Psychological impact of breast cancer screening in Japan

OBJECTIVE

The purpose of this study was to evaluate the psychological impact of breast cancer screening by use of mammography and/or ultrasound, and to reveal factors related to psychological distress.

METHODS

Three hundred and twenty women were recalled to our hospital because of suspicious malignant findings from breast cancer screening between March and November 2012. They were asked to complete three questionnaires: the Hospital Anxiety and Depression Scale (HADS) for anxiety and depression, the Brief Coping Orientations to Problems Experienced scale (Brief COPE) for coping styles, and an original questionnaire for personal information.

RESULTS

Complete data were available for 312 of 320 women (97.5 %). The median age was 45 years (range 23-73). The HADS revealed borderline or clinically significant anxiety for 70 % of the women. Family history of breast cancer, area of residence, number of times screened, number of recalls, and the period before the first visit were significantly related to psychological distress (p < 0.05). Brief COPE scores showed that self-blame, behavioral disengagement, self-distraction, use of emotional support, venting, denial, and less acceptance were related to increased anxiety.

CONCLUSION

Seventy percent of women who were recalled after breast cancer screening experienced psychological distress. Thus, negative psychological impact should be regarded as an adverse effect of breast cancer screening.

Role of breast tomosynthesis in diagnosis of breast cancer for Japanese women

INTRODUCTION

Mammography is the most basic modality in breast cancer imaging. However, the overlap of breast tissue depicted on conventional two-dimensional mammography (2DMMG) may create significant obstacles to detecting abnormalities, especially in dense or heterogeneously dense breasts. In three-dimensional digital breast tomosynthesis (3DBT), tomographic images of the breast are reconstructed from multiple projections acquired at different angles. It has reported that this technology allows the generation of 3D data, therefore overcoming the limitations of conventional 2DMMG for Western women. We assessed the detectability of lesions by conventional 2DMMG and 3DBT in diagnosis of breast cancer for Japanese women.

METHODS

The subjects were 195 breasts of 99 patients (median age of 48 years, range 34~82 years) that had been pathologically diagnosed with breast cancer from December 20, 2010 through March 31, 2011. Both conventional 2DMMG and 3DBT imaging were performed for all patients. Detectability of lesions was assessed based on differences in category class.

RESULTS

Of the affected breasts, 77 (75.5%) had lesions assigned to the same categories by 2DMMG and 3DBT. For 24 (23.5%) lesions, the category increased in 3DBT indicating improvement in diagnostic performance compared to 2DMMG. 3DBT improved diagnostic sensitivity for patients with mass, focal asymmetric density (FAD), and architectural distortion. However, 3DBT was not statistically superior in diagnosis of the presence or absence of calcification.

CONCLUSIONS

In this study, 3DBT was superior in diagnosing lesions in form of mass, FAD, and/or architectural distortion. 3DBT is a novel technique that may provide a breakthrough in solving the difficulties of diagnosis caused by parenchyma overlap for Japanese women.

A new method for differentiating benign and malignant pleomorphic clustered calcifications in mammography

OBJECTIVE

Retrospective study to determine whether new mammography imaging characteristics can improve identification of an isolated cluster of coarse heterogeneous and fine pleomorphic calcifications as benign or malignant.

MATERIALS AND METHODS

Institutional review board approval and informed consent were obtained. The study included 123 women (mean age, 50 years: age range, 34-79 years), in whom mammograms had found pleomorphic clustered calcifications, but without abnormal ultrasound findings and who underwent stereotactically-guided vaccum-assisted breast biopsy. Pleomorphic clustered calcifications were classified on the basis of 5 characteristics density, heterogeneity of density, number, heterogeneity of size, and distribution area size (DAS) of calcifications in the mediolateral oblique view (multiplication of the greatest length by the width of the total zone of clustered calcifications in mm(2)), and correlated with pathological findings.

RESULTS

The chi-square test showed significant differences in whether a calcification was malignant or benign only in terms of DAS of calcification (p 0.009). There were significant differences in the association with malignancy of a DAS of 32- to 55 mm(2) (p=0.023, odds ratio=4.22), and the association more likely with a DAS of 56 mm(2) or larger (p=0.01, odds ratio=5.55) than with a DAS smaller than 18 mm(2) as a reference.

CONCLUSION

The DAS is a new and reliable variable for differentiating between benign and malignant pleomorphic clustered calcifications. The DAS improves diagnostic accuracy and is useful for determining whether to proceed with biopsies.

Clinicopathological significance of 'atypical ductal proliferation' in core needle biopsy of the breast

Atypical ductal proliferation or ADP has been used in histopathological diagnosis of core needle biopsy (CNB) but its details have not been well studied. Therefore, we examined the clinicopathological characteristics of the initial CNB cases diagnosed as 'ADP ' who subsequently turned out to be malignant, and compared the findings to those that did not. Among 101 cases initially diagnosed as ADP in CNB, the second biopsy revealed no carcinoma (38), ductal carcinoma in situ (DCIS) (45) and invasive carcinoma (18). Significant differences were detected between those which turned out to be carcinoma and those that did not, in the status of myoepithelial cells identified by p63 immunohistochemistry (P = 0.026) and ultrasound (US) categories (P < 0.001). We further compared the histopathological characteristics of those initially diagnosed as ADP and subsequently as DCIS or invasive ductal carcinoma (IDC) with those initially diagnosed as such. DCIS or IDC cases initially diagnosed as ADP had significantly lower Ki67 labeling index (P < 0.01, P < 0.01) and histological grade using Van nuys prognostic index (P < 0.01) or Nottingham histological grades (P < 0.01) respectively than those initially as DCIS or IDC. An assessment of myoepithelial components with US findings might contribute to determine the subsequent clinical algorithm of the patients diagnosed as ADP at initial CNB.

Humanization and simultaneous optimization of monoclonal antibody

Antibody humanization is an essential technology for reducing the potential risk of immunogenicity associated with animal-derived antibodies and has been applied to a majority of the therapeutic antibodies on the market. For developing an antibody molecule as a pharmaceutical at the current biotechnology level, however, other properties also have to be considered in parallel with humanization in antibody generation and optimization. This section describes the critical properties of therapeutic antibodies that should be sufficiently qualified, including immunogenicity, binding affinity, physiochemical stability, expression in host cells and pharmacokinetics, and the basic methodologies of antibody engineering involved. By simultaneously optimizing the antibody molecule in the light of these properties, it should prove possible to shorten the research and development period necessary to identify a highly qualified clinical candidate and consequently accelerate the start of the clinical trial.

Abstract P3-14-10: Conversion to node-negative after neoadjuvant chemotherapy is a surrogate prognostic marker in patients with hormone receptor-positive breast cancer

Background: While pathologic complete response (pCR) after neoadjuvant chemotherapy (NAC) improves patients’ survival with HER2-positive and triple-negative (TN) breast cancers, it has been reported not to be the same for patients with hormone receptor (HR)-positive breast cancer. However, it is not well known whether chemosensitivity presented by change in tumor stage or nodal status after NAC contributes to improve the prognosis with HR-positive breast cancer. The aim of this study was to evaluate the impact of change in tumor stage or nodal status after NAC on prognosis in patients with primary breast cancer.

Patients and Methods: We assessed retrospectively 599 consecutive patients with primary breast cancer (a median age of 49 years, ranging 26-79 years) who underwent surgical resection after NAC between 2001 and 2008. HR (ER and PR) statuses were determined by immunohistochemistory (IHC). HER2 status was determined by IHC and/or fluorescent in situ hybridization assays. ER-positive and PR-positive patients were 426 (71.1%) and 353 patients (58.9%), respectively. HER2 status was positive in 130 patients (21.7%). HR-positive subtype was defined as ER and/or PR-positive and HER2 negative. We compared the patients with respect to disease-free survival (DFS) and overall survival (OS) based on change in tumor stage and nodal status after NAC. pCR was defined as no residual invasive tumor and ypN0.

Results: After NAC, 84 (14.0%) patients had pCR. Two hundred ninety one (48.6%) decreased tumor stage and 308 (51.4%) did not decrease tumor stage. Regarding nodal status, 190 (31.7%) had cN0 and 409 (68.3%) had cN+ before NAC, and 286 had ypN0 (47.7%) and 313 had ypN+ (52.2%). For patients with TN breast cancer, patients with pCR had excellent prognosis compared to those with residual tumor in either the breast or lymph node (non-pCR) (DFS, p&lt;0.01, and OS, p = 0.035, respectively). Among the non-pCR group, patients with ypN0 also have longer DFS and OS than patients with ypN+ (p&lt;0.01, and p = 0.031, respectively). However, for ypN0 patients with TN breast cancer, patients with residual primary tumor had significantly shorter DFS and OS than patients with ypT0. For HR-positive breast cancer patients, there was a trend that patients with pCR had better DFS than patients with non-pCR (p = 0.069). In terms of OS, there was no significant difference between pCR and non-pCR (p = 0.285). Patients with ypN0 had significantly longer DFS and OS than those with ypN+ regardless of residual tumor stage (p&lt; 0.001 and p = 0.01, respectively). Change in tumor stage itself did not contribute to improve patients’ survival.

Conclusions: Our results revealed that HR-positive breast cancer patients with conversion to lymph nodes metastasis after NAC have a good prognosis even if they have residual tumor in the breast, while TN breast cancer patients require pCR to have a good prognosis. It indicated that conversion to node-negative after neoadjuvant chemotherapy might be a surrogate prognostic marker in patients with HR-positive breast cancer.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-14-10.

Clinicopathologic characteristics and survival outcomes in multifocal and multicentric breast cancer

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Background: Although multifocal and multicentric (MF/MC) breast cancers are a common entity, their clinical behaviors are not well characterized. We evaluated the impact of MF/MC on the disease-free survival (DFS) and distant disease free survival (DDFS) of breast cancer patients and compared clinicopathological characteristics between MF/MC breast cancers and breast cancers with single lesion. Methods: We retrospectively analyzed 734 consecutive patients who had invasive breast carcinoma and underwent definitive surgery at the St Luke’s International Hospital from January 2004 to December 2006. MF or MC ware defined as more than one lesion in the same quadrant or in separate quadrants, respectively. DDFS and DFS ware calculated by The Kaplan–Meier method. Univariate analysis was performed using the log rank test and multivariate analysis by Cox proportional hazards models. Results: Of 734 patients, 136 (18.5%) had MF/MC disease. MF/MC disease was associated with smaller tumor size (P <0.001). Multivariate analysis shows that MF/MC disease did not have an independent impact on DDFS or DFS adjusting by age, ER status, tumor size, lymphovascular invasion, lymph node metastases and nuclear grade. Conclusions: MF/MC breast cancers were not associated with poor prognostic factors, and were not independent predictors of worse survival outcomes. Our findings support the current TNM staging system of using the diameter of the largest lesion to assign T stage.

The negative prognostic impact of downstaging after neoadjuvant chemotherapy in patients with hormone-receptor positive breast cancer

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Background: While pathologic complete response (pCR) after neoadjuvant chemotherapy (NAC) improves patients’ survival, it is not well known whether or not chemosensitivity contributes to improve survival of patients who had non-pCR. The aim of this study was to evaluate the impact of chemosensitivity presented by downstaging after NAC on prognosis in patients with primary breast cancer. Methods: We assessed retrospectively 773 patients with primary breast cancer who underwent surgical resection after NAC between 2001 and 2008 (a median age 49 years, range 26-79 years). 572 patients (74.0%) had hormone-receptor positive tumor and 131 patients (16.9%) had HER2 positive tumor. One hundred forty six patients (18.9%) underwent sentinel node biopsy before NAC. We divided patients into two groups based on chemosensitivity: the downstaging (DS) group and the non-downstaging (non-DS) group. We compared the groups with respect to both disease-free survival (DFS) and overall survival (OS).According to hormone-receptor status and HER2 positivity, pCR was defined as no residual invasive and ypN0. Results: Before NAC, 37 patients had clinical Stage I (4.8%), 613 had cStage II (79.3%), and 123 had cStage III (15.9%). After NAC, 181 had ypStage I (23.4%), 306 had ypStage II (39.6%), and 175 had ypStage III (22.6%). One hundred eleven patients (14.4%) had pCR. Two hundred ninety seven patients (38.4%) had DS and 476 patients (61.6%) had non-DS. Of all patients, patients with DS had significantly longer DFS and OS than non-DS patients (p=0.01, 0.04, respectively). However, among 252 hormone-receptor positive patients with ypStage II, patients with DS (cStage III, n=21) had significantly shorter DFS than patients with non-DS (c Stage±/II, n = 231) (p<0.001). In terms of overall survival, patients with DS had a similar trend compared to patients with non-DS in this population. Conclusions: Our results indicated that hormone-receptor positive breast cancer patients with cStage III before NAC, even after having ypStage II, have worse prognosis than patients with cStage II, therefore, these patients may need additional treatment in the adjuvant setting.

Clinicopathologic features of multiple phyllodes tumors of the breast

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Background: Phyllodes tumor of the breast is one of the rare neoplasm accounting for 0.3-0.5% of all breast tumors. It is difficult to diagnose the histological type of phyllodes tumors preoperatively by radiological and even pathological findings. The aim of this study is to clarify the clinicopathological features of phyllodes tumors. Methods: We retrospectively reviewed records from 116 patients with phyllodes tumors who underwent surgery between 2003 and 2011. We determined the clinicopathological characteristics, including the presense of multiple lesions and the type of surgical procedure, of each histological type of phyllodes tumors which were classified as benign, borderline, and malignant. Results: The median follow-up time was 23.3 months. Benign phyllodes tumors were presented in 91 patients (78.4 %), borderline were in 17 patients (14.6 %), and malignant were in 8 patients (6.9 %). Ten patients (8.6 %) had multiple phyllodes tumors; 9 for ipsilateral and one for bilateral breasts. One hundred two patients underwent lumpetcomy and 14 patients underwent mastectomy. No patients received chemotherapy or radiation therapy. Noteworthy, all multiple tumors were diagnosed histologically benign. The median age at operation were 41 years (range, 12-72 years) for benign tumors, 44 years (26-67 years) for borderline, and 47 years (39-60 years) for malignant. The size of malignant tumors was significantly large (a median, 11.3 cm; range, 6-27 cm) compared to benign (a median, 4.4 cm; range 1-21 cm) and borderline (a median, 4.7cm; range 1-16 cm) (p = 0.001, and 0.03, respectively). Local recurrence developed in 14 of the 91 patients (15.4 %) with benign, 2 of the 17 patients (11.8 %) with borderline, and 2 of the 8 patients (25 %) with malignant tumors. Four patients (50 %) with malignant tumors but none with benign and borderline developed distant metastasis. Of the 4 patients, 3 had undergone mastectomy and one had lumpetcomy for initial treatment. No benign and borderline tumor had malignant change when tumors recurred. Conclusions: Our new findings indicated that multiple phyllodes tumors may be histologically benign. Furthermore, patients with benign or borderline phyllodes tumors had good prognosis regardless of surgical procedure.

Opportunistic breast cancer screening by mammography in Japan for women in their 40s at our preventive medical center: harm or benefit?

Background

After recent revised grading by the US Preventive Services Task Force of mammography (MMG) recommendations for women in their 40s, it is urgent to collect data on the benefits and harm of MMG screenings in Japan. In this paper, we study the actual status and effectiveness of opportunistic breast cancer screening by MMG for women in their 40s.

Methods

From January to December 2008, the total number of opportunistic breast cancer screenings by MMG at our institute was 12823. Of them, 398 (3.1 %) who were diagnosed as category 3 or more on MMG required further exams. The data were compared between two groups (women in their 40s, women aged 50 and older). Recall rate, detection rate of breast cancers, and implementation rate of further exams were evaluated.

Results

Recall rate was 4.0 % (166/4138) for women in their 40s and 2.4 % (166/6949) for women aged 50 and older. Detection rate of breast cancers was higher in women in their 40s (0.56 %) than women aged 50 and older (0.26 %). Non-cancer rate among women receiving invasive examination was higher in women in their 40s (0.76 %) than women aged 50 and older (0.42 %) (p = 0.02). The number of false positives required to detect one true cancer patient was smaller in women in their 40s (4.5) than women aged 50 and older (5.3).

Conclusion

The results from our single institute revealed that opportunistic breast cancer screening by MMG for women in their 40s shows higher net benefits than for women aged 50 and older.

High prevalence of neuroendocrine carcinoma in breast lesions detected by the clinical symptom of bloody nipple discharge

AIM

Bloody nipple discharge (BND) is an important clinical symptom in breast disorders, especially cancers. However, the association between this symptom and breast neuroendocrine carcinomas (NECs) has not been sufficiently investigated or well understood.

METHODS

We clinicopathologically studied 89 cases using biopsy and/or resection in 144 patients who came to the hospital for a thorough examination of symptomatic BND.

RESULTS

Of these 89 cases examined histologically, 24 (27%) were neuroendocrine carcinomas (NECs) in which >50% of cells immuno-expressed chromogranin A and/or synaptophysin. Moreover, NECs made up 44% (24/55) of the mammary cancers found because of the BND. The frequency of diagnosing malignancy preoperatively in 24 NECs was 4% by nipple discharge cytology, 40% by fine needle aspiration cytology, 62% by core needle biopsy and 67% by mammotome biopsy. There were neither postoperative recurrences nor metastases in the NEC cases during a mean follow-up of 83.7 months. The 24 NECs were subclassified into neuroendocrine ductal carcinoma in situ (NE-DCIS) (9 cases) and microinvasive (7 cases) and invasive (8 cases) NECs with extensive NE-DCIS components. Most NECs had early-stage and low-grade pathological parameters: pTis or pT1 (96%), pN0 (96%), low nuclear grade (83%), absence of necrosis (88%), immuno-positivity of estrogen and progesterone receptors (100%) and absence of HER2 protein overexpression (100%).

CONCLUSIONS

NECs predominantly with NE-DCIS lesions, often under-diagnosed preoperatively, accounted for an important share of breast conditions associated with BND. It is, therefore, worth keeping this type of breast cancer in mind when performing medical examinations on patients with BND.

Radiographic features for triple negative ductal carcinoma in situ of the breast

BACKGROUND

Triple negative (TN) breast cancer is characterized as having a high malignancy potential and a poor prognosis. An understanding of the radiological features of TN DCIS will enable the early detection of intractable TN invasive breast cancer.

METHODS

Our cohort of 494 DCIS patients, including 18 TN DCIS cases (3.6%), was diagnosed and treated between January 2006 and November 2009. We reviewed the TN DCIS cases in order to assess mammogram (MMG), ultrasound (US), magnetic resonance imaging (MRI), and pathology findings. Routine diagnostic MMG, US, and MRI were performed before surgery in our institution.

RESULTS

The average age of TN DCIS patients was 54.2 years (40-73). MMG findings were as follows: no abnormal findings (n = 4), masses (n = 3), focal asymmetric density (n = 2), architectural distortion (n = 5), and calcifications (n = 4). US findings included low echoic masses (n = 17) and architectural distortion (n = 4). MRI findings (two patients did not undergo this examination) included mass (n = 6) and non-mass-like enhancements (n = 10). The average lesion measured 3.3 cm in diameter (0.5-8.5 cm). The histological findings were non-comedo type (n = 9) and mixed type including some comedo components (n = 9). Notably, our study revealed that only 22% of TN DCIS cases were detected via mammographic abnormal calcifications. This percentage was less than in non-TN DCIS cases. TN DCIS cases were detected mainly because of masses or asymmetry. US and MRI findings of TN DCIS revealed the same features considered to be common DCIS findings.

CONCLUSION

We diagnosed TN DCIS in 3.6% of our cohort including 494 DCIS patients. Incidences of TN DCIS with mammographic abnormal calcifications were fewer than those of non-TN DCIS cases.