201
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Kelley L, Silverstein M. Reply. Ann Surg Oncol 2011. [DOI: 10.1245/s10434-010-1537-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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202
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Lyons JA, Woods C, Galanopoulos N, Silverman P. Emerging radiation techniques for early-stage breast cancer after breast-conserving surgery. Future Oncol 2011; 7:915-25. [PMID: 21732760 DOI: 10.2217/fon.11.61] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Standard whole-breast irradiation consisting of a dose of 45-50 Gy over 5 weeks with or without the addition of a boost to the tumor bed has equivalent survival to mastectomy and is considered to be the standard of care for most patients with early-stage breast cancer. Newer techniques have been developed to shorten the course of radiation or limit normal tissue exposure in an attempt to increase accessibility to and tolerance of radiation therapy. This article will review some of the newer regimens and techniques for treating early-stage breast cancer after breast-conserving surgery.
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Affiliation(s)
- Janice A Lyons
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Cleveland, OH, USA.
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203
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Fortunato L, Mascaro A, Poccia I, Andrich R, Amini M, Costarelli L, Cortese G, Farina M, Vitelli C. Lobular breast cancer: same survival and local control compared with ductal cancer, but should both be treated the same way? analysis of an institutional database over a 10-year period. Ann Surg Oncol 2011; 19:1107-14. [PMID: 21913022 DOI: 10.1245/s10434-011-1907-9] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2011] [Indexed: 11/18/2022]
Abstract
BACKGROUND Invasive lobular carcinoma (ILC) is believed to be more often multicentric and bilateral compared with invasive ductal cancer (IDC), leading clinicians to pursue a more aggressive local and contralateral approach. METHODS Retrospective review of a consecutive cohort of breast cancer patients operated at one institution from January 2000 to January 2010 was performed. Median follow-up was 4 years. RESULTS There were 171 ILC (14.5%) and 1,011 IDC patients in the study period. Median age (63 vs. 65 years) and tumor diameter (1.7 cm) were similar in the two groups. Diagnoses of ILC were more frequent in the second half of the study period (55/465 vs. 116/662, p<0.01). Multicentricity was reported in 108/1,011 (10.6%) IDC and in 31/171 (18.1%) ILC patients (p<0.01). A positive margin of resection at initial surgery was documented in 71/1,011 (7%) IDC and in 21/171 (12.3%) ILC patients (p<0.001). Although the rate of mastectomy decreased over time in both groups, this was more pronounced for ILC patients (p<0.001). Locoregional control, contralateral cancer, overall survival, disease-free survival, and survival according to diameter, nodal status, and type of surgical intervention did not differ between IDC and ILC. On multivariate analysis, stage of disease and hormone receptor status were associated with disease-free survival, but histology was not. CONCLUSIONS Although ILC is more often multicentric, bilateral, and associated with a positive margin of resection, local control and survival are similar to IDC. ILC can be treated similarly to IDC with good results.
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Affiliation(s)
- Lucio Fortunato
- Department of Surgery, Senology Unit, San Giovanni Addolorata Hospital, Rome, Italy.
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204
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Suhrke P, Mæhlen J, Schlichting E, Jørgensen KJ, Gøtzsche PC, Zahl PH. Effect of mammography screening on surgical treatment for breast cancer in Norway: comparative analysis of cancer registry data. BMJ 2011; 343:d4692. [PMID: 21914765 PMCID: PMC3172323 DOI: 10.1136/bmj.d4692] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To determine the effect of mammography screening on surgical treatment for breast cancer. DESIGN Comparative analysis of data from Norwegian cancer registry. SETTING Mammography screening, Norway (screening of women aged 50-69 was introduced sequentially from 1996 to 2004). PARTICIPANTS 35,408 women aged 40-79 with invasive breast cancer or ductal carcinoma in situ treated surgically from 1993 to 2008. MAIN OUTCOME MEASURES Rates of breast surgery (mastectomy plus breast conserving treatment) and rates of mastectomy for three age groups of women: 40-49, 50-69, and 70-79. Changes in rates from pre-screening period (1993-5) to introduction of screening phase (1996-2004) and then to screening period (2005-8) are presented as hazard ratios in invited and non-invited women. RESULTS The annual rate for breast surgery from the pre-screening period (1993-5) to screening period (2005-8) in Norway increased by 70% (hazard ratio 1.70, 95% confidence interval 1.62 to 1.78), from 180 to 305 per 100,000 women in the invited age group (50-69 years). In the younger, non-invited age group (40-49 years), however, the increase was only 8% (1.08, 1.00 to 1.16), from 133 to 144 per 100,000 women per year, whereas in the older, non-invited age group (70-79 years) the rate decreased by 8% (0.92, 0.86 to 1.00), from 227 to 214 per 100,000 women per year. The rates for mastectomy decreased similarly from the pre-screening period to screening period in invited and non-invited women. From the pre-screening period to the introduction phase of screening (1996-2004), however, the annual mastectomy rate in women aged 50-69 invited to screening increased by 9% (1.09, 1.03 to 1.14), from 156 to 167 per 100,000 women, and in the younger non-invited women declined by 17% (0.83, 0.78 to 0.90), from 109 to 91 per 100,000 women. In consequence, the mastectomy rate was 31% (1.31, 1.20 to 1.43) higher in the invited than in the non-invited younger age group. CONCLUSIONS Mammography screening in Norway was associated with a noticeable increase in rates for breast cancer surgery in women aged 50-69 (the age group invited to screening) and also an increase in mastectomy rates. Although over-diagnosis is likely to have caused the initial increase in mastectomy rates and the overall increase in surgery rates in the age group screened, the more recent decline in mastectomy rates has affected all age groups and is likely to have resulted from changes in surgical policy.
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Affiliation(s)
- Pål Suhrke
- Department of Pathology, Oslo University Hospital, N-0407 Oslo, Norway.
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205
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Croshaw RL, Marshall ML, Williams TL, Erb KM, Julian TB. Prophylactic and Therapeutic Breast Conservation in BRCA1/2 Mutation Carriers. Int J Breast Cancer 2011; 2011:481563. [PMID: 22295226 PMCID: PMC3262559 DOI: 10.4061/2011/481563] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Revised: 04/12/2011] [Accepted: 05/11/2011] [Indexed: 01/11/2023] Open
Abstract
Breast-conserving therapy (BCT) for sporadic breast cancer has been widely accepted by surgeons and patients alike. While BCT is associated with a higher risk of ipsilateral breast tumor recurrence (IBTR), it has not been shown to decrease overall survival (OS) in comparison with mastectomy. Many women with a BRCA1/2 mutation opt for mastectomy instead of breast-conserving measures at the time of a breast cancer diagnosis. In some cases, this is due to fear of aggressive disease, but to date, there have been no studies offering strong evidence that breast conservation should not be offered to these women. BRCA1/2-associated breast cancer has not been found to be more aggressive or resistant to treatment than comparable sporadic tumors, and no study has shown an actual survival advantage for mastectomy in appropriately treated affected mutation carriers. This paper reviews the available literature for breast conservation and surgical decision making in BRCA1/2 mutation carriers.
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Affiliation(s)
- Randal L Croshaw
- Allegheny General Hospital, 320 E North Avenue, Pittsburgh, PA 15212-4746, USA
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206
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Consequences of Axillary Ultrasound in Patients with T2 or Greater Invasive Breast Cancers. Indian J Surg Oncol 2011. [DOI: 10.1007/s13193-011-0085-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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207
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Kimple RJ, Klauber-DeMore N, Kuzmiak CM, Pavic D, Lian J, Livasy CA, Chiu WM, Moore DT, Sartor CI, Ollila DW. Local control following single-dose intraoperative radiotherapy prior to surgical excision of early-stage breast cancer. Ann Surg Oncol 2011; 18:939-45. [PMID: 21061074 DOI: 10.1245/s10434-010-1392-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2010] [Indexed: 11/18/2022]
Abstract
BACKGROUND Multiple partial breast radiotherapy techniques are available. We have previously presented the technical details of our procedure of delivering partial breast irradiation with a single fraction of intraoperative radiotherapy (IORT) targeting the tumor in situ prior to partial mastectomy. This study details our completed, single-institution trial. MATERIALS AND METHODS An IRB-approved, DSMB-monitored phase II trial was performed with the following inclusion criteria: women age ≥48, ultrasound-visible invasive ductal cancers <3 cm, clinically negative axillary nodes. IORT was delivered using mobile electron irradiator, at least a 1.5-cm radial and 1-cm deep margin; patients received 15 Gy and immediately underwent partial mastectomy. Ipsilateral breast recurrence was classified as true/marginal, elsewhere in the breast or nodal basin. Kaplan-Meier methods were used to estimate survival functions and exact 95% confidence intervals are reported. RESULTS Between 2003 and 2007, 71 women underwent IORT (median follow-up: 3.5 years). For patients with tumor-involved or close margins, additional therapy was required: 7 patients, total mastectomy; 11, whole breast radiation. Four women experienced invasive ipsilateral breast failures (1 new primary, 3 margin recurrences) for a 3-year local control rate of 49 of 53 (94.8%; 95% confidence interval 92.4% [95% CI] 84.2–98.3%), actuarial three-year in breast recurrence was 8% (95% CI 2–18%), and breast cancer-specific survival was 100%. CONCLUSIONS Intraoperative radiotherapy delivered to an in situ tumor is feasible, but our local control rate at 3.5 years is concerning. Possible changes to this technique to improve local control rates include better preoperative imaging (MRI), routine intraoperative ultrasound, and improved IORT delivery (larger cone, increased dose).
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Affiliation(s)
- Randall J Kimple
- Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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208
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Jibaja-Weiss ML, Volk RJ, Granchi TS, Neff NE, Robinson EK, Spann SJ, Aoki N, Friedman LC, Beck JR. Entertainment education for breast cancer surgery decisions: a randomized trial among patients with low health literacy. PATIENT EDUCATION AND COUNSELING 2011; 84:41-48. [PMID: 20609546 DOI: 10.1016/j.pec.2010.06.009] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2009] [Revised: 05/04/2010] [Accepted: 06/04/2010] [Indexed: 05/29/2023]
Abstract
OBJECTIVE To evaluate an entertainment-based patient decision aid for early stage breast cancer surgery in low health literacy patients. METHODS Newly diagnosed female patients with early stage breast cancer from two public hospitals were randomized to receive an entertainment-based decision aid for breast cancer treatment along with usual care (intervention arm) or to receive usual care only (control arm). Pre-decision (baseline), pre-surgery, and 1-year follow-up assessments were conducted. RESULTS Patients assigned to the intervention arm of the study were more likely than the controls to choose mastectomy rather than breast-conserving surgery; however, they appeared better informed and clearer about their surgical options than women assigned to the control group. No differences in satisfaction with the surgical decision or the decision-making process were observed between the patients who viewed the intervention and those assigned to the control group. CONCLUSIONS Entertainment education may be a desirable strategy for informing lower health literate women about breast cancer surgery options. PRACTICE IMPLICATIONS Incorporating patient decision aids, particularly computer-based decision aids, into standard clinical practice remains a challenge; however, patients may be directed to view programs at home or at public locations (e.g., libraries, community centers).
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Affiliation(s)
- Maria L Jibaja-Weiss
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX 77098, USA.
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209
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Nelson MC, Norton HJ, Greene FL. Breast conservation therapy versus mastectomy in the community-based setting: can this rate be used as a benchmark for cancer care? Surg Oncol Clin N Am 2011; 20:427-37, vii. [PMID: 21640912 DOI: 10.1016/j.soc.2011.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Despite strong evidence supporting the use of breast conservation therapy (BCT) in the treatment of breast carcinoma, the actual rates of use remain low. This article is a retrospective review of a sample of patients from the cancer registry of the Carolinas Medical Center (CMC), comparing breast conservation and mastectomy rates during an 11-year period. BCT rates have increased in CMC during this time frame and have reached national levels. Further research is needed to determine whether BCT rates can be used as a benchmark for the care of patients with cancer.
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Affiliation(s)
- Marsha Criscio Nelson
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Boulevard, Charlotte, NC 28203, USA
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210
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King TA, Sakr R, Patil S, Gurevich I, Stempel M, Sampson M, Morrow M. Clinical Management Factors Contribute to the Decision for Contralateral Prophylactic Mastectomy. J Clin Oncol 2011; 29:2158-64. [DOI: 10.1200/jco.2010.29.4041] [Citation(s) in RCA: 262] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose To determine whether increasing rates of contralateral prophylactic mastectomy (CPM) are due to recognition of risk factors for contralateral breast cancer (CBC) or treatment factors related to the index lesion. Methods From 1997 to 2005, 2,965 patients with stage 0 to III primary unilateral breast cancer underwent mastectomy at Memorial Sloan-Kettering Cancer Center. Patients who did and did not undergo CPM within 1 year of treatment for their index cancer were compared to identify independent predictors of CPM. Results The rate of CPM was 13.8% (n = 407), increasing from 6.7% in 1997 to 24.2% in 2005 (P < .0001). Patients with BRCA mutations or prior mantle radiation (n = 52) accounted for 13% of those having CPM. The rate of CPM by surgeon varied from 1% to 26%. Multivariate logistic regression adjusting for surgeon-identified white race (odds ratio [OR] = 3.3), immediate reconstruction (OR = 3.3), family history of breast cancer (OR = 2.9), magnetic resonance imaging (MRI) at diagnosis (OR = 2.8), age younger than 50 years (OR = 2.2), noninvasive histology (OR = 1.8), and prior attempt at breast conversation (OR = 1.7) to be independent predictors of CPM. Conclusion These data suggest that increasing use of CPM is not associated with increased recognition of patients at high risk for CBC. Treatment factors, such as immediate reconstruction, preoperative MRI, and unsuccessful attempts at breast conservation, are associated with increased rates of CPM. Efforts to optimize breast conservation, minimize unnecessary tests, and improve patient education about the low risk of CBC may help to curb this trend.
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Affiliation(s)
- Tari A. King
- From Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Rita Sakr
- From Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Sujata Patil
- From Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Inga Gurevich
- From Memorial Sloan-Kettering Cancer Center, New York, NY
| | | | | | - Monica Morrow
- From Memorial Sloan-Kettering Cancer Center, New York, NY
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211
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Damle S, Teal CB, Lenert JJ, Marshall EC, Pan Q, McSwain AP. Mastectomy and contralateral prophylactic mastectomy rates: an institutional review. Indian J Surg Oncol 2011; 2:133-40. [PMID: 22696239 PMCID: PMC3373170 DOI: 10.1007/s13193-011-0086-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2010] [Indexed: 01/06/2023] Open
Abstract
Background. Breast conservation surgery (BCS) followed by radiation is as effective as mastectomy for long-term survival and is considered standard of care for early-stage breast cancer. An increasing number of patients are opting for cancer-side mastectomies (CM) and often contralateral prophylactic mastectomies (CPM). Our study investigates if there are increasing trends in our patient population toward CM and CPM and identifies common factors associated with those electing to have more extensive surgery.Methods. A retrospective analysis was performed on 812 breast cancer surgeries between January 2001 and December 2009 at The George Washington University Breast Care Center. BCS-eligible patients who elected to have BCS were compared with those who chose CM. Patients who underwent CM were compared with patients undergoing CM and CPM.Results. A personal or family history of breast cancer and larger tumor size were positively associated with choosing CM in BCS-eligible patients. A nonstatistically significant trend toward CM was seen in younger patients. Age, family history, fewer children, Caucasian race, and reconstructive surgery were positively associated with choosing CPM.Conclusion. Mastectomy rates at this institution have not shown the recent sharp increase observed by some authors. The association of age, race, family history, and parity with CPM has been corroborated in multiple studies. However, there is disagreement between statistically significant findings among investigators evaluating factors associated with CPM, and there is limited data in the literature characterizing BCS-eligible patients who chose CM. Larger prospective studies are necessary to further evaluate CM and CPM rates.
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Affiliation(s)
- Sameer Damle
- Department of Surgery, Breast Care Center, The George Washington University, Washington, DC USA
| | - Christine B. Teal
- Department of Surgery, Breast Care Center, The George Washington University, Washington, DC USA
| | - Joanne J. Lenert
- Department of Surgery, Division of Plastic Surgery, The George Washington University, Washington, DC USA
| | - Elizabeth C. Marshall
- Department of Surgery, Division of Plastic Surgery, The George Washington University, Washington, DC USA
| | - Qing Pan
- Department of Statistics, Biostatistics Center, The George Washington University, Washington, DC USA
| | - Anita P. McSwain
- Department of Surgery, Breast Care Center, The George Washington University, Washington, DC USA
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212
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Han E, Johnson N, Glissmeyer M, Wagie T, Carey B, DelaMelena T, Nelson J. Increasing incidence of bilateral mastectomies: the patient perspective. Am J Surg 2011; 201:615-8. [DOI: 10.1016/j.amjsurg.2011.01.018] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2010] [Revised: 01/25/2011] [Accepted: 01/27/2011] [Indexed: 01/06/2023]
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213
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Janz NK, Hawley ST, Mujahid MS, Griggs JJ, Alderman A, Hamilton AS, Graff JJ, Jagsi R, Katz SJ. Correlates of worry about recurrence in a multiethnic population-based sample of women with breast cancer. Cancer 2011; 117:1827-36. [PMID: 21445916 DOI: 10.1002/cncr.25740] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2010] [Revised: 09/09/2010] [Accepted: 09/27/2010] [Indexed: 12/18/2022]
Abstract
BACKGROUND Worry about recurrence (worry) is a persistent concern of breast cancer survivors. Little is known about whether race/ethnicity or healthcare experiences are associated with worry. METHODS Women with nonmetastatic breast cancer diagnosed from June 2005 to February 2007 and reported to Detroit or Los Angeles Surveillance, Epidemiology, and End Results registries were surveyed (mean 9 months postdiagnosis); 2290 responded (73%). Latinas and African Americans were oversampled. A worry scale was constructed as the mean score of 3 items (on 5-point Likert, higher = more worry): worry about cancer returning to the same breast, occurring in the other breast, or spreading to other parts of the body. Race/ethnicity categories were white, African American, and Latina (categorized into low vs high acculturation). The worry scale was regressed on sociodemographics, clinical/treatment, and healthcare experience factors (eg, care coordination collapsed into low, medium, high). RESULTS Low acculturated Latinas reported more worry and African Americans less worry than whites (P < .001). Other factors independently associated with more worry were younger age, being employed, more pain and fatigue, and radiation (Ps < .05). With all factors in the model, less worry was associated (all Ps < .05) with greater ease of understanding information (2.89, 2.99, 2.81 for low, medium, high), better symptom management (3.19, 2.89, 2.87 for low, medium, high), and more coordinated care (3.36, 2.94, 2.82 for low, medium, high). Race/ethnicity remained significant controlling for all factors (P < .001). CONCLUSIONS Less acculturated Latina breast cancer patients are vulnerable to high levels of worry. Interventions that improve information exchange, symptom management, and coordinating care hold promise in reducing worry.
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Affiliation(s)
- Nancy K Janz
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan 48109-20296, USA.
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214
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Tuttle TM, Rueth NM, Abbott A, Virnig BA. Trends in the local treatment of breast cancer: Should we be worried? J Surg Oncol 2011; 103:313-6. [DOI: 10.1002/jso.21699] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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215
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Vanderwalde LH, Dang CM, Tabrizi R, Saouaf R, Phillips EH. Breast MRI after Bilateral Mastectomy: Is It Indicated? Am Surg 2011. [DOI: 10.1177/000313481107700217] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Little is known about the use of breast MRI as a diagnostic or surveillance tool in patients after bilateral mastectomy. The objective of this study was to evaluate breast MRI after bilateral mastectomy. Participants consisted of 48 women with prior bilateral mastectomy who underwent breast MRI between 2003 and 2009. Seventy-nine breast MRIs were obtained. The median time between mastectomy and first MRI was 36 months. MRI was ordered most often by a medical oncologist (71%). Median age at bilateral mastectomy was 49 years (range, 33 to 72 years). Reasons for obtaining MRI included surveillance in 60 (76%), mass in eight (10%), lymph nodes in four (5%), pain in three (4%), and abscess in one (1%). Overall, 68 (86%) MRIs showed benign imaging findings only. Within the surveillance group, six patients had MRIs with findings that changed management; four patients had some residual breast tissue, and two patients had findings outside the breast that were better evaluated by CT or bone scan and were ultimately benign. MRI confirmed locoregional recurrence in two patients with highly suspicious physical findings. Overall, postmastectomy breast MRI had limited use, finding no unsuspected recurrences within our study group. Although MRI can be helpful to establish the presence of residual breast tissue after bilateral mastectomy, subsequent routine screening breast MRI should be questioned if no residual breast tissue is identified.
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Affiliation(s)
- Lindi H. Vanderwalde
- Saul and Joyce Brandman Breast Center, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Catherine M. Dang
- Saul and Joyce Brandman Breast Center, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Robert Tabrizi
- Saul and Joyce Brandman Breast Center, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Rola Saouaf
- Saul and Joyce Brandman Breast Center, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Edward H. Phillips
- Saul and Joyce Brandman Breast Center, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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216
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Hoopes DJ, Kaziska D, Chapin P, Weed D, Smith BD, Hale ER, Johnstone PA. Patient preferences and physician practice patterns regarding breast radiotherapy. Int J Radiat Oncol Biol Phys 2011; 82:674-81. [PMID: 21277106 DOI: 10.1016/j.ijrobp.2010.11.077] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2010] [Revised: 11/10/2010] [Accepted: 11/11/2010] [Indexed: 11/19/2022]
Abstract
PURPOSE There are multiple current strategies for breast radiotherapy (RT). The alignment of physician practice patterns with best evidence and patient preferences will enhance patient autonomy and improve cancer care. However, there is little information describing patient preferences for breast RT and physician practice patterns. METHODS AND MATERIALS Using a reliable and valid instrument, we assessed the preferences of 5,000 randomly selected women (with or without cancer) undergoing mammography. To assess practice patterns, 2,150 randomly selected physician-members of American Society for Radiation Oncology were surveyed. RESULTS A total of 1,807 women (36%) and 363 physicians (17%) provided usable responses. The 95% confidence interval is < ± 2.3% for patients and < ± 5.3% for physicians. Patient preferences were hypofractionated whole breast irradiation (HF-WBI) 62%, partial breast irradiation (PBI) 28%, and conventionally fractionated whole breast irradiation (CF-WBI) 10%. By comparison, 82% of physicians use CF-WBI for more than 2/3 of women and 56% never use HF-WBI. With respect to PBI, 62% of women preferred three-dimensional (3D)-PBI and 38% favor brachytherapy-PBI, whereas 36% of physicians offer 3D-PBI and 66% offer brachytherapy-PBI. 70% of women prefer once-daily RT over 10 days vs. twice-daily RT over 5 days. 55% of physicians who use PBI do not offer PBI on clinical trial. CONCLUSIONS HF-WBI, while preferred by patients and supported by evidence, falls behind the unproven and less preferred strategy of PBI in clinical practice. There is a discrepancy between women's preferences for PBI modality and type of PBI offered by physicians. Further alignment is needed between practice patterns, patient preferences, and clinical evidence.
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Affiliation(s)
- David J Hoopes
- Department of Radiology and Radiological Sciences, Uniformed Services University of the Health Sciences, WPAFB, OH, USA.
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217
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Adkisson CD, Vallow LA, Kowalchik K, McNeil R, Hines S, Deperi E, Moreno A, Roy V, Perez EA, McLaughlin SA. Patient age and preoperative breast MRI in women with breast cancer: biopsy and surgical implications. Ann Surg Oncol 2011; 18:1678-83. [PMID: 21207171 DOI: 10.1245/s10434-010-1491-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2010] [Indexed: 11/18/2022]
Abstract
BACKGROUND The influence of patient age on multidisciplinary treatment planning after preoperative breast magnetic resonance imaging (MRI) and its influence on the surgical decision-making process are unclear. METHODS We performed a retrospective review of 710 women with breast cancer who underwent preoperative MRI at our institution between January 2003 and December 2008. Analysis by patient age included the number of additional ipsilateral MRI findings, the number of biopsies recommended/performed, the number of additional cancers found, and the percentage of patients undergoing mastectomy. RESULTS Of the 710 patients, 343 (48%) had additional ipsilateral MRI findings. After stratifying by age, the incidence of additional ipsilateral findings differed between decades (P = 0.004). However, fewer biopsies were recommended in older patients (P = 0.043). The number of women pursuing preoperative needle biopsy increased with age (P = 0.0018), while the incidence of a second focus of breast cancer did not change with age (P = 0.07). The mastectomy rate decreased from 65% in women younger than 50 to 40% in women older than 70 (P < 0.001). CONCLUSIONS In the setting of newly diagnosed breast cancer, the value of MRI is not influenced by patient age, with at least 40% of women in all age groups having additional findings on MRI. Insisting on preoperative needle biopsy of additional findings may decrease mastectomy rates. Further study is needed to determine the reasons for the increased percentage of mastectomies in younger women.
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Preoperative MRI and surgical management in patients with nonpalpable breast cancer: the MONET - randomised controlled trial. Eur J Cancer 2010; 47:879-86. [PMID: 21195605 DOI: 10.1016/j.ejca.2010.11.035] [Citation(s) in RCA: 210] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2010] [Revised: 11/26/2010] [Accepted: 11/30/2010] [Indexed: 01/08/2023]
Abstract
BACKGROUND We evaluated whether performing contrast-enhanced breast MRI in addition to mammography and/or ultrasound in patients with nonpalpable suspicious breast lesions improves breast cancer management. METHODS The MONET - study (MR mammography of nonpalpable breast tumours) is a randomised controlled trial in patients with a nonpalpable BIRADS 3-5 lesion. Patients were randomly assigned to receive routine medical care, including mammography, ultrasound and lesion sampling by large core needle biopsy or additional MRI preceding biopsy. Patients with cancer were referred for surgery. Primary end-point was the rate of additional surgical procedures (re-excisions and conversion to mastectomy) in patients with a nonpalpable breast cancer. FINDINGS Four hundred and eighteen patients were randomised, 207 patients were allocated to MRI, and 211 patients to the control group. In the MRI group 74 patients had 83 malignant lesions, compared to 75 patients with 80 malignant lesions in the control group. The primary breast conserving surgery (BCS) rate was similar in both groups; 68% in the MRI group versus 66% in the control group. The number of re-excisions performed because of positive resection margins after primary BCS was increased in the MRI group; 18/53 (34%) patients in the MRI group versus 6/50 (12%) in the control group (p=0.008). The number of conversions to mastectomy did not differ significantly between groups. Overall, the rate of an additional surgical intervention (BCS and mastectomy combined) after initial breast conserving surgery was 24/53 (45%) in the MRI group versus 14/50 (28%) in the control group (p=0.069). INTERPRETATION Addition of MRI to routine clinical care in patients with nonpalpable breast cancer was paradoxically associated with an increased re-excision rate. Breast MRI should not be used routinely for preoperative work-up of patients with nonpalpable breast cancer.
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Damle S, Teal CB, Lenert JJ, Marshall EC, Pan Q, McSwain AP. Mastectomy and Contralateral Prophylactic Mastectomy Rates: An Institutional Review. Ann Surg Oncol 2010; 18:1356-63. [DOI: 10.1245/s10434-010-1434-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2010] [Indexed: 01/06/2023]
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Abstract
As most solid tumors, surgery is often the first step of the multidisciplinary management for breast cancers. Although mastectomy and axillar lymphadenectomy still have indications, conservative treatment and sentinel node detection are commonly used. Thanks to induction chemotherapy and oncoplastic techniques, surgery is conservative in most cases, even for important tumors without overall survival prejudice. There is no consensus about resection margins status but a limit of 2 to 3 mm seems to be reasonable while oncoplastic surgery allows large resection and good cosmetic outcomes. In this overview, we present the state of the art for breast cancer surgery including conservative and radical treatments, axillar lymphadenectomy and sentinel lymph node detection, margins status, oncoplastic techniques.
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Stucky CCH, Gray RJ, Wasif N, Dueck AC, Pockaj BA. Increase in contralateral prophylactic mastectomy: echoes of a bygone era? Surgical trends for unilateral breast cancer. Ann Surg Oncol 2010; 17 Suppl 3:330-7. [PMID: 20853055 DOI: 10.1245/s10434-010-1259-x] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2010] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Surgical therapy for invasive breast cancer includes breast conservation therapy (BCT), unilateral mastectomy (UM), or bilateral mastectomy, including contralateral prophylactic mastectomy (CPM) with or without reconstruction (± R). The goal of this study was to determine factors associated with CPM. METHODS A breast cancer database collected from 2000 through 2008 was retrospectively reviewed. Treatment groups analyzed included BCT, UM ± R, and CPM ± R. Variables were compared using ANOVA F-tests and chi-square tests. Multivariate analysis was performed using logistic regression. RESULTS A total of 1,391 patients underwent surgery for invasive breast cancer: 69% BCT, 21% UM, and 10% bilateral mastectomy. Of those undergoing bilateral mastectomy, 30% had bilateral cancer and were excluded from analysis. The rate of CPM increased significantly from 0 to 20% (p < 0.001), whereas the rate of UM remained relatively stable. Factors associated with CPM included younger age, significant family history, genetic testing, positive BRCA gene mutation, and preoperative magnetic resonance imaging (MRI). Tumor characteristics associated with CPM included positive axillary lymph node metastases and triple-negative disease (ER-/PR-/HER2 normal). Breast reconstruction was more common among women who underwent CPM (p < 0.001). On multivariate regression comparing BCT with CPM, younger age, larger tumors, multifocal disease, and MRI significantly predicted CPM. Comparing UM with CPM, only age and genetic testing significantly predicted CPM. CONCLUSIONS The rate of bilateral mastectomy for unilateral breast cancer is increasing. This is particularly true for younger patients with strong family history. The availability of breast reconstruction may play a role and the effects of stage and multifocal disease needs further exploration.
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van Steenbergen LN, van de Poll-Franse LV, Wouters MWJM, Jansen-Landheer MLEA, Coebergh JWW, Struikmans H, Tjan-Heijnen VCG, van de Velde CJH. Variation in management of early breast cancer in the Netherlands, 2003-2006. Eur J Surg Oncol 2010; 36 Suppl 1:S36-43. [PMID: 20620013 DOI: 10.1016/j.ejso.2010.06.021] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Accepted: 06/08/2010] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND To describe variation in staging and primary treatment by hospital characteristics including type and volume and region in patients with early breast cancer (BC) in the Netherlands, 2003-2006 after completion of national guidelines in 2002. METHODS All patients newly diagnosed with invasive BC in 2003-2006 and recorded in the Netherlands Cancer Registry were included (n = 51 354). Multivariable logistic regression analyses examined the influence of patient and hospital characteristics, also by region, on type of breast surgery, axillary lymph node dissection (ALND), sentinel node procedure (SNP), and adjuvant irradiation and/or systemic treatment. RESULTS Patients <40 years more often underwent breast conserving surgery (BCS) in general hospitals (OR 1.4 (95%CI 1.1-1.5)) than in teaching and academic hospitals, whereas patients of 40-69 years less often received BCS in an academic hospital (OR 0.9 (95%CI 0.8-1.0)) than in teaching hospitals. Patients with pT1-2N0 cancer more often underwent primary ALND in a general hospital than in a larger teaching or academic hospital. Type of hospital did not seem to affect utilization of adjuvant systemic therapy, but patient age and tumour size and grade did. Over time, patients more often received SNP, BCS, and adjuvant systemic therapy, primary ALND being on the decline, but with substantial regional variation between geographic regions. CONCLUSION With detailed evidence-based national guidelines since 2002 the considerable regional and hospital variation in staging procedures and primary treatment among newly diagnosed patients with early breast cancer in the Netherlands decreased markedly, suggesting the presence of late adaptors rather than specific hospital characteristics.
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James TA, McCahill LE. Variant Mastectomy Rates: Implications for Quality of Care in Breast Cancer Surgery. J Clin Oncol 2010; 28:e364; author reply e365. [DOI: 10.1200/jco.2009.27.9703] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Reintgen C, Reintgen D, Solin LJ. Advances in local-regional treatment for patients with early-stage breast cancer: a review of the field. Clin Breast Cancer 2010; 10:180-7. [PMID: 20497916 DOI: 10.3816/cbc.2010.n.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This review highlights advances in the field of the local-regional treatment for patients with early-stage breast cancer. Through the years, the surgical treatment for early-stage breast cancer has evolved into more conservative treatment, with breast-conserving measures replacing the mastectomy as the most common procedure performed to treat the primary tumor. Likewise, nodal staging has evolved so that the lymphatic mapping procedures have replaced axillary dissection, resulting in a less morbid procedure and better staging information. Advances in radiation treatment have resulted in increasingly tailored approaches to adding radiation treatment after breast-conserving surgery or mastectomy. These improvements in local-regional treatment have benefitted patients through increased breast conservation treatment, improved local control, increased survival, and improved quality of life.
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Affiliation(s)
- Christian Reintgen
- Department of Surgical Oncology, The Lakeland Regional Cancer Center, FL 33647, USA
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Mack LA, Dabbs K, Temple WJ. Synoptic operative record for point of care outcomes: a leap forward in knowledge translation. Eur J Surg Oncol 2010; 36 Suppl 1:S44-9. [PMID: 20609548 DOI: 10.1016/j.ejso.2010.06.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2010] [Accepted: 06/01/2010] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Modern information technology coupled with synoptic methodology allows point of care, real time outcomes generation. Our objective was to review province-wide breast cancer surgery outcomes from a prospective synoptic operative record to demonstrate its value in knowledge translation. METHODS All synoptic reports for breast cancer procedures from 2006 until March 2010 were reviewed and descriptively analyzed. Key outcomes included frequency of breast cancer procedures captured over time, methods of breast cancer detection, clinical staging, method of axillary staging, breast conservation and reconstruction rates. Further analysis involved important decision-making for mastectomy and resource allocation for surgery. RESULTS Four thousand nine hundred fifty-five breast cancer procedures were recorded synoptically; greater than 80% of cases provincially. Method of breast cancer detection was 49%, 45% and 4% by screening radiology, patient or family, and physician, respectively. Pathologic diagnoses were via core or mammotome biopsy in 94%; nearly half of all patients were clinical Stage I at time of operation. Overall rate of breast conservation was 48%. Of the 65% who had no contra-indication to breast conservation surgery, 76% had breast conservation and 4% had primary reconstruction. Of those having mastectomy, one third were due to patient choice. Seventy-nine percent had sentinel node staging, 18% had full axillary dissection and 3% had no axillary staging. CONCLUSION A new paradigm of creating medical records using synoptic electronic templates allows prospective outcomes generation at point of care by the surgeon which is unparalleled in its depth of surgical detail capturing surgical decision-making.
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Affiliation(s)
- L A Mack
- Department of Surgery and Oncology, University of Calgary, 1331-29th Street NW, Calgary, Alberta, Canada
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Lee MC, Eatrides J, Chau A, Han G, Kiluk JV, Khakpour N, Cox CE, Carter WB, Laronga C. Consequences of axillary ultrasound in patients with T2 or greater invasive breast cancers. Ann Surg Oncol 2010; 18:72-7. [PMID: 20585876 DOI: 10.1245/s10434-010-1171-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2010] [Indexed: 02/05/2023]
Abstract
BACKGROUND Axillary ultrasound (AUS) with needle biopsy is used to detect metastasis in patients with invasive breast cancers. Our hypothesis is that preoperative AUS significantly reduces sentinel node biopsy (SLNB) use in patients with invasive breast tumors >2 cm upon clinical examination. METHODS A single-institution database of patients with breast cancer and AUS was reviewed. Patients with incomplete records, clinical tumor <2 cm, or postoperative AUS were excluded. A control cohort of non-AUS patients with clinical T2 (cT2) or greater disease was identified. Clinicopathologic data were collected. Simple Kappa coefficient and chi-square statistical analyses were performed. RESULTS AUS was performed in 153 patients vs. 370 controls. Of AUS patients, 112 (73.2%) had cT2 disease vs. 272 (73.5%) controls. Median AUS patient age was 53.7 (range, 22.8-85.8) years vs. 53.8 (range, 26.7-91.6) years; median pathologic tumor was 3.8 (range, 1.0-20.0) cm in AUS patients vs. 2.5 (range, 0.1-11.0) cm. Among AUS patients, 78% had needle biopsy; 85 of 120 (70.8%) were positive. Sixty-eight patients had SLNB: 33 after negative AUS and 35 after negative needle biopsy. Twenty-three SLNB (37.3%) were positive; 15 of 33 after negative AUS and 8 of 35 after a negative needle biopsy. Axillary dissection was performed in 102 of 153 vs. 225 of 370 controls. Sensitivity and specificity of AUS was 86.2% and 40.5%. Sensitivity of AUS plus needle biopsy was 89.3% with 100% specificity. Neoadjuvant chemotherapy was given to 49.7% of AUS patients. AUS reduced costs by more than $4,000 per patient. CONCLUSIONS AUS reduces SLNB use and affects treatment in patients with cT2 or greater breast cancer. Routine AUS should be considered in this population.
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Affiliation(s)
- M Catherine Lee
- Comprehensive Breast Program, Moffitt Cancer Center, Tampa, FL, USA.
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Habermann EB, Abbott A, Parsons HM, Virnig BA, Al-Refaie WB, Tuttle TM. Are mastectomy rates really increasing in the United States? J Clin Oncol 2010; 28:3437-41. [PMID: 20548000 DOI: 10.1200/jco.2009.27.6774] [Citation(s) in RCA: 168] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE After the National Institutes of Health Consensus Statement in 1990, breast-conserving surgery (BCS) became more common while mastectomy rates decreased. However, several recently published single-institution studies have reported an increase in mastectomy rates in the past decade. We conducted a population-based study to evaluate national trends in the surgical treatment of breast cancer from 2000 through 2006. PATIENTS AND METHODS Using the Surveillance, Epidemiology, and End Results database, we conducted a retrospective cohort analysis of women undergoing surgical treatment for breast cancer. We evaluated variation in mastectomy rates by demographic and tumor factors and calculated differences in mastectomy rates across time. We utilized logistic regression to identify time trends and patient and tumor factors associated with mastectomy, testing for significance using two-sided methods. RESULTS We identified 233,754 patients diagnosed with ductal carcinoma in situ or stage I to III unilateral breast cancer from 2000 to 2006. The proportion of women treated with mastectomy decreased from 40.8% in 2000 to 37.0% in 2006 (P < .001). These patterns were maintained across patient and tumor factors. Although the unilateral mastectomy rate decreased during the study period, the contralateral prophylactic mastectomy rate increased. Women were less likely to receive mastectomy over time (odds ratio, 1.18 for 2000 v 2006; 95% CI, 1.14 to 1.23; P < .0001), after adjusting for patient and tumor factors. CONCLUSION In contrast to single-institution studies, our population-based analysis found a decrease in unilateral mastectomy rates from 2000 to 2006 in the United States. Variations in referral patterns and patient selection are potential explanations for these differences between single institutions and national trends.
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Harissis HV, Ziogas D, Baltogiannis G. Mastectomy vs breast-conserving surgery: an old dilemma comes again for early breast cancer. Ann Surg Oncol 2010; 17:1966-7. [PMID: 20443141 DOI: 10.1245/s10434-010-1103-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2009] [Indexed: 11/18/2022]
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O'Neill SC, Valdimarsdottir HB, Demarco TA, Peshkin BN, Graves KD, Brown K, Hurley KE, Isaacs C, Hecker S, Schwartz MD. BRCA1/2 test results impact risk management attitudes, intentions, and uptake. Breast Cancer Res Treat 2010; 124:755-64. [PMID: 20383578 DOI: 10.1007/s10549-010-0881-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2010] [Accepted: 03/29/2010] [Indexed: 12/25/2022]
Abstract
Women who receive positive or uninformative BRCA1/2 test results face a number of decisions about how to manage their cancer risk. The purpose of this study was to prospectively examine the effect of receiving a positive versus uninformative BRCA1/2 genetic test result on the perceived pros and cons of risk-reducing mastectomy (RRM) and risk-reducing oophorectomy (RRO) and breast cancer screening. We further examined how perceived pros and cons of surgery predict intention for and uptake of surgery. 308 women (146 positive, 162 uninformative) were included in RRM and breast cancer screening analyses. 276 women were included in RRO analyses. Participants completed questionnaires at pre-disclosure baseline and 1-, 6-, and 12-months post-disclosure. We used linear multiple regression to assess whether test result contributed to change in pros and cons and logistic regression to predict intentions and surgery uptake. Receipt of a positive BRCA1/2 test result predicted stronger pros for RRM and RRO (P < 0.001), but not perceived cons of RRM and RRO. Pros of surgery predicted RRM and RRO intentions in carriers and RRO intentions in uninformatives. Cons predicted RRM intentions in carriers. Pros and cons predicted carriers' RRO uptake in the year after testing (P < 0.001). Receipt of BRCA1/2 mutation test results impacts how carriers see the positive aspects of RRO and RRM and their surgical intentions. Both the positive and negative aspects predict uptake of surgery.
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Affiliation(s)
- Suzanne C O'Neill
- Cancer Control Program and Fisher Center for Familial Cancer Research, Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC 20007, USA.
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Solin LJ. Breast Conservation Treatment With Radiation: An Ongoing Success Story. J Clin Oncol 2010; 28:709-11. [DOI: 10.1200/jco.2009.26.1164] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Lawrence J. Solin
- Department of Radiation Oncology, Albert Einstein Medical Center, Philadelphia, PA
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Affiliation(s)
- Monica Morrow
- Breast Surgery Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Jay R. Harris
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Balch CM, Jacobs LK. Mastectomies on the rise for breast cancer: "the tide is changing". Ann Surg Oncol 2009; 16:2669-72. [PMID: 19644723 PMCID: PMC2749168 DOI: 10.1245/s10434-009-0634-y] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2009] [Accepted: 07/07/2009] [Indexed: 12/28/2022]
Affiliation(s)
- Charles M. Balch
- Johns Hopkins Departments of Surgery and Oncology and the Avon Foundation Breast Center, Johns Hopkins Medical Institutions, Baltimore, MD USA
| | - Lisa K. Jacobs
- Johns Hopkins Departments of Surgery and Oncology and the Avon Foundation Breast Center, Johns Hopkins Medical Institutions, Baltimore, MD USA
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