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Boland MR. Modern management of the axilla. J Surg Oncol 2024; 130:23-28. [PMID: 38643485 DOI: 10.1002/jso.27649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 03/11/2024] [Indexed: 04/23/2024]
Abstract
Surgical management of the axilla has evolved considerably in recent years, with a strong focus on de-escalation to minimise morbidity whilst maintaining oncological outcomes. Current trials will focus on the omission of Sentinel node biopsy in select groups of patients, while axillary lymph node dissection will be reserved for those with more aggressive disease.
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Affiliation(s)
- Michael R Boland
- Department of Breast Surgery, St Vincent's University Hospital, Dublin, Ireland
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2
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Kelley K, Sener SF. Who still needs surgical staging of the axilla for invasive breast cancer? J Surg Oncol 2024. [PMID: 39031783 DOI: 10.1002/jso.27753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2024] [Accepted: 06/12/2024] [Indexed: 07/22/2024]
Abstract
Sentinel lymphadenectomy may be safely omitted for postmenopausal patients with low-risk estrogen-receptor-positive cancers who have a negative pretreatment axillary ultrasound. Surgical staging should still be done for patients who are premenopausal or postmenopausal with high-risk estrogen receptor-positive cancers, for those having neoadjuvant chemotherapy, or those with estrogen-receptor-negative or human epidermal growth factor receptor-positive cancers.
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Affiliation(s)
- Kathryn Kelley
- University of Southern California-Hoag Memorial Hospital Presbyterian Breast Surgical Oncology Fellowship, Los Angeles, California, USA
- Los Angeles General Medical Center, Los Angeles, California, USA
- Department of Surgery and Norris Comprehensive Cancer Center, Keck School of Medicine of USC, University of Southern California, Los Angeles, California, USA
| | - Stephen F Sener
- Los Angeles General Medical Center, Los Angeles, California, USA
- Department of Surgery and Norris Comprehensive Cancer Center, Keck School of Medicine of USC, University of Southern California, Los Angeles, California, USA
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Bazyar S, Mannuel H, Tran PT. Stereotactic ablative radiation therapy in metastatic prostate cancer. Curr Opin Oncol 2024; 36:180-185. [PMID: 38362949 PMCID: PMC10990008 DOI: 10.1097/cco.0000000000001025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
PURPOSE OF REVIEW The evolving role of stereotactic ablative radiation therapy (SABR) as metastasis-directed therapy (MDT) for oligometastatic prostate cancer (omPCa) will be discussed. RECENT FINDINGS Oligometastatic disease (OMD) is an intermediate state between localized and wide-spread malignant disease. OMD has recently been spotlighted given the increasing demonstration of clinical benefit from local therapies despite presence of metastatic disease and allure of the curative potential of MDT in select cases. Among the different forms of MDT, SABR has rapidly become a widely adopted treatment modality. Significant efforts in this space have focused on omPCa, owing to its relatively indolent biology, presence of a sensitive and specific serum biomarker and recent advances in molecular imaging. While most studies have evaluated the role of SABR MDT in hormone sensitive omPCa, new emerging clinical data also suggests benefits of SABR MDT for even castration-resistant disease. SUMMARY Treating omPCa with SABR MDT appears to generate an efficacy signal with minimal morbidity across both hormone-sensitive and castration-resistant disease. However, additional definitive omPCa trial data are needed. Future research efforts should investigate biomarkers for this heterogeneous disease space and the role of SABR MDT in combination with systemic agents to improve upon standard of care treatments.
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Affiliation(s)
| | - Heather Mannuel
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Haque W, Butler EB, Teh BS. Personalized Radiation Therapy for Breast Cancer. Curr Oncol 2024; 31:1588-1599. [PMID: 38534954 PMCID: PMC10969188 DOI: 10.3390/curroncol31030121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 03/08/2024] [Accepted: 03/18/2024] [Indexed: 05/26/2024] Open
Abstract
Breast cancer is diagnosed in nearly 3 million people worldwide. Radiation therapy is an integral component of disease management for patients with breast cancer, and is used after breast-conserving surgery or a mastectomy to reduce the risk of a local recurrence. The following review describes the methods used to personalize radiation therapy by optimizing patient selection, using advanced treatment techniques to lessen the radiation dose to normal organs, and using hypofractionation in order to shorten the duration of radiation treatment.
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Affiliation(s)
- Waqar Haque
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX 77030, USA; (E.B.B.); (B.S.T.)
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5
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Kaidar-Person O, Tramm T, Kuehn T, Gentilini O, Prat A, Montay-Gruel P, Meattini I, Poortmans P. Optimising of axillary therapy in breast cancer: lessons from the past to plan for a better future. LA RADIOLOGIA MEDICA 2024; 129:315-327. [PMID: 37922004 DOI: 10.1007/s11547-023-01743-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 10/12/2023] [Indexed: 11/05/2023]
Abstract
In this narrative review, we aim to explore the ability of radiation therapy to eradicate breast cancer regional node metastasis. It is a journey through data of older trials without systemic therapy showing the magnitude of axillary therapy (surgery versus radiation) on cancer control. Considering that both systemic and loco-regional therapies were shown to reduce any recurrence with a complex interaction, our review includes surgical, radiation, and radiobiology consideration for breast cancer, and provide our view of future practise. The aim is to provide information optimise radiation therapy in the era of primary systemic therapy.
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Affiliation(s)
- Orit Kaidar-Person
- Breast Radiation Unit, Sheba Tel Hashomer, Ramat Gan, Israel.
- School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
- Department Radiation Oncology (Maastro), GROW-School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, The Netherlands.
| | - Trine Tramm
- Department of Pathology, Aarhus University Hospital, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Oreste Gentilini
- Breast Surgery, IRCCS Ospedale San Raffaele, Milano, Italy
- Università Vita-Salute San Raffaele, UniSR, Milano, Italy
| | - Aleix Prat
- University of Barcelona, Barcelona, Spain
- Cancer Insititute, IDIBAPS, Barcelona, Spain
| | | | - Icro Meattini
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence, Florence, Italy
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
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6
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Kaidar-Person O, Giasafaki P, Boersma L, De Brouwer P, Weltens C, Kirkove C, Peignaux-Casasnovas K, Budach V, van der Leij F, Vonk E, Weidner N, Rivera S, van Tienhoven G, Fourquet A, Noel G, Valli M, Guckenberger M, Koiter E, Racadot S, Abdah-Bortnyak R, Bartelink H, Struikmans H, Fortpied C, Poortmans PM. Mapping the location of local and regional recurrences according to breast cancer surgery and radiation therapy: Results from EORTC 22922/10925. Radiother Oncol 2023; 185:109698. [PMID: 37211281 DOI: 10.1016/j.radonc.2023.109698] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/01/2023] [Accepted: 05/03/2023] [Indexed: 05/23/2023]
Abstract
The purpose of this study is to evaluate the influence of the extent of surgery and radiation therapy (RT) on the rates and sites of local (LR) and regional recurrences (RR) in the EORTC 22922/10925 trial. PATIENTS AND METHODS All data were extracted from the trial's individual patients' case report forms (CRF) and analysed with a median follow-up of 15.7 years. Cumulative incidence curves were produced for LR and RR accounting for competing risks: an exploratory analysis of the effect of the extent of surgical and radiation treatments on LR rate was conducted using the Fine & Gray model accounting for competing risks and adjusted for baseline patient and disease characteristics. The significance level was set at 5%, 2-sided. Frequency tables were used to describe the spatial location of LR and RR. RESULTS Out of 4004 patients included in the trial, 282 (7%) patients experienced LR and 165 (4.1%) RR, respectively. Cumulative incidence rate of LR at 15 years was lower after mastectomy (3.1%) compared to BCS + RT (7.3%) (F&G: HR (Hazard Ratio) = 0.421, 95%CI = 0.282-0.628, p-value < 0.0001). LR were similar up to 3 years for both mastectomy and BCS but continued to occur at a steady rate for BCS + RT, only. The spatial location of the recurrence was related to the locoregional therapy applied and the absolute gain of RT correlated to stage of disease and extent of surgery. CONCLUSIONS The extent of locoregional therapies impacts significantly on LR and RR rates and spatial location.
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Affiliation(s)
- Orit Kaidar-Person
- Breast Cancer Radiation Therapy Unit, Sheba Medical Center, Ramat Gan, Israel; The Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Dept. Radiation Oncology (Maastro), GROW-School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, The Netherlands.
| | | | - Liesbeth Boersma
- Dept. Radiation Oncology (Maastro), GROW-School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Peter De Brouwer
- Department of Radiation Oncology, Institute Verbeeten, Tilburg, The Netherlands
| | - Caroline Weltens
- Department of Radiation Oncology, University Hospital Leuven, KU Leuven faculty of medicine, Leuven, Belgium
| | - Carine Kirkove
- Department of Radiation Oncology, University Hospital Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | | | - Volker Budach
- Department of Radiation Oncology and Radiotherapy, Comprehensive Cancer Center, Charite University Medicine, Berlin, Germany
| | - Femke van der Leij
- Department of Radiation Oncology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Ernest Vonk
- Institute for Radiation Oncology RISO, Deventer, The Netherlands
| | - Nicola Weidner
- Department of Radiation Oncology, University Hospital, Tübingen, Germany
| | - Sofia Rivera
- Department of Radiation Oncology, Gustave Roussy Cancer Centre, Villejuif, France
| | - Geertjan van Tienhoven
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Alain Fourquet
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Georges Noel
- Department of Radiation Oncology, Centre Paul Strauss, Strasbourg, France
| | - Mariacarla Valli
- Department of Radiation Oncology, Sant Anna Hospital, Como, Italy
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Switzerland
| | - Eveline Koiter
- Department of Radiation Oncology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Severine Racadot
- Department of Radiation Oncology, Centre Léon Bérard, Lyon, France
| | | | - Harry Bartelink
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Henk Struikmans
- Department of Radiation Oncology, Leiden University Medical Centre, Leiden, The Netherlands
| | | | - Philip M Poortmans
- Department of Radiation Oncology, Iridium Netwerk, Wilrijk-Antwerp, Belgium; University of Antwerp, Faculty of Medicine and Health Sciences, Wilrijk-Antwerp, Belgium
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Suresh GM, Yeshwanth R, Arjunan R, Ramachandra C, Altaf S. Who Needs Level III Lymph Node Dissection in Carcinoma Breast-Study from a Tertiary Care Center. Indian J Surg Oncol 2023; 14:324-330. [PMID: 37324309 PMCID: PMC10267033 DOI: 10.1007/s13193-020-01243-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Accepted: 09/24/2020] [Indexed: 10/23/2022] Open
Abstract
In Indian females, breast cancer is the most common cancer with a late stage of presentation leading to one-third of patients undergoing modified radical mastectomy (MRM). Our study is undertaken to find out predictors of level III axillary lymph node metastasis in breast cancer and who needs complete axillary lymph node dissection (ALND). Retrospective study of 146 patients who undergone MRM or breast-conserving surgery (BCS) with complete ALND at Kidwai Memorial Institute of Oncology was done, and data was analyzed to find out the frequency of level III lymph nodes and the demographic relation and its relation to positive lymph nodes in level I + II. Positive metastatic level III lymph node was found in 6% of patients, with the median age of the patient in our study with level III positivity was 48.5 years with 63% pathological stage II with 88% perinodal spread (PNS)- and lymphovascular invasion (LVI)-positive. Involvement of level III lymph node was associated with gross disease in level I + II lymph node having more than four lymph node-positive and with pT3 stage or more which has higher chances of level III lymph node involvement. Level III lymph node involvement, though rare in early-stage breast cancer, is associated with larger clinical and pathological sizes (T3 or more), more than 4 lymph node-positive in level I + II and with PNS and LVI. Hence, based on these results, we recommend that for inpatient with more than 5-cm tumor size and those with the gross disease in axilla, complete ALND is recommended.
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Affiliation(s)
- Girish Mysore Suresh
- Department of surgical oncology, Kidwai Memorial Institute of Oncology (KMIO), Dr. MH Mariagowda road, Near Bangalore Dairy, Bengaluru, Karnataka 560029 India
| | - R. Yeshwanth
- Department of surgical oncology, Kidwai Memorial Institute of Oncology (KMIO), Dr. MH Mariagowda road, Near Bangalore Dairy, Bengaluru, Karnataka 560029 India
| | - Ravi Arjunan
- Department of surgical oncology, Kidwai Memorial Institute of Oncology (KMIO), Dr. MH Mariagowda road, Near Bangalore Dairy, Bengaluru, Karnataka 560029 India
| | - C. Ramachandra
- Department of surgical oncology, Kidwai Memorial Institute of Oncology (KMIO), Dr. MH Mariagowda road, Near Bangalore Dairy, Bengaluru, Karnataka 560029 India
| | - Syed Altaf
- Department of surgical oncology, Kidwai Memorial Institute of Oncology (KMIO), Dr. MH Mariagowda road, Near Bangalore Dairy, Bengaluru, Karnataka 560029 India
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Safety and Accuracy of Sentinel Lymph Node Biopsy Alone in Clinically Node-Positive Patients Undergoing Upfront Surgery for Invasive Breast Cancer: A Systematic Review. Curr Oncol 2023; 30:3102-3110. [PMID: 36975448 PMCID: PMC10047769 DOI: 10.3390/curroncol30030235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 02/20/2023] [Accepted: 02/22/2023] [Indexed: 03/09/2023] Open
Abstract
Landmark trials (Z0011 and AMAROS) have demonstrated that axillary lymph node dissection (ALND) can be safely omitted in patients with breast cancer and 1–2 positive sentinel nodes. Extrapolating from these and other cardinal studies such as NSABP B-04, guidelines state that patients with 1–2 needle biopsy-proven positive lymph nodes undergoing upfront surgery can have sentinel lymph node biopsy (SLNB) alone. The purpose of this study is to systematically review the literature to identify studies examining the direct application of SLNB in such patients. EMBASE and Ovid MEDLINE were searched from inception to 3 May 2022. Studies including patients with nodal involvement confirmed on pre-operative biopsy and undergoing SLNB were identified. Studies with neoadjuvant chemotherapy were excluded. Search resulted in 2518 records, of which 68 full-text studies were reviewed, ultimately yielding only 2 studies meeting inclusion criteria. Both studies used targeted axillary surgery (TAS) with pre-operative localization of the biopsy-proven positive node in addition to standard SLNB techniques. In a non-randomized single-center prospective study, Lee et al. report no regional recurrences in patients undergoing TAS or ALND, and no difference in distant recurrence or mortality at 5 years. In the prospective multicenter TAXIS trial by Webber et al., the median number of positive nodes retrieved with TAS in patients undergoing upfront surgery was 2 (1, 4 IQR). Within the subset of patients who underwent subsequent ALND, 61 (70.9%) had additional positive nodes, with 26 (30.2%) patients having ≥4 additional positive nodes. Our review demonstrates that there is limited direct evidence for SLNB alone in clinically node-positive patients undergoing upfront surgery. Available data suggest a high proportion of patients with residual disease in this setting. While the totality of the data, mostly indirect evidence, suggests SLNB alone may be safe, we call on clinicians and researchers to prospectively collect data on this patient population to better inform decision-making.
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Dwivedi S, Shankaran R, Saidha N, Sharma R, Mukherjee D, Dwivedi S, Agarwal V, Arnav A, Chaudhary A, Hans R. Observational Study to Determine the Involvement of Level III Lymph Nodes in Case of Clinically Positive Level II Nodes in Carcinoma Breast. Indian J Surg Oncol 2023; 14:106-112. [PMID: 36891429 PMCID: PMC9986151 DOI: 10.1007/s13193-022-01618-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 08/06/2022] [Indexed: 12/24/2022] Open
Abstract
Management of breast cancer has gradually shifted from era of radical surgery to present days of multimodality management and conservatism. Management of carcinoma breast is primarily multimodality of which surgery is one of the important roles to play. Our study is a prospective observational study to determine the involvement of level III axillary lymph nodes in clinically involved axilla with grossly involved lower-level axillary nodes. Underestimation of a number of involved nodes at level III shall result in inaccuracy of subset risk stratification leading to substandard prognostication. The enigma of not addressing presumably involved nodes thereby altering the staging vs acquired morbidity has always been a contentious issue. Mean lymph node harvest at the lower level (I and II) was 17.9 ± 6.3 (range: 6-32) while positive lower-level axillary lymph node involvement was 6.5 ± 6.5 (range: 1-27). The mean ± SD for level III positive lymph node involvement was 1.46 ± 1.69 (range: 0-8). Our prospective observational study though limited by the number and years of follow-up has demonstrated that the presence of more than three positive LN at a lower level increases the risk for higher nodal involvement substantially. It is also evident in our study that PNI, ECE, and LVI increased the probability of stage up-gradation. LVI was found to be a significant prognostic factor for apical LN involvement in multivariate analysis. On multivariate logistic regression > 3 pathological positive lymph nodes at the level I and II and LVI involvement elevated the risk of involvement at level III by 11 and 46 times, respectively. It is recommended that patients who have a positive pathological surrogate marker of aggressiveness should be evaluated perioperatively for level III involvement, especially in the setting of visible grossly involved nodes. The patient should be counseled and informed decision to perform complete axillary lymph node dissection with the added risk of morbidity should be contemplated.
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Affiliation(s)
- Surjeet Dwivedi
- Dept of Surgery, Surgical Oncologist, Command Hospital Air Force Bangalore, Bengaluru, India 560007
| | - R. Shankaran
- INHS Ashvini, Command Hospital Mumbai, Mumbai, India
| | | | - Rohit Sharma
- Dept of MDTC, Army Hospital Delhi, New Delhi, India
| | | | | | | | | | | | - Raj Hans
- Army Hospital R & R New, Delhi, New Delhi, India
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Clinical Trials in Breast Cancer. Surg Clin North Am 2023; 103:17-33. [DOI: 10.1016/j.suc.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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The Impact of Oncoplastic Reduction on Initiation of Adjuvant Radiation and Need for Reexcision. Ann Plast Surg 2022; 89:e11-e17. [DOI: 10.1097/sap.0000000000003313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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De-Escalating the Management of In Situ and Invasive Breast Cancer. Cancers (Basel) 2022; 14:cancers14194545. [PMID: 36230468 PMCID: PMC9559495 DOI: 10.3390/cancers14194545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 09/01/2022] [Accepted: 09/11/2022] [Indexed: 11/20/2022] Open
Abstract
Simple Summary De-escalation of breast cancer treatment reduces morbidity and toxicity for patients. De-escalation is safe if cancer outcomes, such as recurrence and survival, remain unaffected compared to more radical regimens. This review provides an overview on treatment de-escalation for ductal carcinoma in situ (DCIS), local treatment of breast cancer, and surgery after neoadjuvant systemic therapy. Improvements in understanding the natural history and biology of breast cancer, imaging modalities, and adjuvant treatments have facilitated de-escalation of treatment over time. Abstract It is necessary to identify appropriate areas of de-escalation in breast cancer treatment to minimize morbidity and maximize patients’ quality of life. Less radical treatment modalities, or even no treatment, have been reconsidered if they offer the same oncologic outcomes as standard therapies. Identifying which patients benefit from de-escalation requires particular care, as standard therapies will continue to offer adequate cancer outcomes. We provide an overview of the literature on the de-escalation of treatment of ductal carcinoma in situ (DCIS), local treatment of breast cancer, and surgery after neoadjuvant systemic therapy. De-escalation of breast cancer treatment is a key area of investigation that will continue to remain a priority. Improvements in understanding the natural history and biology of breast cancer, imaging modalities, and adjuvant treatments will expand this even further. Future efforts will continue to challenge us to consider the true role of various treatment modalities.
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Age disparities in triple-negative breast cancer treatment and outcomes: An NCDB analysis. Surgery 2022; 172:821-830. [PMID: 35927082 DOI: 10.1016/j.surg.2022.05.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/07/2022] [Accepted: 05/23/2022] [Indexed: 10/16/2022]
Abstract
BACKGROUND Race, access to care, and molecular features result in outcome disparities in triple-negative breast cancer (TNBC). We sought to determine the role of age in TNBC disparity by hypothesizing that younger patients receive more comprehensive treatment, resulting in survival differences. METHODS The National Cancer Database was used to identify women with unilateral TNBC treated from 2005 through 2017. Patients were stratified by age (≤40, 41-70, >70); demographics, clinical characteristics, and treatment factors were compared. Logistic regression determined factors associated with treatment received. Survival outcomes were analyzed using a stratified log-rank test. RESULTS Of the 168,715 patients, 16,287 (9.6%) were ≤40 years. Patients ≤40 were significantly more likely to present at higher clinical stage (P < .001) and receive neoadjuvant chemotherapy (NAC, P < .001). Bilateral mastectomy was the most common surgery for patients ≤40 (37%), whereas partial mastectomy was most often used in patients 41 to 70 years old (48%) and those >70 (49%) (P < .001). Patients ≤40 years were significantly more likely to undergo both NAC and mastectomy than those >40 (odds ratio 1.5, both P < .05) despite a greater in-breast tumor response in the youngest patients. Patients treated with mastectomy and axillary lymph node dissection had inferior survival outcomes compared to those treated with partial mastectomy and sentinel lymph node biopsy across all 3 age groups (P < .001). CONCLUSION The clinical characteristics of TNBC differ significantly at the extremes of age, likely driving treatment decisions. Although patients ≤40 present with a more advanced disease and appropriately receive NAC, they also undergo more extensive surgery that does not yield a survival benefit. Further research is needed to determine if age disparity is due to oncologic factors or patient and provider preferences.
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14
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Evaluation of Breast Problems. Clin Obstet Gynecol 2022; 65:430-447. [PMID: 35708978 DOI: 10.1097/grf.0000000000000717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Breast disorders arise from a myriad of etiologies. They are frequent reasons for patient encounters in primary care and obstetric and gynecologic practices. The most common complaints include breast pain, nipple discharge and breast lumps or masses. Given widespread and well-known screening recommendations, breast cancers are regularly diagnosed during routine screening. Regardless of the presenting complaint, a patient's presentation, physical examination, and diagnostic imaging may require a unique framework for adequate and timely diagnosis for appropriate intervention and treatment. This manuscript aims to discuss and guide assessment to manage breast disorders.
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Nelson JA, Rubenstein RN, Haglich K, Chu JJ, Yin S, Stern CS, Morrow M, Mehrara BJ, Gemignani ML, Matros E. Analysis of a Trend Reversal in US Lumpectomy Rates From 2005 Through 2017 Using 3 Nationwide Data Sets. JAMA Surg 2022; 157:702-711. [PMID: 35675047 DOI: 10.1001/jamasurg.2022.2065] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Importance Rates of lumpectomy for breast cancer management in the United States previously declined in favor of more aggressive surgical options, such as mastectomy and contralateral prophylactic mastectomy (CPM). Objective To evaluate longitudinal trends in the rates of lumpectomy and mastectomy, including unilateral mastectomy vs CPM rates, and to determine characteristics associated with current surgical practice using 3 national data sets. Design and Setting Data from the National Surgical Quality Improvement Program (NSQIP), Surveillance, Epidemiology, and End Results (SEER) program, and National Cancer Database (NCDB) were examined to evaluate trends in lumpectomy and mastectomy rates from 2005 through 2017. Mastectomy rates were also evaluated with a focus on CPM. Longitudinal trends were analyzed using the Cochran-Armitage test for trend. Multivariate logistic regression models were performed on the NCDB data set to identify predictors of lumpectomy and CPM. Results A study sample of 3 467 645 female surgical breast cancer patients was analyzed. Lumpectomy rates reached a nadir between 2010 and 2013, with a significant increase thereafter. Conversely, in comparison with lumpectomy rates, overall mastectomy rates declined significantly starting in 2013. Cochran-Armitage trend tests demonstrated an annual decrease in lumpectomy rates of 1.31% (95% CI, 1.30%-1.32%), 0.07% (95% CI, 0.01%-0.12%), and 0.15% (95% CI, 0.15%-0.16%) for NSQIP, SEER, and NCDB, respectively, from 2005 to 2013 (P < .001, P = .01, and P < .001, respectively). From 2013 to 2017, the annual increase in lumpectomy rates was 0.96% (95% CI, 0.95%-0.98%), 1.60% (95% CI, 1.59%-1.62%), and 1.66% (95% CI, 1.65%-1.67%) for NSQIP, SEER, and NCDB, respectively (all P < .001). Comparisons of specific mastectomy types showed that unilateral mastectomy and CPM rates stabilized after 2013, with unilateral mastectomy rates remaining higher than CPM rates throughout the entire time period. Conclusions This observational longitudinal analysis indicated a trend reversal with an increase in lumpectomy rates since 2013 and an associated decline in mastectomies. The steady increase in CPM rates from 2005 to 2013 has since stabilized. The reasons for the recent reversal in trends are likely multifactorial. Further qualitative and quantitative research is required to understand the factors driving these recent practice changes and their associations with patient-reported outcomes.
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Affiliation(s)
- Jonas A Nelson
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Robyn N Rubenstein
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kathryn Haglich
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jacqueline J Chu
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Shen Yin
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Carrie S Stern
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Babak J Mehrara
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Mary L Gemignani
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Evan Matros
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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16
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Abstract
INTRODUCTION As breast cancer treatment options have multiplied and biologic diversity within breast cancer has been recognized, the use of the same treatment strategies for patients with early-stage and favorable disease, and for those with biologically aggressive disease, has been questioned. In addition, as patient-reported outcome measures have called attention to the morbidity of many common treatments, and as the cost of breast cancer care has continued to increase, reduction in the overtreatment of breast cancer has assumed increasing importance. AREAS COVERED Here we review selected aspects of surgery, radiation oncology, and medical oncology for which scientific evidence supports de-escalation for invasive carcinoma and ductal carcinoma in situ, and assess strategies to address overtreatment. EXPERT OPINION The problems of breast cancer overtreatment we face today are based on improved understanding of the biology of breast cancer and abandonment of the 'one-size-fits-all' approach. As breast cancer care becomes increasingly complex, and as our knowledge base continues to increase exponentially, these problems will only be magnified in the future. To continue progress, the move must be made from advocating the maximum-tolerated treatment to advocating the minimum-effective one.
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Affiliation(s)
- Linda M Pak
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York
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17
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Duan S, Buxton ILO. Evolution of Medical Approaches and Prominent Therapies in Breast Cancer. Cancers (Basel) 2022; 14:2450. [PMID: 35626053 PMCID: PMC9140094 DOI: 10.3390/cancers14102450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/06/2022] [Accepted: 05/09/2022] [Indexed: 12/10/2022] Open
Abstract
An examination of the origins of medical approaches to breast cancer marks this disease as one of the most difficult to manage. As the early identification, diagnosis and treatment of breast cancer evolve, we will move to a time when each patient and their cancer can be assessed to determine unique patient-specific (personalized) approaches to therapy. Humans have attempted to manage breast cancer for millennia. Even today, the disease claims thousands of lives each year. In light of the increasingly sophisticated understanding of cancer diagnosis and treatment, together with our ultimate failure to offer a cure in the most difficult cases, it is instructive to reflect on the beginnings of our understanding.
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Affiliation(s)
- Suzann Duan
- Department of Pharmacology, University of Nevada, Reno School of Medicine, Reno, NV 89557, USA;
| | - Iain L. O. Buxton
- Department of Medicine, University of Arizona College of Medicine, Tucson, AZ 85724, USA
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18
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Le-Petross HT, Slanetz PJ, Lewin AA, Bao J, Dibble EH, Golshan M, Hayward JH, Kubicky CD, Leitch AM, Newell MS, Prifti C, Sanford MF, Scheel JR, Sharpe RE, Weinstein SP, Moy L. ACR Appropriateness Criteria® Imaging of the Axilla. J Am Coll Radiol 2022; 19:S87-S113. [PMID: 35550807 DOI: 10.1016/j.jacr.2022.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 02/19/2022] [Indexed: 11/26/2022]
Abstract
This publication reviews the current evidence supporting the imaging approach of the axilla in various scenarios with broad differential diagnosis ranging from inflammatory to malignant etiologies. Controversies on the management of axillary adenopathy results in disagreement on the appropriate axillary imaging tests. Ultrasound is often the appropriate initial imaging test in several clinical scenarios. Clinical information (such as age, physical examinations, risk factors) and concurrent complete breast evaluation with mammogram, tomosynthesis, or MRI impact the type of initial imaging test for the axilla. Several impactful clinical trials demonstrated that selected patient's population can received sentinel lymph node biopsy instead of axillary lymph node dissection with similar overall survival, and axillary lymph node dissection is a safe alternative as the nodal staging procedure for clinically node negative patients or even for some node positive patients with limited nodal tumor burden. This approach is not universally accepted, which adversely affect the type of imaging tests considered appropriate for axilla. This document is focused on the initial imaging of the axilla in various scenarios, with the understanding that concurrent or subsequent additional tests may also be performed for the breast. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Huong T Le-Petross
- The University of Texas MD Anderson Cancer Center, Houston, Texas; Director of Breast MRI.
| | - Priscilla J Slanetz
- Panel Chair, Boston University School of Medicine, Boston, Massachusetts; Vice Chair of Academic Affairs, Department of Radiology, Boston Medical Center; Associate Program Director, Diagnostic Radiology Residency, Boston Medical Center; Program Director, Early Career Faculty Development Program, Boston University Medical Campus; Co-Director, Academic Writing Program, Boston University Medical Group; President, Massachusetts Radiological Society; Vice President, Association of University Radiologists
| | - Alana A Lewin
- Panel Vice-Chair, New York University School of Medicine, New York, New York; Associate Program Director, Breast Imaging Fellowship, NYU Langone Medical Center
| | - Jean Bao
- Stanford University Medical Center, Stanford, California; Society of Surgical Oncology
| | | | - Mehra Golshan
- Smilow Cancer Hospital, Yale Cancer Center, New Haven, Connecticut; American College of Surgeons; Deputy CMO for Surgical Services and Breast Program Director, Smilow Cancer Hospital at Yale; Executive Vice Chair for Surgery, Yale School of Medicine
| | - Jessica H Hayward
- University of California San Francisco, San Francisco, California; Co-Fellowship Direction, Breast Imaging Fellowship
| | | | - A Marilyn Leitch
- UT Southwestern Medical Center, Dallas, Texas; American Society of Clinical Oncology
| | - Mary S Newell
- Emory University Hospital, Atlanta, Georgia; Interim Director, Division of Breast Imaging at Emory; ACR: Chair of BI-RADS; Chair of PP/TS
| | - Christine Prifti
- Boston Medical Center, Boston, Massachusetts, Primary care physician
| | | | | | | | - Susan P Weinstein
- Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania; Associate Chief of Radiology, San Francisco VA Health Systems
| | - Linda Moy
- Specialty Chair, NYU Clinical Cancer Center, New York, New York; Chair of ACR Practice Parameter for Breast Imaging, Chair ACR NMD
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19
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Karadeniz Cakmak G. Innovative Standards in Oncoplastic Breast Conserving Surgery: From Radical Mastectomy to Extreme Oncoplasty. Breast Care (Basel) 2022; 16:559-573. [PMID: 35087359 DOI: 10.1159/000518992] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 08/11/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Oncoplastic breast conserving surgery (OBCS), which is the current procedure of choice for eligible BC patients, describes a philosophy that prioritizes oncologic and cosmetic outcomes. However, knowledge gaps regarding training, acceptance, and practice preclude standardization and make it difficult to design algorithmic guidelines to optimize individualized management in the era of precision medicine. SUMMARY The harmony between patient expectations and oncologic goals creates the state of the art of OBCS. Nevertheless, to achieve these goals, multidisciplinary approach is a must. Surgical decisions require a comprehensive evaluation including patient factors, tumor biology, genetics, technical considerations, and adjunct therapies. Moreover, the quality-of-life (QOL) issues should be considered as the highest level of priority with a shared decision making instituted on realistic discussions with the patient. KEY MESSAGES The standardization in OBCS should be initiated via defining a breast surgeon who should gain theorical and practical competence on techniques via national or international educational programs. The algorithmic patient assessment with appropriate documentation before and after surgery should be established. A simple and safe global lexicon should be designed regarding techniques to be proposed and quality metrics to be considered. Additionally, international multicenter prospective trials should be instituted to overcome knowledge gaps. It is evident that OBCS is the perfect union of science with art. Nevertheless, at the very end, the question is not the nature of the surgeon/artist who would be the extremist, the innovator, or the conservative, but the patient's satisfaction, prognosis, and QOL that conclude the cascade of state of the art of OBCS.
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20
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Abstract
Dr. Bernard Fisher (1918-2019) was an early proponent of evidence-based medicine using the mechanism of prospective, multicenter, randomized clinical trials to test biological and clinical hypotheses. In this article, I trace how his early scientific work in striving to understand the nature of cancer metastasis through animal experiments led to a new, testable, clinical hypothesis: that surgery to remove only the tumor and a small amount of tissue around it was as effective as the more disfiguring operations that were then the standard treatment. Fisher's work with the National Surgical Adjuvant Breast and Bowel Project (NSABP) using large, randomized clinical trials to demonstrate the veracity of this hypothesis led to a new paradigm in which the emphasis was placed on how systemic therapies used at an early stage of disease could effectively eradicate breast cancer for many patients. This new therapeutic approach led to the successful development of new treatments, many of which are widely used today. Ultimately, the new paradigm led to successfully preventing breast cancer in women who were at high risk for the disease but who had not yet been diagnosed with the disease. Throughout his entire career, Fisher championed the use of large prospective, randomized clinical trials despite criticism from many in the medical community who strongly criticized his use of randomization as a mechanism for testing clinical hypotheses. The approach he and the NSABP employed is still considered to be the highest standard of evidence in conducting clinical studies.
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Affiliation(s)
- Stewart Anderson
- University of Pittsburgh Graduate School of Public Health - Biostatistics, Pittsburgh, PA, USA
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21
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Hersh EH, King TA. De-escalating axillary surgery in early-stage breast cancer. Breast 2021; 62 Suppl 1:S43-S49. [PMID: 34949533 PMCID: PMC9097808 DOI: 10.1016/j.breast.2021.11.018] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 11/23/2021] [Accepted: 11/25/2021] [Indexed: 02/06/2023] Open
Abstract
The role of axillary surgery has evolved over the last three decades from routine axillary lymph node dissection (ALND) to sentinel lymph node biopsy to omission of axillary surgery altogether in select patients. This evolution has been achieved through the design and conduct of multiple clinical trials demonstrating that ALND does not impact survival and is not necessary for local control in patients with early-stage breast cancer and limited nodal involvement. Importantly, this practice-changing shift mirrored the trend towards earlier stage at diagnosis and the recognition of the interplay between local and systemic therapies in maintaining local control. There are numerous clinical scenarios today in which axillary staging can be safely avoided, including (1) DCIS treated with lumpectomy, (2) at the time of contralateral prophylactic mastectomy, and (3) in elderly patients with early-stage, HR+/HER2-clinically node-negative (cN0) disease. Ongoing clinical trials seek to expand the cohorts in which surgical nodal staging can be omitted. These populations include a broader range of early-stage, cN0 patients undergoing upfront surgery, as seen in the SOUND, INSEMA, BOOG 2013-08, SOAPET and NAUTILUS trials. Omission of axillary surgery in cN0 patients with HER2+ or triple-negative disease treated with neoadjuvant chemotherapy is also being tested in the ASICS and EUBREAST-01 trials. Continued advances in imaging and the growing role of genomic assays in selecting patients for systemic therapy are likely to further minimize the need for axillary surgery; thereby further reducing the morbidity of local therapy for women with breast cancer.
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Affiliation(s)
- Eliza H Hersh
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Tari A King
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA; Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.
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22
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Moorman AM, Rutgers EJT, Kouwenhoven EA. Omitting SLNB in Breast Cancer: Is a Nomogram the Answer? Ann Surg Oncol 2021; 29:2210-2218. [PMID: 34739639 DOI: 10.1245/s10434-021-11007-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 10/13/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUNDS Sentinel lymph node biopsy (SLNB) is standard care as a staging procedure in patients with invasive breast cancer. The axillary recurrence rate, even after positive SLNB, is low. This raises serious doubts regarding the clinical value of SLNB in early breast cancer. The purpose of this study is to select patients with low suspected axillary burden in whom SLNB might be omitted. PATIENTS AND METHODS We retrospectively analyzed 2015 primary breast cancer patients between 2007 and 2015, with 982 patients allocated to the training and 961 to the validation cohort. Variables associated with nodal disease were analyzed and used to build a nomogram for predicting nodal disease. RESULTS A total of 32.8% of patients had macrometastatic disease. A predictive model was constructed based on age, cN0, morphology, grade, multifocality, and tumor size with an area under the receiver operating characteristic curve (AUC) of 0.83. Considering a false-negative rate of 5%, 32.8% of patients could be spared axillary surgery. In a subanalysis of patients with relatively favorable characteristics, 26.8% had less than 5% chance of macrometastases. CONCLUSIONS We present a model with excellent predictive value that can select one-third of patients in whom SLNB is deemed not necessary because of less than 5% chance of nodal involvement. Whether missing 1 in 20 patients with macrometastatic disease is worthwhile balanced against preventing side-effects of the SLN procedure remains to be established. A number of ongoing large prospective trials evaluating the outcome of omitting SLNB are awaited. Meanwhile, this nomogram may be used for individual decision-making.
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Affiliation(s)
- A M Moorman
- Department of Surgery, Hospital Group Twente, Almelo, The Netherlands.
| | - E J Th Rutgers
- Department of Surgery, Antoni van Leeuwenhoek/The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - E A Kouwenhoven
- Department of Surgery, Hospital Group Twente, Almelo, The Netherlands
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23
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Bove S, Fragomeni SM, Romito A, DI Giorgio D, Rinaldi P, Pagliara D, Verri D, Romito I, Paris I, Tagliaferri L, Marazzi F, Visconti G, Franceschini G, Masetti R, Garganese G. Techniques for sentinel node biopsy in breast cancer. Minerva Surg 2021; 76:550-563. [PMID: 34338468 DOI: 10.23736/s2724-5691.21.09002-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Sentinel node biopsy (SNB) is the standard of care in women with breast cancer (BC) and clinically non suspicious axillary lymph nodes (LNs), due to its high negative predictive value (NPV) in the assessment of nodal status. SNB has significantly reduced complications related to the axillary lymph node dissection, such as lymphedema and upper limb dysfunction. EVIDENCE ACQUISITION The gold standard technique for SNB is the blue dye (BD) and technetium labelled nanocolloid (Tc-99m) double technique. However, nuclear medicine is not available in all Institutions and several new tracers and devices have been proposed, such as indocyanine green (ICG) and superparamagnetic iron oxides (SPIO). All these techniques show an accuracy and detection rate not inferior to that of the standard technique, with different specific pros and cons. The choice of how to perform a SNB primarily depends on the surgeon's confidence with the procedure, the availability of nuclear medicine and the economic resources of the Institutions. In this setting, new tracers, hybrid tracers and imaging techniques are being evaluated in order to improve the detection rate of sentinel lymph nodes (SNs) and minimize the number of unnecessary axillary surgeries through an accurate preoperative assessment of nodal status and to guide new minimally invasive diagnostic procedures of SNs. In particular, the contrast-enhanced ultrasound (CEUS) is an active field of research but cannot be recommended for clinical use at this time. EVIDENCE SYNTHESIS The ICG fluorescence technique was superior in terms of DR, as well as having the lowest FNR. The DR descending order was SPIO, Tc, dual modality (Tc/BD), CEUS and BD. CONCLUSIONS This paper is a narrative review of the most common SNB techniques in BC with a focus on recent innovations.
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Affiliation(s)
- Sonia Bove
- Gynecology and Breast Care Center, Mater Olbia Hospital, Olbia, Italy
| | - Simona M Fragomeni
- Unità di Ginecologia Oncologica, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Alessia Romito
- Gynecology and Breast Care Center, Mater Olbia Hospital, Olbia, Italy -
| | | | - Pierluigi Rinaldi
- Radiology and Interventional Radiology Unit, Mater Olbia Hospital, Olbia, Italy.,Dipartimento di Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Domenico Pagliara
- Gynecology and Breast Care Center, Mater Olbia Hospital, Olbia, Italy
| | - Debora Verri
- Gynecology and Breast Care Center, Mater Olbia Hospital, Olbia, Italy
| | - Ilaria Romito
- Gynecology and Breast Care Center, Mater Olbia Hospital, Olbia, Italy
| | - Ida Paris
- Unità di Ginecologia Oncologica, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Luca Tagliaferri
- Dipartimento di Diagnostica per immagini, Radioterapia Oncologica ed Ematologia - Gemelli ART (Advanced Radiation Therapy), Interventional Oncology Center (IOC), Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Fabio Marazzi
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, UOC di Radioterapia Oncologica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giuseppe Visconti
- Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, UOC Chirurgia Plastica, Università Cattolica del Sacro Cuore - Fondazione Policlinico Universitario A. Gemelli IRCSS, Rome, Italy
| | - Gianluca Franceschini
- Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Multidisciplinary Breast Center, Università Cattolica del Sacro Cuore - Fondazione Policlinico Universitario A. Gemelli IRCSS, Rome, Italy
| | - Riccardo Masetti
- Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Multidisciplinary Breast Center, Università Cattolica del Sacro Cuore - Fondazione Policlinico Universitario A. Gemelli IRCSS, Rome, Italy
| | - Giorgia Garganese
- Gynecology and Breast Care Center, Mater Olbia Hospital, Olbia, Italy.,Dipartimento Scienze della Vita e Sanità Pubblica, Università Cattolica del Sacro Cuore, Rome, Italy
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24
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Cheng D, Baynosa J, Cross C, Kirgan D, Williams SJ, St Hill C. Comparing the effect of distance to treatment facility on reconstruction and breast conservation therapy for early-stage invasive ductal carcinoma between the nation and the mountain region. Am J Surg 2021; 224:1049-1056. [PMID: 34001333 DOI: 10.1016/j.amjsurg.2021.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 04/10/2021] [Accepted: 04/20/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Our objective is to evaluate the effect of distance to facility on the use of breast conservation therapy and reconstruction for early stage breast cancer. METHODS Utilizing the National Cancer Database, we identified females, age <65, with Stage I invasive ductal carcinoma from 2004 to 2015. Using logistic regression, we compared radiation, mastectomy, and reconstruction treatment patterns. A subgroup analysis was performed within the mountain region (MR). RESULTS Nationwide, there are decreasing odds of radiation, increasing odds of mastectomy, and increasing odds of reconstruction. Patients living farther were less likely to receive radiation, more likely to undergo mastectomy, with no effect on reconstruction. Within the MR, patients living farther from their facility were less likely to receive radiation, more likely to undergo mastectomy, however, they were less likely to undergo reconstruction. CONCLUSIONS Nationwide and within the MR, patients living farther from their facility are less likely to receive radiation and more likely to undergo mastectomy. There is a disparity between the MR and the nation in use of reconstruction for this population.
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Affiliation(s)
- Daniel Cheng
- University of Nevada, Las Vegas, School of Medicine, USA.
| | | | - Chad Cross
- University of Nevada, Las Vegas, School of Medicine, USA; University of Nevada, Las Vegas, School of Public Health, USA.
| | - Daniel Kirgan
- University of Nevada, Las Vegas, School of Medicine, USA.
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25
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Hochman G, Shacham-Shmueli E, Raskin SP, Rosenbaum S, Bunimovich-Mendrazitsky S. Metastasis Initiation Precedes Detection of Primary Cancer-Analysis of Metastasis Growth in vivo in a Colorectal Cancer Test Case. Front Physiol 2021; 11:533101. [PMID: 33391005 PMCID: PMC7773782 DOI: 10.3389/fphys.2020.533101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 11/20/2020] [Indexed: 11/16/2022] Open
Abstract
Most cases of deaths from colorectal cancer (CRC) result from metastases, which are often still undetectable at disease detection time. Even so, in many cases, shedding is assumed to have taken place before that time. The dynamics of metastasis formation and growth are not well-established. This work aims to explore CRC lung metastasis growth rate and dynamics. We analyzed a test case of a metastatic CRC patient with four lung metastases, with data of four serial computed tomography (CT) scans measuring metastasis sizes while untreated. We fitted three mathematical growth models—exponential, logistic, and Gompertzian—to the CT measurements. For each metastasis, a best-fitted model was determined, tumor doubling time (TDT) was assessed, and metastasis inception time was extrapolated. Three of the metastases showed exponential growth, while the fourth showed logistic restraint of the growth. TDT was around 93 days. Predicted metastasis inception time was at least 4–5 years before the primary tumor diagnosis date, though they did not reach detectable sizes until at least 1 year after primary tumor resection. Our results support the exponential growth approximation for most of the metastases, at least for the clinically observed time period. Our analysis shows that metastases can be initiated before the primary tumor is detectable and implies that surgeries accelerate metastasis growth.
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Affiliation(s)
- Gili Hochman
- Department of Mathematics, Ariel University, Ariel, Israel
| | | | | | - Sara Rosenbaum
- Department of Mathematics, Ariel University, Ariel, Israel
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26
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Hewitt K, Son J, Glencer A, Borowsky AD, Cooperberg MR, Esserman LJ. The Evolution of Our Understanding of the Biology of Cancer Is the Key to Avoiding Overdiagnosis and Overtreatment. Cancer Epidemiol Biomarkers Prev 2020; 29:2463-2474. [PMID: 33033145 DOI: 10.1158/1055-9965.epi-20-0110] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 04/06/2020] [Accepted: 10/01/2020] [Indexed: 11/16/2022] Open
Abstract
There has been a tremendous evolution in our thinking about cancer since the 1880s. Breast cancer is a particularly good example to evaluate the progress that has been made and the new challenges that have arisen due to screening that inadvertently identifies indolent lesions. The degree to which overdiagnosis is a problem depends on the reservoir of indolent disease, the disease heterogeneity, and the fraction of the tumors that have aggressive biology. Cancers span the spectrum of biological behavior, and population-wide screening increases the detection of tumors that may not cause harm within the patient's lifetime or may never metastasize or result in death. Our approach to early detection will be vastly improved if we understand, address, and adjust to tumor heterogeneity. In this article, we use breast cancer as a case study to demonstrate how the approach to biological characterization, diagnostics, and therapeutics can inform our approach to screening, early detection, and prevention. Overdiagnosis can be mitigated by developing diagnostics to identify indolent disease, incorporating biology and risk assessment in screening strategies, changing the pathology rules for tumor classification, and refining the way we classify precancerous lesions. The more the patterns of cancers can be seen across other cancers, the more it is clear that our approach should transcend organ of origin. This will be particularly helpful in advancing the field by changing both our terminology for what is cancer and also by helping us to learn how best to mitigate the risk of the most aggressive cancers.See all articles in this CEBP Focus section, "NCI Early Detection Research Network: Making Cancer Detection Possible."
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Affiliation(s)
- Kelly Hewitt
- Department of Surgery, University of California, San Francisco, San Francisco, California
| | - Jennifer Son
- Department of Surgery, University of California, San Francisco, San Francisco, California
| | - Alexa Glencer
- Department of Surgery, University of California, San Francisco, San Francisco, California
| | - Alexander D Borowsky
- Department of Pathology, University of California, Davis, Davis, California.,Athena Breast Health Network
| | - Matthew R Cooperberg
- Department of Urology, University of California, San Francisco, San Francisco, California.,Department of Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, California
| | - Laura J Esserman
- Department of Surgery, University of California, San Francisco, San Francisco, California. .,Athena Breast Health Network
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27
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Veronesi P, Ghidinelli F, Corso G. Axillary surgery in breast cancer: evolution and de-escalation. MINERVA CHIR 2020; 75:383-385. [PMID: 33006452 DOI: 10.23736/s0026-4733.20.08598-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Paolo Veronesi
- Division of Breast Surgery, IRCCS European Institute of Oncology, Milan, Italy - .,Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy -
| | | | - Giovanni Corso
- Division of Breast Surgery, IRCCS European Institute of Oncology, Milan, Italy.,Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
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28
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Elmore LC, Dietz JR, Myckatyn TM, Margenthaler JA. The Landmark Series: Mastectomy Trials (Skin-Sparing and Nipple-Sparing and Reconstruction Landmark Trials). Ann Surg Oncol 2020; 28:273-280. [PMID: 32886286 DOI: 10.1245/s10434-020-09052-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 08/08/2020] [Indexed: 11/18/2022]
Abstract
Despite advances in medical therapy, the foundation of breast cancer treatment is surgery. The landscape of operative intervention for breast cancer has shifted toward less invasive techniques, resulting in improved cosmesis and lower morbidity while maintaining oncologic integrity. In this article, we review the body of literature contributing to landmark advances in mastectomy for the treatment of breast cancer.
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Affiliation(s)
- Leisha C Elmore
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Jill R Dietz
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Terence M Myckatyn
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Julie A Margenthaler
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA.
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29
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Habrawi Z, Melkus MW, Khan S, Henderson J, Brandi L, Chu V, Layeequr Rahman R. Cryoablation: A promising non-operative therapy for low-risk breast cancer. Am J Surg 2020; 221:127-133. [PMID: 32788081 DOI: 10.1016/j.amjsurg.2020.07.028] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 07/20/2020] [Accepted: 07/29/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND The aim of this study was to evaluate the feasibility of cryoablation for early-stage low-risk breast cancer without tumor resection. METHODS Women diagnosed with ER+, PR+, and HER2-infiltrating ductal carcinomas ≤1.5 cm were treated with cryoablation. The non-surgical procedure used a Visica® 2 Treatment System with ultrasound guidance for ablation of the tumor with a 1 cm margin. Patients were monitored at 6-month intervals by MRI, mammogram, and ultrasound. RESULTS Twelve patients with unifocal breast cancer were treated with cryoablation for local control without follow-up tumor resection. All patients received adjuvant endocrine therapy, and none had radiation. The median follow-up was 28.5 (range = 4-41) months with 11 patients having at least one six-month follow-up. All imaging modalities showed complete ablation of target zone 11/11 (100%). Four patients (33.3%) have been followed up for ≥ 2 years with no local failure or residual disease. CONCLUSION Cryoablation of early-stage low-risk (ER+, PR+, and HER2-) breast cancer is a safe alternative to surgery.
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Affiliation(s)
- Zaina Habrawi
- Department of Surgery, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, 79430, USA
| | - Michael W Melkus
- Department of Surgery, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, 79430, USA
| | - Sonia Khan
- Department of Surgery, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, 79430, USA
| | - James Henderson
- Texas Tech University Health Sciences Center, Breast Center of Excellence, Lubbock, TX, 79430, USA
| | - Luis Brandi
- Department of Pathology, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, 79430, USA
| | - Victoria Chu
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, 79430, USA
| | - Rakhshanda Layeequr Rahman
- Department of Surgery, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, 79430, USA; Texas Tech University Health Sciences Center, Breast Center of Excellence, Lubbock, TX, 79430, USA.
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Naxerova K. Defining the role of lymph node metastasis in systemic breast cancer evolution. EBioMedicine 2020; 57:102852. [PMID: 32574957 PMCID: PMC7322247 DOI: 10.1016/j.ebiom.2020.102852] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 06/06/2020] [Indexed: 11/23/2022] Open
Affiliation(s)
- Kamila Naxerova
- Center for Systems Biology, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States.
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Joshi S, Noronha J, Hawaldar R, Kundgulwar G, Vanmali V, Parmar V, Nair N, Shet T, Badwe R. Merits of Level III Axillary Dissection in Node-Positive Breast Cancer: A Prospective, Single-Institution Study From India. J Glob Oncol 2020; 5:1-8. [PMID: 30811304 PMCID: PMC6426546 DOI: 10.1200/jgo.18.00165] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE A complete axillary lymph node (ALN) dissection is therapeutic in node-positive breast cancer. Presently, there is no international consensus regarding anatomic levels to be addressed in complete axillary dissection. We assessed the burden of disease in level III axilla. MATERIALS AND METHODS A prospectively maintained database was assessed for 1,591 consecutive patients with nonmetastatic breast cancer registered at Tata Memorial Center, Mumbai, between January 2009 and December 2014. RESULTS A median of four (zero to 20) level III ALNs were dissected and a median of two (one to 17) nodes were positive. A total of 27.3% (434 of 1,591) patients had level III ALN metastasis, and 4.7% of patients had positive interpectoral nodes. Some 53.2% of patients had level III metastases in the presence of four or more positive level I and II ALNs. A total of 9.4% of patients had level III involvement when one to three ALNs were positive in level I and II ( P < .001). Some 53.2% of patients had level III metastases in the presence of four or more positive level I and II ALNs. On logistic regression analysis, four or more positive ALNs in level I or II ( P < .001), inner/central quadrant tumor location ( P = .013), and perinodal extension ( P < .001) were associated with level III ALN involvement. At a median follow-up of 36 months, the disease-free survival was significantly worse for level III ALN metastases on univariate analysis ( P < .001). On multivariate Cox regression analysis, histologic grade ( P = .006), four or more positive ALNs ( P < .001), hormone receptor status ( P < .001), and tumor size ( P = .037) were independent prognostic factors for disease-free survival. CONCLUSION The axillary nodal burden is high in patients with breast cancer in developing countries like India. One of two women with four or more positive level I and II ALNs may have residual disease in level III if it is not cleared during surgery. Intraoperative interpectoral space clearance should be considered in the presence of either palpable interpectoral lymph nodes or multiple positive ALNs.
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Affiliation(s)
- Shalaka Joshi
- Tata Memorial Hospital Parel, Mumbai, Maharastra, India
| | - Jarin Noronha
- Tata Memorial Hospital Parel, Mumbai, Maharastra, India
| | | | | | | | - Vani Parmar
- Tata Memorial Hospital Parel, Mumbai, Maharastra, India
| | - Nita Nair
- Tata Memorial Hospital Parel, Mumbai, Maharastra, India
| | - Tanuja Shet
- Tata Memorial Hospital Parel, Mumbai, Maharastra, India
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Affiliation(s)
- Norman Wolmark
- NSABP Foundation, Pittsburgh, PA
- University of Pittsburgh, Pittsburgh, PA
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33
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Veronesi P, Corso G. Standard and controversies in sentinel node in breast cancer patients. Breast 2020; 48 Suppl 1:S53-S56. [PMID: 31839161 DOI: 10.1016/s0960-9776(19)31124-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Axillary management in breast cancer is still controversial. Recent clinical trials have clearly demonstrated that in breast-conserving surgery, axillary dissection could be an overtreatment when metastases are present in only 1-2 sentinel lymph nodes. Nonetheless, axillary dissection remains the principal treatment in patients undergoing mastectomy with at least one metastatic sentinel lymph node and in patients eligible for breast conserving surgery with three or more positive sentinel lymph nodes. In this analytical review, we discuss the clinical evidence, taking into account recent guidelines, for axillary management.
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Affiliation(s)
- P Veronesi
- Breast Surgery Division, European Institute of Oncology, IRCCS, Milan, Italy; Faculty of Medicine, University of Milan, Italy.
| | - G Corso
- Breast Surgery Division, European Institute of Oncology, IRCCS, Milan, Italy; Faculty of Medicine, University of Milan, Italy
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34
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Mayr NA, Komaki RU, Donaldson SS. Dr. Eleanor D. Montague. Clin Imaging 2020. [DOI: 10.1016/j.clinimag.2019.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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35
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Arjunan R, Ramamani TA, Ramachandra C, Swamyvelu K, Chunduri S, Althaf S, Usha A, Namrata R. Sentinel Lymph Node Biopsy in Locally Advanced Breast Cancer After Neoadjuvant Chemotherapy-an Indian Perspective. Indian J Surg Oncol 2020; 11:242-247. [PMID: 32523270 DOI: 10.1007/s13193-020-01035-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 01/03/2020] [Indexed: 02/06/2023] Open
Abstract
Sentinel lymph node biopsy (SLNB) alone in early breast cancer is an established standard of care. However, the same results have not been replicated in locally advanced breast cancer (LABC) after neoadjuvant chemotherapy (NACT). We aim to examine the feasibility of SLNB in LABC patients post NACT to determine identification rates (IR) and false negative rates (FNR). This was a single tertiary cancer center-based prospective study from February 2017 to November 2018. Forty-four patients with LABC (T3, T4 with N0 or N1) were studied and response after NACT was assessed. Only those patients who were N0 or who converted from N1 to N0 after NACT were included. Those patients who remained node positive after NACT directly proceeded with axillary dissection without SLNB and were excluded from the study. Demographic and clinical data is expressed in ratios and percentage and presented in table format. The median age at the time of study was 45.18 years. Most of the patients had T3 and above (97.7%) and N1 (86.3%) disease at the start of neoadjuvant therapy. The mean number of axillary lymph nodes dissected was 13.97. Dual method of sentinel lymph node mapping (methylene blue dye and radiolabeled colloid) was used in 26 (59.1%) patients. At least 1 SLN was identified in 86.4% patients with 100% identification in those patients in whom the dual method of SLN mapping was used. Median of 2 SLN was removed. Overall, false negative rate was 21.4%. FNR was high with the single method of SLN mapping (50% and 33.3% with methylene blue and radioactive colloid respectively) while it was considerably low when both were used simultaneously (11%). An average of 2 (range 0-4) SLN were identified and FNR were zero when 2 or more SLN were identified. Our study shows that SLNB in patients with LABC post NACT though viable cannot be recommended at present due to unacceptable high FNR. However, this should not dissuade us from exploring recurrence-free survival and overall survival associated with such IR and FNR albeit strictly under a clinical trial setting.
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Affiliation(s)
- Ravi Arjunan
- Department of Surgical Oncology, Kidwai Cancer Institute, Bangalore, India
| | | | | | | | - Srinivas Chunduri
- Department of Surgical Oncology, Kidwai Cancer Institute, Bangalore, India
| | - Syed Althaf
- Department of Surgical Oncology, Kidwai Cancer Institute, Bangalore, India
| | - Amirtham Usha
- Department of Pathology, Kidwai Cancer Institute, Bangalore, India
| | - Ranganath Namrata
- Department of Anaesthesia and Pain Relief, Kidwai Cancer Institute, Bangalore, India
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36
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Participation in Clinical Trials as a Clinical Trialist for the Community Surgeon. Clin Trials 2020. [DOI: 10.1007/978-3-030-35488-6_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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37
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Trial Design: Overview of Study Designs. Clin Trials 2020. [DOI: 10.1007/978-3-030-35488-6_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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38
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Euhus DM. Management of the clinically positive axilla. Breast J 2019; 26:35-38. [PMID: 31876073 DOI: 10.1111/tbj.13719] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 10/01/2019] [Indexed: 01/02/2023]
Abstract
Axillary dissection has been the standard of care for any patient with clinically positive lymph nodes at initial breast cancer presentation. However, modern neo-adjuvant therapies can convert positive nodes to negative nodes, especially in the setting of HER2-positive disease. Accurate axillary staging can be achieved after neo-adjuvant therapy in initially node-positive patients using dual tracer lymphatic mapping, removal of three or more lymph nodes, and confirmation of excision of the previously biopsied and clipped lymph node. Currently accruing clinical trials are designed to determine which patients can safely avoid axillary dissection and/or axillary radiation.
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Affiliation(s)
- David M Euhus
- Johns Hopkins University School of Medicine, Baltimore, Maryland
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39
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A Radiation Oncologist’s Guide to Axillary Management in Breast Cancer: a Walk Through the Trials. CURRENT BREAST CANCER REPORTS 2019; 11:293-302. [DOI: 10.1007/s12609-019-00330-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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40
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Fricker J. Bernard Fisher: US surgeon who pioneered a scientific approach for breast cancer treatment. Assoc Med J 2019. [DOI: 10.1136/bmj.l6657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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41
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Moiel D, Thompson J, Larsen KD. Mastectomy or Breast-Conserving Therapy: Which Factors Influence A Patient's Decision? Perm J 2019; 23:18-049. [PMID: 31314719 PMCID: PMC6636508 DOI: 10.7812/tpp/18-049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The choice between mastectomy and breast-conserving therapy (BCT) is a first step for patients with breast cancer who are confronting decisions about treatment. OBJECTIVE To identify the most important determinants in treatment decision making by patients with breast cancer. METHODS Between 2003 and 2013, a total of 5258 patients with breast cancer were recorded in Kaiser Permanente Northwest's cancer registry. Patients had similar clinical-pathologic profiles, education, and insurance coverage, and were managed by 1 surgical group. A total of 2604 patients with invasive breast cancer chose mastectomy or BCT as they met unambiguous criteria for equivalent outcomes with either option. We examined the influence of the patient's surgeon on patient preferences. RESULTS Our retrospective analyses examined a study population that had similar risk profiles (age, family history of breast cancer, T category on tumor-node-metastasis staging system, tumor size, physical examination findings), surgeons consulting on similar patient types, and managed by surgeons with similar surgical performance patterns (case volumes, reexcision rates, number of reoperations, and ability to meet patient's expectations). Patients who preferred mastectomy were strongly influenced by tumor size (p < 0.001) and abnormal physical examination findings (palpable mass; p = 0.004), rather than age, family history of breast cancer, T category, or surgeon. CONCLUSION Physical examination findings and tumor size were statistically significant determinants influencing patients to choose mastectomy. Because geographic and practice style explanations fail to explain these variations, surgeons can identify, anticipate, and consider these factors when counseling patients about mastectomy and BCT therapeutic equivalency.
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Affiliation(s)
- David Moiel
- Retired, Department of Surgery, Kaiser Permanente Northwest, Portland, OR
| | - John Thompson
- Retired, Department of Pathology, Kaiser Permanente Northwest, Portland, OR
| | - Kenneth D Larsen
- Retired, Department of Anesthesiology, Kaiser Permanente Northwest, Portland, OR
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Koca B, Kuru B. Axiller lenf nodu pozitif meme kanserinde non-sentinel lenf nodu pozitifliğine etki eden faktörler ve nomogramların etkinliğinin karşılaştırılması. DICLE MEDICAL JOURNAL 2018. [DOI: 10.5798/dicletip.497892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Lazzaretti MG, Ponti A, Mano MP, Barca A, Casella D, Frigerio A, Giordano L, Mantellini P, Paduos A, Pitarella S, Ravaioli A, Taffurelli M, Tomatis M, Segnan N. Reducing harms from treatment. Sixteen years of surgery of the axilla for screen-detected breast cancers in Italy. Breast 2018; 42:15-22. [PMID: 30138762 DOI: 10.1016/j.breast.2018.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Revised: 07/16/2018] [Accepted: 08/01/2018] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES Available evidence on axillary surgery has accumulated dramatically in the last two decades in favor of less invasive care. The aim of this paper is to study 16-years trends in the surgical management of the axilla in a large population-based data set of screen-detected breast cancers in Italy and to document at what extent recommendations have been adopted in actual clinical care. MATERIAL AND METHODS This is a retrospective cohort study documenting the surgical management of the axilla in primary breast cancer patients over time. We retrieved from the Italian database of screen-detected cancers 41213 cases diagnosed in women aged 50-69 between years 2000 and 2015 in twelve Italian Regions. RESULTS In pN0 cases, an increasing trend (p < 0.001) in the number of patients who received sentinel lymph node biopsy (SLNB) as the only axillary staging procedure was observed. In pN + cases SLNB was the only staging procedure in an increasing number of patients (p < 0.001) especially since the publication of the ACOSOG-Z0011 paper. In ductal carcinoma in situ (DCIS) SLNB was more frequent in mastectomies and in high grade and large lesions. However, 45% of low grade, small DCIS over the whole time period had some form of axillary surgery. CONCLUSION This large series of screen-detected cases documents a strong time trend in the direction of reducing axillary surgery and hence potential harms from treatment. The continuing practice of SLNB in low risk DCIS is of concern in an era of increasing awareness towards overdiagnosis and overtreatment.
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Affiliation(s)
| | - Antonio Ponti
- CPO Piemonte, AOU Città della Salute e della Scienza, Torino, Italy.
| | - Maria Piera Mano
- CPO Piemonte, AOU Città della Salute e della Scienza, Torino, Italy
| | - Alessandra Barca
- Area Prevenzione e Promozione della Salute, Ufficio Screening, Regione Lazio, Italy
| | - Denise Casella
- CPO Piemonte, AOU Città della Salute e della Scienza, Torino, Italy
| | - Alfonso Frigerio
- SSD Screening, AOU Città della Salute e della Scienza, Torino, Italy
| | - Livia Giordano
- CPO Piemonte, AOU Città della Salute e della Scienza, Torino, Italy
| | - Paola Mantellini
- SC Prevenzione Secondaria Screening, Istituto per lo Studio e la Prevenzione Oncologica, Firenze, Italy
| | - Adriana Paduos
- Department of Surgery, ASL Biella, Italy, and Fondazione Edo Tempia, Italy
| | - Sabina Pitarella
- CPO Piemonte, AOU Città della Salute e della Scienza, Torino, Italy
| | | | - Mario Taffurelli
- Chief of Breast Surgery, S.Orsola-Malpighi Hospital, Bologna, Italy
| | - Mariano Tomatis
- CPO Piemonte, AOU Città della Salute e della Scienza, Torino, Italy
| | - Nereo Segnan
- CPO Piemonte, AOU Città della Salute e della Scienza, Torino, Italy; Director of WHO Collaborating Centre for Cancer Early Detection and Screening, Torino, Italy
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Tsai WC, Kung PT, Wang YH, Kuo WY, Li YH. Influence of the time interval from diagnosis to treatment on survival for early-stage liver cancer. PLoS One 2018; 13:e0199532. [PMID: 29933395 PMCID: PMC6014663 DOI: 10.1371/journal.pone.0199532] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 06/08/2018] [Indexed: 01/02/2023] Open
Abstract
Objectives Liver cancer is the fifth most common cancer in men and the ninth most common cancer in women, and the WHO expects that there will be 1,341,344 cases in 2034 worldwide. Liver cancer also has the second-highest cancer death rate, accounting for 7% of all cancers. The study is going to explore the relationship between time interval from diagnosis to treatment and survival status of early-stage liver cancer patients. Materials and methods This is a retrospective cohort study using the national database from Taiwan. The datasets include the Taiwan Cancer Registry Database (TCR), the National Health Insurance Research Database (NHIRD), and the National Registry of Deaths. The target population for the study was patients newly diagnosed with stage I and stage II liver cancer between the years 2004 and 2010. Total of 26,038 cases were included in the study. Except descriptive analysis, the relationship between patient characteristics and the time interval from diagnosis to treatment was examined by chi-square tests. In addition, modified Cox proportional hazard models were used to analyze the hazard ratio of patient death with various treatment delay durations. Results There were 20,430 patients (78.46%) who received treatment less than 30 days after diagnosis, while 2,674 patients (10.27%) received treatment between 31 and 60 days after diagnosis, and 2,068 patients (7.94%) received treatment between 61 and 180 days after diagnosis, and 866 patients (3.33%) who received treatment 181 days after diagnosis. Those treated more than 181 days and 61–180 days after diagnosis had a 1.68-fold increased risk of death (95% confidence interval: 1.50–1.88) and a 1.39-fold increased risk of death (95% confidence interval: 1.31–1.17), respectively. Being male, being elderly, having a higher CCI level, and being treated in a hospital with a low service volume were factors associated with a poorer prognosis. Conclusion Overall, this study utilized a national cohort to conclude that for early-stage liver cancer patients, a longer the time interval from diagnosis to treatment results in a lower survival rate.
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Affiliation(s)
- Wen-Chen Tsai
- Department of Health Services Administration, China Medical University, Taichung, Taiwan
| | - Pei-Tseng Kung
- Department of Healthcare Administration, Asia University, Taichung, Taiwan
| | - Yueh-Hsin Wang
- Department of Health Services Administration, China Medical University, Taichung, Taiwan
| | - Wei-Yin Kuo
- Department of Health Services Administration, China Medical University, Taichung, Taiwan
| | - Ya-Hsin Li
- Department of Health Policy and Management, Chung Shan Medical University, Chung Shan Medical University Hospital, Taichung, Taiwan
- * E-mail:
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Filleron T, Lusque A, Dalenc F, Ferron G, Roche H, Martinez A, Jouve E. Alternative methodological approach to randomized trial for surgical procedures routinely used. Contemp Clin Trials 2018; 68:109-115. [PMID: 29608972 DOI: 10.1016/j.cct.2018.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Revised: 03/27/2018] [Accepted: 03/28/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND In medical oncology, changes in practices are almost always based on randomized trials but medical history shows that it is different in surgical oncology. In the past, many surgical procedures were routinely performed without a rigorous evaluation of the risk-benefit. To highlight the complexity of developing randomized surgical trials, disquisitions on methodology presented in the medical literature. This is particularly true when we consider breast reconstruction after surgical treatment for breast cancer. It is illusory to perform and conduct a randomized clinical trial (RCT) when a surgical procedure is routinely used by most surgeons. METHODS As a case study, we present the scientific rationale and the design of the MAPAM01 trial which evaluates the security of the nipple sparing mastectomy. Other alternative approaches, such as propensity score and CUSUM, are presented. RESULTS In this situation, to design surgical trials using alternative methodological approaches present a particularly important challenge both for surgeons and methodologists. Alternative approach to randomized trials can be useful to evaluate surgical procedures routinely used. CONCLUSION Close collaboration between surgeons and methodologists is needed to propose appropriate and well-designed surgical trials.
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Affiliation(s)
- T Filleron
- Biostatistics Unit, Institut Claudius Regaud, IUCT-O, Toulouse, France.
| | - A Lusque
- Biostatistics Unit, Institut Claudius Regaud, IUCT-O, Toulouse, France
| | - F Dalenc
- Oncology Department, Institut Claudius Regaud-IUCT-O, Toulouse, France
| | - G Ferron
- Surgical Department, Institut Claudius Regaud-IUCT-O, Toulouse, France
| | - H Roche
- Oncology Department, Institut Claudius Regaud-IUCT-O, Toulouse, France
| | - A Martinez
- Surgical Department, Institut Claudius Regaud-IUCT-O, Toulouse, France
| | - E Jouve
- Surgical Department, Institut Claudius Regaud-IUCT-O, Toulouse, France
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Layeequr Rahman R, Marshall AJ. Evidence basis for sentinel node biopsy post neoadjuvant chemotherapy - Bias is a 4-letter word. Eur J Surg Oncol 2018; 44:541-542. [PMID: 29395436 DOI: 10.1016/j.ejso.2017.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 12/29/2017] [Indexed: 11/19/2022] Open
Affiliation(s)
| | - Andrew J Marshall
- University Health System, Southwest Cancer Treatment and Research Center, Research Department, 602 Indiana Ave., Lubbock TX 79415, USA
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Zahoor S, Haji A, Battoo A, Qurieshi M, Mir W, Shah M. Sentinel Lymph Node Biopsy in Breast Cancer: A Clinical Review and Update. J Breast Cancer 2017; 20:217-227. [PMID: 28970846 PMCID: PMC5620435 DOI: 10.4048/jbc.2017.20.3.217] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 08/22/2017] [Indexed: 12/20/2022] Open
Abstract
Sentinel lymph node biopsy has become a standard staging tool in the surgical management of breast cancer. The positive impact of sentinel lymph node biopsy on postoperative negative outcomes in breast cancer patients, without compromising the oncological outcomes, is its major advantage. It has evolved over the last few decades and has proven its utility beyond early breast cancer. Its applicability and efficacy in patients with clinically positive axilla who have had a complete clinical response after neoadjuvant chemotherapy is being aggressively evaluated at present. This article discusses how sentinel lymph node biopsy has evolved and is becoming a useful tool in new clinical scenarios of breast cancer management.
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Affiliation(s)
- Sheikh Zahoor
- Department of Surgical Oncology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Altaf Haji
- Department of Surgical Oncology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Azhar Battoo
- Department of Surgical Oncology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Mariya Qurieshi
- Department of Community Medicine, Government Medical College, Srinagar, India
| | - Wahid Mir
- Department of Surgical Oncology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Mudasir Shah
- Department of Surgical Oncology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
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Mamounas EP, Kuehn T, Rutgers EJT, von Minckwitz G. Current approach of the axilla in patients with early-stage breast cancer. Lancet 2017:S0140-6736(17)31451-4. [PMID: 28818521 DOI: 10.1016/s0140-6736(17)31451-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Revised: 02/28/2017] [Accepted: 04/10/2017] [Indexed: 02/01/2023]
Abstract
The surgical approach of the axilla in patients with early-stage breast cancer has witnessed considerable evolution during the past 25 years. The previously undisputed gold standard of axillary-lymph-node dissection for staging has now been replaced by sentinel-lymph-node biopsy for patients with clinically negative axilla. For selected patients with limited sentinel-lymph-node involvement, completion axillary-lymph-node dissection can be omitted or replaced by axillary radiotherapy, reducing morbidity. The clinical interest of axillary staging after neoadjuvant chemotherapy is increasing and this approach might contribute to morbidity reduction, and to the further tailoring of future systemic and locoregional treatment decisions by response assessment. Refinement of the sentinel-lymph-node biopsy technique might overcome the slightly impaired success rates in this setting. New techniques for lymphatic mapping attempt to further simplify the procedure. In view of the declining influence of axillary nodal status on adjuvant therapy decision-making, ongoing clinical trials will evaluate whether sentinel-lymph-node biopsy can be avoided altogether in selected patients.
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Affiliation(s)
- Eleftherios P Mamounas
- University of Florida Health Cancer Center-Orlando Health, and University of Central Florida, Orlando, FL, USA.
| | - Thorsten Kuehn
- Interdisciplinary Breast Cancer Center, Department of Gynecology and Obstetrics, Klinikum Esslingen, Esslingen, Germany
| | - Emiel J T Rutgers
- Netherlands Cancer Institute, Amsterdam, Netherlands; University of Amsterdam, Amsterdam, Netherlands
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49
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Dull B, Conant L, Myckatyn T, Tenenbaum M, Cyr A, Margenthaler JA. Nipple-sparing mastectomies: Clinical outcomes from a single academic institution. Mol Clin Oncol 2017; 6:737-742. [PMID: 28515925 DOI: 10.3892/mco.2017.1208] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 02/15/2017] [Indexed: 11/06/2022] Open
Abstract
Nipple-sparing mastectomies (NSMs) are increasingly used in the surgical treatment of patients with breast cancer and for prevention of breast cancer. The present study was performed to review the outcomes of patients undergoing NSMs at a single large university setting. A retrospective chart review was performed on all patients undergoing NSMs from 2008-2014. Charts were reviewed for demographic data and patient characteristics. Tumor and breast size, cancer recurrence and complications were also evaluated. Descriptive statistics were utilized to summarize the findings. From 2008-2014, 110 patients underwent 197 NSMs. The mean patient age was 44.4 years (range, 20-77). The average body mass index was 24 (range, 18-47). Breast weight was available for 106 specimens, with a mean weight of 475.5 g (range, 124.1-1,625.0 g). Seventy-three NSMs were performed for cancer and 124 were performed prophylactically. The mean tumor width was 1.38 cm (range, 0-6.0 cm), with an average nipple to tumor distance of 5.87 cm (range, 2.93-10.0 cm). Three (4%) patients required removal of the nipple areolar complex (NAC) due to pathological extension of the tumor. A total of 34 (17.2%) complications occurred, including infections, hematomas and nipple necrosis, with 9 requiring removal of the NAC and 13 requiring removal of the tissue expander or implant. Smokers had a 36.0% (9/25) complication rate, compared with 14.5% (25/172) of nonsmokers (P<0.05). During follow-up, one recurrence was noted, located on the chest wall. There were no recurrences in the NAC group. Therefore, NSMs may safely be performed without compromising oncologic outcomes or increasing complication rates in properly selected patients.
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Affiliation(s)
- Barbara Dull
- Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Leah Conant
- Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Terence Myckatyn
- Division of Plastic and Reconstructive Surgery, Washington University, St. Louis, MO 63110, USA
| | - Marissa Tenenbaum
- Division of Plastic and Reconstructive Surgery, Washington University, St. Louis, MO 63110, USA
| | - Amy Cyr
- Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Julie A Margenthaler
- Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
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50
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Rastogi P, Wickerham DL, Geyer CE, Mamounas EP, Julian TB, Wolmark N. Milestone clinical trials of the National Surgical Adjuvant Breast and Bowel Project (NSABP). Chin Clin Oncol 2017; 6:7. [PMID: 28285537 DOI: 10.21037/cco.2017.02.02] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 01/08/2017] [Indexed: 11/06/2022]
Abstract
The National Surgical Adjuvant Breast and Bowel Project (NSABP) has made significant contributions in reducing the extent of breast surgery and in improving outcomes of patients with early-stage breast cancer through the conduct of large randomized clinical trials evaluating local and systemic therapy. In 2014, the NSABP merged with two other US National Cancer Institute-funded cooperative groups, the Radiation Therapy Oncology Group (RTOG) and the Gynecologic Oncology Group (GOG), to form NRG Oncology. The combined organization has 218 member institutions with more than 600 affiliate centers located throughout the United States, Canada, Puerto Rico, and other international sites. Over the past half century, the NSABP has entered more than 150,000 women into clinical trials of breast cancer treatment and breast cancer prevention. Many of these trials have been instrumental in establishing new standards of care for patients with breast cancer.
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Affiliation(s)
- Priya Rastogi
- National Surgical Adjuvant Breast and Bowel Project (NSABP), Pittsburgh, PA, USA; University of Pittsburgh Cancer Institute School of Medicine, Pittsburgh, PA, USA.
| | - D Lawrence Wickerham
- National Surgical Adjuvant Breast and Bowel Project (NSABP), Pittsburgh, PA, USA; Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Charles E Geyer
- National Surgical Adjuvant Breast and Bowel Project (NSABP), Pittsburgh, PA, USA; Virginia Commonwealth University, Massey Cancer Center, Richmond, VA, USA
| | - Eleftherios P Mamounas
- National Surgical Adjuvant Breast and Bowel Project (NSABP), Pittsburgh, PA, USA; UF Health Cancer Center at Orland Health, Orlando, FL, USA
| | - Thomas B Julian
- National Surgical Adjuvant Breast and Bowel Project (NSABP), Pittsburgh, PA, USA; Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Norman Wolmark
- National Surgical Adjuvant Breast and Bowel Project (NSABP), Pittsburgh, PA, USA; Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
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