anastrozole) from age 30 or 40 years, RRM at age 30 to 40 years, both RRSO and RRM, BC surveillance and medical prevention, or no intervention.

Main Outcomes and Measures

The incremental cost-effectiveness ratio (ICER) was calculated as incremental cost per quality-adjusted life-year (QALY) gained. OC and BC cases and deaths were estimated.

Results

In the simulated cohort of women aged 30 years with no cancer, undergoing both RRSO and RRM was most cost-effective for individuals carrying BRCA1 (RRM at age 30 years; RRSO at age 35 years), BRCA2 (RRM at age 35 years; RRSO at age 40 years), and PALB2 (RRM at age 40 years; RRSO at age 45 years) PVs. The corresponding ICERs were -£1942/QALY (-$2680/QALY), -£89/QALY (-$123/QALY), and £2381/QALY ($3286/QALY), respectively. RRSO at age 45 years was cost-effective for RAD51C, RAD51D, and BRIP1 PV carriers compared with nonsurgical strategies. The corresponding ICERs were £962/QALY ($1328/QALY), £771/QALY ($1064/QALY), and £2355/QALY ($3250/QALY), respectively. The most cost-effective preventive strategy per 1000 PV carriers could prevent 923 OC and BC cases and 302 deaths among those carrying BRCA1; 686 OC and BC cases and 170 deaths for BRCA2; 464 OC and BC cases and 130 deaths for PALB2; 102 OC cases and 64 deaths for RAD51C; 118 OC cases and 76 deaths for RAD51D; and 55 OC cases and 37 deaths for BRIP1. Probabilistic sensitivity analysis indicated both RRSO and RRM were most cost-effective in 96.5%, 89.2%, and 84.8% of simulations for BRCA1, BRCA2, and PALB2 PVs, respectively, while RRSO was cost-effective in approximately 100% of simulations for RAD51C, RAD51D, and BRIP1 PVs.

Conclusions and Relevance

In this cost-effectiveness study, RRSO with or without RRM at varying optimal ages was cost-effective compared with nonsurgical strategies for individuals who carried BRCA1, BRCA2, PALB2, RAD51C, RAD51D, or BRIP1 PVs. These findings support personalizing risk-reducing surgery and guideline recommendations for individual CSG-specific OC and BC risk management.

Cost-Effectiveness of Population-Based Multigene Testing for Breast and Ovarian Cancer Prevention

Importance

The current method of BRCA testing for breast and ovarian cancer prevention, which is based on family history, often fails to identify many carriers of pathogenic variants. Population-based genetic testing offers a transformative approach in cancer prevention by allowing for proactive identification of any high-risk individuals and enabling early interventions.

Objective

To assess the lifetime incremental effectiveness, costs, and cost-effectiveness of population-based multigene testing vs family history-based testing.

Design, Setting, and Participants

This economic evaluation used a microsimulation model to assess the cost-effectiveness of multigene testing (BRCA1, BRCA2, and PALB2) for all women aged 30 to 35 years compared with the current standard of care that is family history based. Carriers of pathogenic variants were offered interventions, such as magnetic resonance imaging with or without mammography, chemoprevention, or risk-reducing mastectomy and salpingo-oophorectomy, to reduce cancer risk. A total of 2000 simulations were run on 1 000 000 women, using a lifetime time horizon and payer perspective, and costs were adjusted to 2022 US dollars. This study was conducted from September 1, 2020, to December 15, 2023.

Main Outcomes and Measures

The main outcome measure was the incremental cost-effectiveness ratio (ICER), quantified as cost per quality-adjusted life-year (QALY) gained. Secondary outcomes included incremental cost, additional breast and ovarian cancer cases prevented, and excess deaths due to coronary heart disease (CHD).

Results

The study assessed 1 000 000 simulated women aged 30 to 35 years in the US. In the base case, population-based multigene testing was more cost-effective compared with family history-based testing, with an ICER of $55 548 per QALY (95% CI, $47 288-$65 850 per QALY). Population-based multigene testing would be able to prevent an additional 1338 cases of breast cancer and 663 cases of ovarian cancer, but it would also result in 69 cases of excess CHD and 10 excess CHD deaths per million women. The probabilistic sensitivity analyses show that the probability that population-based multigene testing is cost-effective was 100%. When the cost of the multigene test exceeded $825, population-based testing was no longer cost-effective (ICER, $100 005 per QALY; 95% CI, $87 601-$11 6323).

Conclusions and Relevance

In this economic analysis of population-based multigene testing, population-based testing was a more cost-effective strategy for the prevention of breast cancer and ovarian cancer when compared with the current family history-based testing strategy at the $100 000 per QALY willingness-to-pay threshold. These findings support the need for more comprehensive genetic testing strategies to identify pathogenic variant carriers and enable informed decision-making for personalized risk management.

Toxicity of external beam accelerated partial-breast irradiation (APBI) in adjuvant therapy of early-stage breast cancer: prospective randomized study

BACKGROUND

Accelerated partial breast irradiation (APBI) is an alternative breast-conserving therapy approach where radiation is delivered in less time compared to whole breast irradiation (WBI), resulting in improved patient convenience, less toxicity, and cost savings. This prospective randomized study compares the external beam APBI with commonly used moderate hypofractionated WBI in terms of feasibility, safety, tolerance, and cosmetic effects.

METHODS

Early breast cancer patients after partial mastectomy were equally randomized into two arms- external APBI and moderate hypofractionated WBI. External beam technique using available technical innovations commonly used in targeted hypofractionated radiotherapy to minimize irradiated volumes was used (cone beam computed tomography navigation to clips in the tumor bed, deep inspiration breath hold technique, volumetric modulated arc therapy dose application, using flattening filter free beams and the six degrees of freedom robotic treatment couch). Cosmetics results and toxicity were evaluated using questionnaires, CTCAE criteria, and photo documentation.

RESULTS

The analysis of 84 patients with a median age of 64 years showed significantly fewer acute adverse events in the APBI arm regarding skin reactions, local and general symptoms during a median follow-up of 37 months (range 21-45 months). A significant difference in favor of the APBI arm in grade ≥ 2 late skin toxicity was observed (p = 0.026). Late toxicity in the breast area (deformation, edema, fibrosis, and pain), affecting the quality of life and cosmetic effect, occurred in 61% and 17% of patients in WBI and APBI arms, respectively. The cosmetic effect was more favorable in the APBI arm, especially 6 to 12 months after the radiotherapy.

CONCLUSION

External APBI demonstrated better feasibility and less toxicity than the standard regimen in the adjuvant setting for treating early breast cancer patients. The presented study confirmed the level of evidence for establishing the external APBI in daily clinical practice.

TRIAL REGISTRATION

NCT06007118.

Who can benefit from postmastectomy radiotherapy among HR+/HER2- T1-2 N1M0 breast cancer patients? An explainable machine learning mortality prediction based approach

Objective

The necessity of postmastectomy radiotherapy(PMRT) for patients with HR+/HER2 T1-2 N1M0 breast cancer remains controversial. We want to use explainable machine learning to learn the feature importance of the patients and identify the subgroup of the patients who may benefit from the PMRT. Additionally, develop tools to provide guidance to the doctors.

Methods

In this study, we trained and validated 2 machine learning survival models: deep learning neural network and Cox proportional hazard model. The training dataset consisted of 35,347 patients with HR+/HER2- T1-2 N1M0 breast cancer who received mastectomies from the SEER database from 2013 to 2018. The performance of survival models were assessed using a concordance index (c-index).Then we did subgroup analysis to identify the subgroup who could benefit from PMRT. We also analyzed the global feature importance for the model and individual feature importance for individual survival prediction. Finally, we developed a Cloud-based recommendation system for PMRT to visualize the survival curve of each treatment plan and deployed it on the Internet.

Results

A total of 35,347 patients were included in this study. We identified that radiotherapy improved the OS in patients with tumor size >14mm and age older than 54: 5-year OS rates of 91.9 versus 87.2% (radio vs. nonradio, P <0.001) and cohort with tumor size >14mm and grade worse than well-differentiated, 5-year OS rates of 90.8 versus 82.3% (radio vs. nonradio, P <0.001).The deep learning network performed more stably and accurately in predicting patients survival than the random survival forest and Cox proportional hazard model on the internal test dataset (C-index=0.776 vs 0.641) and in the external validation(C-index=0.769 vs 0.650).Besides, the deep learning model identified several key factors that significantly influence patient survival, including tumor size, examined regional nodes, age at 45-49 years old and positive regional nodes (PRN).

Conclusion

Patients with tumor size >14mm and age older than 54 and cohort with tumor size >14mm and grade worse than well-differentiated could benefit from the PMRT. The deep learning network performed more stably and accurately in predicting patients survival than Cox proportional hazard model on the internal test. Besides, tumor size, examined regional nodes, age at 45-49 years old and PRN are the most significant factors to the overall survival (OS).

The role of digital mammographic surveillance for detection of asymptomatic recurrence in autologous flap reconstructions

OBJECTIVE

To evaluate the utility of digital mammography in detecting asymptomatic malignancy in autologous flap reconstructions after mastectomy.

METHODS

A retrospective database review identified all mammograms performed on asymptomatic patients with flap reconstructions over a 9-year period (1/1/2009 to 12/31/2017). A negative examination was defined as BI-RADS 1 or 2 and a positive examination was defined as BI-RADS 0, 4, or 5 assigned to the mastectomy side. Malignant outcomes were determined by pathology results. Interval cancers, or false negatives, were defined as locoregional malignant diagnosis within one year of a negative mammogram. Sensitivity, specificity, predictive values, abnormal interpretation rate, and cancer detection rate were calculated.

RESULTS

626 mammograms of asymptomatic flap reconstructions were performed in 183 patients. The most common flap type was TRAM (83.5 %, 523/626) and DIEP (13.4 %, 84/626). Most exams (98.2 %, 615/626) were negative, assessed as BI-RADS 1 or 2, with no interval cancers at follow-up. Eleven exams (1.8 %, 11/626) were positive, assessed as BI-RADS 0, 4, or 5. After diagnostic work-up of all BI-RADS 0 exams, 9 cases had a final recommendation for biopsy of which 3 were malignant. Mammography yielded a cancer detection rate of 0.5 % (3/626), abnormal interpretation rate of 1.8 % (11/626), NPV of 100 % (615/615), overall PPV of 27.3 % (3/11), PPV2 (positive predictive value of a biopsy recommendation) of 33.3 % (3/9), sensitivity of 100 % (3/3), and specificity of 98.7 % (615/623).

CONCLUSION

Digital mammography of asymptomatic autologous flap reconstructions after mastectomy demonstrated high sensitivity and low abnormal interpretation rate. Cancer detection rate was comparable to current national benchmarks for mammographic screening in the general U.S. population without mastectomy.

[Current status of local treatment for multifocal / multicentric breast cancer]

The detection rate of multifocal / multicentric breast cancer (MMBC) is increasing, and the local treatment of MMBC is attracting more attention. Relevant research focuses on the selection of surgical methods, the application of radiotherapy, and the feasibility of local ablation. Currently, due to the high rate of local recurrence in breast conserving surgery, most Chinese doctors recommend mastectomy to patients with MMBC. Recent studies have shown that with the development of imaging technology, surgical techniques, accurate judgment of the resection margin, the emergence of new therapeutic drugs and the improvement of the accuracy of radiotherapy, for eligible patients with MMBC, breast conserving surgery did not increase the local recurrence rate while ensuring negative margin and cosmetic results. Whether patients with MMBC must receive adjuvant radiotherapy after mastectomy is controversial, with some evidence suggesting that MMBC may increase the risk of local recurrence and should be an important consideration for radiotherapy, and there is also evidence that the local recurrence rate of MMBC was higher regardless of the type of surgery. In general, the local treatment modality for MMBC is essentially the same as that for unifocal breast cancer, but more prospective studies are needed for further evaluation.

Sonographic Assessment of Breast Implants Using Strain Elastography and Shear Wave Elastography in an Animal Model

BACKGROUND/AIM

To date, magnetic resonance imaging (MRI) remains the gold standard for diagnosing breast implant rupture. As MRI is an expensive procedure with limited availability, the improvement of sonographic assessment is desirable. A potentially useful tool in this regard is elastography. To evaluate the diagnostic benefits of strain elastography and shear wave elastography under standardized conditions we developed an animal model.

MATERIALS AND METHODS

An animal model was created by preparing an implant site in a chicken breast, imitating tissue layers covering a breast implant after mastectomy. Different broken and intact implants were inserted. Thereby, measurements were performed using strain elastography and shear wave elastography. For strain elastography, the resulting images were investigated on repeated patterns. The data generated by shear wave elastography were analyzed for significant differences between the ruptured and intact implants.

RESULTS

The animal model using chicken breast generated realistic images and measurements comparable to those of a human breast. Hence, ruptured and intact implants could be compared under standardized conditions. Statistical analysis showed no significant difference between intact and ruptured implants with respect to the data generated by shear wave elastography. Qualitative analysis using strain wave elastography showed different patterns between intact and ruptured implants in the animal model. Intact implants showed a characteristic sonographic image of three layers in certain levels.

CONCLUSION

Shear wave elastography does not seem to produce reliable data for the evaluation of breast implants, whereas qualitative analysis using strain elastography might be a useful tool to improve diagnostic accuracy.

Perioperative treatments for and postoperative activity of daily living of patients with early-stage breast cancer according to age group: A retrospective observational study

INTRODUCTION

The number of older patients with breast cancer is increasing worldwide. However, no studies have clarified to what extent activities of daily living (ADL) decline in older patients after surgery. This study aimed to identify perioperative treatments and the proportion of patients with a postoperative decline in ADL among those with early-stage breast cancer, according to age groups (<65, 65-74, ≥75 years).

MATERIALS AND METHODS

This retrospective study used healthcare utilization data of women aged ≥40 years who were diagnosed with breast cancer in 431 Japanese hospitals. Patients who underwent breast conserving surgery and mastectomy at clinical stages 0-III were included. ADL were assessed using the Barthel index (100 points indicated independent ADL).

RESULTS

Overall, 37,161 patients were analyzed, including 17,313 undergoing a breast conserving surgery and 19,848 undergoing a mastectomy. The difference in the proportion of patients with a postoperative decline in ADL between those in the <65-year and ≥75-year group who underwent mastectomy was approximately 1%. In each age group, a higher proportion of patients received adjuvant chemotherapy (9.4-27.5% for breast conserving surgery; 15.6-40.3% for mastectomy) than neoadjuvant chemotherapy (breast conserving surgery, 2.1-12.0%; mastectomy, 3.0-18.1%). A lower proportion of patients in the ≥75-year group underwent radiotherapy than that in the <65-year group.

CONCLUSION

Physical burden of surgery was low in both younger and older patients. Low proportions of patients in the ≥75-year group who underwent surgery received neoadjuvant and adjuvant chemotherapy and adjuvant radiotherapy. Healthcare providers should inform this to patients.

Oncoplastic reduction mammoplasty: Systematic review and proportional meta-analysis of surgical outcomes

BACKGROUND

Breast-conserving surgery is the standard of care for early-stage breast cancer but can often result in unsatisfactory cosmetic outcomes. Oncoplastic surgery aims to address these issues by combining local excision with plastic surgery techniques to improve oncologic and esthetic outcomes. By incorporating breast reduction techniques into cancer surgery, wider margins of excision can be achieved, leading to enhanced oncological safety and reduced recurrence rates without causing significant asymmetry. This systematic review and meta-analysis aims to provide an updated understanding of the surgical outcomes associated with oncoplastic reduction mammoplasty.

METHODS

A systematic review of the literature was conducted according to PRISMA guidelines. Articles reporting post-operative outcomes following the oncoplastic reduction mammoplasty were included. A proportional meta-analysis of post-operative complications was performed to obtain their proportions and 95% Confidence Intervals (CIs).

RESULTS

Eighteen studies met the inclusion criteria, representing a total of 2711 oncoplastic reduction mammoplasty procedures in 2680 patients. The overall complication rate was 20% (95% CI: 15-25%). The positive margin rate following oncoplastic reduction mammoplasty was 11% (95% CI: 6-17%). The re-excision rate was 6% (95% CI: 3-12%). The completion mastectomy rate was 3% (95% CI: 2-6%).

CONCLUSIONS

Oncoplastic reduction mammoplasty is a safe and effective alternative to mastectomy and traditional breast-conserving surgery in the treatment of early-stage breast cancers.

Unlocking the Power of the Homing Phenomenon: Why Breast Conserving Surgery Outshines Mastectomy in Overall Survival

Breast cancer stands as the most frequently diagnosed malignancy in women, holding a prominent position among the leading causes of cancer-related fatalities on a global scale. Despite significant advances in treatment modalities, approximately 20% of patients experience relapses after the first 5 years of postdiagnosis surveillance. While initial investigations from the 1970s indicated comparable survival rates between breast-conserving surgery (BCS) coupled with radiation therapy and mastectomy, recent research suggests that, within the context of modern systemic and radiation therapy, BCS followed by radiation may offer an improved overall survival benefit. Nevertheless, extended follow-up studies have unveiled a notable increase in the risk of locoregional recurrence associated with breast conserving therapy in contrast to mastectomy. This article introduces a novel hypothesis rooted in the biological phenomenon of homing to elucidate this intriguing clinical observation. We postulate that a breast homing mechanism of reactivated circulating and disseminated tumor cells mediated by chemotaxis involving at least the CXCR4-SDF-1 axis may provide a biological rationale for this clinical phenomenon.

A Machine Learning-Based Model for Breast Volume Prediction Using Preoperative Anthropometric Measurements

BACKGROUND

Accurate assessment of breast volume is helpful in preoperative planning and intraoperative judgment in both cosmetic and reconstructive breast surgery. In this prospective study, a formula was derived using machine learning algorithm (Gradient Boosted Model).

METHOD

A prospective study was performed on 39 female-to-male transgender patients. Bilateral mastectomy was done for all patients. Preoperative anthropometric measurements were performed on 78 breasts of these patients. Weight of breasts was calculated postoperatively with digital scale (weight), and then volume of breasts was calculated with the calibrated container (water displacement technique). Authors built a model based on Python CatBoostClassifier. Finally, an android application was built for ease of real-time utilization.

RESULTS

Eight anthropometric measurements were collected preoperatively as independent variables. Breast vertical perimeter at lower half, upper pole, sternal notch to nipple and nipple to IMF had most correlation with volume and weight. Based on machine learning model, the following formula established: Breast volume = (breast width) × 24.69 + (nipple to IMF) × 49.03 - (sternal notch to nipple) × 1.34 + (anterior axillary line to medial border) × 6.57 - (upper pole) × 1.27 - (chest perimeter IMF) × 5.63 + (chest perimeter nipple) × 10.40 + (breast vertical perimeter at lower half) × 9.20 - 1133.74. The R2 of the model is 0.93, and RMSE is 62.4.

CONCLUSION

Our formula is an accurate method for preoperative breast volume assessment. We built an android App (Breast Volume Predictor) for the real-time utilization of resulting formula. It is available at Google Play Store for free download.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A randomized Phase I pre-operative window trial of transdermal endoxifen in women planning mastectomy: Evaluation of dermal safety, intra-mammary drug distribution, and biologic effects

Breast cancer prevention only requires local exposure of the breast to active drug. However, oral preventive agents entail systemic exposure, causing adverse effects that limit acceptance by high-risk women. Drug-delivery through the breast skin is an attractive option, but requires demonstration of dermal safety and drug distribution throughout the breast. We formulated the tamoxifen metabolite (E/Z)-endoxifen for transdermal delivery and tested it in a placebo-controlled, double-blinded Phase I trial with dose escalation from 10 to 20 mg daily. The primary endpoint was dermal toxicity. Thirty-two women planning mastectomy were randomized (2:1) to endoxifen-gel or placebo-gel applied to both breasts for 3-5 weeks. Both doses of endoxifen-gel incurred no dermal or systemic toxicity compared to placebo. All endoxifen-treated breasts contained the drug at each of five sampling locations; the median per-person tissue concentration in the treated participants was 0.6 ng/g (IQR 0.4-1.6), significantly higher (p < 0.001) than the median plasma concentration (0.2 ng/mL, IQR 0.2-0.2). The median ratio of the more potent (Z)-isomer to (E)-isomer at each breast location was 1.50 (IQR 0.96-2.54, p < 0.05). No discernible effects of breast size or adiposity on tissue concentrations were observed. At the endoxifen doses and duration used, and the tissue concentration achieved, we observed a non-significant overall reduction of tumor proliferation (Ki67 LI) and significant downregulation of gene signatures known to promote cancer invasion (FN1, SERPINH1, PLOD2, PDGFA, ITGAV) (p = 0.03). Transdermal endoxifen is an important potential breast cancer prevention agent but formulations with better dermal penetration are needed.

Surgical Delay of Thoracodorsal Artery Perforator Flaps for Total Autologous Breast Reconstruction

BACKGROUND

When abdomen-based free flap reconstruction is contraindicated, the muscle-sparing thoracodorsal artery perforator (TDAP) flap may be considered for total autologous breast reconstruction. The TDAP flap is often limited by volume and is prone to distal flap necrosis. We aim to demonstrate our experience combining the delay phenomenon with TDAP flaps for total autologous breast reconstruction.

METHODS

Patients presenting for autologous breast reconstruction between April 2021 and August 2023 were recruited for surgically delayed TDAP flap reconstruction when abdominally based free flap reconstruction was contraindicated because of previous abdominal surgery or poor perforator anatomy. We dissected the TDAP flap except for a distal skin bridge and then reconstructed the breast 1 to 7 days later. Data included flap dimensions (in centimeters × centimeters), delay time (in days), predelay and postdelay perforator caliber (in millimeters) and flow (in centimeters per second), operative time (in minutes), hospital length of stay (in days), complications/revisions, and follow-up time (in days).

RESULTS

Fourteen patients and 16 flaps were included in this study. Mean age and body mass index of patients were 55.9 ± 9.6 years and 30.1 ± 4.3 kg/m2, respectively. Average flap skin island length and width were 32.1 ± 3.3 cm (n = 8 flaps) and 8.8 ± 0.7 cm (n = 5 flaps), respectively. Beveled flap width reached 16.0 ± 2.2 cm (n = 3 flaps). Average time between surgical delay and reconstruction was 2.9 days, ranging from 1 to 7 days (n = 18 flaps). Mean predelay and postdelay TDAP vessel caliber and flow measured by Doppler ultrasound increased from 1.4 ± 0.3 to 1.8 ± 0.3 mm (P = 0.03) and 13.3 ± 5.2 to 43.4 ± 18.8 cm/s (P = 0.03), respectively (n = 4 flaps). Complications included 1 donor site seroma and 1 mastectomy skin flap necrosis. Follow-up ranged from 4 to 476 days (n = 17 operations).

CONCLUSIONS

We demonstrate surgically delayed TDAP flaps as a viable option for total autologous breast reconstruction. Our series of flaps demonstrated increased perforator caliber and flow and enlarged volume capabilities and had no incidences of flap necrosis.

Ectopic Breast Cancer Arising within an Axillary Lymph Node

We report our experience with the diagnosis and treatment of an ectopic breast cancer arising within an axillary lymph node. The patient was a 65-year-old woman diagnosed breast cancer and axillary lymph node metastasis. We performed a partial mastectomy and axillary lymph node dissection. Postoperative pathology revealed no malignant lesions in the breast; however, a nodule in one of axillary lymph nodes had mixed benign and malignant components, leading to a diagnosis of invasive ductal carcinoma derived from ectopic mammary tissue. This case represents a very rare form of breast cancer, and the malignancy was difficult to distinguish from metastasis.

Latissimus dorsi flap with immediate fat transfer (LIFT) for autologous breast reconstruction: Single institution experience

BACKGROUND

Few studies have reported the outcomes of LDF and immediate fat transfer (LIFT) during breast reconstruction. The aim of this study was to compare the perioperative outcomes and complications of LIFT and standard LDF (without immediate fat transfer) for breast reconstruction.

METHODS

We retrospectively reviewed charts from patients undergoing autologous breast reconstruction after total mastectomy between 2011 and 2021. We compared intraoperative and postoperative outcomes between groups.

RESULTS

One hundred nineteen reconstructions (61.02%) were performed with LIFT, while seventy-six (38.98%) were performed with standard LDF. The median volume of total fat transferred during LIFT was 125-cc [110-170 ​cc]. The rates of donor site wound disruption (23.7% versus 12.6%, p ​= ​0.044) were higher using the standard LDF compared to LIFT. Reconstructions performed with LIFT (HR 4.01, p ​< ​0.001) were found to be associated with secondary fat grafting procedures.

CONCLUSION

LIFT is a safe procedure to enhance the volume of LDF in patients desiring autologous reconstruction without increasing recipient-site morbidity. On a time-to-event analysis, LIFT was associated with the requirement of further revision procedures using secondary fat grafting.

Patterns of breast reconstruction and the influence of a surgical multidisciplinary clinic

BACKGROUND

Of the 40% of breast cancer patients who have a mastectomy as part of their surgical treatment, only approximately 29% have a breast reconstruction. In 2016, Alfred Health established a multidisciplinary surgical clinic with breast and plastic surgeons, aiming to improve interdisciplinary collaboration. This study aimed to assess the provision of breast reconstruction at an Australian tertiary public hospital and examine whether the multidisciplinary surgical clinic have improved our reconstructive service provision.

METHODS

A retrospective cohort study of patients who underwent mastectomy at Alfred Health between October 2011 and September 2021 was conducted. Patients were divided into before and after groups, treated during the 5-year period before and after establishing the multidisciplinary clinic respectively. Demographic data, operative details, histopathology, and treatments were compared.

RESULTS

Over the 10-year period, 423 mastectomies were performed for 351 patients. Of those, 153 patients underwent breast reconstruction, providing an overall reconstruction rate of 43.6%. There was a statistically significant increase in the breast reconstruction rate from 36.5% before to 53.4% after the creation of the multidisciplinary surgical clinic. Patient factors such as age and tumour receptor status did not differ significantly between the groups.

CONCLUSION

The establishment of a surgical multidisciplinary clinic has led to a statistically significant increase in the rate of breast reconstruction from 36.5% to 53.4%, leading to improved healthcare provision for our patients. Factors identified to be associated with increased uptake in the reconstruction service include younger age and node negative disease.

[Nursing Experience Using Art Therapy to Help Women With Breast Cancer Face Changes in Body Image]

The subject in this study was a female professional painter who underwent bilateral mastectomy because of bilateral breast cancer, experienced postoperative wound scarring, and developed alopecia due to the side effects of chemotherapy, which caused the patient to lose body image confidence and the motivation to engage in artistic creativity. The patient had shed tears early in the intervention and complained of difficulties with body image adjustment due to her altered appearance. Mastectomy patients must not only undergo drug treatment but also adjust psychologically to body image changes to decrease negative emotions. This was the author's motivation for involvement in this case. The nursing period was from 23 September to 30 December 2021. Physical, mental, spiritual, social, and family data were collected using observations and interviews. These data were evaluated and the main problems were determined to be disturbed body image related to altered body perception post-surgery, alopecia caused by chemotherapy, impaired physical mobility due to upper limb mobility limitations post-surgery, and nausea due to chemotherapy. The patient was encouraged to paint again and to use artistic creativity to comfort herself. Moreover, she was guided to express her innermost thoughts to face the impact of her changes in appearance. In addition, a care consultation channel was provided to facilitate experience sharing with other breast cancer patients, thus assisting the patient to cope with the mental impact of her treatments and face subsequent cancer treatments with a more positive attitude. Art therapy embraces a diverse variety of methods, including drawing and music. Art therapy is a valuable tool that facilitates both physical and mental healing. Based on this experience, nurses should include patients' close relatives when performing art therapy to facilitate shared care to overcome difficulties. We hope this nursing experience provides a practical reference for nurses.

Lobular-Like Features and Outcomes of Mixed Invasive Ductolobular Breast Cancer (MIDLC): Insights from 54,403 Stage I-III MIDLC Patients

BACKGROUND

Mixed invasive ductolobular breast cancer (MIDLC) is a rare histological subtype of breast cancer (BC), with components of both invasive ductal cancer (IDC) and invasive lobular cancer (ILC). Its clinicopathological features and outcomes have not been well characterized.

METHOD

The National Cancer Database 2010-2017 was reviewed to identify women with stage I-III BCs. Univariate analysis was performed using Chi-square or Wilcoxon rank-sum tests and multivariable analysis with logistic regression to predict surgical decisions. Survival was assessed using multivariable Cox proportional hazards regression analysis.

RESULTS

We identified 955,828 women with stage I-III BCs (5.7% MIDLC, 10.3% ILC, and 84.0% IDC). MIDLC was more like ILC than IDC in terms of multicentricity (14.2% MIDLC, 13.0% ILC, 10.0% IDC), hormone receptor positivity (96.6% MIDLC, 98.2% ILC, 81.2% IDC), and use of neoadjuvant chemotherapy (NAC; 5.8% MIDLC, 5.2% ILC, 10.8% IDC). 744,607 women underwent upfront surgery. The mastectomy rates were 42.3% for MIDLC, 46.5% for ILC, and 33.3% for IDC (all p < 0.001). With 5.5 years of median follow-up, the adjusted overall survival in the upfront surgery hormone receptor-positive/human epidermal growth factor receptor 2-negative (HR+/HER2-) biological subgroup was better in MIDLC (hazard ratio 0.88, p < 0.001) and ILC (hazard ratio 0.91, p < 0.001) than in IDC. Like ILC, MIDLC also had a lower pathological complete response to NAC than IDC (12.3% MIDLC, 7.3% ILC, 28.6% IDC).

CONCLUSIONS

MIDLC displays a mixed pattern of characteristics favoring features of ILC compared with IDC, with favorable 5-year overall survival compared with IDC within the HR+/HER2- subtype who underwent upfront surgery.

Racial/ethnic disparities in the association between patient care experiences and receipt of initial surgical breast cancer care: findings from SEER-CAHPS

PURPOSE

We determined whether racial/ethnic differences in patient experiences with care influence timeliness and type of initial surgical breast cancer treatment for a sample of female Medicare cancer patients.

METHODS

We conducted a retrospective cohort study using the linked Epidemiology and End Results-Consumer Assessment of Healthcare Providers and Systems (SEER-CAHPS) dataset. The outcomes were: (1) time-to-initial surgical treatment, and (2) type of treatment [breast conserving surgery (BCS) vs. mastectomy]. The indicators were reports of four types of patient experiences with care including doctor communication, getting care quickly, getting needed care, and getting needed Rx. Interaction terms in each multivariable logistic model examined if the associations varied by race/ethnicity.

RESULTS

Of the 2069 patients, 84.6% were White, 7.6% Black and 7.8% Hispanic. After adjusting for potential confounders, non-Hispanic Black patients who provided excellent reports of their ability to get needed prescriptions had lower odds of receiving surgery within 2-months of diagnosis, compared to NH-Whites who provided less than excellent reports (aOR: 0.29, 95% CI 0.09-0.98). There were no differences based on 1-month or 3-month thresholds. We found no other statistically significant effect of race/ethnicity. As to type of surgery, among NH Blacks, excellent reports of getting care quickly were associated with higher odds of receiving BCS versus mastectomy (aOR: 2.82, 95% CI 1.16-6.85) compared to NH Whites with less than excellent reports. We found no other statistically significant differences by race/ethnicity.

CONCLUSION

Experiences with care are measurable and modifiable factors that can be used to assess and improve aspects of patient-centered care. Improvements in patient care experiences of older adults with cancer, particularly among minorities, may help to eliminate racial/ethnic disparities in timeliness and type of surgical treatment.

In vivo lymph node CEST-Dixon MRI in breast cancer patients with metastatic lymph node involvement

PURPOSE

Axillary lymph nodes (LNs) often present a reservoir for metastatic breast cancer, yet metastatic LN involvement cannot be discerned definitively using diagnostic imaging. This study investigated whether in vivo CEST may discriminate LNs with versus without metastatic involvement.

METHODS

3T MRI was performed in patients with breast cancer before clinically-indicated mastectomy or lumpectomy with LN removal, after which LN metastasic involvement was determined using histological evaluation. Non-contrast anatomical imaging, as well as B0 and B1 field maps, were acquired in sequence with three-point CEST-Dixon (3D turbo-gradient-echo; factor = 25; TR/TE1/ΔTE = 851/1.35/1.1 ms; spatial-resolution = 2.5 × 2.5 × 6 mm; slices = 10; four sinc-gauss pulses with duty-cycle = 0.5, total saturation duration = 701.7 ms; B1  = 1.5 μT; saturation offsets = -5.5 to +5.5 ppm; stepsize = 0.2 ppm; scan duration = 6 min 30 s). The mean z-spectrum from LNs with (n = 20) versus without (n = 22) metastatic involvement were analyzed and a Wilcoxon rank-sum test (significance: p < 0.05) was applied to evaluate differences in B0, B1 , and magnetization transfer ratio (MTR) in differing spectral regions of known proton exchange (nuclear Overhauser effect [NOE], amide, amine, and hydroxyl) between cohorts.

RESULTS

No difference in axillary B1 (p = 0.634) or B0 (p = 0.689) was observed between cohorts. Elevated MTR was observed for the NOE (-1.7 ppm; MTR = 0.285 ± 0.075 vs. 0.248 ± 0.039; p = 0.048), amine (+2.5 ppm; MTR = 0.284 ± 0.067 vs. 0.234 ± 0.31; p = 0.005), and hydroxyl (+1 ppm; MTR = 0.394 ± 0.075 vs. 0.329 ± 0.055; p = 0.002) protons in LNs from participants with versus without metastatic involvement.

CONCLUSIONS

Findings are consistent with a unique metastatic LN microenvironment detectable by CEST-Dixon and suggest that CEST MRI may have potential for mapping LN metastasis non-invasively in vivo.

Association of clinicopathologic and molecular factors with the occurrence of positive margins in breast cancer

PURPOSE

To explore the association of clinicopathologic and molecular factors with the occurrence of positive margins after first surgery in breast cancer.

METHODS

The clinical and RNA-Seq data for 951 (75 positive and 876 negative margins) primary breast cancer patients from The Cancer Genome Atlas (TCGA) were used. The role of each clinicopathologic factor for margin prediction and also their impact on survival were evaluated using logistic regression, Fisher's exact test, and Cox proportional hazards regression models. In addition, differential expression analysis on a matched dataset (71 positive and 71 negative margins) was performed using Deseq2 and LASSO regression.

RESULTS

Association studies showed that higher stage, larger tumor size (T), positive lymph nodes (N), and presence of distant metastasis (M) significantly contributed (p ≤ 0.05) to positive surgical margins. In case of surgery, lumpectomy was significantly associated with positive margin compared to mastectomy. Moreover, PAM50 Luminal A subtype had higher chance of positive margin resection compared to Basal-like subtype. Survival models demonstrated that positive margin status along with higher stage, higher TNM, and negative hormone receptor status was significant for disease progression. We also found that margin status might be a surrogate of tumor stage. In addition, 29 genes that could be potential positive margin predictors and 8 pathways were identified from molecular data analysis.

CONCLUSION

The occurrence of positive margins after surgery was associated with various clinical factors, similar to the findings reported in earlier studies. In addition, we found that the PAM50 intrinsic subtype Luminal A has more chance of obtaining positive margins compared to Basal type. As the first effort to pursue molecular understanding of the margin status, a gene panel of 29 genes including 17 protein-coding genes was also identified for potential prediction of the margin status which needs to be validated using a larger sample set.

Tumor Characteristics of Bilateral Breast Cancer Compared with Unilateral Breast Cancer

BACKGROUND

Bilateral breast cancer (BC) has an incidence of 1 to 3 %. This study aimed to describe the clinicopathologic characteristics and management of bilateral BC, estimate disease-free survival (DFS), and compare DFS with unilateral BC.

METHODS

A retrospective analysis was performed for patients who had bilateral invasive BC or unilateral invasive BC and contralateral ductal carcinoma in situ (DCIS) treated at Mayo Clinic Rochester from 2008 to 2022. A 4:1 matched cohort of patients with unilateral invasive BC was used for comparison. The groups were compared using Wilcoxon rank-sum or chi-square tests. Disease-free survival was analyzed using the Kaplan-Meier method and log-rank test, with Cox proportional hazards regression used for multivariable analysis.

RESULTS

The study identified 278 cases of bilateral breast cancer (177 cases of bilateral invasive cancer and 101 cases of unilateral invasive cancer with contralateral DCIS), representing 4.1 % of invasive BCs. Biologic subtype was concordant between sides in 79.8 % of the patients. Initial surgery was bilateral mastectomy for 76.6 %, bilateral lumpectomy for 20.5 %, and unilateral mastectomy with unilateral lumpectomy for 2.9 % of the patients. Pathogenic variants in breast cancer predisposition genes were present in 21.7 % of those tested. The patients who had bilateral BC presented with a higher cT category than the patients who had unilateral BC (p = 0.02), and a higher proportion presented with ILC (17.3 % vs 10.9 %; p = 0.004), estrogen receptor-positive (ER+) disease (89.2 % vs 84.2 %; p = 0.04), multicentric/multifocal disease (37.1 % vs 24.3 %; p < 0.001), breast cancer pathogenic variant (21.7 % vs 12.4 %; p = 0.02), and palpable presentation (48.2 % vs 40.8 %; p = 0.03). The patients with bilateral BC showed DFS similar to that for the unilateral BC cohort (p = 0.71).

CONCLUSIONS

Bilateral BCs most commonly are biologically concordant between sides. Bilateral BC presented more commonly with larger tumors, lobular histology, ER+ status, multicentricity or multifocality, pathogenic variant, and palpable disease. Bilateral BC is not associated with worse DFS than unilateral BC.

Cross-Cultural Adaptation and Validation of the Korean Version of the Body Image After Mastectomy Scale

OBJECTIVE

This study aimed to evaluate the psychometric properties and validity of the Korean version of the Body Image After Mastectomy Scale (K-BIMS).

METHODS

This validation study was divided into two phases. Phase 1 included the translation of the K-BIMS according to the World Health Organization recommendations, investigation of content validity by five experts, and a pilot study involving 10 participants for the final list of K-BIMS items. The study participants included 156 women who met the inclusion and exclusion criteria to verify the validity-reliability of the K-BIMS. Phase 2 included a validity-reliability analysis of the K-BIMS. This included convergent validity, known-group validity, construct validity assessed by confirmatory factor analysis, and item-total score correlation. We assessed internal consistency using the Cronbach α.

RESULTS

The K-BIMS confirmatory factor analysis demonstrated good fitness of indices and validity including content validity, convergent validity, and known-group validity was satisfactory. Internal consistency reliability was satisfying with a Cronbach α reliability of .89.

CONCLUSIONS

The results revealed that the K-BIMS is a valid and reliable instrument for assessing appearance-based behaviors and beliefs about body image distress among women who underwent reconstructive surgery after mastectomy.

IMPLICATIONS FOR NURSING PRACTICE

To identify individuals who exhibit maladaptive symptoms and are at risk of developing long-term body image problems, the K-BIMS can be used as a point-of-care screening tool. Therefore, the K-BIMS can be used as an early screening tool to proactively offer accessible and affordable solutions.

Risk-reducing mastectomy and breast cancer mortality in women with a BRCA1 or BRCA2 pathogenic variant: an international analysis

BACKGROUND

Risk-reducing mastectomy (RRM) is offered to women with a BRCA1 or BRCA2 pathogenic variant, however, there are limited data on the impact on breast cancer mortality.

METHODS

Participants were identified from a registry of women with BRCA1/2 pathogenic variants. We used a pseudo-randomised trial design and matched one woman with a RRM to one woman without a RRM on year of birth, gene, and country. We estimated the hazard ratio (HR) and 95% confidence intervals (CI) for dying of breast cancer in the follow-up period.

RESULTS

There were 1654 women included; 827 assigned to the RRM arm and 827 assigned to the control arm. After a mean follow-up of 6.3 years, there were 20 incident breast cancers (including 15 occult cancers) and two breast cancer deaths in the RRM arm, and 100 incident breast cancers and 7 breast cancer deaths in the control arm (HR = 0.26; 95% CI 0.05-1.35; p = 0.11). The probability of dying of breast cancer within 15 years after RRM was 0.95%.

CONCLUSIONS

In women with a BRCA1 or BRCA2 pathogenic variant, RRM reduces the risk of breast cancer, and the probability of dying of breast cancer is low.

The Effect of Preoperative Education Given to Patients Who Will Have a Mastectomy: A Randomized Controlled Trial

PURPOSE

The aim of this study was to determine the effect of the education provided to patients who would undergo mastectomy on psychological well-being and quality of recovery.

DESIGN

The study had a randomized controlled trial design.

METHODS

The study was completed with 62 patients (30 in the experimental group and 32 in the control group). The experimental group received education the day before the operation, and the applications were made 3 days after the operation. A questionnaire form, the psychological well-being scale, and the quality of recovery questionnaire-40 (QoR-40) were used to collect the study data.

FINDINGS

The mean total score of the final measurement of the psychological well-being scale was higher in the experimental group than in the control group, and the difference was statistically significant. The difference between the final measurement total score average of QoR-40 and the final measurement point average of the subdimensions of the patients in the experimental and control groups was measured. The difference was statistically significant and the mean score of the experimental group was higher.

CONCLUSIONS

Education can increase the level of psychological well-being and quality of recovery in patients who undergo mastectomy. Physiological and psychological education can be used as a tool in nursing practice to improve the level of psychological well-being and quality of recovery in postoperative patients.

Examining hypertension risk among Black and White breast cancer survivors

PURPOSE

Breast cancer survivors are at increased risk of cardiovascular dysfunction following their diagnosis; however, hypertension remains underexplored within this context. This retrospective cohort study examined the incidence of hypertension in breast cancer survivors and the association of race with hypertension risk among them.

METHODS

Data for this study were abstracted from the electronic health records of women diagnosed with Stages I-III breast cancer. Incident hypertension diagnosis was identified through International Classification of Diseases codes. Bivariate associations were tested using Student's t-test and chi-squared test of independence. Bivariable Cox regression analysis was used to determine demographic and clinical factors that may have been associated with the development of hypertension.

RESULTS

A total of 664 women were included. Most women were 50 years of age or younger (52.0%), White (33.0% Black), and received a mastectomy (80.6%). Overall, 45.5% of the cohort developed hypertension. The 1-year hypertension-free survival estimates were 47% (95% confidence interval [CI], 41-54) in Black women and 73% (95% CI, 69-77) in White women (p < 0.0001). Besides race, statistically significant predictors of hypertension included: age greater than 50 (vs. ≤50) (adjusted Hazard Ratio [HR]: 1.40; 95% CI, 1.09-1.80) and residing in a non-metropolitan area (vs. metropolitan) (adjusted HR: 1.60; 95% CI, 1.19-2.16).

CONCLUSIONS

This study suggests that breast cancer survivors who are older, Black, or residing in non-metropolitan areas may benefit from added surveillance and hypertension prevention strategies during treatment. Future studies are needed to identify contributors to the observed racial and geographic disparities.

Correlation of intra operative specimen imaging with final histopathology in breast conserving surgery for breast cancer

Objectives

To determine the effectiveness of specimen mammography in breast conserving surgery cases with respect to reduction in margin positivity rate, and to see whether the rate of secondary surgeries is decreased by intra-operative excision based on specimen mammography evaluation.

METHODS

The retrospective study was conducted at the Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan, and comprised data from January 2018 to December 2019 related to all female breast cancer patients who underwent mastectomy or breast conserving surgery with the involvement of specimen mammography. Sensitivity, specificity, positive predictive value and negative predictive value of specimen mammography were calculated. Data was analysed using SPSS 20.

RESULTS

Of the 226 patients initially assessed, 65(28.7%) were excluded, and the final sample comprised 161(71.2%) women with mean age 46.71±10.47 years. The sensitivity, specificity, positive predictive value and negative predictive value of specimen mammography for the sample were 65.8%, 80.8%, 54% and 87.3%, respectively. Performing specimen mammography for intra-operative margin assessment in 12 patients was likely to spare one patient from re-excision.

CONCLUSIONS

Intra-operative specimen mammography was found to be a reliable tool for assessing margin status.

Awareness and Candidacy for Endocrine Prevention and Risk Reducing Mastectomy in Unaffected High-Risk Women Referred for Breast Cancer Risk Assessment

INTRODUCTION

Primary prevention of breast cancer in women at elevated risk includes several strategies such as endocrine prevention and risk-reducing mastectomy (RRM). The objective of this study was to evaluate awareness of different preventive strategies across high-risk subgroups.

PATIENTS AND METHODS

Women referred for high risk evaluation between 2020 and 2023 completed an initial risk-assessment questionnaire that included questions around perceived lifetime risk and consideration of preventive strategies. One-way analysis of variance (ANOVA) and chi-squared tests were used to compare differences across different high-risk subgroups.

RESULTS

482 women with a median age of 43 years (20-79 years) met inclusion criteria; 183 (38.0%) germline pathogenic variant carriers (GPV), 90 (18.7%) with high-risk lesions (HRL) on breast biopsy, and 209 (43.4%) with strong family history (FH) without a known genetic predisposition. Most high-risk women reported that they had considered increased screening and surveillance (83.7%) and lifestyle strategies (80.6%), while fewer patients had considered RRM (39.8%) and endocrine prevention (27.0%). Prior to initial consultation, RRM was more commonly considered in GPV carriers (59.4%) relative to those with HRL (33.3%) or strong FH (26.3%, p < 0.001). Based on current guidelines, 206 (43%) patients were deemed eligible for endocrine prevention, including 80.5% with HRL and 39.0% with strong FH. Prior consideration of endocrine prevention was highest in patients with HRL and significantly lower in those with strong FH (47.2% HRL versus 31.1% GPV versus 18.7% FH, p = 0.001).

CONCLUSIONS

Endocrine prevention is the least considered preventive option for high-risk women, despite eligibility in a significant proportion of those presenting with HRL or strong FH.

[Emphasizing the homogenization of mastoscopy]

As a major development in breast surgery, mastoscopy has been proven safe and been involved in almost all breast surgery operative procedures. Its extensive development has cultivated a group of positively young and middle-aged academic backbones, at the same time nurtured high-level breast subject leaders, providing innovative ideas and useful reference for the high-quality development of breast specialty. However, due to the relatively weak breast specialty, uneven technical treatment ideas, insufficient promotion of endoscopic technology, unique learning curve, and inhomogeneous technical aspects, the development of mastoscopy technology is uneven and the level of homogenization is low. It should be started from four aspects, including strategic focus, treatment idea, endoscopic technical training, and mastoscopic operation. Multiple measures should be taken to comprehensively improve the homogenization of mastoscopic level.

Beyond a decade: a comparative study of 15-year survival rates in screen-detected vs. symptomatic breast cancer patients in Hungary

BACKGROUND

Breast cancer is the leading cancer in women globally. Despite decreasing mortality rates, largely due to early detection and modern treatment, the effectiveness of screening on long-term survival outcomes remains unclear.

AIMS

This study evaluates the 15-year survival outcomes of a national breast cancer screening program initiated in Hungary in 2002.

METHODS

Using a prospectively maintained patient database, the study included individuals from the first 6 years of the program who underwent surgery for histologically confirmed breast cancer and had available follow-up information. Patients were categorized based on the method of breast cancer detection into two groups: those diagnosed during or 2 years after the population-based screening exam (Group A), and those who self-detected or sought medical attention for symptoms (Group B).

RESULTS

Of the 309 patients who underwent breast cancer surgery, 208 were screen-detected (Group A) and 101 were symptomatic (Group B). The 15-year overall survival was 75.0% for Group A and 76.2% for Group B (p = 0.927). The 15-year disease-specific survival was 85.6% and 81.2% (p = 0.249), respectively. A statistically not significant positive trend in disease-free survival was observed in Group A (81.7% vs. 75.2%; p = 0.144).

CONCLUSIONS

The study underscores the importance of extended follow-up periods in evaluating the outcomes of breast cancer screening programs. While the screening program may not significantly enhance overall survival rates, it has demonstrated a reduction in the mastectomy rate and could potentially extend periods of disease-free survival. These findings contribute to the ongoing discourse about the long-term benefits of breast cancer screening programs.

Superparamagnetic iron oxide (SPIO) for axillary mapping in patients with ductal carcinoma in situ undergoing mastectomy: single-institution experience

PURPOSE

Unnecessary axillary surgery can potentially be avoided in patients with DCIS undergoing mastectomy. Current guidelines recommend upfront sentinel lymph node biopsy during the index operation due to the potential of upstaging to invasive cancer. This study reviews a single institution's experience with de-escalating axillary surgery using superparamagnetic iron oxide dye for axillary mapping in patients undergoing mastectomy for DCIS.

METHODS

This is a retrospective single-institution cross-sectional study. All medical records of patients who underwent mastectomy for a diagnosis of DCIS from August 2021 to January 2023 were reviewed and patients who had SPIO injected at the time of the index mastectomy were included in the study. Descriptive statistics of demographics, clinical information, pathology results, and interval sentinel lymph node biopsy were performed.

RESULTS

A total of 41 participants underwent 45 mastectomies for DCIS. The median age of the participants was 58 years (IQR = 17; range 25 to 76 years), and the majority of participants were female (97.8%). The most common indication for mastectomy was diffuse extent of disease (31.7%). On final pathology, 75.6% (34/45) of mastectomy specimens had DCIS without any type of invasion and 15.6% (7/45) had invasive cancer. Of the 7 cases with upgrade to invasive disease, 2 (28.6%) of them underwent interval sentinel lymph node biopsy. All sentinel lymph nodes biopsied were negative for cancer.

CONCLUSION

The use of superparamagnetic iron oxide dye can prevent unnecessary axillary surgery in patients with DCIS undergoing mastectomy.

[Quality Control Indexes for Oncology (2023 edition) and hot topics in breast surgery]

The National Health Commission of the People's Republic of China has formulated the Quality Control Indexes for Oncology (2023 edition), with the objective of improving medical quality scientifically, refined and standardized. Among these indexes, the rate of pretreatment clinical TNM staging and the coincidence rate of evaluation of pretreatment TNM staging lay national standards for patients to formulate rational and targeted treatment strategies. This article reviewed the literature and referred to Chinese Medical Association Clinical Practice Guide for Breast Surgery, and presented recommendations for the hot topics of breast surgery, such as pathological sampling of the breast specimen, sentinel lymph node biopsy for early-stage breast cancer, breast conserving surgery, axillary lymph node dissection, breast reconstruction surgery, endoscopic-assisted breast surgery, the principles of surgical treatment for metastatic breast cancer, neoadjuvant treatment for advanced disease, and surgical grade of breast surgery, which have been widely concerned in recent years, to help improve homogenization of breast cancer treatment in China.

Utility of GATA-3 immunocytochemistry for the assessment of fine-needle aspiration in breast cancer patients with suspicious axillary lymph nodes at ultrasound

BACKGROUND

Ultrasound-guided fine-needle aspiration cytology (FNAC) is a routine preoperative method for evaluating suspicious axillary lymph nodes (ALNs) in patients with breast cancer. However, a range of reasons such as morphological pitfalls, technical artifacts, and sampling errors restrict the sensitivity and accuracy of FNAC. This retrospective study investigated the diagnostic value of GATA-binding protein 3 (GATA-3) immunocytochemistry for FNAC.

METHODS

Breast cancer patients who underwent preoperative FNAC for suspicious ALNs, relevant GATA-3 immunocytochemistry, and postoperative status of ALNs were reviewed from the period of March 2020 to February 2022. Altogether, 102 patients were included in the study. FNAC material smears stained with hematoxylin and eosin was initially assessed by two cytopathologists and categorized into five groups: nondiagnostic, negative, atypical, suspicious, and positive for malignancy. Only group of cells positive for malignancy was considered positive. For each case, two selected slides were digitized (whole slide imaged) at ×40 magnification and decolored for GATA-3 immunocytochemistry. The expression of GATA-3 was scored ranging from 0 to 9 (Score ≥3: Positive, Score ≤2: Negative). If either FNAC or GATA-3 immunocytochemistry was positive or the combined test positive, then the case was considered positive. The sensitivity, specificity, and accuracy of FNAC, GATA-3 immunocytochemistry, and combined FNAC/GATA-3 immunocytochemistry were analyzed by χ2 and Fisher's tests.

RESULTS

The mean age of the study participants was 50.62 (ranging: 30-73 years). Invasive breast carcinoma (not otherwise specified) accounted for most histological subtypes, and grade 2 was the leading Nottingham grade. Sixteen cases directly underwent mastectomy while the other 86 patients had neoadjuvant therapy. A more serious diagnosis was made based on GATA-3 detection in 22.5% (n = 23) of 102 cases. Of the 23 cases, metastasis was confirmed by GATA-3 detection in 21 cases, and an uncertain diagnosis was ascertained based on GATA-3 immunocytochemistry in 2 with nondiagnostic FNAC results. The sensitivity (77/87, 88.5%) of GATA-3 detection for distinguishing malignancies from benign lesions was higher than that of FNAC alone (62/87, 71.3%) (p < .05).

CONCLUSIONS

GATA-3 immunocytochemistry exhibited high diagnostic efficacy in distinguishing malignant breast cancer cells. Moreover, combined FNAC and GATA-3 immunocytochemistry achieved optimal results in terms of reducing the false-negative rate and promoting accuracy.

Examining Race and Patient-Reported Outcomes After Contralateral Prophylactic Mastectomy with Reconstruction

BACKGROUND

Little is known regarding racial differences in satisfaction and quality of life (QOL) after contralateral prophylactic mastectomy (CPM). In this study, we aim to characterize associations between race, and postoperative satisfaction and well-being, utilizing the validated BREAST-Q patient-reported outcome measure.

PATIENTS AND METHODS

Patients were eligible if they were diagnosed with stage 0-III unilateral breast cancer and underwent mastectomy with immediate reconstruction at our institution between 2016 and 2022. BREAST-Q surveys were administered in routine clinical care preoperatively and postoperatively to assess QOL. We assessed whether the relationship between race, and domains of satisfaction with breasts and psychosocial well-being differed by receipt of CPM compared with unilateral mastectomy at 6 months, 1 year, 2 years, and 3 years following reconstruction.

RESULTS

Of 3334 women, 2040 (61%) underwent unilateral mastectomy and 1294 (39%) underwent CPM. Compared with White and Asian women who received CPM, Black women who underwent CPM were more likely to have higher BMI (p < 0.001), undergo autologous reconstruction (p = 0.006), and receive postmastectomy radiation (PMRT) (p < 0.001). There was no association between race and domains of satisfaction of breasts or psychosocial well-being for women who underwent unilateral mastectomy (p = 0.6 and p > 0.9, respectively) or CPM (p = 0.8 and p = 0.9, respectively). PMRT was negatively associated with both satisfaction with breasts (p < 0.001) and psychosocial well-being (p = 0.007).

CONCLUSIONS

Differences in satisfaction with breasts and psychosocial well-being at 3-year follow-up were not associated with race but rather treatment variables, particularly the receipt of PMRT. Further investigations with a larger and more diverse population are needed to validate these findings.

Development and testing of patient-centered education about hormone replacement therapy for women at high genetic risk of breast and ovarian cancer

OBJECTIVE

In this study, we aimed to develop education to assist BRCA mutation carriers in making informed decisions about HRT in the context of risk-reducing surgery, while simultaneously clarifying their treatment-specific values and reducing decisional conflict.

METHODS

We enrolled premenopausal BRCA mutation carriers ages 19-49 without prior cancer or risk-reducing salpingo-oophorectomy to structured interviews in which they reviewed education about the risks and benefits of HRT. Materials included literature-derived data demonstrating associations between HRT and commonly considered health outcomes (breast cancer, vasomotor symptoms, sexual functioning, cardiovascular disease, osteoporosis, and blood clots). Participants completed the 16-item Decisional Conflict Scale (DCS) before and after education, communicated their preferences by rating and ranking the six outcomes, and provided feedback to inform iterative revisions of the educational content.

RESULTS

25 participants completed interviews. DCS scores decreased significantly from 54.6 to 22.8 following education (p < 0.001); sub-scores for uncertainty (71.7 to 37.3), informed (71.7 to 15.3), values clarity (53.7 to 17.0), effective decision (44.2 to 25.5), and support (35.0 to 17.7) also decreased significantly. Participants ranked cardiovascular disease as the most important outcome to consider, followed by breast cancer, osteoporosis, blood clots, decline in sexual function, and hot flashes. Participants with prior mastectomy (N = 10) ranked breast cancer as the most important outcome 25% of the time, compared to 80% in participants without mastectomy (N = 15).

CONCLUSION

Following education, BRCA mutation carriers had significantly less decisional conflict regarding the choice to use HRT. This pilot study was successful in generating a prototype educational aid for further testing.

Treatments and Prognosis of the Breast Ductal Carcinoma In Situ

INTRODUCTION

With progress in treatments, breast ductal carcinoma in situ (DCIS) outcomes have substantially improved. However, as various treatment methods are used in different countries and institutions, consensus on the optimal treatment method is lacking. This study aimed to analyze the prognostic factors and provide a reference for optimizing the clinical treatment of DCIS.

PATIENTS AND METHODS

This retrospective clinical study collected data from DCIS patients at the Sun Yat-sen University Cancer Center from 2010 to 2017. The Kaplan-Meier method and Cox regression model were used to assess disease-free survival (DFS), overall survival (OS), and local control (LC) rates.

RESULTS

Among the 483 included patients, 83.6% (404) underwent mastectomies. The median follow-up time was 101 months. The number of patients undergoing breast-conserving surgery (BCS) with radiotherapy has gradually increased. Axillary lymph node dissection was the main surgery performed from 2010 to 2015, and the proportion of sentinel lymph node biopsies (SLNBs) has increased. LC and DFS rates with BCS without radiotherapy were significantly lower than those with mastectomy (P = .002; P < .001). Additionally, the patients who did not undergo axillary surgery had worse LC and OS rates than those who underwent SLNB (P = .028 and P = .038). Endocrine therapy (ET) or its duration had no significant effect on prognosis.

CONCLUSION

In conclusion, BCS without radiotherapy and lack of axillary surgery were independent prognostic factors. We recommend performing BCS with radiotherapy and SLNB more in clinical practice, as well as shortening the ET duration.

A long-term follow up of the laparoscopically harvested free omental flap for breast reconstruction

BACKGROUND

There are different types of reconstruction after mastectomy and breast-conserving surgery. Autologous reconstructions are nowadays more often preferred over implant-based reconstructions for many reasons. A more natural looking breast with a durable long-term result is one of the advantages. The greater omentum is frequently used in the general field of reconstructive surgery but has not been widely adopted in breast surgery. This report is the first larger series of patients who underwent a breast reconstruction using the laparoscopically harvested omental free flap (LHOFF). The aim of this report is to provide information about indication, surgical technique, short- and long-term complications, and patient satisfaction with aesthetic outcomes and health-related quality of life (HR-QoL).

METHODS

Patients underwent a breast reconstruction with the LHOFF from 2014 to 2021 in Máxima Medical Center, Veldhoven, the Netherlands. All patients underwent a diagnostic laparoscopy prior to the reconstruction to examine whether the volume of omentum was deemed sufficient. Outcome measures included the Breast-Q for HR-QoL, patient satisfaction, short- and long-term complications, and abdominal complaints related to the transplanted omentum. Surgical data were retrieved retrospectively.

RESULTS

Twenty-six patients were included in this article. Patients were 40 to 71 years old with a mean BMI of 21.5 (range 17.0-25.0). Mean weight of the omental free flap was 228 g (range 112-395). Four out of 26 cases underwent surgery due to venous congestion. There was one case of flap failure due to venous thrombosis. Mean time of follow-up was 54 months (range 8-179). Secondary corrections include a nipple reconstruction (n = 11), lipofilling (n = 11), a contralateral breast reduction (n = 3) or a breast implant (n = 2). Patients reported improvement in HR-QoL and good satisfaction with aesthetic outcomes. No abdominal complications were reported during the follow-up period.

CONCLUSION

The LHOFF is an autologous breast reconstruction technique that results in a soft, small breast with natural ptosis and minimal donor site morbidities. Patients report satisfactory aesthetic outcomes and good quality of life. The main limitation of this technique is the limited amount of volume of the omentum and the possible need for secondary corrections. No abdominal complications were reported. In the future, larger prospective studies are required to support implementation of the LHOFF reconstruction on a broader scale.