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Kim M, Tadros AB, Boe LA, Vingan P, Allen RJ, Mehrara BJ, Morrow M, Nelson JA. Breast-Conserving Therapy Versus Postmastectomy Breast Reconstruction: Propensity Score-Matched Analysis. Ann Surg Oncol 2024:10.1245/s10434-024-15294-w. [PMID: 39075246 DOI: 10.1245/s10434-024-15294-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 03/28/2024] [Indexed: 07/31/2024]
Abstract
BACKGROUND Although studies have compared patient-reported outcomes (PROs) after breast conserving-therapy (BCT) and postmastectomy breast reconstruction (PMBR), they often have been confounded by treatment or other factors that complicate a direct comparison. This study aimed to compare PROs after BCT and PMBR by using propensity score-matching analysis. METHODS Patients who underwent BCT or PMBR between 2010 and 2022 and completed the BREAST-Q were identified. Each BCT patient was matched to a PMBR patient using nearest-neighbor 1:1 matching with replacement for each BREAST-Q time point. Outcomes included all prospectively collected BREAST-Q domains preoperatively, at 6 months, and at 1, 2, and 3 years postoperatively. A 4-point difference was considered clinically meaningful. RESULTS For this study, 6215 patients (2501 BCT [40.2%] and 3714 PMBR [59.8%] patients) were eligible, and 2616 unique patients were matched. Preoperatively, 463 BCT and 463 PMBR patients were matched for analysis (6 months [443 matched pairs], 1 year [639 matched pairs], 2 years [421 matched pairs], 3 years [254 matched pairs]). At 6 months postoperatively, the BCT patients scored higher on all BREAST-Q domains than the PMBR patients (p < 0.05; differences > 4 points). At 1, 2, and 3 years, the patients who underwent BCT consistently had superior Satisfaction With Breasts, Psychosocial Well-Being, and Sexual Well-Being (p < 0.05), and the differences were clinically meaningful. CONCLUSION In this statistically powered study, the BCT patients reported higher quality of life than the PMBR patients in early assessment and also through 3 years of follow-up evaluation. Given the equivalency in survival and recurrence outcomes between BCT and PMBR, patients eligible for either surgery should be counseled regarding the superiority of BCT in terms of PROs.
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Affiliation(s)
- Minji Kim
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Audree B Tadros
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Lillian A Boe
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Perri Vingan
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Robert J Allen
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Babak J Mehrara
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jonas A Nelson
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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2
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Leonardis JM, Momoh AO, Lipps DB. Choosing breast-conserving therapy or mastectomy and subpectoral implant breast reconstruction: implications for pectoralis major function. Breast Cancer Res Treat 2024:10.1007/s10549-024-07381-z. [PMID: 38851662 DOI: 10.1007/s10549-024-07381-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 05/17/2024] [Indexed: 06/10/2024]
Abstract
BACKGROUND An increasing number of women are choosing mastectomy and subpectoral implant (SI) breast reconstruction over breast-conserving therapy (BCT). It is unclear to what extent these procedures differ in their effect on the pectoralis major (PM). The purpose of this study was to assess the impact of choosing BCT or SI breast reconstruction on PM function. METHODS Ultrasound shear wave elastography images were acquired from the PM fiber regions and surface electromyography obtained activity from six shoulder muscles, while 14 BCT participants, 14 SI participants, and 14 age-matched controls remained at rest or generated submaximal shoulder torques. RESULTS BCT and SI participants were significantly weaker in shoulder adduction, while BCT participants were also weaker in internal and external rotation (all p ≤ 0.003). PM function was altered following either BCT or SI. In all treatment groups, the clavicular fiber region contributed primarily to flexion, and the sternocostal primarily contributed to adduction. However, healthy participants utilized the clavicular region more during adduction and the sternocostal region more during flexion when compared to BCT or SI participants (all p ≤ 0.049). The still intact clavicular region increased its contributions to flexion torques in SI participants compared to controls (p = 0.016). Finally, BCT and SI participants compensated for changes in PM function using synergistic shoulder musculature. CONCLUSION Both BCT and SI breast reconstruction result in significant long-term upper extremity strength deficits. Our results suggest changes to the underlying function of the PM and the adoption of unique but inadequate neuromuscular compensation strategies drive these deficits.
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Affiliation(s)
- Joshua M Leonardis
- College of Applied Health Sciences, University of Illinois Urbana-Champaign, 906 S. Goodwin Avenue, Urbana, IL, 61801, USA.
- Beckman Institute for Advanced Science and Technology, University of Illinois Urbana-Champaign, Urbana, IL, USA.
| | - Adeyiza O Momoh
- Department of Surgery, Section of Plastic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - David B Lipps
- School of Kinesiology, University of Michigan, Ann Arbor, MI, USA
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Orozco JIJ, Keller JK, Chang SC, Fancher CE, Grumley JG. Impact of Locoregional Treatment on Survival in Young Patients with Early-Stage Breast Cancer undergoing Upfront Surgery. Ann Surg Oncol 2022; 29:6299-6310. [PMID: 35896922 DOI: 10.1245/s10434-022-12190-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 06/27/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Randomized, controlled trials comparing breast-conserving therapy (BCT) with mastectomy have demonstrated equivalent overall survival (OS), but recent observational studies have shown improved OS in patients undergoing BCT. These studies provide limited data on young patients who are traditionally offered mastectomy due to perceived higher disease risk. This study examines the OS in a contemporary series of young women with breast cancer undergoing upfront BCT compared with mastectomy. METHODS Women ≤40 years old with primary invasive T1-T2, N0-N1 breast cancer were identified from the National Cancer Database between 2006 and 2016. Patient cohorts were based according to locoregional treatment: BCT, mastectomy alone (Mx), and mastectomy with radiotherapy (Mx/RT). Kaplan-Meier method followed by Cox proportional-hazards regression with inverse probability of treatment weighting (IPTW) were performed to account for treatment selection bias effects in OS. RESULTS A total of 15,611 patients met the study criteria; 9,509 patients (60.9%) had BCT, 4,020 (25.8%) had Mx/RT, and 2,082 (13.3%) had Mx alone. The median follow-up was 4.6 years (interquartile range [IQR] 3.0-6.4). After IPTW-adjustment, the 5-year OS was similar for BCT (95%), Mx (95%), and Mx/RT (94%), and there was no significant difference in OS in Mx (hazard ratio [HR] = 1.16, 95% confidence interval [CI] 0.90-1.51) and Mx/RT (HR = 1.08, 95% CI 0.88-1.34) compared with BCT. Mx/RT was associated with decreased survival in patients with pT2N0 (HR = 1.78, 95% CI 1.12-2.84). CONCLUSIONS Among young patients with early-stage breast cancer, overall survival was equivalent regardless of surgical approach. Breast-conserving therapy remains a safe option in young women despite the clinical tendency to offer upfront mastectomy in young patients.
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Affiliation(s)
- Javier I J Orozco
- Saint John's Cancer Institute, Providence Saint John's Health Center, Santa Monica, CA, USA
| | - Jennifer K Keller
- Saint John's Cancer Institute, Providence Saint John's Health Center, Santa Monica, CA, USA
| | - Shu-Ching Chang
- Center for Cardiovascular Analytics, Research and Data Science (CARDS), Providence Saint Joseph Health, Portland, OR, USA
| | - Crystal E Fancher
- Saint John's Cancer Institute, Providence Saint John's Health Center, Santa Monica, CA, USA
| | - Janie G Grumley
- Saint John's Cancer Institute, Providence Saint John's Health Center, Santa Monica, CA, USA.
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Machuca MPG, Wu WC, Yu BL, Cheng CT. Determinants of Breast-Conserving Therapy in Early-Stage Breast Cancer Patients: A Nationwide Study. Clin Breast Cancer 2021; 22:e473-e479. [PMID: 34974964 DOI: 10.1016/j.clbc.2021.11.007] [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: 08/23/2021] [Revised: 11/21/2021] [Accepted: 11/25/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Evidence from previous studies and treatment guidelines suggested that breast-conserving therapy (BCT) is the treatment of choice for early-stage breast cancer. However, in the last decades, surgeons have noticed a high percentage of mastectomies done in this population. The aim of this study is to explore the factors associated with not choosing BCT among eligible patients with early-stage breast cancer. MATERIALS AND METHODS This study uses a retrospective cohort design. Demographic and clinical characteristics derived from The Taiwan Cancer Registry Database, the National Health Insurance Database and the Death File Database from January 1, 2004 to December 31, 2014. Patients were followed until December 31, 2015. To explore the associated factors related to BCT, we used univariate and multivariate logistic regression analysis. RESULTS A total sample of 25,967 stage I breast cancer patients was included. Among them, 12,191 underwent BCT and 13,776 underwent mastectomy as their primary treatment. The logistic regression analysis reveals that age, pay-for-performance (P4P) program participation, number of affected lymph nodes, tumor size and location, were determinants of BCT. Interestingly enough, histological type did not reach the significance level. CONCLUSION This study shows that personal and clinical characteristics influence the treatment choice in stage 1 breast cancer patients.
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Affiliation(s)
| | - Wen-Ching Wu
- Department of Medical Research, Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan
| | - Ben-Long Yu
- Department of Surgery, Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan
| | - Chih-Tao Cheng
- Department of Medical Research, Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan; Department of Psychology and Social Work, National Defense University, Taipei, Taiwan.
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Unukovych D, Gümüscü R, Wärnberg F, de Boniface J, Eriksen C, Sund M, Nåsell P, Åhsberg K, Olofsson P, Lewin R, Lambe M, Brandberg Y, Folkvaljon F, Mani M. Breast reconstruction patterns from a Swedish nation-wide survey. Eur J Surg Oncol 2020; 46:1867-1873. [PMID: 32698944 DOI: 10.1016/j.ejso.2020.04.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 04/01/2020] [Accepted: 04/15/2020] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES The overall aim of the Swedish Breast Reconstruction Outcome Study was to investigate national long-term outcomes after mastectomy with or without breast reconstruction. The current report evaluates breast reconstruction (BR) patterns in Sweden over time. MATERIALS AND METHODS This is a cross-sectional, registry-based study where all women operated with mastectomy 2000, 2005, 2010 were identified (N = 5853). Geographical differences in type of BR were investigated using heatmaps. Distribution of continuous variables were compared using the Mann-Whitney U test, categorical variables were compared using the chi-square test. RESULTS Mean age at survey was 69 years (SD=±11.4) and response rate was 50%, responders were on average six years younger than the non-responders and had a more favourable tumor stage (both p < 0.01). Of the 2904 responders, 31% (895/2904) had received a BR: implant-based in 58% (516/895)autologous in 31% (281/895). BR was immediate in 20% (176/895) and delayed in 80% (719/895) women. Women with BR were on average one year older, more often had a normal BMI, reported to be married or had a partner, had a higher educational level and a higher annual income when compared to those without BR (all p < 0.001). The independent factors of not receiving BR were older age and given radiotherapy. CONCLUSIONS To our knowledge, this is the first national long-term follow-up study on women undergoing mastectomy with and without BR. Around 30% of the survey responders have had a BR with a significant geographical variation highlighting the importance of information, availability and standardisation of indications for BR.
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Affiliation(s)
- Dmytro Unukovych
- Department of Surgical Sciences, Section of Plastic Surgery, Uppsala University, Uppsala University Hospital, Sweden; Department of Surgery, Capio S:t Görans Hospital, Stockholm, Sweden.
| | - Rojda Gümüscü
- Department of Surgical Sciences, Section of Plastic Surgery, Uppsala University, Uppsala University Hospital, Sweden
| | - Fredrik Wärnberg
- Department of Surgical Sciences, Uppsala University, Uppsala University Hospital, Sweden
| | - Jana de Boniface
- Department of Surgery, Capio S:t Görans Hospital, Stockholm, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Catharina Eriksen
- Department of Clinical Science and Education, Southern General Hospital, Stockholm, Sweden
| | - Malin Sund
- Department of Surgical and Perioperative Sciences/Surgery, Umeå University, Umeå, Sweden
| | - Petra Nåsell
- Department of Surgery, Capio S:t Görans Hospital, Stockholm, Sweden
| | - Kristina Åhsberg
- Department of Breast and Melanoma Surgery, Skåne University Hospital, Malmö Lund, Sweden
| | - Pia Olofsson
- Department of Hand Surgery and Plastic Surgery, Linköping University Hospital, Linköping, Sweden
| | - Richard Lewin
- Department of Clinical Sciences, Department of Plastic Surgery, Sahlgrenska Akademin, Gothenburg, Sweden
| | - Mats Lambe
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Yvonne Brandberg
- Department of Oncology Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Folke Folkvaljon
- Department of Surgical Sciences, Section of Plastic Surgery, Uppsala University, Uppsala University Hospital, Sweden
| | - Maria Mani
- Department of Surgical Sciences, Section of Plastic Surgery, Uppsala University, Uppsala University Hospital, Sweden
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Abstract
BACKGROUND The impact of insurance and socioeconomic status on breast reconstruction modalities when access to care is controlled is unknown. METHODS Records for patients who underwent breast reconstruction at an academic medical center between 2013 and 2017 were reviewed and analyzed using chi-square analysis and logistic regression. RESULTS One thousand six hundred eighty-three breast reconstructions were analyzed. The commercially insured were more likely to undergo microvascular autologous breast reconstruction (44.4 percent versus 31.3 percent; p < 0.001), with an odds ratio of 2.22, whereas patients with Medicare and Medicaid were significantly more likely to receive tissue expander/implant breast reconstruction, with an odds ratio of 1.42 (41.7 percent versus 47.7 percent; p = 0.013). Comparing all patients with microvascular reconstruction, the commercially insured were more likely to receive a perforator flap (79.7 percent versus 55.3 percent versus 43.9 percent), with an odds ratio of 4.23 (p < 0.001). When stratifying patients by median household income, those in the highest income quartile were most likely to receive a perforator flap (82.1 percent) (p < 0.001), whereas those in the lowest income quartile were most likely to receive a muscle-sparing transverse rectus abdominis myocutaneous flap (36.4 percent) (p < 0.001). CONCLUSIONS Patients at the same academic medical center had significantly different breast reconstruction modalities when stratified by insurance and household income. Despite similar access to care, differences in insurance types may favor higher rates of perforator flap breast reconstruction among the commercially insured. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
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7
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Collins IM, Lum C, Versace VL. Influence of socioeconomic factors and distance to radiotherapy on breast-conserving surgery rates for early breast cancer in regional Australia; implications of change. Asia Pac J Clin Oncol 2017; 14:e224-e230. [PMID: 29159936 DOI: 10.1111/ajco.12828] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 10/19/2017] [Indexed: 10/18/2022]
Abstract
AIMS Breast conserving surgery rates are affected by many factors including distance to radiotherapy and tumor-related features. Numerous studies have found women who must travel further for radiotherapy are more likely to choose mastectomy and avoid radiotherapy. We examined relationships between socioeconomic group, distance to radiotherapy services and mastectomy rates across a range of rural and metropolitan settings. METHODS We used a dataset extracted from the Evaluation of Cancer Outcomes Barwon South Western Registry, which captured data on new breast cancer diagnoses in the southwest region of Victoria, Australia. Using logistic regression, we modeled treatment choice of women with early breast cancer (mastectomy vs breast conserving surgery) using explanatory variables that included distance to radiotherapy, and area-level socioeconomic data from the Australian Bureau of Statistics, while controlling for clinical factors. RESULTS Mastectomy was associated with tumor size, nodal burden and younger age at surgery. Distance to a radiotherapy center was also strongly associated with increased rates of mastectomy for women who traveled 100-200 km for radiotherapy (odds ratio = 1.663; P = 0.03) compared to the reference group who were within 100 km of radiotherapy. No socioeconomic differences were seen between the two groups. CONCLUSION A strong association between distance to radiotherapy and the type of surgery for early breast cancer was found. Improving access to radiotherapy therefore has the potential to improve breast cancer outcomes for women in regional Australia.
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Affiliation(s)
- Ian M Collins
- School of Medicine, Deakin University, Warrnambool, Victoria, Australia
| | - Caroline Lum
- Border Medical Oncology, Deakin University, Deakin Rural Health, Warrnambool, Victoria, Australia
| | - Vincent L Versace
- School of Medicine, Deakin University, Deakin Rural Health, Warrnambool, Victoria, Australia
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8
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Dutta SW, Trifiletti DM, Grover S, Romano KD, Janowski EM, Showalter SL. The Effect of Receptor Status on Mastectomy and Contralateral Prophylactic Mastectomy Rates in Early Stage Invasive Breast Carcinoma. Clin Breast Cancer 2017; 18:121-127. [PMID: 28811185 DOI: 10.1016/j.clbc.2017.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 06/25/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND There is an established relationship between hormone receptor (HR; estrogen and/or progesterone receptors) status, HER2 status, and locoregional recurrence. The purpose of this study was to analyze how HR and HER2 receptor status have influenced the surgical management trends among patients with early stage breast cancer. PATIENTS AND METHODS The National Cancer Database was queried for patients with cT1 to cT3, cN0, and cM0 breast carcinoma from 2004 to 2012. Patients were grouped on the basis of receptor status and surgical management (mastectomy or breast-conserving surgery [BCS]). Multivariable analyses were performed to investigate factors associated with increased odds of receiving mastectomy over BCS. Among a subgroup of patients who underwent ipsilateral mastectomy, analyses were performed to determine any association between contralateral prophylactic mastectomy (CPM) and receptor status. RESULTS We found 280,241 patients who met inclusion criteria for analyzing mastectomy or BCS surgical decision. Patients with HER2-positive (HER2+) tumors (HR+/HER+ and HR-/HER2+) were the most likely to undergo mastectomy (odds ratio [OR], 1.212 and 1.499 respectively, compared with HR+/HER2- patients, each P < .001). HR status alone did not affect ipsilateral surgical management as patients with HR+/HER2- and HR-/HER2- tumors demonstrated similar mastectomy rates (P = .391). Among the 108,018 who underwent mastectomy, 20% underwent CPM. After adjustment, patients with HR+/HER2+, HR-/HER2+, and HR-/HER2- were all more likely to undergo CPM (OR 1.356, 1.608, and 1.358, respectively compared with HR+/HER2- patients, each P < .001). CONCLUSION This analysis indicates that patients with early stage breast cancer are more likely to undergo a mastectomy and CPM if they have HER2+ tumors.
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MESH Headings
- Adult
- Aged
- Breast Neoplasms/pathology
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/surgery
- Clinical Decision-Making
- Female
- Humans
- Mastectomy, Segmental/statistics & numerical data
- Middle Aged
- Neoplasm Recurrence, Local/pathology
- Neoplasm Recurrence, Local/prevention & control
- Neoplasm Staging
- Patient Selection
- Prophylactic Mastectomy/statistics & numerical data
- Receptor, ErbB-2/metabolism
- Receptors, Estrogen/metabolism
- Receptors, Progesterone/metabolism
- SEER Program/statistics & numerical data
- Young Adult
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Affiliation(s)
- Sunil W Dutta
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA.
| | - Daniel M Trifiletti
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA
| | - Surbhi Grover
- Department of Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
| | - Kara D Romano
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA
| | | | - Shayna L Showalter
- Division of Surgical Oncology, Department of Surgery, University of Virginia School of Medicine, Charlottesville, VA
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Abstract
It is known that survival is unaffected by the choice of surgical management for breast cancer (BC) patients. Despite this fact, recent literature reveals that the number of bilateral mastectomies (BMs) in the United States is increasing. In an effort to elucidate potential factors influencing this trend, we investigated socioeconomic and clinicopathologic characteristics of our patient cohort that could have affected a patient's decision between unilateral mastectomy (UM) versus BM. Five-hundred-eight patients with unilateral BC who underwent mastectomy between 2000 and 2009 were analyzed: 397-UM; 111-BM. Influence of patient's age, insurance status, residence (rural versus urban), subsequent reconstruction, marital status, smoking history, family cancer history, cancer stage and grade on the BM versus UM patient's decision were analyzed using independent sample t tests, χ2 and logistic regression analysis. BM was more likely to be chosen by younger (<50 years) patients (P < 0.001); patients with private insurance [odds ratio (OR) = 2.22, 95% confidence interval (CI) = 1.4–3.5]; residence in urban settings (OR = 5.09, 95% CI = 2.5–10.4); and plans for subsequent reconstruction (OR = 2.31, 95% CI = 1.4–3.8). Marital status, smoking history, family cancer history, BC stage and grade did not significantly impact patient's choice of BM versus UM. We found that patients with unilateral BC who are younger (<50 year) have private insurance, reside in urban settings, or plan for subsequent reconstruction are more likely to undergo BM for unilateral BC. Genetic specific data were not evaluated for this patient cohort, and will be the subject of future analysis.
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10
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Churilla TM, Egleston B, Bleicher R, Dong Y, Meyer J, Anderson P. Disparities in the Local Management of Breast Cancer in the US according to Health Insurance Status. Breast J 2016; 23:169-176. [PMID: 27797159 DOI: 10.1111/tbj.12705] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Although standard practice guidelines for breast cancer are clear, the interplay between insurance and practice patterns for the US is poorly defined. This study was performed to test for associations between patient insurance status and presentation of breast cancer as well as local therapy patterns in the US, via a large national dataset. We queried the NCI Surveillance, Epidemiology, and End Results data base for breast cancer cases diagnosed from 2007 to 2011 in women aged 18-64 with nonmetastatic ductal/lobular cancers, treated surgically. We tested for associations between insurance status (insured/Medicaid/uninsured) and choice of surgical procedure (mastectomy/breast conserving surgery [BCS]), omission of radiotherapy (RT) following BCS, and administration of post-mastectomy radiation (PMRT). There were 129,565 patients with localized breast cancer analyzed. The health insurance classification included insured (84.5%), Medicaid (11.5%), uninsured (2.1%) and unknown (1.9%). Medicaid or uninsured status was associated with large, node positive tumors, black race, and low income. The BCS rate varied by insurance status: insured (52.2%), uninsured (47.7%), and Medicaid (45.2%), p < 0.001. In multivariable analysis, Medicaid insurance remained significantly associated with receipt of mastectomy (OR [95% CI] = 1.07 [1.03-1.11]), while RT was more frequently omitted after BCS in both Medicaid (OR [95% CI] = 1.14 [1.07-1.21]) and uninsured (OR [95% CI] = 1.29 [1.14-1.47]) patients. Insurance status was associated with significant variations in breast cancer care in the US. Although patient choice cannot be determined from this dataset, departure from standard of care is associated with specific types of insurance coverage. Further investigation into the reasons for these departures is strongly suggested.
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Affiliation(s)
- Thomas M Churilla
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Brian Egleston
- Department of Biostatistics and Bioinformatics Facility, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Richard Bleicher
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Yanqun Dong
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Joshua Meyer
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Penny Anderson
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
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Fisher S, Yasui Y, Dabbs K, Winget M. Using Multilevel Models to Explain Variation in Clinical Practice: Surgeon Volume and the Surgical Treatment of Breast Cancer. Ann Surg Oncol 2016; 23:1845-51. [PMID: 26842490 DOI: 10.1245/s10434-016-5118-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Indexed: 11/18/2022]
Abstract
PURPOSE To investigate the relationship between surgeon caseload and surgery type, and variation in the surgical treatment of early stage breast cancer patients in Alberta, Canada. METHODS All women diagnosed with stage I to III breast cancer in Alberta from 2002 to 2010 were identified from the Alberta Cancer Registry. Type of surgery, surgeon (anonymized), and hospital were obtained from provincial physician claims data. Multilevel logistic regression with surgeons and hospitals as crossed random effects was used to estimate adjusted odds ratios (OR) of receiving mastectomy by surgeon volume. Empirical Bayes estimation was used to estimate adjusted OR for individual surgeons and hospitals. RESULTS Mastectomy was found to be inversely related to surgeon volume among stage I and II patients. Patients whose surgery was conducted by a low-volume surgeon had twice the odds of receiving mastectomy as those that had surgery performed by a very high-volume surgeon (stage I OR 2.36, 95 % confidence interval 1.40, 3.97; stage II OR 1.96, 95 % confidence interval 1.13, 3.42). OR of mastectomy varied widely by individual surgeon beyond the variation explained by the factors investigated. CONCLUSIONS Surgeon characteristics, including surgeon volume, are associated with surgery type received by breast cancer patients in Alberta. Significant variation in the likelihood of breast-conserving surgery (BCS) by surgeon is concerning given the potential benefits of BCS for those who are eligible.
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Affiliation(s)
- Stacey Fisher
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Yutaka Yasui
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Kelly Dabbs
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Marcy Winget
- School of Public Health, University of Alberta, Edmonton, AB, Canada. .,Department of Medicine, Stanford University, Stanford, CA, USA.
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12
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Fisher S, Gao H, Yasui Y, Dabbs K, Winget M. Survival in stage I-III breast cancer patients by surgical treatment in a publicly funded health care system. Ann Oncol 2015; 26:1161-1169. [PMID: 25712459 PMCID: PMC4516043 DOI: 10.1093/annonc/mdv107] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 02/02/2015] [Accepted: 02/16/2015] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Recent investigations of breast cancer survival in the United States suggest that patients who receive mastectomy have poorer survival than those who receive breast-conserving surgery (BCS) plus radiotherapy, despite clinically established equivalence. This study investigates breast cancer survival in the publicly funded health care system present in Alberta, Canada. PATIENTS AND METHODS Surgically treated stage I-III breast cancer cases diagnosed in Alberta from 2002 to 2010 were included. Demographic, treatment and mortality information were collected from the Alberta Cancer Registry. Unadjusted overall and breast cancer-specific mortality was assessed using Kaplan-Meier and cumulative incidence curves, respectively. Cox proportional hazards models were used to calculate stage-specific mortality hazard estimates associated with surgical treatment received. RESULTS A total of 14 939 cases of breast cancer (14 633 patients) were included in this study. The unadjusted 5-year all-cause survival probabilities for patients treated with BCS plus radiotherapy, mastectomy, and BCS alone were 94% (95% CI 93% to 95%), 83% (95% CI 82% to 84%) and 74% (95% CI 70% to 78%), respectively. Stage II and III patients who received mastectomy had a higher all-cause (stage II HR = 1.36, 95% CI 1.13-1.48; stage III HR = 1.74, 95% CI 1.24-2.45) and breast cancer-specific (stage II HR = 1.39, 95% CI 1.09-1.76; stage III HR = 1.79, 95% CI 1.21-2.65) mortality hazard compared with those who received BCS plus radiotherapy, adjusting for patient and clinical characteristics. BCS alone was consistently associated with poor survival. CONCLUSIONS Stage II and III breast cancer patients diagnosed in Alberta, Canada, who received mastectomy had a significantly higher all-cause and breast cancer-specific mortality hazard compared with those who received BCS plus radiotherapy. We suggest greater efforts toward educating and encouraging patients to receive BCS plus radiotherapy rather than mastectomy when it is medically feasible and appropriate.
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Affiliation(s)
| | | | | | - K Dabbs
- Department of Surgery, University of Alberta, Edmonton
| | - M Winget
- School of Public Health; Cancer Care, Alberta Health Services, Edmonton, Canada; Department of Medicine, Stanford University, Stanford, USA.
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The Oncologic Safety and Practicality of Breast Conservation Surgery in Large Breast Tumors 5 Centimeters or More. Clin Breast Cancer 2015; 15:e47-53. [DOI: 10.1016/j.clbc.2014.06.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Revised: 05/31/2014] [Accepted: 06/17/2014] [Indexed: 11/23/2022]
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Teh YC, Shaari NEN, Taib NA, Ng CH, See MH, Tan GH, Jamaris S, Yip CH. Determinants of choice of surgery in Asian patients with early breast cancer in a middle income country. Asian Pac J Cancer Prev 2015; 15:3163-7. [PMID: 24815464 DOI: 10.7314/apjcp.2014.15.7.3163] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Breast-conserving surgery (BCS) plus radiotherapy is equivalent to modified radical mastectomy (MRM) in terms of outcome. However there is wide variation in mastectomy rates dependent both on tumour and patient characteristics. OBJECTIVE This study aimed to assess the determinants of surgery choice in Asian patients with early breast cancer in a middle-income country. MATERIALS AND METHODS 184 patients with early breast cancer treated between Jan 2008 and Dec 2010 were recruited to complete a questionnaire. Chi-square test was used to analyze the association between surgery choice and demographic and tumour factors, surgeon recommendation, family member and partner opinions, fear of recurrence, avoidance of second surgery, fear of disfigurement, interference with sex life, fear of radiation and loss of femininity. RESULTS 85 (46%) had BCS while 99 (54%) had mastectomy. Age >60, Chinese ethnicity, lower education level, and larger tumour size were significantly associated with mastectomy. Surgeon recommendation was important in surgery choice. Although both groups did not place much importance on interference with sex life, 14.1% of the BCS group felt it was very important compared to 5.1% in the mastectomy group and this was statistically significant. There was no statistical difference between the two groups in terms of the other factors. When analyzed by ethnicity, significantly more Malay and Indian women considered partner and family member opinions very important and were more concerned about loss of femininity compared to Chinese women. There were no statistical differences between the three ethnic groups in terms of the other factors. CONCLUSIONS When counseling on surgical options, the surgeon has to take into account the ethnicity, social background and education level, age and reliance on partner and family members. Decision-making is usually a collective effort rather than just between the patient and surgeon, and involving the whole family into the process early is important.
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Affiliation(s)
- Yew-Ching Teh
- Breast Surgery Unit, Department of Surgery, University of Malaya Medical Centre, Kuala Lumpur, Malaysia E-mail :
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Factors which affect the use of lumpectomy and mastectomy in an underinsured, safety net hospital population. Am J Surg 2014; 209:985-91. [PMID: 25457245 DOI: 10.1016/j.amjsurg.2014.07.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Revised: 06/25/2014] [Accepted: 07/21/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND This study was performed to evaluate variables that affect the use of mastectomy and lumpectomy in an underinsured population. METHODS A retrospective review of all patients who underwent breast cancer operations from July 2001 to February 2011 at a safety net hospital was performed. Univariate and multivariate analyses were performed to identify variables, which were associated with the type of operation. RESULTS Of the 412 patients, 81% of the patients were underinsured or uninsured. Most patients (58%) presented with clinical stage 2A/B disease. Mastectomy was performed in 37% of patients and lumpectomy in 63%. In multivariate analysis, clinical tumor size (P = .035) and pathologic stage (P = .003) remained associated with mastectomy, while use of preoperative chemotherapy (P = .004) and type of surgeon (P = .001) was associated with lumpectomy. CONCLUSIONS Most patients underwent lumpectomy despite later stage at presentation. Preoperative chemotherapy was associated with increased likelihood of lumpectomy.
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Olsen-Deeter L, Hsu CH, Nodora JN, Bouton ME, Nalagan J, Martinez ME, Komenaka IK. Factors which affect use of breast conservation and mastectomy in an underinsured Hispanic population. Surg Oncol 2014; 23:186-91. [PMID: 25443563 DOI: 10.1016/j.suronc.2014.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 08/19/2014] [Accepted: 09/11/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND Despite no difference in overall survival between breast conservation and mastectomy, significant variation exists between institutions and within populations. Less data exists about racial and ethnic minority populations. The current study was performed to evaluate variables that affect use of breast conservation and mastectomy in an underinsured Hispanic population. METHODS A retrospective review was performed of all patients who self-identified as of Hispanic ethnicity and underwent breast cancer operations from July 2001 to February 2011 at a safety net hospital. Sociodemographic, clinical, and treatment variables were evaluated. All patients with documented contraindications to breast conservation were excluded. Univariate analysis and multivariate analysis were performed to identify variables which were associated with type of operation. RESULTS The average age of the 219 patients included was 50 years. Most of the patients (93%) were insured with Medicaid or uninsured and 59% presented with clinical stage 2A/B cancers. Mastectomy was performed in 33% of patients and 67% had breast conservation. In adjusted multivariate analysis higher pathologic stage (p=0.01) and English speakers (p=0.03) were associated with mastectomy. By contrast, higher BMI (p=0.03) and use of preoperative chemotherapy (p=0.01) were associated with breast conservation. CONCLUSIONS In this underinsured Hispanic population, patients with higher pathologic stage and English speaking patients were more likely to undergo mastectomy. Patients who underwent preoperative chemotherapy and who had higher BMI were more likely to undergo breast conservation.
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Affiliation(s)
| | - Chiu-Hsieh Hsu
- Arizona Cancer Center, University of Arizona, Tucson, AZ, USA; Mel and Enid Zuckerman Arizona College of Public Health, University of Arizona, Tucson, AZ, USA
| | - Jesse N Nodora
- Moores University of California San Diego Cancer Center, San Diego, CA, USA
| | | | | | | | - Ian K Komenaka
- Maricopa Medical Center, Phoenix, AZ, USA; Arizona Cancer Center, University of Arizona, Tucson, AZ, USA.
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Rocco N, Rispoli C, Iannone L, Testa S, Antonio Della Corte G, Compagna R, Amato B, Accurso A. Intraoperative radiation therapy with electrons in breast cancer conservative treatment: Our experience. Int J Surg 2014; 12 Suppl 1:S75-8. [DOI: 10.1016/j.ijsu.2014.05.049] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2014] [Accepted: 05/03/2014] [Indexed: 12/01/2022]
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McGuire KP, Hwang ES, Cantor A, Golshan M, Meric-Bernstam F, Horton JK, Nanda R, Amos KD, Forero A, Hudis CA, Meszoely I, De Los Santos JF. Surgical patterns of care in patients with invasive breast cancer treated with neoadjuvant systemic therapy and breast magnetic resonance imaging: results of a secondary analysis of TBCRC 017. Ann Surg Oncol 2014; 22:75-81. [PMID: 25059792 DOI: 10.1245/s10434-014-3948-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Indexed: 01/23/2023]
Abstract
BACKGROUND Neoadjuvant chemotherapy (NCT) downstages advanced primary tumors, with magnetic resonance imaging (MRI) being the most sensitive imaging predictor of response. However, the impact of MRI evaluation on surgical treatment decisions in the neoadjuvant setting has not been well described. We report surgical patterns of care across 8 National Cancer Institute comprehensive cancer centers in women receiving both NCT and MRI to evaluate the impact of MRI findings on surgical planning. METHODS Seven hundred seventy women from 8 institutions received NCT with MRI obtained both before and after systemic treatment. Univariate and multivariate analyses of imaging, patient-, and tumor-related covariates associated with choice of breast surgery were conducted. RESULTS MRI and surgical data were available on 759 of 770 patients. A total of 345 of 759 (45 %) patients received breast-conserving surgery and 414 of 759 (55 %) received mastectomy. Mastectomy occurred more commonly in patients with incomplete MRI response versus complete (58 vs. 43 %) (p = 0.0003). On multivariate analysis, positive estrogen receptor status (p = 0.02), incomplete MRI response (p = 0.0003), higher baseline T classification (p < 0.0001), younger age (p < 0.0006), and institution (p = 0.003) were independent predictors of mastectomy. A statistically significant trend toward increasing use of mastectomy with increasing T stage at presentation (p < 0.0001) was observed in patients with incomplete response by MRI only. Among women with complete response on MRI, 43 % underwent mastectomy. CONCLUSIONS Within a multi-institutional cohort of women undergoing neoadjuvant treatment for breast cancer, MRI findings were not clearly associated with extent of surgery. This study shows that receptor status, T stage at diagnosis, young age, and treating institution are more significant determinants of surgical treatment choice than MRI response data.
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Affiliation(s)
- Kandace P McGuire
- Department of Surgery, Magee-Womens Hospital, University of Pittsburgh, Pittsburgh, PA, USA,
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Sen S, Soulos PR, Herrin J, Roberts KB, Yu JB, Lesnikoski BA, Ross JS, Krumholz HM, Gross CP. For-profit hospital ownership status and use of brachytherapy after breast-conserving surgery. Surgery 2014; 155:776-88. [PMID: 24787104 PMCID: PMC4008843 DOI: 10.1016/j.surg.2013.12.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 12/06/2013] [Indexed: 11/21/2022]
Abstract
BACKGROUND Little is known about the relationship between operative care for breast cancer at for-profit hospitals and subsequent use of adjuvant radiation therapy (RT). Among Medicare beneficiaries, we examined whether hospital ownership status is associated with the use of breast brachytherapy--a newer and more expensive modality--as well as overall RT. METHODS We conducted a retrospective study of female Medicare beneficiaries who received breast-conserving surgery for invasive breast cancer in 2008 and 2009. We assessed the relationship between hospital ownership and receipt of brachytherapy or overall RT by using hierarchical generalized linear models. RESULTS The sample consisted of 35,118 women, 8.0% of whom had breast-conserving operations at for-profit hospitals. Among patients who received RT, those who underwent operation at for-profit hospitals were more likely to receive brachytherapy (20.2%) than patients treated at not-for-profit hospitals (15.2%; odds ratio [OR] for for-profit versus not-for-profit: 1.50; 95% confidence interval [95% CI] 1.23-1.84; P < .001). Among women aged 66-79 years, there was no relationship between hospital ownership status and overall use of RT. Among women ages 80-94 years of age--the group least likely to benefit from RT due to shorter life expectancy--undergoing breast-conserving operations at a for-profit hospital was associated with greater overall use of RT (OR 1.22; 95% CI 1.03-1.45, P = .03) and brachytherapy use (OR 1.66; 95% CI 1.18-2.34, P = .003). CONCLUSION Operative care at for-profit hospitals was associated with increased use of the newer and more expensive RT modality, brachytherapy. Among the oldest women who are least likely to benefit from RT, operative care at a for-profit hospital was associated with greater overall use of RT, with this difference largely driven by the use of brachytherapy.
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Affiliation(s)
- Sounok Sen
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale University School of Medicine, New Haven, CT
| | - Pamela R Soulos
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale University School of Medicine, New Haven, CT; Section of General Internal Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Jeph Herrin
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale University School of Medicine, New Haven, CT; Health Research & Educational Trust, Chicago, IL; Department of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
| | - Kenneth B Roberts
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale University School of Medicine, New Haven, CT; Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT
| | - James B Yu
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale University School of Medicine, New Haven, CT; Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT
| | | | - Joseph S Ross
- JFK Medical Center, Atlantis, FL; Robert Wood Johnson Clinical Scholars Program, New Haven, CT; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT
| | - Harlan M Krumholz
- Department of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT; Robert Wood Johnson Clinical Scholars Program, New Haven, CT; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT; Section of Health Policy and Administration, Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, CT
| | - Cary P Gross
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale University School of Medicine, New Haven, CT; Section of General Internal Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT.
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Mac Bride MB, Neal L, Dilaveri CA, Sandhu NP, Hieken TJ, Ghosh K, Wahner-Roedler DL. Factors associated with surgical decision making in women with early-stage breast cancer: a literature review. J Womens Health (Larchmt) 2013; 22:236-42. [PMID: 23428286 DOI: 10.1089/jwh.2012.3969] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Current recommendations for surgical management of early-stage breast cancer include breast-conserving surgery with postoperative irradiation. However, studies show that mastectomy is still being used by women with early-stage breast cancer. METHODS Review of the medical literature published between 2000 and 2010 to determine the factors associated with the decision of patients for surgical treatment in early-stage breast cancer. RESULTS The following patient characteristics affect the surgical decision-making process in early-stage breast cancer: age, socioeconomic factors, geographic area in which the patient lives, proximity to a radiation therapy center, testing for BRCA gene, breast imaging, and decision aids. CONCLUSIONS Of increasing importance in the decision making about treatment of women with early-stage breast cancer are the woman's perception of having a surgical choice and the influence of that choice on postoperative quality of life.
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Affiliation(s)
- Maire Brid Mac Bride
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA.
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Kaur P, Santillan AA, McGuire K, Turaga KK, Shamehdi C, Meade T, Ramos D, Mathias M, Parbhoo J, Davis M, Khakpour N, King J, Balducci L, Cox CE. The Surgical Treatment of Breast Cancer in the Elderly: A Single Institution Comparative Review of 5235 Patients with 1028 Patients ≥70 years. Breast J 2012; 18:428-35. [DOI: 10.1111/j.1524-4741.2012.01272.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Peltoniemi P, Huhtala H, Holli K, Pylkkänen L. Effect of surgeon's caseload on the quality of surgery and breast cancer recurrence. Breast 2012; 21:539-43. [DOI: 10.1016/j.breast.2012.04.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2012] [Accepted: 04/18/2012] [Indexed: 11/30/2022] Open
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Fisher CS, Martin-Dunlap T, Ruppel MB, Gao F, Atkins J, Margenthaler JA. Fear of Recurrence and Perceived Survival Benefit are Primary Motivators for Choosing Mastectomy over Breast-Conservation Therapy Regardless of Age. Ann Surg Oncol 2012; 19:3246-50. [DOI: 10.1245/s10434-012-2525-x] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Indexed: 11/18/2022]
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Ivanov S. Biochemical markers predicting response to radiation- and radiochemo-therapy in cancer patients. ACTA ACUST UNITED AC 2012; 58:635-50. [DOI: 10.18097/pbmc20125806635] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
In last years there is increasing interest in radiogenomics and the characterization of DNA array molecular profiles that can predict tumor and no tumor tissues radioresponse. Ongoing studies carried out worldwide in the banking of tumor and no tumor samples give evidence that perspective markers for response prediction in individual patient to intended radiation therapy can be some apoptotic indexes, spectrum a number of specific proteins, and DNA-based microarray molecular profiling analysis as well determination of single nucleotide polymorphisms in genome of the patients. So far there are only a few robust reports of molecular markers predicting tumor and no tumor tissues response to radiation. The results of new studies, which in future should be validated in larger definitive trials, are likely to see in nearest years. It is needed to determine technologies of methods and to define more precisely areas of its applications.
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Affiliation(s)
- S.D. Ivanov
- Russian Research Center for Radiology and Surgical Technologies
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Balabram D, Araújo FB, Porto SS, Rodrigues JS, Sousa AS, Siqueira AL, Gobbi H. Changes in mastectomy rates at a Brazilian public hospital over 20 years (1989 to 2008). SAO PAULO MED J 2012; 130:360-6. [PMID: 23338732 PMCID: PMC10522311 DOI: 10.1590/s1516-31802012000600002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Revised: 10/13/2011] [Accepted: 03/16/2012] [Indexed: 02/06/2023] Open
Abstract
CONTEXT AND OBJECTIVE Recently, breast-conserving surgery (BCS) has been replacing mastectomy for breast cancer treatment. The aim of this study was to evaluate the changes in mastectomy and BCS rates and the factors relating to these shifts. DESIGN AND SETTING A retrospective study in a Brazilian public hospital. METHODS Pathological records from female patients who underwent surgery for breast cancer at Hospital das Clínicas, Universidade Federal de Minas Gerais (HC-UFMG), between 1989 and 2008 were reviewed. The mastectomy and BCS rates were calculated. The chi-square test was used to assess factors associated with type of surgical treatment and to compare trends in treatment type over the years. Logistic regression was used for multivariate analysis. RESULTS From 1989 to 2008, 2050 breast cancer surgical specimens were received in our service, corresponding to 1973 patients; 1324 (64.6%) of them were from mastectomy and 726 (35.4%) from BCS. A shift from mastectomy towards BCS was observed (P < 0.001). In multivariate analysis, earlier year of surgery (P < 0.001), larger tumor size (P < 0.001), having at least one positive axillary lymph node (P < 0.001) and patients' age greater than 68 years (P = 0.007) were predictors of mastectomy. CONCLUSIONS There was a shift from mastectomy towards BCS in our institution over the years. This may reflect consolidation of BCS (plus radiotherapy) as an equivalent treatment to mastectomy in terms of survival and a shift to earlier diagnosis for the disease.
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Affiliation(s)
- Débora Balabram
- MD, PhD Student. General Surgeon, Department of Anatomical Pathology, Faculdade de Medicina da Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil.
| | - Fábio Braga Araújo
- Medical Student, Department of Anatomical Pathology, Faculdade de Medicina da Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil.
| | - Simone Souza Porto
- Medical Student, Department of Anatomical Pathology, Faculdade de Medicina da Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil.
| | - Joyce Soares Rodrigues
- Statistics Student, Department of Statistics, Instituto de Ciências Exatas, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil.
| | - Atila Silva Sousa
- Medical Student, Department of Anatomical Pathology, Faculdade de Medicina da Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil.
| | - Arminda Lucia Siqueira
- PhD. Associate Professor, Department of Statistics, Instituto de Ciências Exatas, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil.
| | - Helenice Gobbi
- MD, PhD. Associate Professor, Department of Anatomical Pathology, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil.
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Njeh CF, Saunders MW, Langton CM. Accelerated partial breast irradiation using external beam conformal radiation therapy: A review. Crit Rev Oncol Hematol 2012; 81:1-20. [PMID: 21376625 DOI: 10.1016/j.critrevonc.2011.01.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2010] [Revised: 01/03/2011] [Accepted: 01/25/2011] [Indexed: 01/03/2023] Open
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Suhrke P, Mæhlen J, Schlichting E, Jørgensen KJ, Gøtzsche PC, Zahl PH. Effect of mammography screening on surgical treatment for breast cancer in Norway: comparative analysis of cancer registry data. BMJ 2011; 343:d4692. [PMID: 21914765 PMCID: PMC3172323 DOI: 10.1136/bmj.d4692] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To determine the effect of mammography screening on surgical treatment for breast cancer. DESIGN Comparative analysis of data from Norwegian cancer registry. SETTING Mammography screening, Norway (screening of women aged 50-69 was introduced sequentially from 1996 to 2004). PARTICIPANTS 35,408 women aged 40-79 with invasive breast cancer or ductal carcinoma in situ treated surgically from 1993 to 2008. MAIN OUTCOME MEASURES Rates of breast surgery (mastectomy plus breast conserving treatment) and rates of mastectomy for three age groups of women: 40-49, 50-69, and 70-79. Changes in rates from pre-screening period (1993-5) to introduction of screening phase (1996-2004) and then to screening period (2005-8) are presented as hazard ratios in invited and non-invited women. RESULTS The annual rate for breast surgery from the pre-screening period (1993-5) to screening period (2005-8) in Norway increased by 70% (hazard ratio 1.70, 95% confidence interval 1.62 to 1.78), from 180 to 305 per 100,000 women in the invited age group (50-69 years). In the younger, non-invited age group (40-49 years), however, the increase was only 8% (1.08, 1.00 to 1.16), from 133 to 144 per 100,000 women per year, whereas in the older, non-invited age group (70-79 years) the rate decreased by 8% (0.92, 0.86 to 1.00), from 227 to 214 per 100,000 women per year. The rates for mastectomy decreased similarly from the pre-screening period to screening period in invited and non-invited women. From the pre-screening period to the introduction phase of screening (1996-2004), however, the annual mastectomy rate in women aged 50-69 invited to screening increased by 9% (1.09, 1.03 to 1.14), from 156 to 167 per 100,000 women, and in the younger non-invited women declined by 17% (0.83, 0.78 to 0.90), from 109 to 91 per 100,000 women. In consequence, the mastectomy rate was 31% (1.31, 1.20 to 1.43) higher in the invited than in the non-invited younger age group. CONCLUSIONS Mammography screening in Norway was associated with a noticeable increase in rates for breast cancer surgery in women aged 50-69 (the age group invited to screening) and also an increase in mastectomy rates. Although over-diagnosis is likely to have caused the initial increase in mastectomy rates and the overall increase in surgery rates in the age group screened, the more recent decline in mastectomy rates has affected all age groups and is likely to have resulted from changes in surgical policy.
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Affiliation(s)
- Pål Suhrke
- Department of Pathology, Oslo University Hospital, N-0407 Oslo, Norway.
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Dickson-Witmer D, Bleznak AD, Kennedy JS, Stewart AK, Palis BE, Bailey L, Laidley AL, Penman EJ. Breast Cancer Care in the Community: Challenges, Opportunities, and Outcomes. Surg Oncol Clin N Am 2011; 20:555-80, ix. [DOI: 10.1016/j.soc.2011.01.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
Whole breast irradiation (WBI) is the standard after breast conservation surgery. However, WBI in selected patients has been questioned. Accelerated partial breast irradiation (APBI) focuses treatment on the lumpectomy bed. Many modalities of delivering APBI have been developed: multicatheter interstitial brachytherapy, MammoSite balloon catheter, single insertion multicatheter devices, three-dimensional conformal external-beam radiation therapy and intraoperative techniques. Numerous studies of APBI have demonstrated excellent local control and cosmetic outcomes in early-stage breast cancer patients.
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Chen F, Puig M, Yermilov I, Malin J, Schneider EC, Epstein AM, Kahn KL, Ganz PA, Gibbons MM. Using breast cancer quality indicators in a vulnerable population. Cancer 2011; 117:3311-21. [PMID: 21264846 DOI: 10.1002/cncr.25915] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2010] [Revised: 11/16/2010] [Accepted: 12/02/2010] [Indexed: 11/08/2022]
Abstract
BACKGROUND Adherence to quality indicators may be especially important to disease-specific outcomes for uninsured, vulnerable patients. The objective of this study was to measure adherence to National Initiative for Cancer Care Quality (NICCQ) breast cancer quality indicators in a public hospital and compare performance to published rates in a previously collected 5-city cohort. METHODS One hundred five consecutive, newly diagnosed, stage I-III, breast cancer patients at a public hospital (from 2005 to 2007) were identified. Adherence rates to 31 quality indicators were measured by using medical record abstraction. Rates were calculated for individual indicators, aggregated domains, and components of care and were compared with the 5-city cohort results by using a 2-sided test of proportions. RESULTS Overall adherence to the NICCQ indicators at the public hospital was 82%, versus 86% in the 5-city cohort. Public hospital adherence was better in 3 domains and components (Management of Treatment Toxicity 95% vs 73%, Referrals 76% vs 15%, and Documentation of Key Clinical Factors 72% vs 64%, P < .05 for all), but it was lower in others (Testing 82% vs 96%, Adjuvant Therapy 76% vs 83%, Surgery 72% vs 86%, Surveillance 63% vs 94%, and Respect for Patient Preferences 52% vs 72%, P < .001 for all). CONCLUSIONS The results showed that it is possible to deliver breast cancer care to vulnerable patients comparable in quality to the care received by the broader population. Further study should identify the factors that lead to variation in adherence across domains of quality.
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Affiliation(s)
- Formosa Chen
- Department of Surgery, Olive View-UCLA Medical Center, Sylmar, CA, USA
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Dick AW, Sorbero MS, Ahrendt GM, Hayman JA, Gold HT, Schiffhauer L, Stark A, Griggs JJ. Comparative effectiveness of ductal carcinoma in situ management and the roles of margins and surgeons. J Natl Cancer Inst 2011; 103:92-104. [PMID: 21200025 PMCID: PMC3022620 DOI: 10.1093/jnci/djq499] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2009] [Revised: 03/31/2010] [Accepted: 11/09/2010] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The high incidence of ductal carcinoma in situ (DCIS) and variations in its treatment motivate inquiry into the comparative effectiveness of treatment options. Few such comparative effectiveness studies of DCIS, however, have been performed with detailed information on clinical and treatment attributes. METHODS We collected detailed clinical, nonclinical, pathological, treatment, and long-term outcomes data from multiple medical records of 994 women who were diagnosed with DCIS from 1985 through 2000 in Monroe County (New York) and the Henry Ford Health System (Detroit, MI). We used ipsilateral disease-free survival models to characterize the role of treatments (surgery and radiation therapy) and margin status (positive, close [<2 mm], or negative [≥2 mm]) and logistic regression models to characterize the determinants of treatments and margin status, including the role of surgeons. All statistical tests were two-sided. RESULTS Treatments and margin status were statistically significant and strong predictors of long-term disease-free survival, but results varied substantially by surgeon. This variation by surgeon accounted for 15%-35% of subsequent ipsilateral 5-year recurrence rates and for 13%-30% of 10-year recurrence rates. The overall differences in predicted 5-year disease-free survival rates for mastectomy (0.993), breast-conserving surgery with radiation therapy (0.945), and breast-conserving surgery without radiation therapy (0.824) were statistically significant (P(diff) < .001 for each of the differences). Similarly, each of the differences at 10 years was statistically significant (P < .001). CONCLUSIONS Our work demonstrates the contributions of treatments and margin status to long-term ipsilateral disease-free survival and the link between surgeons and these key measures of care. Although variation by surgeon could be generated by patients' preferences, the extent of variation and its contribution to long-term health outcomes are troubling. Further work is required to determine why women with positive margins receive no additional treatment and why margin status and receipt of radiation therapy vary by surgeon.
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MESH Headings
- Adult
- Aged
- Breast Neoplasms/pathology
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/surgery
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/radiotherapy
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Comparative Effectiveness Research
- Disease-Free Survival
- Female
- Humans
- Kaplan-Meier Estimate
- Logistic Models
- Mastectomy/methods
- Mastectomy, Modified Radical
- Mastectomy, Segmental
- Middle Aged
- Multivariate Analysis
- Neoplasm Recurrence, Local/prevention & control
- Neoplasm, Residual/radiotherapy
- Odds Ratio
- Physician's Role
- Radiotherapy, Adjuvant
- Retrospective Studies
- Treatment Outcome
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Komenaka IK, Pennington RE, Schneider BP, Hsu CH, Norton LE, Clare SE, Zork NM, Goulet RJ. Compliance differences between patients with breast cancer in university and county hospitals. Clin Breast Cancer 2011; 10:385-91. [PMID: 20920983 DOI: 10.3816/cbc.2010.n.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE Compliance with recommended breast cancer treatments outside the context of a clinical trial differs from that in study populations. The purpose of this study was to examine differences in compliance of breast cancer treatments. PATIENTS AND METHODS We conducted a retrospective review of 529 patients treated at 2 teaching hospitals in the same city from 2003 to 2006. Compliance with adjuvant therapy recommendations and choice of breast-conserving operations were compared between a university hospital (UH) and a county hospital (CH). RESULTS The 2 populations demonstrated similar rates of breast conservation (72% vs. 69%). Although use of radiation therapy at the CH was acceptable (82%), patients at the UH were more likely to undergo radiation therapy (95%). The use of hormone therapy was similar at the UH and the CH (> 93%). Patients were more likely to follow physician recommendations for adjuvant chemotherapy at the UH (89%) compared with the CH (70%; P = .0005). Univariate analysis revealed that patient age, tumor size, stage, grade, and estrogen receptor status were all significant predictors of patient compliance with chemotherapy. Preoperative chemotherapy was a strong predictor of patient compliance with chemotherapy (P < .0001). In multivariate analysis, all of the factors predictive of patient compliance in univariate analysis remained significant except tumor grade. CONCLUSION Preoperative chemotherapy appeared to increase compliance compared with adjuvant chemotherapy in the CH population. Compared with national standards, breast-conserving operations and radiation therapy compliance can be accomplished in an acceptable percentage of underinsured patients.
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Affiliation(s)
- Ian K Komenaka
- Department of Surgery, Indiana University, IN 46202, USA.
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Kaplan CP, Nápoles AM, Hwang ES, Bloom J, Stewart S, Nickleach D, Karliner L. Selection of treatment among Latina and non-Latina white women with ductal carcinoma in situ. J Womens Health (Larchmt) 2010; 20:215-23. [PMID: 21128819 DOI: 10.1089/jwh.2010.1986] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The growing rates of ductal carcinoma in situ (DCIS) and evidence that Latinas may underuse breast-conserving surgery (BCS) compared with white women highlight the need to better understand how treatment decisions are made in this understudied group. To help address this gap, this study compared surgery and radiation treatment decision making among white and Spanish-speaking and English-speaking Latina women with DCIS recruited from eight population-based cancer registries from 35 California counties. METHODS Women aged ≥18 who self-identified as Latina or non-Latina white diagnosed with DCIS between 2002 and 2005 were selected from eight California Cancer Registry (CCR) regions and surveyed about their DCIS treatment decision making by telephone approximately 24 months after diagnosis. Survey data were merged with CCR hospital-based records to obtain tumor and treatment data. RESULTS Mean age was 57 years. Multivariate analysis indicated no differences by ethnicity or language in the receipt of mastectomy vs. BCS after controlling demographic, health, and personal preferences. English-speaking Latinas were more likely to receive radiation than their Spanish-speaking or white counterparts, controlling for demographic and other factors. Among women receiving BCS, physician recommendation was the strongest predictor of receipt of radiation. CONCLUSIONS Ethnic disparities in surgical treatment choices after breast cancer diagnosis were not seen in this cohort of women diagnosed with DCIS. Physicians play an essential role in patients' treatment choices for DCIS, particularly for adjuvant radiation.
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Affiliation(s)
- Celia P Kaplan
- Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, California 94143-0856, USA.
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Abstract
AbstractPurpose:To determine the pattern of care and survival in older patients with breast cancer.Methods:The study population included 228 women aged ≥60 years with breast cancer treated between 1992 and 2002. Analysis was done for surgery, radiotherapy (RT), chemotherapy and hormonal therapy. Outcomes studied were locoregional recurrence (LRR) distant metastases, disease-free survival (DFS) and overall survival (OS) using univariate and multivariate analyses. Kaplan–Meier method was used to estimate DFS and OS.Results:Mastectomy was done in 208 (91%) patients and conservative breast surgery (CBS) only in 20 (9%) patients. Majority of the patients received adjuvant RT 179 (78.5%). Chemotherapy was given to 49 (21.5%) patients and hormones to 204 (89.5%) patients. LRR with or without distant metastases was 7% and distant metastasis rate was 19.3%. DFS at 10 years was 69%. With RT, DFS was 76% in patients aged <65 years and 73% in aged ≥65 years (p= 0.13). It was 73 and 86%, respectively, with chemotherapy (p= 0.041). DFS with hormones was 96% in patients aged ≥65 years and 79% in aged <65 years (p= 0.028). The OS was 74% at 10 years. RT improved OS in all patients. OS with chemotherapy was 94% in patients ≥65 years, and 82% in patients <65 years (p= 0.044). With hormonal therapy OS was 96% in patients aged ≥65 years and 78% in patients <65 years (p= 0.020).Conclusion:CBS rate and chemotherapy use is very low in elderly women with breast cancer in India. Adjuvant RT, chemotherapy and hormonal therapy offered a therapeutic advantage in these patients.
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Njeh CF, Saunders MW, Langton CM. Accelerated Partial Breast Irradiation (APBI): A review of available techniques. Radiat Oncol 2010; 5:90. [PMID: 20920346 PMCID: PMC2958971 DOI: 10.1186/1748-717x-5-90] [Citation(s) in RCA: 144] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2010] [Accepted: 10/04/2010] [Indexed: 01/08/2023] Open
Abstract
Breast conservation therapy (BCT) is the procedure of choice for the management of the early stage breast cancer. However, its utilization has not been maximized because of logistics issues associated with the protracted treatment involved with the radiation treatment. Accelerated Partial Breast Irradiation (APBI) is an approach that treats only the lumpectomy bed plus a 1-2 cm margin, rather than the whole breast. Hence because of the small volume of irradiation a higher dose can be delivered in a shorter period of time. There has been growing interest for APBI and various approaches have been developed under phase I-III clinical studies; these include multicatheter interstitial brachytherapy, balloon catheter brachytherapy, conformal external beam radiation therapy and intra-operative radiation therapy (IORT). Balloon-based brachytherapy approaches include Mammosite, Axxent electronic brachytherapy and Contura, Hybrid brachytherapy devices include SAVI and ClearPath. This paper reviews the different techniques, identifying the weaknesses and strength of each approach and proposes a direction for future research and development. It is evident that APBI will play a role in the management of a selected group of early breast cancer. However, the relative role of the different techniques is yet to be clearly identified.
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Affiliation(s)
- Christopher F Njeh
- Radiation Oncology Department, Texas Oncology Tyler, 910 East Houston Street, Tyler, Texas, USA
| | - Mark W Saunders
- Radiation Oncology Department, Texas Oncology Tyler, 910 East Houston Street, Tyler, Texas, USA
| | - Christian M Langton
- Physics, Faculty of Science and Technology, Queensland University of Technology, Brisbane, Australia
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Wouters M, Jansen-Landheer M, van de Velde C. The quality of cancer care initiative in the Netherlands. Eur J Surg Oncol 2010; 36 Suppl 1:S3-S13. [DOI: 10.1016/j.ejso.2010.06.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2010] [Accepted: 06/01/2010] [Indexed: 01/08/2023] Open
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A systematic review and meta-analysis of the volume-outcome relationship in the surgical treatment of breast cancer. Are breast cancer patients better of with a high volume provider? Eur J Surg Oncol 2010; 36 Suppl 1:S27-35. [DOI: 10.1016/j.ejso.2010.06.024] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2010] [Accepted: 06/09/2010] [Indexed: 11/17/2022] Open
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Measuring the influence of colleagues on a consultant team's use of breast conserving surgery. Int J Technol Assess Health Care 2010; 26:156-62. [PMID: 20392318 DOI: 10.1017/s0266462310000061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES The aim of this study was to examine potential reasons why the use of breast conserving surgery (BCS) for breast cancer varies substantially between hospital teams in England, and in particular to examine whether colleague influence has a role in influencing BCS rates locally. METHODS Routinely collected Hospital Episode Statistics (HES) data relating to 420 surgical teams in England who performed more than ten breast cancer operations during the financial year 2006/07 were used to identify predictors of team BCS use. Team BCS rates (as a proportion of all types of breast excision surgery) were subject to a regression analysis that incorporated, as independent variables, a range of patient, organizational, and local demographic factors, as well as the BCS rate of colleagues working alongside them in the same hospitals(s). RESULTS After adjusting for the effects of other variables, BCS use by colleagues working in the same hospital(s) was a significant predictor of a team's own BCS rate (standardized b = 0.224; p < .001), denoting a typical 3 percent increase in a team's BCS rate for every 10 percent increase in the BCS rate of colleagues. CONCLUSIONS The practice of colleagues seems to have a measurable influence upon a surgical team's BCS usage. Guidance from HTA organizations can set national standards about the use of new techniques and innovations, but dissemination can be either slowed down or accelerated by the influence of local colleagues. A strategy of disseminating guidance through professional networks or "local champions" could be a powerful avenue for change.
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Yi M, Hunt KK, Arun BK, Bedrosian I, Barrera AG, Do KA, Kuerer HM, Babiera GV, Mittendorf EA, Ready K, Litton J, Meric-Bernstam F. Factors affecting the decision of breast cancer patients to undergo contralateral prophylactic mastectomy. Cancer Prev Res (Phila) 2010; 3:1026-34. [PMID: 20647335 DOI: 10.1158/1940-6207.capr-09-0130] [Citation(s) in RCA: 126] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Increasing numbers of women with breast cancer are electing for contralateral prophylactic mastectomy (CPM) to reduce the risk of developing contralateral breast cancer. The objective of this study was to identify factors that may affect a patient's decision to undergo CPM. We identified 2,504 women with stage 0 to III unilateral primary breast cancer who underwent breast surgery at our institution from January 2000 to August 2006 from a prospectively maintained database. We did logistic regression analyses to determine which factors were associated with undergoing CPM. Of 2,504 breast cancer patients, 1,223 (48.8%) underwent total mastectomy. Of the 1,223 patients who underwent mastectomy, 284 (23.2%) underwent immediate or delayed CPM. There were 33 patients (1.3%) who had genetic testing before the surgery, with the use of testing increasing in the latter years of the study (0.1% in 2000-2002 versus 2.0% in 2003-2006; P < 0.0001). Multivariable analysis revealed several factors that were associated with a patient undergoing CPM: age younger than 50 years, white ethnicity, family history of breast cancer, BRCA1/2 mutation testing, invasive lobular histology, clinical stage, and use of reconstruction. We identified specific patient and tumor characteristics associated with the use of CPM. Although genetic testing is increasing, most women undergoing CPM did not have a known genetic predisposition to breast cancer. Evidence-driven models are needed to better inform women of their absolute risk of contralateral breast cancer as well as their competing risk of recurrence from the primary breast cancer to empower them in their active decision making.
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Affiliation(s)
- Min Yi
- Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, 77030, USA
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Abstract
The role of the breast cancer surgeon has changed from one with performance of one operation, to a position in which the surgeon is the patient's initial contact, leader of a multidisciplinary team, the clinical leader who ensures that the patient receives the most appropriate breast cancer treatment and then also receives follow up and surveillance services. Breast conservation rates, patient satisfaction rates, clear margins, use of oncoplastic surgical techniques, appropriate referral to other consultants, clinical trial referral, and survival rates are all higher when patients are cared for by breast-focused surgeons. This new role requires greater time both before and after surgery to provide the proper planning and care for these patients. Women with breast cancer should have access to these dedicated breast-focused surgeons. Recognition of this expanding responsibility and reimbursement for this time and expertise is needed so that women with breast cancer can be offered the highest quality of care.
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42
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Shaitelman SF, Vicini FA. Status of Accelerated Partial Breast Irradiation. CURRENT BREAST CANCER REPORTS 2010. [DOI: 10.1007/s12609-010-0011-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Olaya W, Wong JH, Morgan JW, Roy-Chowdhury S, Lum SS. Disparities in the Surgical Management of Women with Stage I Breast Cancer. Am Surg 2009. [DOI: 10.1177/000313480907501001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We sought to evaluate factors influencing the choice of surgery for women with early-stage breast cancer. Between 1996 and 2005, 47,837 women who were diagnosed with Stage I breast cancer underwent partial (PM) or total mastectomy (TM) in the California Cancer Registry. A total of 72.8 per cent of women underwent PM. Those treated in the most recent 5-year period were more likely to undergo PM than in the prior 5 years (76.5 vs 69.5%, P < 0.0001). PM rates increased with increasing socioeconomic status (SES): 65.1 per cent of patients in the lowest SES quintile underwent PM versus 77.2 per cent in the highest SES quintile ( P < 0.0001). Forty- to 64-year-old women were more likely to receive PM compared with their older and younger counterparts (74.5 vs 71.2 and 67.0%, respectively; P < 0.0001). Asian/Pacific Islander women were least likely to undergo PM (64.0%), whereas non-Hispanic black women were most likely to undergo PM (75.0%) ( P < 0.0001). On multivariate analysis, these demographic factors remained independent predictors of surgical treatment. PM rates have increased over time; however, significant differences in surgical management exist among women of different race/ethnic groups, ages, and SES. Further research is required to elucidate modifiable factors that impact the choice of surgery for women with early-stage breast cancer.
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Affiliation(s)
- Windy Olaya
- Department of Surgery, Division of Surgical Oncology, Loma Linda University School of Medicine, Loma Linda, California; the
| | - Jan H. Wong
- Department of Surgery, Division of Surgical Oncology, Loma Linda University School of Medicine, Loma Linda, California; the
- Region 5 of the California Cancer Registry, Desert Sierra Cancer Surveillance Program, Loma Linda University Medical Center, Loma Linda, California
| | - John W. Morgan
- School of Public Health, Loma Linda University, Loma Linda, California; and
- Region 5 of the California Cancer Registry, Desert Sierra Cancer Surveillance Program, Loma Linda University Medical Center, Loma Linda, California
| | - Sharmila Roy-Chowdhury
- Department of Surgery, Division of Surgical Oncology, Loma Linda University School of Medicine, Loma Linda, California; the
| | - Sharon S. Lum
- Department of Surgery, Division of Surgical Oncology, Loma Linda University School of Medicine, Loma Linda, California; the
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McGuire KP, Santillan AA, Kaur P, Meade T, Parbhoo J, Mathias M, Shamehdi C, Davis M, Ramos D, Cox CE. Are Mastectomies on the Rise? A 13-Year Trend Analysis of the Selection of Mastectomy Versus Breast Conservation Therapy in 5865 Patients. Ann Surg Oncol 2009; 16:2682-90. [PMID: 19653046 DOI: 10.1245/s10434-009-0635-x] [Citation(s) in RCA: 255] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2009] [Revised: 05/06/2009] [Accepted: 05/07/2009] [Indexed: 02/06/2023]
MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Breast Neoplasms/pathology
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/secondary
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Intraductal, Noninfiltrating/secondary
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Carcinoma, Lobular/secondary
- Carcinoma, Lobular/surgery
- Female
- Humans
- Mastectomy, Segmental/statistics & numerical data
- Middle Aged
- Neoplasm Invasiveness
- Neoplasm Staging
- Patient Preference
- Prognosis
- Prospective Studies
- Retrospective Studies
- Time Factors
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Bilimoria KY, Phillips JD, Rock CE, Hayman A, Prystowsky JB, Bentrem DJ. Effect of Surgeon Training, Specialization, and Experience on Outcomes for Cancer Surgery: A Systematic Review of the Literature. Ann Surg Oncol 2009; 16:1799-808. [DOI: 10.1245/s10434-009-0467-8] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2009] [Revised: 02/24/2009] [Accepted: 02/25/2009] [Indexed: 11/18/2022]
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Impact of MRI-evaluated neoadjuvant chemotherapy response on change of surgical recommendation in breast cancer. Ann Surg 2009; 249:448-54. [PMID: 19247033 DOI: 10.1097/sla.0b013e31819a6e01] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate how MRI imaging of neoadjuvant chemotherapy (NAC) tumor response affects the recommendation for optimal breast cancer surgery, both before and after NAC. SUMMARY BACKGROUND DATA Understanding how imaging findings are incorporated into surgeons' decision-making processes will help establish appropriate imaging guidelines for recommending breast conservation surgery (BCS) after the NAC. METHODS Seventy-six breast cancer patients undergoing NAC with MRI follow-up studies were analyzed. Two experienced breast surgeons reviewed all cases. An initial surgical recommendation was made based on the pre-NAC lesion presentation; a subsequent surgical recommendation was made based on the post-NAC tumor response. Finally, the pathology results were disclosed and the surgeons were asked to decide on the optimal definitive surgical procedure. MRI findings throughout the entire course of the NAC were analyzed to understand how they affected different recommendations. RESULTS Before the NAC, a large tumor size or extent of disease were the primary determinant factors for mastectomy. In this study, the mean tumor size was 5.3 +/- 3.4 cm (RECIST) in the mastectomy group and 3.2 +/- 1.6 cm in the lumpectomy group (P = 0.0001). After the NAC, based on consensus recommendations, 21 mastectomy candidates remained for mastectomy, with tumor size decreasing from 7.4 +/- 4.5 to 1.5 +/- 2.5 cm, and 22 mastectomy candidates were changed to lumpectomy, with tumor size decreasing from 4.2 +/- 2.1 to 0.4 +/- 0.6 cm. When the final pathology revealed pCR or minimal residual disease, the surgeons agreed that BCS is the optimal procedure. On the other hand, for a large extent of residual disease, mastectomy should be performed. CONCLUSION In patients who had more extensive pretreatment disease, despite an excellent response to NAC, the surgeons still tended to apply an aggressive approach and recommended mastectomy. Given that the confirmation of pCR or minimal residual disease would change surgeons' recommendations for less aggressive, conservation surgery, the maturity of MRI for NAC response prediction may provide reliable staging information to aid in the recommendation of the optimal surgical procedure.
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Hawley ST, Fagerlin A, Janz NK, Katz SJ. Racial/ethnic disparities in knowledge about risks and benefits of breast cancer treatment: does it matter where you go? Health Serv Res 2008; 43:1366-87. [PMID: 18384361 PMCID: PMC2517271 DOI: 10.1111/j.1475-6773.2008.00843.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To evaluate the association between provider characteristics and treatment location and racial/ethnic minority patients' knowledge of breast cancer treatment risks and benefits. DATA SOURCES/DATA COLLECTION Survey responses and clinical data from breast cancer patients of Detroit and Los Angeles SEER registries were merged with surgeon survey responses (N=1,132 patients, 277 surgeons). STUDY DESIGN Cross-sectional survey. Multivariable regression was used to identify associations between patient, surgeon, and treatment setting factors and accurate knowledge of the survival benefit and recurrence risk related to mastectomy and breast conserving surgery with radiation. PRINCIPAL FINDINGS Half (51 percent) of respondents had survival knowledge, while close to half (47.6 percent) were uncertain regarding recurrence knowledge. Minority patients and those with lower education were less likely to have adequate survival knowledge and more likely to be uncertain regarding recurrence risk than their counterparts (p<.001). Neither surgeon characteristics nor treatment location attenuated racial/ethnic knowledge disparities. Patient-physician communication was significantly (p<.001) associated with both types of knowledge, but did not influence racial/ethnic differences in knowledge. CONCLUSIONS Interventions to improve patient understanding of the benefits and risks of breast cancer treatments are needed across surgeons and treatment setting, particularly for racial/ethnic minority women with breast cancer.
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Affiliation(s)
- Sarah T Hawley
- Division of General Medicine, University of Michigan Health System and Ann Arbor VA Medical Center, 300 N. Ingalls Room 7C27, Ann Arbor, MI, USA.
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Reitsamer R, Menzel C, Glueck S, Hitzl W, Peintinger F. Predictors of Mastectomy in a Certified Breast Center The Surgeon is an Independent Risk Factor. Breast J 2008; 14:324-9. [DOI: 10.1111/j.1524-4741.2008.00592.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Pass HA, Klimberg SV, Copeland EM. Are "breast-focused" surgeons more competent? Ann Surg Oncol 2008; 15:953-5. [PMID: 18247092 PMCID: PMC2266785 DOI: 10.1245/s10434-008-9835-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2008] [Accepted: 01/09/2008] [Indexed: 11/18/2022]
Affiliation(s)
- Helen A Pass
- Columbia University College of Physicians and Surgeons, 55 Palmer Avenue, Bronxville, NY 10708, USA.
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