A 10-year (1999 ~ 2008) retrospective multi-center study of breast cancer surgical management in various geographic areas of China

Spatial and temporal changes of breast-conserving surgery rates and its influential factors among Chinese patients with breast cancer from 2013 to 2019: a registry-based study

OBJECTIVE

Our study aims to evaluate the spatial and temporal changes of breast-conserving surgery (BCS) rates and influential factors of BCS in Guangdong Province, China.

DESIGN, SETTING AND PARTICIPANTS

This registry-based cohort study analysed the data of patients of all age groups, from the medical record cover page, which was mandatorily collected for inpatients by the Health Administrative Department of Guangdong Province, China. Patients with non-metastatic breast cancer, who underwent breast surgery between 2013 and 2019, were included.

MAIN OUTCOMES AND MEASURES

We analysed the BCS rate in Guangdong Province between 2013 and 2019. Logistic regression was applied to investigate the association between patient-level influential factors and BCS, respectively. We used restricted cubic spline regression to model the non-linear association between hospital volume rank with BCS rate. Linear regression was used to evaluate the association between city-level parameters with BCS rate of each city.

RESULTS

A total of 93 521 patients with non-metastatic breast cancer, who underwent breast surgery, were included in the analyses. Among them, 10 949 (11.7%) had BCS, with the BCS rates increasing from 0.8% in 2013 to 19.2% in 2019. Patients who were older (vs <40 years, 40-49 years: adjusted OR 0.72, 95% CI 0.68 to 0.76; 50-59 years: 0.51, 95% CI 0.48 to 0.54; ≥60 years: 0.37, 95% CI 0.35 to 0.40) and married (vs unmarried, 0.64, 95% CI 0.59 to 0.70) were less likely to undergo BCS. Patients who were employed (vs unemployed, 1.58, 95% CI 1.49 to 1.68), received cross-city surgery (vs local surgery, 1.37, 95% CI 1.31 to 1.44), lived in a high-income city (vs low-income city, β=4.40, 95% CI 1.55 to 7.24) or in a city with a higher number of physicians per 100 000 residents (0.57, 95% CI 0.31 to 0.82) were more likely to receive BCS.

CONCLUSIONS AND RELEVANCE

This study suggests a significant increase in BCS rates from 2013 to 2019 in Guangdong, China. Promotion of BCS is needed, particularly among older patients, lower-volume hospitals and economically underdeveloped areas. Healthcare system should be prepared to support the increased awareness of seeking BCS among younger patients with breast cancer by improving the availability of radiotherapy, multidisciplinary team and patients' education programme.

Current Trends in Breast Cancer Treatment in Chinese and Chinese American Women: The Disparity Between Mastectomy and Breast Reconstruction

BACKGROUND

Breast cancer screening and surgical interventions are often underutilized in the Chinese community. For both Chinese American (CA) and native Chinese (NC) patients, screening rates are well below medical recommendations, which places these patients at risk for late diagnoses and larger tumors. There is also a notable reluctance to breast reconstruction after mastectomy. We investigated the role of sociodemographic and cultural barriers in breast treatment trends among Chinese breast cancer survivors.

METHODS

A literature search for full-text articles published between 2011 and 2021 was performed using PubMed, The Web of Science, and Embase. The articles that were selected contained information regarding Chinese individuals in the United States or China who had undergone breast cancer screening or diagnosis of breast cancer and received treatment with or without reconstructive surgery.

RESULTS

Both patient populations exhibited screening rates that were significantly lower than national recommendations. Of the CA patients, 25% reported never receiving a mammogram, whereas 450 million NCs have been left unscreened despite efforts made by the Chinese government. Misinformation, cultural beliefs, and fear significantly contributed to diminished breast health care among CA and NC women. Fear of recurrence, breast value, community influence, and limited health care resources were found to be the primary drivers of low breast reconstruction uptake.

CONCLUSIONS

In both NC and CA women, there is a critical need for improved breast health information dissemination and overall quality of care. The findings summarized in this review can guide such efforts.

Robustness of VMAT to setup errors in postmastectomy radiotherapy of left-sided breast cancer: Impact of bolus thickness

BACKGROUND

Volumetric modulated arc therapy (VMAT) with varied bolus thicknesses has been employed in postmastectomy radiotherapy (PMRT) of breast cancer to improve superficial target coverage. However, impact of bolus thickness on plan robustness remains unclear.

METHODS

The study enrolled ten patients with left-sided breast cancer who received radiotherapy using VMAT with 5 mm and 10 mm bolus (VMAT-5B and VMAT-10B). Inter-fractional setup errors were simulated by introducing a 3 mm shift to isocenter of the original plans in the anterior-posterior, left-right, and inferior-superior directions. The plans (perturbed plans) were recalculated without changing other parameters. Dose volume histograms (DVH) were collected for plan evaluation. Absolute dose differences in DVH endpoints for the clinical target volume (CTV), heart, and left lung between the perturbed plans and the original ones were used for robustness analysis.

RESULTS

VMAT-10B showed better target coverage, while VMAT-5B was superior in organs-at-risk (OARs) sparing. As expected, small setup errors of 3 mm could induce dose fluctuations in CTV and OARs. The differences in CTV were small in VMAT-5B, with a maximum difference of -1.05 Gy for the posterior shifts. For VMAT-10B, isocenter shifts in the posterior and right directions significantly decreased CTV coverage. The differences were -1.69 Gy, -1.48 Gy and -1.99 Gy, -1.69 Gy for ΔD95% and ΔD98%, respectively. Regarding the OARs, only isocenter shifts in the posterior, right, and inferior directions increased dose to the left lung and the heart. Differences in VMAT-10B were milder than those in VMAT-5B. Specifically, mean heart dose were increased by 0.42 Gy (range 0.10 ~ 0.95 Gy) and 0.20 Gy (range -0.11 ~ 0.72 Gy), and mean dose for the left lung were increased by 1.02 Gy (range 0.79 ~ 1.18 Gy) and 0.68 Gy (range 0.47 ~ 0.84 Gy) in VMAT-5B and VMAT-10B, respectively. High-dose volumes in the organs were increased by approximate 0 ~ 2 and 1 ~ 3 percentage points, respectively. Nevertheless, most of the dosimetric parameters in the perturbed plans were still clinically acceptable.

CONCLUSIONS

VMAT-5B appears to be more robust to 3 mm setup errors than VMAT-10B. VMAT-5B also resulted in better OARs sparing with acceptable target coverage and dose homogeneity. Therefore 5 mm bolus is recommended for PMRT of left-sided breast cancer using VMAT.

The outcome of neoadjuvant chemotherapy and the current trend of surgical treatment in young women with breast cancer: A multicenter real-world study (CSBrS-012)

Background and objectives

The relationship between age and the outcome of breast cancer neoadjuvant chemotherapy (NAC) remains controversial, and little is known about the choice of surgical treatment for young patients. In this multicenter real-world study, we sought to analyze the outcome of NAC as well as the current status and trend of surgical decision-making after NAC in young breast cancer patients.

Methods

The medical records of patients from 20 hospitals in different regions of China were collected retrospectively. The study population included females diagnosed with cT1-4N0-3M0 breast cancer who received NAC from January 2010 to December 2020.

Results

A total of 9,643 eligible patients were included, 1,945 (20.2%) of whom were ≤40 years old. Young patients tend to have a higher tumor stage and a higher proportion of Luminal B and triple-negative breast cancer (TNBC) tumors compared with the >40-year-old group. The breast pathological complete response (pCR) rate in the young group was 20.3%, and Luminal B tumor was more likely to obtain pCR in young patients. The implementation rate of breast-conserving surgery (BCS) and breast reconstruction surgery was higher in young patients and tended to increase over time. In different regions of China, there were great differences in the choice of surgical treatment after NAC among young patients.

Conclusion

Breast cancer in young women has unique clinical characteristics, but age does not affect the overall pCR rate. In China, the BCS rate after NAC is increasing over time but is still at a low level.

Treatment and long-term outcome of breast cancer in very young women: nationwide population-based study

BACKGROUND

The study aimed to assess the correlation between long-term survival and treatment in very young women with breast cancer.

METHODS

Data on women with breast cancer were retrieved from the Taiwan Cancer Registry between 2004 and 2014. Patients who did not undergo surgery or who had stage 0 or IV disease were excluded. Survival analysis was conducted. The participants were divided into very young (20-29.9 years), young (30-39.9 years), and adult (40-50.0 years) groups.

RESULTS

Among 104 115 women, 24 474 (572 very young, 5565 young, and 18 337 adult) were eligible for the study. Median follow-up was 79.5 (range 24-158) months. The mortality rates in the very young, young, and adult groups were 12.9, 10.0, and 8.2 per cent respectively (P < 0.001). Very young patients had higher histological grade, unfavourable subtype, higher TNM stage, and received more breast-conserving surgery (BCS). Kaplan-Meier survival analysis showed that very young patients had the poorest long-term survival. Very young patients with stage II disease had the worst prognosis. In the multivariable regression model, radiotherapy was associated with decreased local recurrence but not with improved overall, cancer-specific, or disease-free survival for stage II disease in the very young group. Surgery type and chemotherapy were not associated with significant improvement in overall survival.

CONCLUSION

Very young patients with stage II disease had poor long-term outcomes. BCS had no detrimental effects on long-term outcomes.

The Uptake and Factors Associated with Mastectomy among Chinese Women with Breast Cancer: A Retrospective Observational Study

OBJECTIVE

There are limited data concerning the use of mastectomy and associated factors in China in recent years. This study aimed to investigate the uptake of mastectomy and determine the associations between patients' characteristics and mastectomy among Chinese women with breast cancer.

METHODS

A retrospective analysis of female breast cancer cases from 1st January 2015 to 31st December 2019 from a tertiary hospital was conducted. Socio-demographic data, clinical data, and surgery types were collected by reviewing the medical record system. Chi-squared test, Fisher's exact test and multivariate logistic regression analysis were used to determine any correlations of patients' characteristics with mastectomy.

RESULTS

A total of 1,171 women with breast cancer were identified, and 76.60% of them underwent a mastectomy. The mastectomy rates showed an increase from 70.62% in 2015 to 86.87% in 2017 and then dropped to 71.91% in 2019. Women undergoing mastectomy were older and were more likely to be married and have at least one child. They had an advanced cancer stage, larger tumour size, and more lymph node invasion and were positive for HER-2 overexpression. Older age, larger tumour size (2-5 cm), higher cancer stages (stage 2- stage 3) and being positive for HER-2 were the four independent variables that significantly predicted the uptake of mastectomy.

CONCLUSIONS

Our results showed a wide application of mastectomy in China and uncovered the factors associated with mastectomy uptake from a single-centre experience. Findings suggested the potential overuse of mastectomy among women with early-stage breast cancer, and highlighted the significance of promoting cancer screening in China. Findings could be also used to develop relevant provisions and interventions to facilitate breast cancer treatment decision-making and screening planning.
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Cost-effectiveness of different surgical treatment approaches for early breast cancer: a retrospective matched cohort study from China

Background

Both breast-conserving surgery and breast reconstruction surgery are less popular in China, although they can improve patients’ quality of life. The main reason comes from the economy. There is currently no economic evaluation of different surgical treatment options for early breast cancer. Our study aims to assess the economic impact and long-term cost-effectiveness of different surgical treatments for early breast cancer. The surgical approaches are including mastectomy (MAST), breast-conserving therapy (BCT), and mastectomy with reconstruction (MAST+RECON).

Methods

Based on demographic data, disease-related information and other treatments, we applied propensity score matching (PSM) to perform 1: 1 matching among patients who underwent these three types of surgery in the tertiary academic medical center from 2011 to 2017 to obtain a balanced sample of covariates between groups. A Markov model was established. Clinical data and cost data were obtained from the medical records. Health utility values were derived from clinical investigations. Strategies were compared using an incremental cost-effectiveness ratio (ICER).

Results

After PSM, there were 205 cases in each group. In the matched data set, the distribution of covariates was fully balanced. The total cost of MAST, MAST+RECON and BCT was $37,392.84, $70,556.03 and $82,330.97, respectively. The quality-adjusted life year (QALYs) were 17.11, 18.40 and 20.20, respectively. Compared with MAST, MAST+RECON and BCT have an ICER of $25,707.90/QALY and $14,543.08/QALY, respectively. The ICER of BCT vs. MAST was less than the threshold of $27,931.04. The reliability and stability of the results were confirmed by Monte Carlo simulation and sensitivity analysis.

Conclusions

We believe that in the context of the limited resources in China, after comparing the three surgical approaches, BCT is the more cost-effective and preferred solution.

The Effect of Low and High Vacuum Drainage on the Postoperative Drainage of Breast Cancer: Insights from a Prospective, Non-Inferiority, Randomized Clinical Trial

Background

Vacuum drains have been extensively applied to prevent seroma formation after breast surgery. However, the usage of negative suction drainage is mainly determined by surgeon’s experience and preferences. The aim of this study is to prospectively compare the drain effect after breast surgery between the low and high vacuum drains.

Methods

This prospectively randomized trial (from January 2018 to June 2019) involved 188 patients who were subjected to modified radical mastectomy (group A, n=128) or immediate breast reconstruction with implants (group B, n=60). In each group, patients were randomized to receive high vacuum drain (pressure=–98 kPa) or low vacuum drain (pressure=–12 kPa) after surgery. Days of drain permanence, which means the duration of drainage, was the primary endpoint.

Results

According to the comparison of days of drain permanence, the effect of a low vacuum drain is not inferior to a high vacuum drain in group A (pectoral drain, P<0.001; axillary drain, P<0.001) or group B (submuscular drain, P=0.002). The complications frequently occurred on patients with high vacuum drain (11.7%), such as seroma formation. The expense of low vacuum drain was significantly lower than high vacuum drain in both groups (P<0.01).

Conclusion

The drain effect of the low vacuum drain is not inferior to a high vacuum drain in both group A and group B. The low vacuum drain was effective, relatively cheap, and did not increase the incidence of complications; it is therefore more recommended after breast surgery.

Pan-Asian adapted ESMO Clinical Practice Guidelines for the management of patients with early breast cancer: a KSMO-ESMO initiative endorsed by CSCO, ISMPO, JSMO, MOS, SSO and TOS

In view of the planned new edition of the most recent version of the European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, treatment and follow-up of primary breast cancer published in 2015, it was decided at the ESMO Asia Meeting in November 2018, by both the ESMO and the Korean Society of Medical Oncology (KSMO), to convene a special face-to-face guidelines meeting in 2019 in Seoul. The aim was to adapt the latest ESMO 2019 guidelines to take into account the ethnic and geographical differences associated with the treatment of early breast cancer in Asian patients. These guidelines represent the consensus opinions reached by experts in the treatment of patients with early breast cancer representing the oncology societies of Korea (KSMO), China (CSCO), India (ISMPO) Japan (JSMO), Malaysia (MOS), Singapore (SSO) and Taiwan (TOS). The voting was based on scientific evidence, and was independent of both the current treatment practices, and the drug availability and reimbursement situations, in the individual participating Asian countries.

Effect of breast-conserving surgery and modified radical mastectomy on operation index, symptom checklist-90 score and prognosis in patients with early breast cancer

The present study aims to analyze the effects of breast-conserving surgery and modified radical mastectomy on operation indexes, Symptom checklist-90 scores and prognosis in patients with early breast cancer.The clinical data of 128 patients with breast cancer who were treated in our hospital from May 2015 to May 2016 were included into the analysis. These patients were divided into 2 groups, according to the different modes of operation (n = 64): control group, patients underwent modified radical mastectomy; observation group, patients underwent early breast conserving surgery. Then, the surgical indexes and prognosis were compared between these 2 groups.Intraoperative bleeding volume, incision length and hospitalization duration were better in the observation group than in the control group (P < .05). Furthermore, postoperative symptom checklist-90 scores in the observation group were better than scores before the operation, and were better than the scores in the control group (P < .05). Moreover, the incidence of postoperative complications was lower in the observation group (3.13%) than in the control group (21.88%, P < .05).Early breast-conserving surgery is more advantageous for breast cancers and results to lesser bleeding, rapid recovery, and fewer complications.

Non-doctoral factors influencing the surgical choice of Chinese patients with breast cancer who were eligible for breast-conserving surgery

Background

The rate of breast-conserving surgery (BCS) is low in China. Many patients choose mastectomy even when informed that there is no difference in the overall survival rate compared with that of BCS plus radiotherapy. This study aimed to investigate the factors that influenced the surgical choice in patients eligible for BCS.

Methods

Female patients with breast carcinoma were enrolled in a single center from March 2016 to January 2017. They made their own decision regarding the surgical approach. Univariate analysis was employed to determine the factors associated with the different breast surgical approaches. Significant factors (defined as P < 0.05) were then incorporated into multivariate logistic regression models to determine the factors that independently influenced patients’ decision.

Results

Of the 271 patients included, 149 were eligible for BCS; 65 chose BCS and 84 chose mastectomy. On the basis of univariate analysis, patients with younger age, higher income and education, shorter admission to surgery interval, and shorter confirmed diagnosis to surgery interval were more likely to choose BCS than mastectomy (P < 0.05). Meanwhile, patients who resided in rural regions, did not have general medicare insurance, and were diagnosed with breast cancer preoperatively were more inclined to choose mastectomy than BCS (P < 0.05). The multivariate model revealed three independent influencing factors: age at diagnosis (P = 0.009), insurance status (P = 0.035), and confirmed diagnosis to surgery interval (P = 0.037). In addition, patients receiving neoadjuvant chemotherapy (NCT) were more inclined to choose mastectomy.

Conclusion

Surgical choice of patients eligible for BCS was affected by several factors, and age at diagnosis, confirmed diagnosis to surgery interval, and insurance status were independent factors.

Trends of mastectomy and breast-conserving surgery and related factors in female breast cancer patients treated at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, 2009-2017: A retrospective cohort study

Background

Breast cancer is the most common cancer in women and accounts for 14.7% of cancer-related deaths among females worldwide. Its core management includes surgical removal of the tumor either by breast-conserving surgery (BCS) or mastectomy. Choosing between these two procedures may be influenced by factors that are not studied in our region. We aimed to determine the prevalence of BCS and mastectomy and the factors that may influence the choice of procedure.

Methods

This retrospective study was carried out by reviewing the records of female breast cancer patients who underwent BCS or mastectomy at between 2009 to June 2017, excluding those with metastasis or recurrence. Frequencies and multivariate tests were used for detecting correlations between procedures and demographic, clinicopathological, and radiological factors.

Results

Of 335 patients (mean age 52.75 ± 12.2 years), 62.4% had mastectomy and 37.6% had BCS. Modified radical mastectomy accounted for 70.8% of mastectomies. Multivariate analysis showed non-Saudi nationality (P = 0.002), multifocal (P = 0.0001) and multicentric tumors (P = 0.0001), large tumor size (P = 0.0001), tumor stages IIIA (P = 0.005) and IIIB (P = 0.014), positive HER2 (0.009), and triple-negative receptor status (P = 0.010) significantly correlated with mastectomy.

Conclusion

Mastectomy has a much higher prevalence than BCS in our study mainly due to advanced tumor stage at the time of diagnosis. This emphasizes the urgent need for early detection of breast cancer to move towards BCS, with education and increasing awareness of breast cancer and the surgical options, especially that it is more common in a significantly younger population in our area.

Breast-conserving surgery versus mastectomy in young women with breast cancer in Asian settings

Background

Mastectomy rates among women with early breast cancer in Asia have traditionally been high. This study assessed trends in the surgical management of young women with early‐stage breast cancer in Asian settings. Survival in women treated with breast‐conserving surgery (BCS; lumpectomy with adjuvant radiotherapy) and those undergoing mastectomy was compared.

Methods

Young women (aged less than 50 years) newly diagnosed with stage I or II (T1–2 N0–1 M0) breast cancer in four hospitals in Malaysia, Singapore and Hong Kong in 1990–2012 were included. Overall survival (OS) was compared for patients treated by BCS and those who had a mastectomy. Propensity score analysis was used to account for differences in demographic, tumour and treatment characteristics between the groups.

Results

Some 63·5 per cent of 3536 women underwent mastectomy. Over a 15‐year period, only a modest increase in rates of BCS was observed. Although BCS was significantly associated with favourable prognostic features, OS was not significantly different for BCS and mastectomy; the 5‐year OS rate was 94·9 (95 per cent c.i. 93·5 to 96·3) and 92·9 (91·7 to 94·1) per cent respectively. Inferences remained unchanged following propensity score analysis (hazard ratio for BCS versus mastectomy: 0·81, 95 per cent c.i. 0·64 to 1·03).

Conclusion

The prevalence of young women with breast cancer treated by mastectomy remains high in Asian countries. Patients treated with BCS appear to survive as well as those undergoing mastectomy.

Distribution of CD4+ and CD8+ exhausted tumor-infiltrating lymphocytes in molecular subtypes of Chinese breast cancer patients

PURPOSE

Breast cancer (BC) is the leading cancer affecting Chinese women; however, the immune microenvironment between molecular subtypes is less reported. This study aimed to investigate the distribution of tumor-infiltrating lymphocyte (TIL) subpopulations, especially exhausted CD4+ and CD8+ TILs in Chinese BC patients.

PATIENTS AND METHODS

A total of 133 patients with breast invasive ductal carcinoma were recruited consecutively from January 1, 2012 to December 31, 2013, and TILs were detected in H&E-stained sections. Expression profiling of PD-1, CD4, and CD8 was determined by immunohistochemistry on 4 µm formalin-fixed paraffin-embedded tissue sections. The distribution of TILs was analyzed based on hormone receptor status and molecular subtypes.

RESULTS

PD-1+, CD4+, and CD8+ TILs distributed differently based on molecular subtypes. Compared to Luminal A, triple-negative breast cancer (TNBC) patients had more PD-1+ TILs (39/high-power field [HPF] vs 11/HPF), PD-1+ helper T (CD4+) cells (28/HPF vs 10/HPF), and PD-1+ cytotoxic (CD8+) T-cells (3/HPF vs 2/HPF).

CONCLUSION

TILs are distributed differently based on molecular subtypes. TNBC patients exhibit more PD-1+ exhausted TILs, representing an inhibitory immune microenvironment. PD-1/PD-L1 pathway is a potential therapeutic target of TNBC.

The influence of partner involvement in the decision-making process on body image and decision regret among women receiving breast reconstruction

PURPOSE

This study examines the influence of partner involvement in decision-making for breast reconstruction (BR) on women's body image and post-BR decision regret.

METHODS

A cross-sectional and correlational approach was used in a convenience sample of 105 women in Taiwan who had breast cancer (BC) whose partners were involved in decision-making for BR. A structured questionnaire including the Involvement in the Breast Reconstruction Decision-Making Process Scale, the Body Image Scale, and the Decision Regret Scale was administered. Pearson's r and path analysis were used to examine the relationships among the dyadic BR decision-making process, women's body image, and decision regret.

RESULTS

The greater the amount of medical information women had, the better their body image and the less decision regret they experienced. Moreover, partner involvement was not related to women's body image, though it was inversely related to women's decision regret. The final path model showed that the amount of medical information women obtained was directly related to body image and decision regret, while body image also directly influenced decision regret. Overall, the amount of medical information women obtained and their body image explained 45% of the variance in decision regret.

CONCLUSIONS

Medical teams should provide female BC patients with complete medical information, and through partner involvement, women can be supported to make an appropriate decision regarding BR to achieve optimal levels of body image and lower levels of decision regret.

Post-operative radiotherapy is beneficial for T1/T2 triple negative breast cancer patients with four or more positive lymph nodes

The efficacy of adjuvant radiotherapy for the treatment of triple negative breast cancer patients with varying numbers of positive lymph nodes is not clear. We assessed the association between adjuvant radiotherapy and survival in 943 T1/T2 triple negative breast cancer patients treated at our institute between 2008 and 2012. We determined that post-operative radiotherapy improved overall survival (OS), disease-free survival (DFS), and local recurrence-free survival (LRFS) in patients with ≥ 4 positive nodes (p = 0.037, p = 0.035, and p = 0.012, respectively). Although Cox regression analysis demonstrated that radiotherapy was a significant prognostic factor in triple negative breast cancer with ≥ 4 positive nodes, post-operative radiotherapy had no clear effect on OS, DFS, or LRFS in patients with 1-3 positive nodes (p = 0.849, p = 0.860, and p = 0.162, respectively). The prognosis (i.e., OS, DFS, and LRFS) of triple negative breast cancer patients without lymph node metastasis who underwent breast-conserving surgery and post-operative radiotherapy was similar to that of patients who underwent mastectomy alone (p = 0.336, p = 0.537, and p = 0.978, respectively). Our findings demonstrate that post-operative radiotherapy is beneficial for T1/T2 triple negative breast cancer patients with ≥ 4 positive lymph nodes.

[Research progress of non-biological meshes for breast reconstruction]

Objective

To review the application progress of non-biological meshes for breast reconstruction (BR).

Methods

The related home and abroad researches in BR were reviewed and summarized.

Results

Non-biological meshes can be divided into degradable and nondegradable. The former has many types, whether its degradation rate can match with the grow rate of repair tissue will significantly affect the wound healing and tissue intergradation. TiLOOP, on behalf of the latter, has a good postoperative performance due to its nano TiO ₂ layer, lightness and flexibility. Non-biological meshes have been gradually used to cover and fix implant in BR. Compared with biological meshes, non-biological meshes are cheaper and have a more positive postoperative performance generally, but definite comparison can't be concluded due to the limited data.

Conclusion

As non-biological meshes are applied to BR preliminarily, their effectiveness are still needed to be observed further.

A prospective study of breast anthropomorphic measurements, volume and ptosis in 605 Asian patients with breast cancer or benign breast disease

OBJECTIVES

The current study aims to summarize breast anthropomorphic measurement features in Chinese patients with breast diseases and to investigate their potential correlations with demographic factors.

MATERIALS AND METHODS

Fifteen breast anthropomorphic parameters of 605 Chinese female patients were collected prospectively. Breast ptosis status was scaled by two methods and breast volume was calculated according to a modified formula of BREAST-V.

RESULTS

Among 1210 breasts, the average breast volume was 340.0±109.1 ml (91.8-919.2 ml). The distance from the nipple to the inframammary fold was 7.5±1.6 cm in the standing position. The width of the breast base was 14.3±1.4 cm (8.5-23.5 cm). The incidence of breast ptosis was 22.8% (274/1204), of which 37 (23.5%) and 79 (31.7%) women had severe ptosis assessed by different criteria. Increased height (OR[odds ratio] = 1.500, P<0.001), post-menopausal status (OR = 1.463, P = 0.02), increased BMI, breastfeeding for 7-12 months (OR = 1.882, P = 0.008) and more than one year (OR = 2.367, P = 0.001) were risk factors for an increased breast volume. Post-menopausal status (OR = 2.390, P<0.001 and OR = 2.621, P<0.001 for different scales), BMI≥24.7 kg/m2 (OR = 3.149, P<0.001 and OR = 2.495, P = 0.002), breastfeeding for 7-12 months (OR = 4.136, P = 0.004 and OR = 4.010, P = 0.002), and breastfeeding for more than one year (OR = 6.934, P<0.001 and OR = 6.707, P<0.001) were independent risk factors for breast ptosis.

CONCLUSIONS

The current study provides anthropomorphic measurements data of Chinese women with breast diseases, which are useful for cosmetic and reconstructive breast surgery decisions. Post-menopausal status, increased BMI, and breastfeeding for more than six months were independent risk factors for both increased breast volume and breast ptosis.

Surgical management of breast cancer in China: A 15-year single-center retrospective study of 18,502 patients

The aim of the study was to review the surgical trends in breast cancer treatment in China over the past 15 years and to explore the possible factors related to the choice of surgical modality.The medical records of 18,502 patients with unilateral early stage breast cancer who underwent surgery from January 1999 to December 2013 at our institute were retrospectively reviewed. The utilization of different surgical modalities and the associated clinicopathological factors were analyzed. Furthermore, the prognostic role of surgical modality was also evaluated.The median patient age was 50.0 years. According to the pTNM staging system, 12.5% of the patients were classified as stage 0; 30.2% as stage I; 40.0% as stage II; and 17.3% as stage III. In total, 9.3% of the patients could not be staged. Overall, 67.1% of the breast cancer cases were estrogen receptor (ER) positive. The pattern of breast cancer surgery has changed tremendously over the past 15 years (P < 0.001). The pattern of mastectomy has shifted from radical mastectomy to modified radical mastectomy and simple mastectomy + sentinel lymph node biopsy. A total of 81.7% of the patients underwent mastectomy without immediate reconstruction, 15.2% underwent breast-conserving surgery (BCS), and 3.7% received immediate breast reconstruction after mastectomy. Age, TNM staging, and pathological characteristics greatly affected the choice of surgical modality. The 5-year recurrence-free survival (RFS) rates for the mastectomy, BCS, and reconstruction groups were 87.6%, 93.2%, and 91.7%, respectively (P < 0.001); the RFS rate was likely affected by distant recurrence instead of loco-regional recurrence. We also identified improved RFS over time, stratified by surgical modality and tumor stage. Multivariate Cox-regression analysis revealed that time of treatment, tumor stage, tumor grade, LVI status, and ER status were independent prognostic factors for RFS in our cohort, whereas surgical modality was not.Mastectomy remains the most prevalent surgical modality used to manage early stage breast cancer in China, although the utilization of BCS has increased in the past decade. However, surgical management was not a prognostic factor for RFS. The selection of appropriate patients depended on the assessment of multiple clinicopathological factors, which is essential for making surgical decisions.

Current status of breast reconstruction in China: an experience of 951 breast reconstructions from a single institute

BACKGROUND

Since mastectomy remained the primary strategy for treating breast cancer in China, post-mastectomy reconstruction is of great importance in the Chinese population. The current study aimed to assess the current status of breast reconstruction in China.

METHODS

We reviewed all patients who received breast reconstruction from August 2000 to July 2015 in the Department of Breast Surgery in our institute. Patients' baseline characteristics, reconstruction strategy, final pathology and loco-regional recurrence (LRR) information were collected.

RESULTS

A total of 951 breast reconstructions were conducted during the past 15 years, among which 247 (27.0%) were abdominal flap reconstruction; 471 (51.5%) were latissimus dorsi myocutaneous ± implant; and 233 (25.5%) were prosthesis-based reconstruction. The majority of cases (78.1%) were invasive breast cancer and up to 894 cases (94.0%) were immediate reconstruction. Prosthesis-based reconstruction rapidly increased in recent years, and was associated with bilateral reconstruction, contralateral augmentation and higher complications. 18 patients (2.0%) developed local-regional recurrence at the median follow-up time of 26.6 months (range, 3.7-62.0 months). A total of 66 nipple-areolar complex-sparing mastectomies (NSMs) (6.9%) were performed, none of which developed recurrence.

CONCLUSIONS

Breast reconstruction cases increased over the 15 years with the change of paradigm. Most strikingly, prosthesis-based reconstruction rapidly gained its prevalence and became the most common strategy. NSM was only performed for highly selected patients. Patients with breast reconstruction were able to achieve satisfactory loco-regional control in our cohort.

Preliminary results for treatment of early stage breast cancer with endoscopic subcutaneous mastectomy combined with endoscopic sentinel lymph node biopsy in China

BACKGROUND AND OBJECTIVES

To evaluate efficacy and aesthetic outcome for combined endoscopic subcutaneous mastectomy (E-SM) and endoscopic sentinel lymph node biopsy (E-SLNB) in early stage breast cancer patients.

METHODS

Combined E-SM+E-SLNB was compared to modified radical resection in a cohort of Chinese patients (n = 49) with stages I and II breast cancer. Patient satisfaction with the aesthetic results was assessed 1 year after surgery with a 5-item-by-4-step scoring system for evaluating cosmetic outcomes.

RESULTS

All patients were alive 1 year following surgery with no locoregional recurrence or distant metastases and without any critical complications. The average length of incision was less in patients receiving E-SM+E-SLNB (4.4 vs. 19.4 cm; P < 0.001), but time in surgery was longer (131.6 vs. 99.2 min; P = 0.024). After 1 year, nearly all E-SM+E-SLNB patients rated satisfaction with their appearance as excellent or good (23/24; 95.8% vs. 19/25; 76.0%; P < 0.001), and exhibited less disturbance of sensory (P < 0.001) and motor function (P = 0.014) relative to modified radical resection.

CONCLUSIONS

E-SM+E-SLNB provides significant aesthetic and functional advantages for patients with early stage breast cancer without compromising medical efficacy as assessed at 16 months postsurgery. J. Surg. Oncol. 2016;113:616-620. © 2016 Wiley Periodicals, Inc.

Psychosocial Predictors and Outcomes of Delayed Breast Reconstruction in Mastectomized Women in Mainland China: An Observational Study

Background

The aim of the present study was to evaluate potential psychosocial factors that impact Chinese female breast cancer patients to select breast reconstruction (BR), and potential connection of psychosocial outcomes with their satisfaction with BR.

Methods

A total of 264 female breast cancer patients with mastectomy were recruited from 2012 to 2014. All patients were informed with BR options at their first visit. Personal and medical profiles were collected. Body image, self-esteem, depression and anxiety were assessed using validated scales. Patients who were selected to undergo BR after the first visit were followed up for six months. The same assessment was performed at 6 months post BR, and their satisfaction with BR was evaluated using the Alderman scale. Multivariate linear and logistic regressions were performed.

Results

Forty-seven percent of the patients (126/264) opted to undergo BR within six months after the initial visit. Multivariate logistic regression analysis revealed that self-esteem (P < 0.05), body image (P < 0.01), education level (P < 0.05), and their husband’s recommendation (P < 0.05) were highly related to the patients’ decision to undergo BR. In addition, multivariate linear regression analysis showed that patient satisfaction with BR was significantly associated with preoperative body image (P < 0.01), postoperative improvement in self-esteem (P < 0.01), improvement in body image (P < 0.01), reduction in depression (P < 0.05), pain (P < 0.05), and scarring (P < 0.01).

Conclusions

The psychosocial factors including self-esteem and body image are highly related to selecting the BR option and post-BR satisfaction in Chinese female breast cancer patients.

Breast Cancer Disparities: A Multicenter Comparison of Tumor Diagnosis, Characteristics, and Surgical Treatment in China and the U.S

BACKGROUND AND OBJECTIVE

Incidence of and mortality rates for breast cancer continue to rise in the People's Republic of China. The purpose of this study was to analyze differences in characteristics of breast malignancies between China and the U.S.

METHODS

Data from 384,262 breast cancer patients registered in the U.S. Surveillance, Epidemiology, and End Results (SEER) program from 2000 to 2010 were compared with 4,211 Chinese breast cancer patients registered in a Chinese database from 1999 to 2008. Outcomes included age, race, histology, tumor and node staging, laterality, surgical treatment method, and reconstruction. The Pearson chi-square and Fisher's exact tests were used to compare rates.

RESULTS

Infiltrating ductal carcinoma was the most common type of malignancy in the U.S. and China. The mean number of positive lymph nodes was higher in China (2.59 vs. 1.31, p < .001). Stage at diagnosis was higher in China (stage IIA vs. I, p < .001). Mean size of tumor at diagnosis was higher in China (32.63 vs. 21.57 mm). Mean age at diagnosis was lower in China (48.28 vs. 61.29 years, p < .001). Moreover, 2.0% of U.S. women underwent radical mastectomy compared with 12.5% in China, and 0.02% in China underwent reconstructive surgery.

CONCLUSION

Chinese women were diagnosed at younger ages with higher stage and larger tumors and underwent more aggressive surgical treatment. Prospective trials should be conducted to address screening, surgical, and tumor discrepancies between China and the U.S.

IMPLICATIONS FOR PRACTICE

Breast cancer patients in China are diagnosed at later stages than those in America, which might contribute to different clinical management and lower 5-year survival rate. This phenomenon suggests that an earlier detection and treatment program should be widely implemented in China. By comparing the characteristics of Chinese and Chinese-American patients, we found significant differences in tumor size, lymph nodes metastasis, and age at diagnosis. These consequences indicated that patients with similar genetic backgrounds may have different prognoses due to the influence of environment and social economic determinates.

Breast Cancer Challenges and Screening in China: Lessons From Current Registry Data and Population Screening Studies

BACKGROUND

As one of its responses to the increasing global burden of breast cancer (BC), China has deployed a national registration and BC screening campaign. The present report describes these programs and the initial results of these national BC control strategies, highlighting the challenges to be considered.

MATERIALS AND METHODS

The primary BC incidence and prevalence data were obtained from the Chinese National Central Cancer Registry. MapInfo software was used to map the geographic distribution and variation. The time trends were estimated by the annual percentage of change from 2003 to 2009. The description of the screening plans and preliminary results were provided by the Ministry of Health.

RESULTS

Chinese cancer registries were primarily developed and activated in the East and Coastal regions of China, with only 12.5% of the registries located in West China. Geographic variation was noted, with the incidence of BC higher in North China than in South China and in urban areas compared with rural areas. Of great interest, these registries reported that the overall BC incidence has been increasing in China, with an earlier age of onset compared with Western countries and a peak incidence rate at age 50. In response to this increasing incidence and early age of onset, BC screening programs assessed 1.46 million women aged 35-59 years, using clinical breast examinations and ultrasound as primary screening tools between 2009 and 2011. The diagnostic rate for this screening program was only 48.0/10(5) with 440 cases of early stage BC. Early stage BC was detected in nearly 70% of screened patients. Subsequently, a second-generation screening program was conducted that included older women aged 35-64 years and an additional 6 million women were screened.

CONCLUSION

The cancer registration system in China has been uneven, with a greater focus on East rather than West China. The data from these registries demonstrate regional variation, an increasing BC incidence, and an early age of onset. The 2009 to 2011 BC screening program targeting women aged 35-59 years had a low detection rate that resulted in a second-generation screening program that extended the cohort size and ages screened to 35-64 years.

IMPLICATIONS FOR PRACTICE

Cancer registration has been active in China for decades; however, a national survey of registries has not been routinely reported. This study used MapInfo to describe the reported data and found asymmetric registration activities, geographic variations in breast cancer (BC) burdens, and an increasing incidence with a peak at age 50. The initial Chinese BC screening programs focused on a relatively young population of women aged 35-59 years and had a low detection rate, but 69.7% of patients had early stage BC. Older women were included in the second-generation screening programs, and an additional 6 million women were screened. Consideration of regional variations and age is necessary to optimize the efficiency and utility of BC screening in China, with the ultimate goal to reduce BC mortality.

Comparison of radiation dose to the left anterior descending artery by whole and partial breast irradiation in breast cancer patients

Purpose

Breast conserving surgery (BCS) followed by whole breast irradiation (WBI) is the standard of care for breast cancer patients. However, there is a risk of coronary events with WBI therapy. In this study, we compared the radiation dose in the left anterior descending artery (LAD) in patients receiving partial breast irradiation (PBI) with WBI.

Material and methods

We evaluated consecutive patients who underwent adjuvant radiotherapy after BCS between October 2008 and July 2014. Whole breast irradiation patients received 50 Gy in fractions of 2 Gy to the entire breast. Partial breast irradiation was performed using multicatheter brachytherapy at a dose of 32 Gy in eight fractions. The mean and maximal cumulative doses to LAD were calculated. The radiotherapeutic biologically effective dose of PBI was adjusted to WBI, and radiation techniques were compared.

Results

Of 379 consecutive patients with 383 lesions receiving radiotherapy (151 WBI and 232 PBI lesions), 82 WBI and 100 PBI patients were analyzed. In WBI patients, the mean and maximal cumulative doses for left-sided breast cancer (2.13 ± 0.11 and 8.19 ± 1.21 Gy, respectively) were significantly higher than those for right-sided (0.37 ± 0.02 and 0.56 ± 0.03 Gy, respectively; p < 0.0001). In PBI patients with left-sided breast cancer, the doses for tumors in inner quadrants or central location (2.54 ± 0.21 and 4.43 ± 0.38 Gy, respectively) were significantly elevated compared to outer quadrants (1.02 ± 0.17 and 2.10 ± 0.29 Gy, respectively; p < 0.0001). After the adjustment, the doses in PBI patients were significantly reduced in patients with tumors only in outer quadrants (1.12 ± 0.20 and 2.43 ± 0.37 Gy, respectively; p = 0.0001).

Conclusions

Tumor control and dose to LAD should be considered during treatment since PBI may reduce the risk of coronary artery disease especially in patients with lateral tumors in the left breast.

Two modified surgical procedures for treating early stage breast cancer in China

Conventional pedicled-flap based surgeries in treating breast cancer have their limitations. New surgical regimens are yet to be explored, which will follow the oncological principle of being "total tumor free", whilst fit into the unique characteristics of China's own medical system as well as patients' demand. From 2007 to 2013, 143 patients with early stage breast cancer were included in the study, with the average age of 46.1 years. Fifty-three patients were subjected to modified breast conserving surgery (MBCS)+latissimus dorsi (LD) flap reconstruction, 41 to skin sparing mastectomy (SSM)+implant+LD flap reconstruction, 29 to MBCS+distal transverse rectus abdominis myocutaneous (DTRAM) flap reconstruction, and 20 to SSM+DTRAM flap reconstruction. The results showed that out of the 143 patients, there was no graft loss. Minor complications included 4 cases of fat liquefaction, and 6 cases of seratoma, which all resolved after conservative treatment. Five patients had visible protuberance in the abdomen, but not leading to any gastrointestinal symptoms. The reconstructed breasts all presented good shape. 96.7% of the patients were satisfied with the outcome. The follow-up period varied from 6 months to 60 months, and only one patient died from tumor metastasis in the brain. No local recurrence occurred. It was concluded that these two modified pedicled-flap surgeries are readily practical, and aesthetically satisfactory, with high applicability in China. They do not compromise the oncological outcomes, but also are well-accepted by Chinese patients.

A clinical database of breast cancer patients reveals distinctive clinico-pathological characteristics: a study from central China

BACKGROUND

Breast cancer is the most common malignant tumor in females worldwide. Many differences exist in clinico-pathological characteristics of breast cancer patients between China and Western countries. This study aimed to analyze clinico-pathological characteristics of breast cancer from central China.

METHODS

Clinico- pathological information on breast cancer from three hospitals in central China was collected and analyzed.

RESULTS

From 1994 to 2012, 2,525 patients with a median age 50 years were included in this study. The 45-49-year age group and invasive ductal carcinoma not otherwise specified accounted for the highest proportions (19.1%, 480/2,525 and 81.0%, 1,982/2,446). Stages 0-I, II and III accounted for 28.0% (682/2,441), 48.4% (1,180/2,441), and 23.7% (578/2,441), respectively. Distribution of N stage showed that N0 accounted for 53.2% (1,344/2,525), and proportion of N0 rose from 51.1% (157/307) in 30-39-year age group to 64.3% (110/171) in ≥ 70-year age group, with an average increase of 2.1% in each age group. Modified radical mastectomy, radical mastectomy, breast-conserving surgery and simple mastectomy were performed for 71.8% (1,812/2,525), 18.0% (454/2,525), 5.2% (131/2,525) and 2.6% (66/2,525), respectively. Proportions of breast-conserving surgery in age ≤ 44-year group (68/132, 51.5%) and simple mastectomy in age ≥ 60-year group (57/89, 64.0%) were higher than in the other age groups. Breast cancers positive for estrogen receptor accounted for 53.0% (1,107/ 2,112). The comparisons among this study and other reports showed higher proportion of younger patients, lower proportion of breast- conserving surgery and positive estrogen receptor patients in China than western countries.

CONCLUSIONS

Clinico-pathological characteristics in this study demonstrated clear differences between the center of China than Western countries. Additional classification systems should be developed to guide grading of early breast cancer more accurately, especially for N0 patients. Invasive ductal carcinoma is a focus for intensive research.

Computer-based image studies on tumor nests mathematical features of breast cancer and their clinical prognostic value

Background

The expending and invasive features of tumor nests could reflect the malignant biological behaviors of breast invasive ductal carcinoma. Useful information on cancer invasiveness hidden within tumor nests could be extracted and analyzed by computer image processing and big data analysis.

Methods

Tissue microarrays from invasive ductal carcinoma (n = 202) were first stained with cytokeratin by immunohistochemical method to clearly demarcate the tumor nests. Then an expert-aided computer analysis system was developed to study the mathematical and geometrical features of the tumor nests. Computer recognition system and imaging analysis software extracted tumor nests information, and mathematical features of tumor nests were calculated. The relationship between tumor nests mathematical parameters and patients' 5-year disease free survival was studied.

Results

There were 8 mathematical parameters extracted by expert-aided computer analysis system. Three mathematical parameters (number, circularity and total perimeter) with area under curve >0.5 and 4 mathematical parameters (average area, average perimeter, total area/total perimeter, average (area/perimeter)) with area under curve <0.5 in ROC analysis were combined into integrated parameter 1 and integrated parameter 2, respectively. Multivariate analysis showed that integrated parameter 1 (P = 0.040) was independent prognostic factor of patients' 5-year disease free survival. The hazard risk ratio of integrated parameter 1 was 1.454 (HR 95% CI [1.017–2.078]), higher than that of N stage (HR 1.396, 95% CI [1.125–1.733]) and hormone receptor status (HR 0.575, 95% CI [0.353–0.936]), but lower than that of histological grading (HR 3.370, 95% CI [1.125–5.364]) and T stage (HR 1.610, 95% CI [1.026 –2.527]).

Conclusions

This study indicated integrated parameter 1 of mathematical features (number, circularity and total perimeter) of tumor nests could be a useful parameter to predict the prognosis of early stage breast invasive ductal carcinoma.