1
|
De-escalation in DCIS Care. CURRENT BREAST CANCER REPORTS 2023. [DOI: 10.1007/s12609-023-00475-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
|
2
|
Fakhry J, Hanna M. Low Radiologic Sensitivity in Detecting Radiation-Associated Breast Angiosarcoma (RAS). Cureus 2023; 15:e36508. [PMID: 37090301 PMCID: PMC10119970 DOI: 10.7759/cureus.36508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2023] [Indexed: 04/25/2023] Open
Abstract
Due to its rarity, literature pertaining to radiation-associated breast angiosarcoma (RAS) remains sparse, with most studies focusing on retrospective review. Of more significant concern is the ambiguity of screening recommendations and modalities used to detect RAS, with current guidelines focusing on yearly mammographic imaging for women who underwent lumpectomy with radiation. Unfortunately, routine post-cancer screening has demonstrated low sensitivity in detecting RAS, often mistaking it for benign changes in roughly half of cases. We present an 83-year-old woman initially diagnosed with stage 1 invasive ductal carcinoma of the left breast who underwent a lumpectomy followed by radiation with 6040 cGy. Five years after her initial diagnosis, the patient noticed a suspicious lesion which then led her to undergo multiple modalities of imaging that described benign features. After continued concern, a biopsy was taken that demonstrated RAS of the left breast within the irradiated site. The patient underwent further radiation and declined surgical intervention. Routine screening with mammography and ultrasonography following breast radiation treatment are not sensitive modalities in detecting RAS. High-risk patient groups treated with greater than 0.5 Gy of radiation with concerning physical features 2-10 years after treatment should undergo MRI with biopsy at the initial concern to rule out angiosarcoma. Benign findings on imaging with patients in these groups should also consider biopsy.
Collapse
Affiliation(s)
- Jonathan Fakhry
- Breast Imaging, University of Florida College of Medicine, Gainesville, USA
| | - Mariam Hanna
- Breast Imaging, University of Florida College of Medicine, Gainesville, USA
| |
Collapse
|
3
|
Fuentes AM, Narayan A, Milligan K, Lum JJ, Brolo AG, Andrews JL, Jirasek A. Raman spectroscopy and convolutional neural networks for monitoring biochemical radiation response in breast tumour xenografts. Sci Rep 2023; 13:1530. [PMID: 36707535 PMCID: PMC9883395 DOI: 10.1038/s41598-023-28479-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 01/19/2023] [Indexed: 01/29/2023] Open
Abstract
Tumour cells exhibit altered metabolic pathways that lead to radiation resistance and disease progression. Raman spectroscopy (RS) is a label-free optical modality that can monitor post-irradiation biomolecular signatures in tumour cells and tissues. Convolutional Neural Networks (CNN) perform automated feature extraction directly from data, with classification accuracy exceeding that of traditional machine learning, in cases where data is abundant and feature extraction is challenging. We are interested in developing a CNN-based predictive model to characterize clinical tumour response to radiation therapy based on their degree of radiosensitivity or radioresistance. In this work, a CNN architecture is built for identifying post-irradiation spectral changes in Raman spectra of tumour tissue. The model was trained to classify irradiated versus non-irradiated tissue using Raman spectra of breast tumour xenografts. The CNN effectively classified the tissue spectra, with accuracies exceeding 92.1% for data collected 3 days post-irradiation, and 85.0% at day 1 post-irradiation. Furthermore, the CNN was evaluated using a leave-one-out- (mouse, section or Raman map) validation approach to investigate its generalization to new test subjects. The CNN retained good predictive accuracy (average accuracies 83.7%, 91.4%, and 92.7%, respectively) when little to no information for a specific subject was given during training. Finally, the classification performance of the CNN was compared to that of a previously developed model based on group and basis restricted non-negative matrix factorization and random forest (GBR-NMF-RF) classification. We found that CNN yielded higher classification accuracy, sensitivity, and specificity in mice assessed 3 days post-irradiation, as compared with the GBR-NMF-RF approach. Overall, the CNN can detect biochemical spectral changes in tumour tissue at an early time point following irradiation, without the need for previous manual feature extraction. This study lays the foundation for developing a predictive framework for patient radiation response monitoring.
Collapse
Affiliation(s)
- Alejandra M Fuentes
- Department of Physics, The University of British Columbia Okanagan Campus, Kelowna, Canada
| | - Apurva Narayan
- Department of Computer Science, Western University, London, Canada
- Department of Computer Science, The University of British Columbia Okanagan Campus, Kelowna, Canada
| | - Kirsty Milligan
- Department of Physics, The University of British Columbia Okanagan Campus, Kelowna, Canada
| | - Julian J Lum
- Department of Biochemistry and Microbiology, The University of Victoria, Victoria, Canada
| | - Alex G Brolo
- Department of Chemistry, The University of Victoria, Victoria, Canada
| | - Jeffrey L Andrews
- Department of Statistics, The University of British Columbia Okanagan Campus, Kelowna, Canada
| | - Andrew Jirasek
- Department of Physics, The University of British Columbia Okanagan Campus, Kelowna, Canada.
| |
Collapse
|
4
|
Silver B, Mattessich S, Yacoub I, Rhee B, Schreiber D. Patterns of Care and Utilization of Radiation for Women With Good-Risk Ductal Carcinoma In Situ: A National Cancer Database Analysis. Cureus 2022; 14:e28223. [PMID: 36158412 PMCID: PMC9486958 DOI: 10.7759/cureus.28223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2022] [Indexed: 11/05/2022] Open
Abstract
Purpose/objective(s) Lumpectomy followed by whole-breast radiation therapy (WBRT) provides a 50% recurrence rate reduction in ductal carcinoma in situ (DCIS) patients when compared to lumpectomy alone. Certain factors increase the risk of recurrence, including higher nuclear grade, large size, age less than 50, and close margins. RTOG 9804 demonstrated a reduction in local failure after WBRT with the use of adjuvant radiation in women with "good-risk disease" (mammographically detected, measuring less than or equal to 2.5 cm, with a predominant nuclear grade of 1 or 2, and a margin of greater than or equal to 1 cm, or a negative re-excision). The purpose of this study is to retrospectively identify the patterns of care in women with low-risk DCIS utilizing the National Cancer Database (NCDB). We hypothesize that with the utilization of hypofractionation, there may be an increase in the delivery of RT for these "good-risk" patients. Materials/methods The National Cancer Database was queried to identify women treated with lumpectomy for <2.5 cm, nuclear grade 1 or 2 DCIS of the breast from 2004 to 2016. Data were collected regarding age, tumor size, endocrine therapy use, ER receptor status, race, insurance type, and distance from the treatment center. The distance was stratified into quartiles consisting of 0-3.9, 4-8, 8.1-15.8, and > 15.8 miles, respectively. Radiation fractionation was collected and categorized as hypofractionation, standard fractionation, or other if fractionation could not be ascertained. Clinical and patient-related factors were compared between patients who received radiation and those who received no radiation. The frequency distributions between categorical variables were compared using the Chi-square test. Multivariable logistic regression was used to identify covariables that impacted the receipt of radiation. Results The eligibility criteria were met by a total of 12,846 patients. Of those, 6,600 (51.4%) received adjuvant WBRT. On multivariable regression, patients whose tumors were ER (OR 1.24, P<0.001) and those who had not received endocrine therapy (OR 2.24, P<0.001) were more likely to receive WBRT. Factors less likely to receive WBRT included increasing age over 50 (age 50-65 OR 0.83, P<0.001; age>65 OR 0.58, P<0.001), and distance of >15.8 miles (OR 0.78, P<0.001). The fractionation technique was categorized as standard or hypofractionated in 52.2% of patients. Of those, the use of hypofractionation increased from 0.4% in 2004 to 8.9% in 2010 and to 53.8% in 2016. Conclusion This NCDB analysis demonstrated that patients who meet the RTOG 9804 criteria for "good-risk" DCIS are less likely to receive RT as time progresses despite an increase in the utilization of hypofractionation techniques. Overall, slightly more than half of these patients receive adjuvant RT.
Collapse
Affiliation(s)
- Benjamin Silver
- Radiation Oncology, State University of New York Downstate Medical Center, Brooklyn, USA
| | - Sarah Mattessich
- Radiation Oncology, State University of New York Downstate Medical Center, Brooklyn, USA
| | - Irini Yacoub
- Radiation Oncology, State University of New York Downstate Medical Center, Brooklyn, USA
| | - Brian Rhee
- Radiation Oncology, State University of New York Downstate Medical Center, Brooklyn, USA
| | - David Schreiber
- Radiation Oncology, Summit Medical Group, Berkeley Heights, USA
| |
Collapse
|
5
|
Visual Evaluation of Ultrafast MRI in the Assessment of Residual Breast Cancer after Neoadjuvant Systemic Therapy: A Preliminary Study Association with Subtype. Tomography 2022; 8:1522-1533. [PMID: 35736873 PMCID: PMC9230716 DOI: 10.3390/tomography8030125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 06/07/2022] [Accepted: 06/09/2022] [Indexed: 11/16/2022] Open
Abstract
The purpose of this study was to investigate the diagnostic performance of ultrafast DCE (UF-DCE) MRI after the completion of neoadjuvant systemic therapy (NST) in breast cancer. In this study, MR examinations of 55 post-NST breast cancers were retrospectively analyzed. Residual tumor sizes were measured in the 20th phase of UF-DCE MRI, early and delayed phases of conventional DCE MRI, and high spatial-resolution CE MRI (UF, early, delayed, and HR, respectively). The diagnostic performance for the detection of residual invasive cancer was calculated by ROC analysis. The size difference between MRI and pathological findings was analyzed using the Wilcoxon signed-rank test with the Bonferroni correction. The overall AUC was highest for UF (0.86 and 0.88 for readers 1 and 2, respectively). The difference in imaging and pathological sizes for UF (5.7 ± 8.2 mm) was significantly smaller than those for early, delayed, and HR (p < 0.01). For luminal subtype breast cancer, the size difference was significantly smaller for UF and early than for delayed (p < 0.01). UF-DCE MRI demonstrated higher AUC and specificity for the more accurate detection of residual cancer and the visualization of tumor extent than conventional DCE MRI.
Collapse
|
6
|
Frasson AL, Falcone AB, Miranda I, Souza ABAD, Vollbrecht B, Barbosa F, Frasson MARM, Lichtenfels M. Nipple-sparing Mastectomy with Immediate Implant-based Reconstruction for Patients with Pure Ductal Carcinoma in Situ. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRICIA : REVISTA DA FEDERACAO BRASILEIRA DAS SOCIEDADES DE GINECOLOGIA E OBSTETRICIA 2022; 44:376-384. [PMID: 35623619 PMCID: PMC9948099 DOI: 10.1055/s-0042-1742315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The presence of an extensive intraductal component is associated to an increasing risk of relapse in the nipple-areola complex. The aim of the present study was to evaluate the outcomes of patients diagnosed with ductal carcinoma in situ (DCIS) who underwent nipple-sparing mastectomy (NSM) with immediate breast reconstruction using silicone implants. METHODS We retrospectively analyzed the postoperative complications and oncological safety of 67 breast cancer patients diagnosed with pure DCIS who underwent NSM with immediate breast reconstruction using silicone implants between 2004 and 2018. RESULTS Among the 127 NSM procedures performed, 2 hematomas (1.5%) and 1 partial nipple necrosis (0.7%) were observed. After a mean follow-up of 60 months, the local recurrence rate was of 8.9%, the disease-free survival rate was of 90%, and 1 of the patients died. CONCLUSION Despite the local recurrence rate, we showed that NSM with immediate breast reconstruction using silicone implants is a feasible surgical approach, with a low rate of complications and high survival rates for patients with a diagnosis of pure DCIS when breast-conserving surgery is not an option.
Collapse
Affiliation(s)
- Antônio Luiz Frasson
- Mastology Service, Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Ana Beatriz Falcone
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.,Mastology Service, Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Isabela Miranda
- Mastology Service, Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | | | - Betina Vollbrecht
- Mastology Service, Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | | | | | - Martina Lichtenfels
- Mastology Service, Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS, Brazil
| |
Collapse
|
7
|
Niwińska A, Kunkiel M. Type of Recurrence, Cause of Death and Second Neoplasms among 737 Patients with Ductal Carcinoma In Situ of the Breast—15-Year Follow-Up. Cancers (Basel) 2022; 14:cancers14030669. [PMID: 35158936 PMCID: PMC8833655 DOI: 10.3390/cancers14030669] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 01/10/2022] [Accepted: 01/15/2022] [Indexed: 12/04/2022] Open
Abstract
Simple Summary A retrospective analysis of 737 consecutive DCIS patients with a 15-year follow-up was carried out. Sixty-six recurrences (42% DCIS, 58% invasive) were reported: 61 in the breast and 5 outside the breast. 79% of local recurrences were true recurrences. The highest number of recurrences was reported in patients after local excision without radiotherapy despite the fact that it was the lowest-risk group. Deaths due to DCIS progression were reported in 0.5% of all patients and in 10.5% of patients with invasive recurrences. The majority of deaths were linked to the age of the patients or other diseases, including other neoplasms. Abstract Aim: To assess the outcomes of 737 consecutive patients with DCIS, with particular attention to the type of recurrences, other malignancies and causes of deaths. Material and Methods: A retrospective analysis of 737 consecutive DCIS patients treated in one institution in the years 1996–2011 was carried out. The cumulative recurrence risk, DFS, OS depending on the method of treatment (mastectomy, breast-conserving treatment (BCT), breast-conserving surgery (BCS)) and cause of death were assessed. Results: Sixty-six recurrences (42% DCIS, 58% invasive) were reported: 61 in the breast and 5 outside the breast. The cumulative recurrence risk after a 15-year observation after mastectomy, BCT and BCS was 3.2%, 19.5% and 31.2%, respectively (p < 0.001). The 15-year DFS after mastectomy, BCT and BCS was 72%, 65% and 48%, respectively (p < 0.001). The 15-year OS after mastectomy, BCT and BCS was 75%, 83% and 70%, respectively (p = 0.329). Deaths due to DCIS progression were reported in four (0.5%) of the overall patients and in 10.5% of patients with invasive recurrences. The majority of deaths were linked to the age of the patients or other diseases, including other neoplasms, but not DCIS. Conclusions: The highest number of recurrences was reported in patients after BCS, despite the fact that it was the lowest-risk group. In total, 79% of local recurrences were true recurrences and 58% were invasive recurrences. Local recurrences were effectively treated without an influence on the OS. The percentage of deaths due to DCIS was low and mainly concerned patients with locoregional and distant failure.
Collapse
|
8
|
Preneoplastic Low-Risk Mammary Ductal Lesions (Atypical Ductal Hyperplasia and Ductal Carcinoma In Situ Spectrum): Current Status and Future Directions. Cancers (Basel) 2022; 14:cancers14030507. [PMID: 35158775 PMCID: PMC8833401 DOI: 10.3390/cancers14030507] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 01/12/2022] [Accepted: 01/17/2022] [Indexed: 02/04/2023] Open
Abstract
Intraepithelial mammary ductal neoplasia is a spectrum of disease that varies from atypical ductal hyperplasia (ADH), low-grade (LG), intermediate-grade (IG), to high-grade (HG) ductal carcinoma in situ (DCIS). While ADH has the lowest prognostic significance, HG-DCIS carries the highest risk. Due to widely used screening mammography, the number of intraepithelial mammary ductal neoplastic lesions has increased. The consequence of this practice is the increase in the number of patients who are overdiagnosed and, therefore, overtreated. The active surveillance (AS) trials are initiated to separate lesions that require active treatment from those that can be safely monitored and only be treated when they develop a change in the clinical/radiologic characteristics. At the same time, the natural history of these lesions can be evaluated. This review aims to evaluate ADH/DCIS as a spectrum of intraductal neoplastic disease (risk and histomorphology); examine the controversies of distinguishing ADH vs. DCIS and the grading of DCIS; review the upgrading for both ADH and DCIS with emphasis on the variation of methods of detection and the definitions of upgrading; and evaluate the impact of all these variables on the AS trials.
Collapse
|
9
|
Kunkiel M, Niwińska A. Assessment of the usefulness of prognostic Van Nuys Prognostic Index in the treatment in ductal carcinoma in situ in 15-year observation. Sci Rep 2021; 11:22645. [PMID: 34811426 PMCID: PMC8608918 DOI: 10.1038/s41598-021-02126-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 11/10/2021] [Indexed: 12/30/2022] Open
Abstract
Ductal carcinoma in situ, a marginal fraction of the mammary gland diseases, is recognized in 25% of breast cancers detected with mammographic screening. The aim of the study was to assess the prognostic value of Van Nuys Prognostic Index, serving to determine the method of treatment according to the recurrence risk. From the 737 of cases of DCIS detection patients treated in our department in the years 1996–2011. The remaining 525 patients whose treatment began from excision of local DCIS and whose further course of treatment was determined after histopathological examination, who were left for observation, treated with lumpectomy and radiotherapy or mastectomy, were qualified for the assessment of mentioned index (Online Appendix 1- Figure S1). The 5-, 10- and 15- year disease recurrence-free survival for the group of 525 patients was 88%, 74% and 62%, respectively. The percentage of 5-, 10- and 15-year disease recurrence-free survival in patients treated in compliance with the VNP Index in individual risk groups did not differ in a statistically significant way. In the low-risk group the percentage of recurrences after local excision, after 5, 10 and 15 years of observation amounted to 8.8%, 22.8% and 28.8%. In patients from this group, the recurrence risk after breast conserving treatment and mastectomy was 2% and 0%, respectively. VNP Index is not an optimal tool for patients with DCIS. It can be helpful only in some clinically difficult cases as one of methods of assessing the risk of recurrence.
Collapse
Affiliation(s)
- Michał Kunkiel
- Department of Breast Cancer and Reconstructive Surgery, Maria Sklodowska-Curie National Research Institute of Oncology, W.K. Roentgena 5, 02-781, Warsaw, Poland.
| | - Anna Niwińska
- Department of Breast Cancer and Reconstructive Surgery, Maria Sklodowska-Curie National Research Institute of Oncology, W.K. Roentgena 5, 02-781, Warsaw, Poland
| |
Collapse
|
10
|
Yotsumoto D, Sagara Y, Kumamaru H, Niikura N, Miyata H, Kanbayashi C, Tsuda H, Yamamoto Y, Aogi K, Kubo M, Tamura K, Hayashi N, Miyashita M, Kadoya T, Saji S, Toi M, Imoto S, Jinno H. Trends in adjuvant therapy after breast-conserving surgery for ductal carcinoma in situ of breast: a retrospective cohort study using the National Breast Cancer Registry of Japan. Breast Cancer 2021; 29:1-8. [PMID: 34665435 DOI: 10.1007/s12282-021-01307-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 10/10/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Radiotherapy (RT) and endocrine therapy (ET) are standard treatment options after breast-conserving surgery (BCS) for ductal carcinoma in situ (DCIS). We investigated the national patterns of adjuvant therapy use after BCS for DCIS in Japan. METHODS We obtained relevant data of patients diagnosed with DCIS undergoing surgery and treated with BCS between 2014 and 2016 from the Japanese Breast Cancer Registry database. The relationship between the clinicopathologic, institutional, and regional factors, and adjuvant treatment was examined using multivariable analyses. RESULTS We identified 9516 patients who underwent BCS for DCIS. Overall, 23% received no adjuvant treatment, 71% received RT, 32% received ET, and 26% received combination therapy. The percentages of patients who received ET and combination therapy in 2016 were significantly lower [odds ratio (OR): 0.71, 0.77, respectively] than in 2014. The proportion of RT was low among young or elderly patients (OR: 0.75, 0.44, respectively) and in non-certified facilities (OR: 0.56). The proportion of ET was high in non-certified facilities (OR: 1.58) and among patients with positive margins (OR: 1.62). Combination therapy was higher among patients with positive margins (OR: 1.53). CONCLUSIONS Our study found a distinct adjuvant treatment pattern after BCS for DCIS depending on clinicopathologic factors, year, age, which indicate that physicians provide individualized treatment according to the background of the patients and the biology of DCIS. The facilities and regions remain significant factors of influencing adjuvant treatment pattern.
Collapse
Affiliation(s)
- Daisuke Yotsumoto
- Department of Breast Surgery, Sagara Hospital Miyazaki, Miyazaki Hakuaikai Medical Corporation, Miyazaki, Japan
| | - Yasuaki Sagara
- Department of Breast Surgery, Sagara Hospital, Hakuaikai Medical Corporation, 3-28 Matsubara Kagoshima City, Kagoshima, 892-0833, Japan.
| | - Hiraku Kumamaru
- Department of Healthcare Quality Assessment, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Naoki Niikura
- Department of Breast and Endocrine Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Hiroaki Miyata
- Department of Healthcare Quality Assessment, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Chizuko Kanbayashi
- Department of Breast Oncology, Niigata Cancer Center Hospital, Niigata, Japan
| | - Hitoshi Tsuda
- Department of Basic Pathology, National Defense Medical College, Saitama, Japan
| | - Yutaka Yamamoto
- Department of Breast and Endocrine Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Kenjiro Aogi
- Department of Breast Oncology, National Hospital Organization Shikoku Cancer Center, Matsuyama, Ehime, Japan
| | - Makoto Kubo
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kenji Tamura
- Department of Medical Oncology, Shimane University Hospital, Izumo, Shimane, Japan
| | - Naoki Hayashi
- Department of Breast Surgical Oncology, St. Luke's International Hospital, Tokyo, Japan
| | - Minoru Miyashita
- Department of Breast and Endocrine Surgical Oncology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Takayuki Kadoya
- Department of Surgical Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Shigehira Saji
- Department of Medical Oncology, Fukushima Medical University, Fukushima, Japan
| | - Masakazu Toi
- Breast Cancer Unit, Graduate School of Medicine, Kyoto University Hospital Breast Surgery, Kyoto University, Kyoto, Japan
| | - Shigeru Imoto
- Department of Breast Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Hiromitsu Jinno
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| |
Collapse
|
11
|
Yashkin AP, Greenup RA, Gorbunova G, Akushevich I, Oeffinger KC, Hwang ES. Outcomes and Costs for Women After Breast Cancer: Preparing for Improved Survivorship of Medicare Beneficiaries. JCO Oncol Pract 2020; 17:e469-e478. [PMID: 32692618 DOI: 10.1200/op.20.00155] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Increasing health care costs, longer life expectancy, improved breast cancer (BC) survival, and higher levels of complex comorbidities have important implications for future Medicare expenditures. METHODS Data from the SEER program linked to Medicare claims records were used. Women with BC (cases) were categorized into 3 groups on the basis of their year of diagnosis (1998, 2003, or 2008) and were propensity score matched to women without a BC diagnosis (controls). All stage and stage-specific longitudinal changes in survival, morbidity levels using the Elixhauser index, and Medicare expenditures in 2018 dollars were calculated and compared. RESULTS More than 15% of BC cases were diagnosed in patients over the age of 85 years. The prevalence of most comorbidities increased over time. Costs among cases increased between 1998 and 2008. Spending directly correlated with the stage of disease at diagnosis, with the lowest per-patient costs in the ductal carcinoma in situ (DCIS) subgroup ($14,792 in 1998 and $19,652 in 2008) and the highest in those with distant cancer ($37,667 in 1998 and $43,675 in 2008). Assuming no significant changes in the distribution of BC stage or age at diagnosis, the total annual costs of caring for patients with BC in women 65 years of age or older at diagnosis increased by at least $1.1 billion between 1998 and 2008. CONCLUSION Improvements in BC survivorship are associated with intensive use of health care resources and substantially higher downstream costs among Medicare beneficiaries. Appropriate planning, in both the fiscal and the oncology care infrastructure, is required to prepare the health system for these emerging health care trends.
Collapse
Affiliation(s)
- Arseniy P Yashkin
- Biodemography of Aging Research Unit, Duke Population Research Center, Duke University, Durham, NC
| | - Rachel A Greenup
- Department of Surgery, Duke University, Durham, NC.,Duke Cancer Institute, Duke University, Durham, NC.,Department of Population Health Sciences, Duke University, Durham, NC
| | - Galina Gorbunova
- Biodemography of Aging Research Unit, Duke Population Research Center, Duke University, Durham, NC
| | - Igor Akushevich
- Biodemography of Aging Research Unit, Duke Population Research Center, Duke University, Durham, NC
| | - Kevin C Oeffinger
- Duke Cancer Institute, Duke University, Durham, NC.,Department of Population Health Sciences, Duke University, Durham, NC.,Department of Medicine, Duke University, Durham, NC
| | - E Shelley Hwang
- Department of Surgery, Duke University, Durham, NC.,Duke Cancer Institute, Duke University, Durham, NC
| |
Collapse
|
12
|
Paszat L, Sutradhar R, Rakovitch E. The impact of ductal carcinoma in situ on health services utilization. Breast Cancer Res Treat 2020; 182:159-168. [PMID: 32385793 DOI: 10.1007/s10549-020-05664-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 05/02/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE To determine the intermediate-term impact of diagnosis and treatment of ductal carcinoma in situ of the breast (DCIS) on health services utilization, we compared utilization by cases of DCIS to unaffected controls. METHODS We identified a population-based cohort of Ontario females diagnosed with DCIS between 2010 and 2015. We matched 5 controls without any history of cancer to each case, on the date of diagnosis of the case (the index date), by age, annual mammography history, socioeconomic status, and comorbidity. We identified billing claims and hospital records, during the interval 13 to 60 months prior to, and subsequent to the index date, and computed rates per 100 person-years during both intervals, to conduct a difference-in-differences analysis. We used negative binomial regression to test if the change in rates in health services differed between cases and controls. RESULTS Visits with a breast diagnosis code, and claims for breast surgery and imaging, were significantly increased among cases compared to controls (all p values < 0.0001) after DCIS;however, there was no increase in visits for anxiety or depression (RR 1.13 (95% CI 0.97, 1.32, p = 0.11), visits to psychiatrists (RR 1.07 (95% CI 0.82, 1.40) p = 0.6), or hospital procedures other than breast surgery (RR 1.10 (95% CI 0.88, 1.37) p = 0.4). CONCLUSIONS DCIS is associated with more visits and procedures related to the breast compared to controls following diagnosis and treatment, but other health services utilization and visits related to anxiety and depression were not increased.
Collapse
Affiliation(s)
- Lawrence Paszat
- University of Toronto, Sunnybrook Research Institute, T2-156-2075 Bayview Avenue, Toronto, ON, M4N 3M45, Canada.
| | - Rinku Sutradhar
- Dalla Lana School of Public Health, University of Toronto, G106 - 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Eileen Rakovitch
- University of Toronto, Sunnybrook Research Institute, T2-152 - 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| |
Collapse
|
13
|
Van Bockstal MR, Agahozo MC, Koppert LB, van Deurzen CHM. A retrospective alternative for active surveillance trials for ductal carcinoma in situ of the breast. Int J Cancer 2019; 146:1189-1197. [PMID: 31018242 PMCID: PMC7004157 DOI: 10.1002/ijc.32362] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 03/25/2019] [Accepted: 04/17/2019] [Indexed: 12/12/2022]
Abstract
Ductal carcinoma in situ (DCIS) of the breast is a nonobligate precursor of invasive breast cancer, accounting for 20 % of screen-detected breast cancers. Little is known about the natural progression of DCIS because most patients undergo surgery upon diagnosis. Many DCIS patients are likely being overtreated, as it is believed that only around 50 % of DCIS will progress to invasive carcinoma. Robust prognostic markers for progression to invasive carcinoma are lacking. In the past, studies have investigated women who developed a recurrence after breast-conserving surgery (BCS) and compared them with those who did not. However, where there is no recurrence, the patient has probably been adequately treated. The present narrative review advocates a new research strategy, wherein only those patients with a recurrence are studied. Approximately half of the recurrences are invasive cancers, and half are DCIS. So-called "recurrences" are probably most often the result of residual disease. The new approach allows us to ask: why did some residual DCIS evolve to invasive cancers and others not? This novel strategy compares the group of patients that developed in situ recurrence with the group of patients that developed invasive recurrence after BCS. The differences between these groups could then be used to develop a robust risk stratification tool. This tool should estimate the risk of synchronous and metachronous invasive carcinoma when DCIS is diagnosed in a biopsy. Identification of DCIS patients at low risk for developing invasive carcinoma will individualize future therapy and prevent overtreatment.
Collapse
Affiliation(s)
- Mieke R Van Bockstal
- Department of Pathology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Marie C Agahozo
- Department of Pathology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Linetta B Koppert
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | | |
Collapse
|
14
|
Yang Y, Pan W, Tang X, Wu S, Sun X. A meta-analysis of randomized controlled trials comparing the efficacy and safety of anastrozole versus tamoxifen for breast cancer. Oncotarget 2018; 8:48362-48374. [PMID: 28415634 PMCID: PMC5564654 DOI: 10.18632/oncotarget.16466] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 03/04/2017] [Indexed: 11/25/2022] Open
Abstract
Whether anastrozole has superior effects to tamoxifen for breast cancer remains controversial. Therefore, we conducted this meta-analysis of randomized controlled trials (RCTs) to compare the efficacy and safety of anastrozole versus tamoxifen as adjuvant therapy in breast cancer. A systematic literature search of PubMed, Web of Science, Embase, and Cochrane library were performed to evaluate the survival benefits and toxicity profiles of patients with breast cancer who were treated with anastrozole or tamoxifen. The main outcome measures included disease-free survival (DFS), recurrence-free survival (RFS), overall survival (OS), overall response rate (ORR), and adverse events. Hazard ratios (HRs) or risk ratios (RRs) with 95% confidence intervals (CIs) were pooled using a fixed-effects model or random-effects model. Nine RCTs with a total of 15,300 patients met the inclusion criteria and were included in this meta-analysis. Pooled estimates suggested that, anastrozole was associated with a significantly improvement in DFS (HR=0.72, 95%CI: 0.55-0.94; P=0.016), and ORR (RR=1.21, 95% CI: 1.05-1.39; P=0.009) than tamoxifen. But it did not prolong OS (HR=0.96, 95%CI: 0.77-1.21; P=0.751). Compared with tamoxifen, anastrozole induced a higher incidence of arthralgia (RR=1.55, 95%CI: 1.20-1.99; P=0.001) and bone pain (RR=1.31, 95%CI: 1.05-1.62; P=0.015), as well as a lower incidence of vaginal bleeding (RR=0.51, 95%CI: 0.28-0.93; P=0.029), vaginal discharge (RR=0.31, 95%CI: 0.12-0.82; P=0.017), and thromboembolic events (RR=0.39, 95%CI: 0.28-0.55; P<0.001). Based on the current evidence, patients with breast cancer would benefit from the anastrozole treatment.
Collapse
Affiliation(s)
- Yan Yang
- Department of Radiation Oncology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Wei Pan
- Department of Radiation Oncology, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, China
| | - Xinyu Tang
- Department of Radiation Oncology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shuqing Wu
- Department of Radiation Oncology, The Affiliated Danyang Hospital of Nantong University, Nantong, China
| | - Xinchen Sun
- Department of Radiation Oncology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| |
Collapse
|
15
|
Wang L, Xia Y, Liu D, Zeng Y, Chang L, Li L, Hou Y, Ge L, Li W, Liu Z. Evaluating the efficacy of post-surgery adjuvant therapies used for ductal carcinoma in situ patients: a network meta-analysis. Oncotarget 2017; 8:79257-79269. [PMID: 29108304 PMCID: PMC5668037 DOI: 10.18632/oncotarget.17366] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Accepted: 03/16/2017] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE Post-surgery adjuvant therapies are very important for patients suffering from ductal carcinoma in situ (DCIS). In this study we conducted a network meta-analysis (NMA) to evaluate the efficacy of different post-surgery adjuvant therapies including tamoxifen, anastrozole and radiation therapy (RT) and their combinations (RT+ tamoxifen and RT+ anastrozole). METHODS We searched several databases, including Embase, MEDLINE / PUBMED, Cochrane Library, and Science Citation Index, for relevant studies. We then extracted the data from eligible studies in order to perform our NMA. We measured the comparative efficacy of each treatment option based on the calculated odds ratios (ORs) and the corresponding 95% credibility interval (95%CrI) for each treatment option. We calculated the surfaces under the cumulative ranking curves (SUCRA) in order to rank the therapies according to their different outcomes. RESULTS In this study, local recurrence (LC) was chosen as the primary outcome. Metastasis, contralateral-breast cancer (CBC), ipsilateral-breast cancer (IBC) and death were secondary outcomes. Patients treated with RT and RT + tamoxifen exhibited a lower risk of LC compared with control group (OR=0.54, 95%CrI: 0.40-0.73; OR=0.41, 95%CrI: 0.19-0.90). Patients treated by RT and RT + tamoxifen also exhibited a significantly lower risk of IBC compared with control group (OR=0.55, 95%CrI: 0.37-0.82; OR=0.42, 95%CrI: 0.18-0.99). Results from the SUCRA indicated that RT + anastrozole and RT + tamoxifen were potentially the best adjuvant treatments for patients with DCIS. CONCLUSIONS In conclusion, the RT + anastrozole and RT + tamoxifen are recommended for their performance and effectiveness.
Collapse
Affiliation(s)
- Li Wang
- Department of Radiation Oncology, The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, China
- The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, China
| | - Yaoxiong Xia
- Department of Radiation Oncology, The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, China
- The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, China
| | - Dequan Liu
- Department of Breast surgery, the Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, China
- The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, China
| | - Yueqin Zeng
- Department of Breast Surgery, The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, China
| | - Li Chang
- Department of Radiation Oncology, The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, China
- The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, China
| | - Lan Li
- Department of Radiation Oncology, The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, China
- The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, China
| | - Yu Hou
- Department of Radiation Oncology, The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, China
- The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, China
| | - Lv Ge
- The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, China
| | - Wenhui Li
- Department of Radiation Oncology, The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, China
- The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, China
| | - Zhijie Liu
- Department of Breast Surgery, The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, China
| |
Collapse
|
16
|
Pérez M, Schootman M, Hall LE, Jeffe DB. Accelerated partial breast irradiation compared with whole breast radiation therapy: a breast cancer cohort study measuring change in radiation side-effects severity and quality of life. Breast Cancer Res Treat 2017; 162:329-342. [PMID: 28132391 PMCID: PMC5374079 DOI: 10.1007/s10549-017-4121-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 01/18/2017] [Indexed: 10/20/2022]
Abstract
PURPOSE Radiotherapy (RT) after breast-conserving surgery for early-stage breast cancer patients has similar survival benefits with whole breast RT (WBRT) or accelerated partial breast irradiation (APBI). However, the impact of RT type and side-effects severity on change in quality of life (QOL) is unknown. We examined changes in RT side-effects severity and QOL by RT type. METHODS We analyzed data from a cohort of 285 newly diagnosed early-stage breast cancer patients with tumor size ≤3.0 cm and lymph node-negative disease. Patients (93 [32.6%] stage 0; 49 [17.2%] non-white; mean age = 59.3 years) completed four interviews (6 weeks, 6, 12, and 24 months) after definitive surgical treatment. We measured severity of RT side effects, fatigue and skin irritation, using a 5-point scale (1 "not at all" to 5 "all the time") and measured QOL using the Functional Assessment of Cancer Therapy-Breast (FACT-B) and RAND 36-item Health Survey Vitality subscale. Repeated-measures analysis of covariance of each outcome controlled for demographic, clinical/treatment, and psychosocial factors. RESULTS Patients initiated RT by 6 months (113 received APBI; 172 received WBRT) and completed RT by 12 months. Patients receiving WBRT (vs. APBI) reported greater increase in fatigue and skin irritation severity from 6-week to 6-month interviews (each P < 0.001). Improvement in neither total FACT-B nor Vitality differed significantly by RT type over 2-year follow-up. CONCLUSIONS Findings suggest that early-stage breast cancer patients can benefit from less-severe, short-term side effects of APBI with no differential impact on QOL change within 2-year follow-up.
Collapse
Affiliation(s)
- M Pérez
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA.
| | - M Schootman
- Saint Louis University College for Public Health and Social Justice, St. Louis, Missouri, USA
- Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine, St. Louis, Missouri, USA
| | - L E Hall
- Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - D B Jeffe
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
- Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine, St. Louis, Missouri, USA
| |
Collapse
|
17
|
Current treatment trends and the need for better predictive tools in the management of ductal carcinoma in situ of the breast. Cancer Treat Rev 2017; 55:163-172. [PMID: 28402908 DOI: 10.1016/j.ctrv.2017.03.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 03/21/2017] [Accepted: 03/23/2017] [Indexed: 12/14/2022]
Abstract
Ductal carcinoma in situ (DCIS) of the breast represents a group of heterogeneous non-invasive lesions the incidence of which has risen dramatically since the advent of mammography screening. In this review we summarise current treatment trends and up-to-date results from clinical trials studying surgery and adjuvant therapy alternatives, including the recent consensus on excision margin width and its role in decision-making for post-excision radiotherapy. The main challenge in the clinical management of DCIS continues to be the tailoring of treatment to individual risk, in order to avoid the over-treatment of low-risk lesions or under-treatment of DCIS with higher risk of recurring or progressing into invasion. While studies estimate that only about 40% of DCIS would become invasive if untreated, heterogeneity and complex natural history have prevented adequate identification of these higher-risk lesions. Here we discuss attempts to develop prognostic tools for the risk stratification of DCIS lesions and their limitations. Early results of a UK-wide audit of DCIS management (the Sloane Project) have also demonstrated a lack of consistency in treatment. In this review we offer up-to-date perspectives on current treatment and prediction of DCIS, highlighting the pressing clinical need for better prognostic indices. Tools integrating both clinical and histopathological factors together with molecular biomarkers may hold potential for adequate stratification of DCIS according to risk. This could help develop standardised practices for optimal management of patients with DCIS, improving clinical outcomes while providing only the amount of therapy required for each individual patient.
Collapse
|
18
|
Wai ES, Lesperance M, Lu L, Alexander CS, Truong PT. Effect of Referral Patterns and Treatment Type on Oncologic Outcomes for Women with Ductal Carcinoma In Situ. Cureus 2017; 9:e1128. [PMID: 28465875 PMCID: PMC5409819 DOI: 10.7759/cureus.1128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Objective Management of ductal carcinoma in situ (DCIS) remains controversial. This study examined long-term outcomes in a population-based cohort of patients with pure DCIS treated with breast-conserving surgery (BCS) alone, BCS + radiotherapy (RT), and mastectomy. Outcomes were compared between patients referred versus not referred for oncologic assessment after definitive surgery. Materials and methods Subjects were 2575 women diagnosed between 1985 and 1999. Data from several electronic databases were linked and analyzed. Outcomes were invasive local recurrence-free survival (ILRFS), mastectomy-free survival (MFS), breast cancer-specific survival (BCSS), and overall survival (OS). Results Median follow-up time was 9.8 years. Overall, 56% (n = 1448) of subjects were referred to a cancer centre. Factors associated with non-referral were older age, comorbidities, and travel distance. Ten-year MFS, BCSS, and OS were higher among referred patients (all p ≤ 0.001). In cohorts treated with BCS alone (n = 1314) vs. BCS + RT (n = 510) vs. mastectomy (n = 751), 10-year ILRFS were 93.7% vs. 96.6% vs. 97.7%, (p < 0.001) and BCSS were 97.6% vs. 99.8% vs. 98.6%, (p = 0.01). Corresponding rates of ipsilateral invasive breast relapse at 10 years were 6.3% after BCS alone, 3.4% after BCS + RT, and 2.3% after mastectomy (p < 0.001). On multivariable analysis, factors associated with improved ILRFS were older age at diagnosis, low comorbidity score, absence of comedo histology, mastectomy, and post-BCS RT. Conclusion Patients with DCIS referred for oncologic assessment were more likely to undergo post-BCS RT, resulting in lower mastectomy and higher survival rates compared to non-referred patients. Patients with significant comorbidities were less likely to be referred and experienced lower ILRFS and BCSS. Referral for multidisciplinary oncologic assessment after surgery is warranted to individualize management and optimize outcomes for patients with DCIS.
Collapse
Affiliation(s)
- Elaine S Wai
- Radiation Oncology, University of British Columbia, BC Cancer Agency
| | | | | | | | - Pauline T Truong
- Radiation Oncology, University of British Columbia, BC Cancer Agency
| |
Collapse
|
19
|
10-Year follow-up of 621 patients treated using high-dose rate brachytherapy as ambulatory boost technique in conservative breast cancer treatment. Radiother Oncol 2017; 122:11-16. [DOI: 10.1016/j.radonc.2016.06.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 06/26/2016] [Accepted: 06/26/2016] [Indexed: 11/20/2022]
|
20
|
Mao X, Qiao Z, Fan C, Guo A, Yu X, Jin F. Expression pattern and methylation of estrogen receptor α in breast intraductal proliferative lesions. Oncol Rep 2016; 36:1868-74. [PMID: 27498697 PMCID: PMC5022874 DOI: 10.3892/or.2016.4988] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Accepted: 07/13/2016] [Indexed: 01/12/2023] Open
Abstract
Intraductal proliferative lesions of the breast including usual ductal hyperplasia (UDH), atypical ductal hyperplasia (ADH) and ductal carcinoma in situ (DCIS) are associated with increased risk, albeit of greatly different magnitudes, for the subsequent development of invasive carcinoma. Estrogen receptor α (ERα) has been widely accepted as a prognostic marker and a predictor for endocrine therapy response of breast cancer. To investigate the ERα expression and methylation in breast intraductal proliferative lesions, we analyzed ERα expression in breast intraductal proliferative lesions including pure UDH (N=98), ADH without DCIS (N=160), DCIS without invasive breast cancer (N=149) by immunohistochemistry. Furthermore, the methylation status of ERα by methylation-specific PCR (MSP) was defined in 217 cases of breast intraductal proliferative lesions. Immunohistochemistry showed that 98/98 (100%) of the UDH cases were positive for ERα expression. ERα protein expression in ADH (132/160) (92.5%) was higher than in DCIS (101/149) (67.8%). But the ERα expression pattern was different with histological diversity of breast intraductal proliferative lesions. The average percent cells staining positive for ERα was 35.33% in UDH, 87.75% in ADH and 71.45% in DCIS. ERα methylation in 32/60 (53.3%) UDH, 11/77 (10.2%) ADH and 32/80 (40.0%) DCIS. Our results demonstrated a strong negative correlation between the percent of cells staining positive for ERα and ERα methylation (r=−0.831, p<0.001). Taken together, our results underlined that ERα expression or methylation may be involved in the breast carcinogenesis and advancement, thus it is not parallel to breast cancer risk in breast intraductal proliferative lesions. No obvious watershed between ERα-positive and -negative breast carcinogenesis was established. Estrogen receptor (ER) methylation or expression is a reversible signal in breast carcinogenesis which affected biological behavior of cells.
Collapse
Affiliation(s)
- Xiaoyun Mao
- Department of Breast Surgery, Department of Surgical Oncology, Research Unit of General Surgery, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning 110001, P.R. China
| | - Zhen Qiao
- Department of Breast Surgery, Department of Surgical Oncology, Research Unit of General Surgery, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning 110001, P.R. China
| | - Chuifeng Fan
- Department of Pathology, The First Affiliated Hospital and College of Basic Medical Sciences of China Medical University, Shenyang, Liaoning 110001, P.R. China
| | - Ayao Guo
- Department of Breast Surgery, Department of Surgical Oncology, Research Unit of General Surgery, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning 110001, P.R. China
| | - Xinmiao Yu
- Department of Breast Surgery, Department of Surgical Oncology, Research Unit of General Surgery, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning 110001, P.R. China
| | - Feng Jin
- Department of Breast Surgery, Department of Surgical Oncology, Research Unit of General Surgery, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning 110001, P.R. China
| |
Collapse
|
21
|
Guerrieri-Gonzaga A, Sestak I, Lazzeroni M, Serrano D, Rotmensz N, Cazzaniga M, Varricchio C, Pruneri G, Leonardi MC, Orecchia R, Galimberti V, Bonanni B, DeCensi A. Benefit of low-dose tamoxifen in a large observational cohort of high risk ER positive breast DCIS. Int J Cancer 2016; 139:2127-34. [DOI: 10.1002/ijc.30254] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 06/14/2016] [Accepted: 06/21/2016] [Indexed: 11/09/2022]
Affiliation(s)
| | - Ivana Sestak
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London; United Kingdom
| | - Matteo Lazzeroni
- Divisions of Cancer Prevention and Genetics; European Institute of Oncology Milan; Italy
| | - Davide Serrano
- Divisions of Cancer Prevention and Genetics; European Institute of Oncology Milan; Italy
| | - Nicole Rotmensz
- Epidemiology and Biostatistics; European Institute of Oncology Milan; Italy
| | - Massimiliano Cazzaniga
- Divisions of Cancer Prevention and Genetics; European Institute of Oncology Milan; Italy
| | - Clara Varricchio
- Divisions of Cancer Prevention and Genetics; European Institute of Oncology Milan; Italy
| | - Giancarlo Pruneri
- Pathology; European Institute of Oncology Milan; Italy
- University of Milan, School of Medicine; Milan Italy
| | | | - Roberto Orecchia
- University of Milan, School of Medicine; Milan Italy
- Radiotherapy; European Institute of Oncology Milan; Italy
| | | | - Bernardo Bonanni
- Divisions of Cancer Prevention and Genetics; European Institute of Oncology Milan; Italy
| | - Andrea DeCensi
- Divisions of Cancer Prevention and Genetics; European Institute of Oncology Milan; Italy
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London; United Kingdom
- Division of Medical Oncology; E.O. Ospedali Galliera; Genoa Italy
| |
Collapse
|
22
|
Variation in the management of ductal carcinoma in situ in the UK: Results of the Mammary Fold National Practice Survey. Eur J Surg Oncol 2016; 42:1153-61. [PMID: 27344543 DOI: 10.1016/j.ejso.2016.05.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Revised: 05/04/2016] [Accepted: 05/13/2016] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Ductal carcinoma in situ (DCIS) accounts for approximately 10% of all newly-diagnosed breast cancers in the UK. The latest national guidelines were published in 2009 and may not reflect current best practice. We aimed to explore variation in the current management of DCIS to support the need for updated guidelines. METHODS A national practice questionnaire was developed by the Mammary Fold Academic Committee (MFAC) focussing on the pre, intra and post-operative management of DCIS. Trainees at UK breast units were invited to complete the questionnaire at their multidisciplinary team meeting to provide a comprehensive picture of current national practice. RESULTS 76 of 144 UK breast units (52.8%) participated in the survey. Variation was observed in radiological pre-operative assessment with only 33/76 units (43.4%) performing routine ultrasound assessment of the tumour or axilla. There was no clear consensus regarding indications for mastectomy; multifocality (38.2%) and extensive microcalcifications (34.2%) were the most frequent indications. 34/76 units (44.7%) offered nipple sparing mastectomy. 33/76 units (43.3%) perform sentinel node biopsy in the presence of a palpable/mass lesion and 51/76 (67.1%) at the time of mastectomy. The most widely accepted pathological radial margin remained 2 mm (36.8%). The commonest factors in decision-making for radiotherapy were tumour grade (51.3%) and size (35.5%). Only 12 units (15.8%) routinely used the Van Nuys Prognostic Index. Approximately half of all breast units offer clinical long-term follow-up. DISCUSSION There is marked variation in the management of DCIS in the UK. Updated evidence-based guidelines may standardise practice and improve outcomes for patients.
Collapse
MESH Headings
- Antineoplastic Agents, Hormonal/therapeutic use
- Axilla/diagnostic imaging
- Breast Neoplasms/diagnostic imaging
- Breast Neoplasms/metabolism
- Breast Neoplasms/pathology
- Breast Neoplasms/therapy
- Carcinoma, Intraductal, Noninfiltrating/diagnostic imaging
- Carcinoma, Intraductal, Noninfiltrating/metabolism
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/therapy
- Disease Management
- Female
- Humans
- Lymph Nodes/diagnostic imaging
- Magnetic Resonance Imaging/statistics & numerical data
- Mammaplasty/statistics & numerical data
- Mastectomy/statistics & numerical data
- Mastectomy, Segmental/statistics & numerical data
- Practice Guidelines as Topic
- Practice Patterns, Physicians'/statistics & numerical data
- Radiotherapy, Adjuvant/statistics & numerical data
- Receptor, ErbB-2/metabolism
- Receptors, Estrogen/metabolism
- Receptors, Progesterone/metabolism
- Sentinel Lymph Node Biopsy/statistics & numerical data
- Surveys and Questionnaires
- Ultrasonography/statistics & numerical data
- Ultrasonography, Mammary/statistics & numerical data
- United Kingdom
Collapse
|
23
|
Forbes JF, Sestak I, Howell A, Bonanni B, Bundred N, Levy C, von Minckwitz G, Eiermann W, Neven P, Stierer M, Holcombe C, Coleman RE, Jones L, Ellis I, Cuzick J. Anastrozole versus tamoxifen for the prevention of locoregional and contralateral breast cancer in postmenopausal women with locally excised ductal carcinoma in situ (IBIS-II DCIS): a double-blind, randomised controlled trial. Lancet 2016; 387:866-73. [PMID: 26686313 PMCID: PMC4769326 DOI: 10.1016/s0140-6736(15)01129-0] [Citation(s) in RCA: 123] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Third-generation aromatase inhibitors are more effective than tamoxifen for preventing recurrence in postmenopausal women with hormone-receptor-positive invasive breast cancer. However, it is not known whether anastrozole is more effective than tamoxifen for women with hormone-receptor-positive ductal carcinoma in situ (DCIS). Here, we compare the efficacy of anastrozole with that of tamoxifen in postmenopausal women with hormone-receptor-positive DCIS. METHODS In a double-blind, multicentre, randomised placebo-controlled trial, we recruited women who had been diagnosed with locally excised, hormone-receptor-positive DCIS. Eligible women were randomly assigned in a 1:1 ratio by central computer allocation to receive 1 mg oral anastrozole or 20 mg oral tamoxifen every day for 5 years. Randomisation was stratified by major centre or hub and was done in blocks (six, eight, or ten). All trial personnel, participants, and clinicians were masked to treatment allocation and only the trial statistician had access to treatment allocation. The primary endpoint was all recurrence, including recurrent DCIS and new contralateral tumours. All analyses were done on a modified intention-to-treat basis (in all women who were randomised and did not revoke consent for their data to be included) and proportional hazard models were used to compute hazard ratios and corresponding confidence intervals. This trial is registered at the ISRCTN registry, number ISRCTN37546358. RESULTS Between March 3, 2003, and Feb 8, 2012, we enrolled 2980 postmenopausal women from 236 centres in 14 countries and randomly assigned them to receive anastrozole (1449 analysed) or tamoxifen (1489 analysed). Median follow-up was 7·2 years (IQR 5·6-8·9), and 144 breast cancer recurrences were recorded. We noted no statistically significant difference in overall recurrence (67 recurrences for anastrozole vs 77 for tamoxifen; HR 0·89 [95% CI 0·64-1·23]). The non-inferiority of anastrozole was established (upper 95% CI <1·25), but its superiority to tamoxifen was not (p=0·49). A total of 69 deaths were recorded (33 for anastrozole vs 36 for tamoxifen; HR 0·93 [95% CI 0·58-1·50], p=0·78), and no specific cause was more common in one group than the other. The number of women reporting any adverse event was similar between anastrozole (1323 women, 91%) and tamoxifen (1379 women, 93%); the side-effect profiles of the two drugs differed, with more fractures, musculoskeletal events, hypercholesterolaemia, and strokes with anastrozole and more muscle spasm, gynaecological cancers and symptoms, vasomotor symptoms, and deep vein thromboses with tamoxifen. CONCLUSIONS No clear efficacy differences were seen between the two treatments. Anastrozole offers another treatment option for postmenopausal women with hormone-receptor-positive DCIS, which may be be more appropriate for some women with contraindications for tamoxifen. Longer follow-up will be necessary to fully evaluate treatment differences. FUNDING Cancer Research UK, National Health and Medical Research Council Australia, Breast Cancer Research Fund, AstraZeneca, Sanofi Aventis.
Collapse
Affiliation(s)
- John F Forbes
- Australia and New Zealand Breast Cancer Trials Group, University of Newcastle, Waratah, NSW, Australia
| | - Ivana Sestak
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | | | - Bernardo Bonanni
- Division of Cancer Prevention and Genetics, European Institute of Oncology, Milan, Italy
| | - Nigel Bundred
- South Manchester University Hospital, Manchester, UK
| | | | | | | | - Patrick Neven
- Department of Oncology, KU Leuven, University of Leuven, Leuven, Belgium
| | - Michael Stierer
- Austrian Breast and Colorectal Cancer Study Group, Vienna, Austria
| | - Chris Holcombe
- Linda McCartney Centre, Royal Liverpool University Hospital, Liverpool, UK
| | - Robert E Coleman
- Department of Oncology and Metabolism, Weston Park Hospital, Sheffield, UK
| | - Louise Jones
- Barts Cancer Institute, Queen Mary University of London, London, UK
| | - Ian Ellis
- Department of Histopathology University of Nottingham, Nottingham, UK
| | - Jack Cuzick
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK.
| |
Collapse
|
24
|
Worni M, Akushevich I, Greenup R, Sarma D, Ryser MD, Myers ER, Hwang ES. Trends in Treatment Patterns and Outcomes for Ductal Carcinoma In Situ. J Natl Cancer Inst 2015; 107:djv263. [PMID: 26424776 DOI: 10.1093/jnci/djv263] [Citation(s) in RCA: 141] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 08/25/2015] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Impact of contemporary treatment of pre-invasive breast cancer (ductal carcinoma in situ [DCIS]) on long-term outcomes remains poorly defined. We aimed to evaluate national treatment trends for DCIS and to determine their impact on disease-specific (DSS) and overall survival (OS). METHODS The Surveillance, Epidemiology, and End Results (SEER) registry was queried for patients diagnosed with DCIS from 1991 to 2010. Treatment pattern trends were analyzed using Cochran-Armitage trend test. Survival analyses were performed using inverse probability weights (IPW)-adjusted competing risk analyses for DSS and Cox proportional hazard regression for OS. All tests performed were two-sided. RESULTS One hundred twenty-one thousand and eighty DCIS patients were identified. The greatest proportion of patients was treated with lumpectomy and radiation therapy (43.0%), followed by lumpectomy alone (26.5%) and unilateral (23.8%) or bilateral mastectomy (4.5%) with significant shifts over time. The rate of sentinel lymph node biopsy increased from 9.7% to 67.1% for mastectomy and from 1.4% to 17.8% for lumpectomy. Compared with mastectomy, OS was higher for lumpectomy with radiation (hazard ratio [HR] = 0.79, 95% confidence interval [CI] = 0.76 to 0.83, P < .001) and lower for lumpectomy alone (HR = 1.17, 95% CI = 1.13 to 1.23, P < .001). IPW-adjusted ten-year DSS was highest in lumpectomy with XRT (98.9%), followed by mastectomy (98.5%), and lumpectomy alone (98.4%). CONCLUSIONS We identified substantial shifts in treatment patterns for DCIS from 1991 to 2010. When outcomes between locoregional treatment options were compared, we observed greater differences in OS than DSS, likely reflecting both a prevailing patient selection bias as well as clinically negligible differences in breast cancer outcomes between groups.
Collapse
Affiliation(s)
- Mathias Worni
- Division of Advanced Oncologic and GI Surgery, Department of Surgery, (MW, RG, DS, ESH), Center for Population Health and Aging (IA), Department of Obstetrics and Gynecology (ERM), and Department of Mathematics (MDR), Duke University Medical Center, Durham NC; Department of Visceral Surgery and Medicine, Inselspital, Berne University Hospital and University of Berne, Berne, Switzerland (MW)
| | - Igor Akushevich
- Division of Advanced Oncologic and GI Surgery, Department of Surgery, (MW, RG, DS, ESH), Center for Population Health and Aging (IA), Department of Obstetrics and Gynecology (ERM), and Department of Mathematics (MDR), Duke University Medical Center, Durham NC; Department of Visceral Surgery and Medicine, Inselspital, Berne University Hospital and University of Berne, Berne, Switzerland (MW)
| | - Rachel Greenup
- Division of Advanced Oncologic and GI Surgery, Department of Surgery, (MW, RG, DS, ESH), Center for Population Health and Aging (IA), Department of Obstetrics and Gynecology (ERM), and Department of Mathematics (MDR), Duke University Medical Center, Durham NC; Department of Visceral Surgery and Medicine, Inselspital, Berne University Hospital and University of Berne, Berne, Switzerland (MW)
| | - Deba Sarma
- Division of Advanced Oncologic and GI Surgery, Department of Surgery, (MW, RG, DS, ESH), Center for Population Health and Aging (IA), Department of Obstetrics and Gynecology (ERM), and Department of Mathematics (MDR), Duke University Medical Center, Durham NC; Department of Visceral Surgery and Medicine, Inselspital, Berne University Hospital and University of Berne, Berne, Switzerland (MW)
| | - Marc D Ryser
- Division of Advanced Oncologic and GI Surgery, Department of Surgery, (MW, RG, DS, ESH), Center for Population Health and Aging (IA), Department of Obstetrics and Gynecology (ERM), and Department of Mathematics (MDR), Duke University Medical Center, Durham NC; Department of Visceral Surgery and Medicine, Inselspital, Berne University Hospital and University of Berne, Berne, Switzerland (MW)
| | - Evan R Myers
- Division of Advanced Oncologic and GI Surgery, Department of Surgery, (MW, RG, DS, ESH), Center for Population Health and Aging (IA), Department of Obstetrics and Gynecology (ERM), and Department of Mathematics (MDR), Duke University Medical Center, Durham NC; Department of Visceral Surgery and Medicine, Inselspital, Berne University Hospital and University of Berne, Berne, Switzerland (MW)
| | - E Shelley Hwang
- Division of Advanced Oncologic and GI Surgery, Department of Surgery, (MW, RG, DS, ESH), Center for Population Health and Aging (IA), Department of Obstetrics and Gynecology (ERM), and Department of Mathematics (MDR), Duke University Medical Center, Durham NC; Department of Visceral Surgery and Medicine, Inselspital, Berne University Hospital and University of Berne, Berne, Switzerland (MW).
| |
Collapse
|
25
|
[Radiotherapy also for good-risk ductal carcinoma in situ? Results from a prospective randomized RTOG trial]. Strahlenther Onkol 2015. [PMID: 26221647 DOI: 10.1007/s00066-015-0836-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
26
|
Singh P, Kulkarni SA. Is Wide Excision Alone an Appropriate Therapy for DCIS? CURRENT SURGERY REPORTS 2015. [DOI: 10.1007/s40137-015-0097-y] [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]
|
27
|
Elshof LE, Tryfonidis K, Slaets L, van Leeuwen-Stok AE, Skinner VP, Dif N, Pijnappel RM, Bijker N, Rutgers EJT, Wesseling J. Feasibility of a prospective, randomised, open-label, international multicentre, phase III, non-inferiority trial to assess the safety of active surveillance for low risk ductal carcinoma in situ - The LORD study. Eur J Cancer 2015; 51:1497-510. [PMID: 26025767 DOI: 10.1016/j.ejca.2015.05.008] [Citation(s) in RCA: 241] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Revised: 04/22/2015] [Accepted: 05/07/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND The current debate on overdiagnosis and overtreatment of screen-detected ductal carcinoma in situ (DCIS) urges the need for prospective studies to address this issue. A substantial number of DCIS lesions will never form a health hazard, particularly if it concerns non- to slow-growing low-grade DCIS. The LORD study aims to evaluate the safety of active surveillance in women with low-risk DCIS. DESIGN This is a randomised, international multicentre, open-label, phase III non-inferiority trial, led by the Dutch Breast Cancer Research Group (BOOG 2014-04) and the European Organization for Research and Treatment of Cancer (EORTC-BCG 1401). Standard treatment will be compared to active surveillance in 1240 women aged ⩾ 45 years with asymptomatic, screen-detected, pure low-grade DCIS based on vacuum-assisted biopsies of microcalcifications only. Both study arms will be monitored with annual digital mammography for a period of 10 years. The primary end-point is 10-year ipsilateral invasive breast cancer free percentage. Secondary end-points include patient reported outcomes, diagnostic biopsy rate during follow-up, ipsilateral mastectomy rate and translational research. FEASIBILITY To explore interest in and feasibility of the LORD study we conducted a survey among EORTC and BOOG centres. A vast majority of EORTC and BOOG responding centres expressed interest in participation in the LORD study. The proposed study design is endorsed by nearly all centres.
Collapse
Affiliation(s)
- Lotte E Elshof
- Department of Surgery, Netherlands Cancer Institute/Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands; Department of Molecular Pathology, Netherlands Cancer Institute/Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands; Department of Epidemiology, Netherlands Cancer Institute/Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands.
| | - Konstantinos Tryfonidis
- Medical Department, European Organisation for Research and Treatment of Cancer, Avenue E. Mounier 83/11, 1200 Brussels, Belgium.
| | - Leen Slaets
- Department of Statistics, European Organisation for Research and Treatment of Cancer, Avenue E. Mounier 83/11, 1200 Brussels, Belgium.
| | | | - Victoria P Skinner
- Department of Surgery, Netherlands Cancer Institute/Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands.
| | - Nicolas Dif
- Department of Clinical Operations, European Organisation for Research and Treatment of Cancer, Avenue E. Mounier 83/11, 1200 Brussels, Belgium.
| | - Ruud M Pijnappel
- Department of Radiology, University Medical Centre Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands.
| | - Nina Bijker
- Department of Radiotherapy, Academic Medical Center, PO Box 227700, 1100 DE Amsterdam, The Netherlands.
| | - Emiel J Th Rutgers
- Department of Surgery, Netherlands Cancer Institute/Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands.
| | - Jelle Wesseling
- Department of Molecular Pathology, Netherlands Cancer Institute/Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands; Department of Pathology, Netherlands Cancer Institute/Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands.
| |
Collapse
|
28
|
Liedtke C, Thill M, Hanf V, Schütz F. AGO Recommendations for the Diagnosis and Treatment of Patients with Early Breast Cancer: Update 2014. Breast Care (Basel) 2014; 9:189-200. [PMID: 25177261 PMCID: PMC4132219 DOI: 10.1159/000363591] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Affiliation(s)
- Cornelia Liedtke
- Klinik für Frauenheilkunde und Geburtshilfe, Universitätsklinikum Schleswig Holstein, Campus Lübeck, Germany
| | - Marc Thill
- Klinik für Gynäkologie und Geburtshilfe, Agaplesion Markus Krankenhaus, Frankfurt/M., Germany
| | - Volker Hanf
- Frauenklinik, Klinikum Fürth, Universitätsklinikum Heidelberg, Germany
| | | | | |
Collapse
|