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Jagtap SV, Jagtap SS. Methylation of BRCA1 promoter in sporadic breast cancer. Indian J Med Res 2023; 158:85-87. [PMID: 37602590 PMCID: PMC10550062 DOI: 10.4103/ijmr.ijmr_1574_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Indexed: 08/10/2023] Open
Affiliation(s)
- Sunil Vitthalrao Jagtap
- Department of Pathology, Krishna Institute of Medical Sciences, Deemed University, Karad 415 539, Maharashtra, India
| | - Swati S. Jagtap
- Department of Physiology, Krishna Institute of Medical Sciences, Deemed University, Karad 415 539, Maharashtra, India
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Mavragani A, Rodrigues PP, Nakazawa-Miklaševiča M, Pinto D, Miklaševičs E, Trofimovičs G, Gardovskis J, Cardoso F, Cardoso MJ. Effectiveness of Secondary Risk-Reducing Strategies in Patients With Unilateral Breast Cancer With Pathogenic Variants of BRCA1 and BRCA2 Subjected to Breast-Conserving Surgery: Evidence-Based Simulation Study. JMIR Form Res 2022; 6:e37144. [PMID: 36580360 PMCID: PMC9837710 DOI: 10.2196/37144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 10/30/2022] [Accepted: 11/01/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Approximately 62% of patients with breast cancer with a pathogenic variant (BRCA1 or BRCA2) undergo primary breast-conserving therapy. OBJECTIVE The study aims to develop a personalized risk management decision support tool for carriers of a pathogenic variant (BRCA1 or BRCA2) who underwent breast-conserving therapy for unilateral early-stage breast cancer. METHODS We developed a Bayesian network model of a hypothetical cohort of carriers of BRCA1 or BRCA2 diagnosed with stage I/II unilateral breast cancer and treated with breast-conserving treatment who underwent subsequent second primary cancer risk-reducing strategies. Using event dependencies structured according to expert knowledge and conditional probabilities obtained from published evidence, we predicted the 40-year overall survival rate of different risk-reducing strategies for 144 cohorts of women defined by the type of pathogenic variants (BRCA1 or BRCA2), age at primary breast cancer diagnosis, breast cancer subtype, stage of primary breast cancer, and presence or absence of adjuvant chemotherapy. RESULTS Absence of adjuvant chemotherapy was the most powerful factor that was linked to a dramatic decline in survival. There was a negligible decline in the mortality in patients with triple-negative breast cancer, who received no chemotherapy and underwent any secondary risk-reducing strategy, compared with surveillance. The potential survival benefit from any risk-reducing strategy was more modest in patients with triple-negative breast cancer who received chemotherapy compared with patients with luminal breast cancer. However, most patients with triple-negative breast cancer in stage I benefited from bilateral risk-reducing mastectomy and risk-reducing salpingo-oophorectomy or just risk-reducing salpingo-oophorectomy. Most patients with luminal stage I/II unilateral breast cancer benefited from bilateral risk-reducing mastectomy and risk-reducing salpingo-oophorectomy. The impact of risk-reducing salpingo-oophorectomy in patients with luminal breast cancer in stage I/II increased with age. Most older patients with the BRCA1 and BRCA2 pathogenic variants in exons 12-24/25 with luminal breast cancer may gain a similar survival benefit from other risk-reducing strategies or surveillance. CONCLUSIONS Our study showed that it is mandatory to consider the complex interplay between the types of BRCA1 and BRCA2 pathogenic variants, age at primary breast cancer diagnosis, breast cancer subtype and stage, and received systemic treatment. As no prospective study results are available at the moment, our simulation model, which will integrate a decision support system in the near future, could facilitate the conversation between the health care provider and patient and help to weigh all the options for risk-reducing strategies leading to a more balanced decision.
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Affiliation(s)
| | - Pedro Pereira Rodrigues
- Information and Health Decision Sciences of the Faculty of Medicine, University of Porto, Porto, Portugal
| | | | - David Pinto
- Breast Cancer Unit, Champalimaud Cancer Center, Lisbon, Portugal
| | | | | | - Jānis Gardovskis
- Department of Surgery, Faculty of Medicine, Pauls Stradins Clinical University Hospital, Rīga Stradiņš University, Riga, Latvia
| | - Fatima Cardoso
- Breast Cancer Unit, Champalimaud Cancer Center, Lisbon, Portugal
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3
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Wu HX, Lin ZW, Song TY, Piao YS. Efficacy of breast conservative surgery versus modified radical mastectomy for triple-negative breast cancer: A systematic review and meta-analysis. Asian J Surg 2022; 45:1491-1493. [PMID: 35331585 DOI: 10.1016/j.asjsur.2022.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 03/03/2022] [Indexed: 11/02/2022] Open
Affiliation(s)
- Hong-Xing Wu
- Key Laboratory of Science and Technology Department in Jilin Province, Cancer Research Center, Medical College of Yanbian University, Yanji, Jilin Province, China; Department of Clinical Medicine, Medical College of Yanbian University, Yanji, Jilin Province, China
| | - Zi-Wen Lin
- Department of Clinical Medicine, Medical College of Yanbian University, Yanji, Jilin Province, China
| | - Tian-Ye Song
- Department of Clinical Medicine, Medical College of Yanbian University, Yanji, Jilin Province, China
| | - Ying-Shi Piao
- Key Laboratory of Science and Technology Department in Jilin Province, Cancer Research Center, Medical College of Yanbian University, Yanji, Jilin Province, China.
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A Review of Breast Cancer Risk Factors in Adolescents and Young Adults. Cancers (Basel) 2021; 13:cancers13215552. [PMID: 34771713 PMCID: PMC8583289 DOI: 10.3390/cancers13215552] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 10/29/2021] [Accepted: 11/03/2021] [Indexed: 12/26/2022] Open
Abstract
Simple Summary Cancer diagnosed in patients between the ages of 15 and 39 deserves special consideration. Diagnoses within this cohort of adolescents and young adults include childhood cancers which present at an older age than expected, or an early presentation of cancers that are typically observed in older adults, such as breast cancer. Cancers within this age group are associated with worse disease-free and overall survival rates, and the incidence of these cases are rising. Knowing an individual’s susceptibility to disease can change their clinical management and allow for the risk-testing of relatives. This review discusses the risk factors that contribute to breast cancer in this unique cohort of patients, including inherited genetic risk factors, as well as environmental and lifestyle factors. We also describe risk models that allow clinicians to quantify a patient’s lifetime risk of developing disease. Abstract Cancer in adolescents and young adults (AYAs) deserves special consideration for several reasons. AYA cancers encompass paediatric malignancies that present at an older age than expected, or early-onset of cancers that are typically observed in adults. However, disease diagnosed in the AYA population is distinct to those same cancers which are diagnosed in a paediatric or older adult setting. Worse disease-free and overall survival outcomes are observed in the AYA setting, and the incidence of AYA cancers is increasing. Knowledge of an individual’s underlying cancer predisposition can influence their clinical care and may facilitate early tumour surveillance strategies and cascade testing of at-risk relatives. This information can further influence reproductive decision making. In this review we discuss the risk factors contributing to AYA breast cancer, such as heritable predisposition, environmental, and lifestyle factors. We also describe a number of risk models which incorporate genetic factors that aid clinicians in quantifying an individual’s lifetime risk of disease.
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5
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Ye F, He M, Huang L, Lang G, Hu X, Shao Z, Di G, Cao A. Insights Into the Impacts of BRCA Mutations on Clinicopathology and Management of Early-Onset Triple-Negative Breast Cancer. Front Oncol 2021; 10:574813. [PMID: 33505905 PMCID: PMC7829963 DOI: 10.3389/fonc.2020.574813] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 11/24/2020] [Indexed: 12/27/2022] Open
Abstract
Background Little is known regarding the clinicopathologic characteristics, oncologic outcomes, and treatment strategies that could be ascribed to BRCA mutation in early-onset triple-negative breast cancer (eTNBC). Methods eTNBC patients who underwent BRCA genetic testing were derived from our clinical database between 2012 and 2018. Differences in clinical features and pathologic characteristics were examined in groups divided by BRCA mutation status, and the contribution of germline mutations in conjunction with treatment modalities to survival outcomes was determined. Results Of the 355 qualifying eTNBC patients, 67 (18.87%) were BRCA mutated and 288 (81.13%) were BRCA wild. Overall, median age at diagnosis was 34 years (range, 24-40 years) in the BRCA mutated subgroup and 35 years (range, 21-40 years) in BRCA wild. The majority of clinicopathologic parameters were parallel; however, tumor size (P = 0.07) and nuclear grade (P =0.08) tend to be more aggressive in the BRCA mutated subgroup. Compared with BRCA wild patients, BRCA mutated patients had a higher likelihood of receiving anthracyclines and taxane-based combination chemotherapy (P = 0.04) and tend to be lower tumor burden (P =0.01). After approximately 5-year median follow-up, the overall survival (OS) (P = 0.021) and breast cancer-specific survival (BCSS) (P = 0.004) in BRCA mutated patients were superior to those in their BRCA wild counterparts. Intriguingly, the clinical outcomes were comparable in patients with breast conserving surgery (BCS) regardless of BRCA mutations and in patients with BRCA mutations in spite of surgical schedules. Conclusions These results suggest that eTNBC patients with BRCA mutations are prone to better OS and BCSS, which might be largely attributed to more benefit from anthracyclines and taxane-based chemotherapy. The BCS procedure could be a safe alternative surgical option for eTNBC patients with BRCA mutations. Future studies with substantial numbers of participants are urgently needed to validate whether BRCA mutation eTNBC patients are more sensitive to chemotherapy.
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Affiliation(s)
- Fugui Ye
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Min He
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Liang Huang
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Guantian Lang
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Xin Hu
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Zhimin Shao
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, China.,Institutes of Biomedical Sciences, Fudan University, Shanghai, China
| | - Genhong Di
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Ayong Cao
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
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6
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Bayraktar S, Zhou JZ, Bassett R, Gutierrez Barrera AM, Layman RM, Valero V, Arun B. Clinical outcome and toxicity from taxanes in breast cancer patients with BRCA1 and BRCA2 pathogenic germline mutations. Breast J 2020; 26:1572-1582. [PMID: 32497289 DOI: 10.1111/tbj.13922] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 05/15/2020] [Accepted: 05/15/2020] [Indexed: 12/18/2022]
Abstract
Germline variations in genes coding for proteins involved in the oxidative stress and DNA repair greatly influence drug response and toxicity. Because BRCA1 and BRCA2 proteins play a role in DNA damage repair, we postulated that taxane-related toxicity is potentially higher and clinical outcome in different in patients with BRCA pathogenic variants (PV). Seven hundred nineteen women who underwent BRCA genetic testing and were treated with taxane-containing chemotherapy for early-stage breast cancer between 1997 and 2018 were included in the study. Patients with BRCA variants of uncertain significance were excluded. The Kaplan-Meier product-limit method was used to estimate recurrence-free survival (RFS) and overall survival (OS) rates. Logistic regression models were used to assess the association between chemotherapy toxicity and factors of interest. Cox regression models were used to assess the association between RFS and OS and factors of interest. Ninety-four (13%) and 54 (7%) patients had BRCA1 and BRCA2-PVs, respectively. While anemia (P = .0025) and leukopenia (P = .001) were more frequently seen in BRCA noncarriers, there was no difference in regards to peripheral neuropathy or other toxicities between the groups. Increasing doses of taxane were associated with increased risk of neutropenia, stomatitis, nausea, vomiting, acne/rash, and peripheral neuropathy across all groups. In a multivariate logistic regression model, BRCA2 status remained as an independent significant predictor for decreased hematologic toxicity (HR: 0.36; 95% CI: 0.20-0.67; P = .001) and increased gastrointestinal toxicity (HR: 1.93; 95% CI: 1.02-3.67; P = .04). Being overweight, obese and African-American race were significant predictors for peripheral neuropathy (P = .04; P = .03; P = .06, respectively). Total taxane dose received did not have any impact on survival outcomes. Our study demonstrates that taxane-containing chemotherapy regimens do not increase risk of peripheral neuropathy or hematologic toxicity in patients with BRCA PVs. The mechanisms for this finding need to be further investigated as it may provide an opportunity to combine taxanes with other agents, such as platinum salts or PARP inhibitors, with less anticipated toxicity.
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Affiliation(s)
- Soley Bayraktar
- Division of Medical Oncology and Hematology, Department of Medicine, Biruni University School of Medicine, Istanbul, Turkey
- Departments of Cancer Medicine, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Jade Z Zhou
- Departments of Cancer Medicine, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Roland Bassett
- Biostatistics, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | | | - Rachel M Layman
- Breast Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Vicente Valero
- Breast Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Banu Arun
- Breast Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
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Qin C, Yang X, Zhan Z. High Expression of Asparagine Synthetase Is Associated with Poor Prognosis of Breast Cancer in Chinese Population. Cancer Biother Radiopharm 2020; 35:581-585. [PMID: 32412789 DOI: 10.1089/cbr.2019.3295] [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] [Indexed: 12/19/2022] Open
Abstract
Aims: This study aimed to determine the expression of asparagine synthetase (ASNS) in breast cancer (BC) tissues and estimate its prognostic value for BC patients. Besides, the roles of ASNS in the proliferation of BC cells were also examined in the study. Methods: Quantitative real-time PCR was conducted to detect the expression of ASNS mRNA in BC tissues and normal controls. The relationship between ASNS expression and clinical characteristics of BC patients was analyzed using χ-square test. MTT assay was performed to explore the effect of ASNS expression on the proliferation of BC cells. Kaplan-Meier curves were plotted to describe the overall survival rate of BC patients. Cox regression analyses were implemented to investigate prognostic factors. Results: ASNS mRNA overexpression was observed in BC tissues (p < 0.05). High expression of ASNS was significantly related to histological grade (p = 0.017), vascular invasion (p = 0.009), and PR status (p = 0.014). The downregulation of ASNS affected the proliferation of BC cells (p < 0.05). Kaplan-Meier survival showed that patients with high ASNS expression lived shorter than those with low expressions (p < 0.001). Finally, Cox regression analyses revealed that ASNS could act as a prognostic marker for BC patients (p < 0.001, HR = 3.293, 95% CI = 1.790-6.058). Conclusion: Taken together, ASNS is a valuable prognostic biomarker for BC patients.
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Affiliation(s)
- Chunxin Qin
- Department of Thyroid Breast Surgery, Weihai Municipal Hospital, Weihai City, China
| | - Xiaoqing Yang
- Department of Thyroid Breast Surgery, Weihai Municipal Hospital, Weihai City, China
| | - Zhiyong Zhan
- Department of Thyroid Breast Surgery, Weihai Municipal Hospital, Weihai City, China
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HEREDITARY BREAST CANCER CURRENT STATE OF PROBLEM. КЛИНИЧЕСКАЯ ПРАКТИКА 2020. [DOI: 10.17816/clinpract18964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
The literature review devoted to the evaluation of various methods of prevention, early diagnosis, and treatment of the hereditary breast cancer has been presented. Methods of surgical prevention, effectiveness of bilateral prophylactic mastectomy are considered.
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Genetic Testing for Cancer Predisposition Syndromes in Adolescents and Young Adults (AYAs). CURRENT GENETIC MEDICINE REPORTS 2020. [DOI: 10.1007/s40142-020-00187-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Chen L, Fu F, Huang M, Lv J, Zhang W, Wang C. The spectrum of BRCA1 and BRCA2 mutations and clinicopathological characteristics in Chinese women with early-onset breast cancer. Breast Cancer Res Treat 2020; 180:759-766. [PMID: 32072338 DOI: 10.1007/s10549-020-05573-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 02/07/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE BRCA1/2 mutations represent a high risk of breast cancer and are related to early-onset breast cancer. However, few studies have reported the relationship between BRCA1/2 mutations and their clinical characteristics in early-onset breast cancers. This study is the first article that characterizes the risk factor profiles in Chinese patients selected by the age of onset (≤ 40 years old). We found some differences in the prevalence of germline BRCA1/2 mutations between Asian and Western countries. METHODS A total of 1371 consecutive unselected Chinese early-onset breast cancer patients were enrolled from the Fujian Medical University Union Hospital, China, and screened for germline BRCA1/2 mutations. Full-exome sequencing in next-generation sequencing technology was performed in all patients to examine BRCA1/2 mutations. RESULTS In our study, 25 (1.8%) and 61 (4.4%) patients were identified with BRCA1 and BRCA2 mutations, respectively, among the unselected early-onset breast cancer patients. BRCA1 mutations were associated with pregnancies (p = 0.026), and BRCA1 carriers had a higher likelihood of being HR positive (p < 0.001), HER2 negative (p < 0.001), or high grade (p = 0.002) than noncarriers. Among BRCA2 mutations, the age of onset was younger in carriers than in noncarriers (p = 0.017), and BRCA2 carriers were more likely to have lymph node metastasis (p = 0.004). HR-positive or HER2-negative patients were likely to be positive for BRCA2 mutations (p < 0.001). Overall, 14 BRCA1 mutations and 8 BRCA2 mutations were first reported in our study CONCLUSION: This study provided some information about the spectrum of BRCA1/2 mutations and characterized the risk factors for early-onset breast cancer in China.
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Affiliation(s)
- Lili Chen
- Department of Breast Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Fangmeng Fu
- Department of Breast Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Meng Huang
- Fujian Center for Disease Control and Prevention, Fuzhou, China
| | - Jinxing Lv
- Department of Breast Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Wenzhe Zhang
- Department of Breast Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Chuan Wang
- Department of Breast Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, China.
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Germline Mutations in BRCA1 and BRCA2 in Breast Cancer Patients with High Genetic Risk in Turkish Population. Int J Breast Cancer 2019; 2019:9645147. [PMID: 30713775 PMCID: PMC6332947 DOI: 10.1155/2019/9645147] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 11/25/2018] [Indexed: 12/23/2022] Open
Abstract
Background The guidelines recommend considering the BRCA1 and BRCA2 germline mutations in female patients with breast carcinomas. In this retrospective study, the BRCA1/2 mutation prevalence in high-risk breast carcinoma patients in a Turkish population was investigated. Materials and Methods In high genetic risk breast carcinoma patients, the BRCA1 and BRCA2 germline mutations were identified by applying next-generation sequencing. Results The results showed BRCA1/2 mutations in 19% of the total patients. In those with first-degree relatives with breast carcinoma histories, the BRCA1/2 mutation prevalence was also 19%. In the patients younger than 40 years old, the BRCA1/2 mutation prevalence was 19.5%. In the triple-negative breast carcinoma patients younger than 60 years old, the BRCA1/2 mutation prevalence was 24.2%. In the patients younger than 40 years old with triple-negative breast carcinomas, BRCA1/2 mutation positivity was found in 37.5% of the patients. Overall, in the Turkish population, the BRCA1/2 mutation prevalence ranges from 19% to 37% in patients with high-risk breast carcinomas. Conclusion It is recommended to check for BRCA1/2 mutations in all high-risk breast carcinoma patients in the Turkish population.
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Augustinsson A, Ellberg C, Kristoffersson U, Borg Å, Olsson H. Accuracy of self-reported family history of cancer, mutation status and tumor characteristics in patients with early onset breast cancer. Acta Oncol 2018; 57:595-603. [PMID: 29164969 DOI: 10.1080/0284186x.2017.1404635] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND The main objectives of this study were to evaluate the concordance between self-reported and registry-reported information regarding family history of breast cancer (BC), ovarian cancer (OvC) and other types of cancer in first-degree relatives of patients with early onset BC, and to determine the frequency of mutation carriers and non-mutation carriers. The secondary objective was to describe tumor characteristics for each mutation group. MATERIAL AND METHODS Between 1993 and 2013, 231 women who were ≤35 years old when diagnosed with BC were registered at the Oncogenetic Clinic at Skåne University Hospital in Lund, Sweden. Self-reported and registry-reported information regarding first-degree family history of cancer was collected together with information regarding tumor characteristics. RESULTS Almost perfect agreement was observed between self-reported and registry-reported information regarding first-degree family history of BC (κ = 0.92) and OvC (κ = 0.86). Lesser agreement was observed between reports regarding family history of other types of cancer (κ = 0.51). Mutation screening revealed pathogenic germline mutations in 30.4%; 18.8% in BRCA1, 7.1% in BRCA2 and 4.5% in other genes. Compared with other mutation groups, BRCA1 mutation carriers were more likely to be diagnosed with high-grade, ER-, PR- and triple-negative tumors. CONCLUSIONS Our results demonstrate that physicians and genetic counselors can rely on self-reported information regarding BC and OvC in first-degree relatives. However, self-reported information regarding other types of cancer is not communicated as effectively, and there should be more focus on retrieving the correct information regarding family history of all tumor types. Furthermore, we observed that even though all BC patients fulfilled the criteria for genetic counseling and testing, a large number of patients diagnosed at ≤35 years of age did not receive genetic counseling at the Oncogenetic Clinic. This finding merits further elucidation.
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Affiliation(s)
- Annelie Augustinsson
- Department of Clinical Sciences in Lund, Oncology and Pathology, Lund University, Lund, Sweden
| | - Carolina Ellberg
- Department of Clinical Sciences in Lund, Oncology and Pathology, Lund University, Lund, Sweden
| | - Ulf Kristoffersson
- Department of Laboratory Medicine, Clinical Genetics, Lund University and University Hospital, Lund, Sweden
| | - Åke Borg
- Department of Clinical Sciences in Lund, Oncology and Pathology, Lund University, Lund, Sweden
| | - Håkan Olsson
- Department of Clinical Sciences in Lund, Oncology and Pathology, Lund University, Lund, Sweden
- Department of Clinical Sciences in Lund, Cancer Epidemiology, Lund University, Lund, Sweden
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Laitman Y, Feldman DM, Sklair-Levy M, Yosepovich A, Barshack-Nakar I, Brodsky M, Halshtok O, Shalmon A, Gotlieb M, Friedman E. Abnormal Findings Detected by Multi-modality Breast Imaging and Biopsy Results in a High-risk Clinic. Clin Breast Cancer 2018; 18:e695-e698. [PMID: 29292184 DOI: 10.1016/j.clbc.2017.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 12/04/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND High-risk BRCA mutation carriers are offered a surveillance scheme aimed at early detection of breast cancer. Although the efficacy of this scheme in breast cancer detection is well-established, the rate of breast cancer diagnosis of radiologically suspicious lesions and the effect of this screening scheme on breast cancer grade and stage are less well-defined. PATIENTS AND METHODS Female BRCA1 and BRCA2 mutation carriers who were cancer-free at the beginning of follow-up at the Meirav High-risk Clinic, Sheba Medical Center, were eligible. Radiological imaging data (mammography, ultrasound, magnetic resonance imaging, Breast Imaging Reporting and Data System scores), and histopathologic data on breast biopsies were retrieved. RESULTS Overall, 1055 women participated in the study; 760 (72%) were Ashkenazim, 661 (62.6%) were BRCA1 mutation carriers, the mean age at first visit was 44.1 ± 11.8 years, and there was a mean follow-up of 6.2 years. All participants underwent 6641 breast imaging tests: 2613 magnetic resonance imagings, 2662 breast ultrasounds, and 1366 mammograms. Overall, 295 biopsies were performed on 254 women: 82 (27%) biopsies on 79 women were diagnosed with breast cancer, including ductal carcinoma in situ: invasive breast cancer was diagnosed in 58 (70.7%), of whom 36 (62% of invasive cancer) were grade 3, and all but 10 were stage 1 to 2. Benign findings were noted in 213 biopsies performed on 175 women, with fibrocystic disease (n = 134; 62.9%) or fibroadenoma (n = 60; 28.16%) most commonly diagnosed. CONCLUSIONS Adherence to a breast cancer surveillance scheme enables breast cancer detection at an early stage but at advanced grade. Most biopsies (72%) performed in this high-risk clinic are benign.
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Affiliation(s)
- Yael Laitman
- Oncogenetics Unit, Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | | | - Miri Sklair-Levy
- Meirav High-risk Clinic, Chaim Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ady Yosepovich
- Department of Pathology, Chaim Sheba Medical Center, Tel-Hashomer, Israel; Breast Pathology Service, Chaim Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Iris Barshack-Nakar
- Department of Pathology, Chaim Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Malka Brodsky
- Meirav High-risk Clinic, Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - Osnat Halshtok
- Meirav High-risk Clinic, Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - Anat Shalmon
- Meirav High-risk Clinic, Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - Michael Gotlieb
- Meirav High-risk Clinic, Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - Eitan Friedman
- Oncogenetics Unit, Chaim Sheba Medical Center, Tel-Hashomer, Israel; Meirav High-risk Clinic, Chaim Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
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Kim JY, Moon HG, Kang YJ, Han W, Noh WC, Jung Y, Moon BI, Kang E, Park SS, Lee MH, Park BY, Lee JW, Noh DY. The Effect of Reproductive Factors on Breast Cancer Presentation in Women Who Are BRCA Mutation Carrier. J Breast Cancer 2017; 20:279-285. [PMID: 28970854 PMCID: PMC5620443 DOI: 10.4048/jbc.2017.20.3.279] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 06/08/2017] [Indexed: 11/30/2022] Open
Abstract
PURPOSE Germline mutations in the BRCA1 and BRCA2 genes confer increased risks for breast cancers. However, the clinical presentation of breast cancer among women who are carriers of the BRCA1 or BRCA2 (BRCA1/2 carriers) mutations is heterogenous. We aimed to identify the effects of the reproductive histories of women with the BRCA1/2 mutations on the clinical presentation of breast cancer. METHODS We retrospectively analyzed clinical data on women with proven BRCA1 and BRCA2 mutations who were recruited to the Korean Hereditary Breast Cancer study, from 2007 to 2014. RESULTS Among the 736 women who were BRCA1/2 mutation carriers, a total of 483 women had breast cancers. Breast cancer diagnosis occurred at significantly younger ages in women who experienced menarche at ≤14 years of age, compared to those who experienced menarche at >14 years of age (37.38±7.60 and 43.30±10.11, respectively, p<0.001). Additionally, the number of full-term pregnancies was significantly associated with the age of diagnosis, especially in women with the BRCA2 mutation. The prevalence of advanced stages (stage II or III vs. stage I) of disease in parous women was higher than in nulliparous women (68.5% vs. 55.2%, p=0.043). This association was more pronounced in women with the BRCA2 mutation (hazard ratio, 2.67; p=0.014). CONCLUSION Our results suggest that reproductive factors, such as the age of onset of menarche and the presence of parity, are associated with the clinical presentation patterns of breast cancer in BRCA1/2 mutation carriers.
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Affiliation(s)
- Ju-Yeon Kim
- Department of Surgery, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Hyeong-Gon Moon
- Department of Surgery, Laboratory of Breast Cancer Biology, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Young-Joon Kang
- Department of Surgery, Laboratory of Breast Cancer Biology, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Wonshik Han
- Department of Surgery, Laboratory of Breast Cancer Biology, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Woo-Chul Noh
- Department of Surgery, Korea Cancer Center Hospital, Korea Institute of Radiological & Medical Science, Seoul, Korea
| | - Yongsik Jung
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Byung-In Moon
- Department of Surgery, Ewha Womans University Hospital, Seoul, Korea
| | - Eunyoung Kang
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sung-Shin Park
- Department of Pathology, Daerim St. Mary's Hospital, Seoul, Korea
| | - Min Hyuk Lee
- Department of Surgery, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Bo Young Park
- Cancer Early Detection Branch, National Cancer Control Institute, National Cancer Center, Goyang, Korea
| | - Jong Won Lee
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Young Noh
- Department of Surgery, Laboratory of Breast Cancer Biology, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
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15
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Aksoy A, Odabas H, Kaya S, Bozkurt O, Degirmenci M, Topcu TO, Aytekin A, Arpaci E, Avci N, Pilanci KN, Cinkir HY, Bozkaya Y, Cirak Y, Gumus M. Hormone receptor status and survival of medullary breast cancer patients. A Turkish cohort. Saudi Med J 2017; 38:156-162. [PMID: 28133688 PMCID: PMC5329627 DOI: 10.15537/smj.2017.2.18055] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Objectives: To analyze the relationship between clinical features, hormonal receptor status, and survival in patients who were diagnosed with medullary breast cancer (MBC). Methods: Demographic characteristics, histopathological features, and survival statuses of 201 patients diagnosed with MBC between 1995 and 2015 were retrospectively recorded. Survival analyses were conducted with uni- and multivariate cox regression analysis. Results: Median follow-up time was 54 (4-272) months. Median patient age at the time of diagnosis was 47 years old (26-90). Of the patients, 91.5% were triple negative. Five-year recurrence free survival time (RFS) rate was 87.4% and overalll survival (OS) rate 95.7%. For RFS, progesterone receptor (PR) negativity, atypical histopathological evaluation, absence of lymphovascular invasion, smaller tumor, lower nodal involvement were found to be favourable prognostic factors by univariate analysis (p<0.05). The PR negativity and smaller tumor were found to be favourable factors by univariate analysis (p<0.05). However, none of these factors were determined as significant independent prognostic factors for OS (p>0.05). Conclusion: Turkish MBC patients exhibited good prognosis, which was comparable with survival outcomes achieved in the literature. The PR negativity was related to a better RFS and OS rates.
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Affiliation(s)
- Asude Aksoy
- Department of Medical Oncology, Medical Faculty, Firat University Elazig, Turkey. E-mail.
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16
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Teixeira N, Maistro S, Del Pilar Estevez Diz M, Mourits MJ, Oosterwijk JC, Folgueira MAK, de Bock GH. Predictability of BRCA1/2 mutation status in patients with ovarian cancer: How to select women for genetic testing in middle-income countries. Maturitas 2017; 105:113-118. [PMID: 28619461 DOI: 10.1016/j.maturitas.2017.06.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 05/22/2017] [Accepted: 06/01/2017] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To evaluate the accuracy of algorithms for predicting BRCA1/2 germ-line mutation carrier probability, and to identify factors that could improve their performance among Brazilian women with ovarian cancer (OC). STUDY DESIGN In this cross-sectional study, we enrolled patients (unselected for family history of cancer) undergoing treatment or follow-up for OC in a single centre in Brazil. Clinical and demographic data, including family history of cancer, were obtained. Blood samples were collected for genetic testing. MAIN OUTCOME MEASURES The entire coding sequence of BRCA1 and BRCA2 was evaluated for mutations. Mutation carrier probability was calculated using BOADICEA, BRCAPRO, Myriad and the Manchester score. Sensitivity, specificity, positive and negative predictive values, and area under the receiver operating characteristic curves (AUC) were calculated for each algorithm. Logistic regression was used to detect additional factors associated with BRCA1/2 status, and these were added to the algorithms before recalculating the AUCs. RESULTS BRCA1/2 mutations were identified in 19 of the 100 included patients. BOADICEA outperformed other algorithms (sensitivity, 73.7%; specificity, 87.7%; AUC, 0.87, with a threshold of a 10% risk of mutation). Later menarche was associated with the presence of a BRCA1/2 mutation. Although adding age at menarche resulted in a larger AUC for all models, this increase was significant only for the Myriad algorithm. CONCLUSION A BOADICEA risk evaluation of 10% or more most accurately predicted BRCA1/2 status, and the inclusion of age at menarche tended to improve the performance of all algorithms. Using these tools could reduce the number of tests, but at the expense of missing a significant proportion of mutation carriers.
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Affiliation(s)
- Natalia Teixeira
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands; Center of Translational Oncology Investigation (CTO), Instituto do Câncer do Estado de São Paulo, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.
| | - Simone Maistro
- Center of Translational Oncology Investigation (CTO), Instituto do Câncer do Estado de São Paulo, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Maria Del Pilar Estevez Diz
- Department of Clinical Oncology, Instituto do Câncer do Estado de São Paulo, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Marian J Mourits
- Department of Gynecologic Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jan C Oosterwijk
- Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Maria Aparecida Koike Folgueira
- Center of Translational Oncology Investigation (CTO), Instituto do Câncer do Estado de São Paulo, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Geertruida H de Bock
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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17
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O'Malley P, Mulla Z, Nesic O. Multiple sclerosis and breast cancer. J Neurol Sci 2015; 356:137-41. [DOI: 10.1016/j.jns.2015.06.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 05/30/2015] [Accepted: 06/13/2015] [Indexed: 02/09/2023]
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18
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Ribnikar D, Ribeiro JM, Pinto D, Sousa B, Pinto AC, Gomes E, Moser EC, Cardoso MJ, Cardoso F. Breast cancer under age 40: a different approach. Curr Treat Options Oncol 2015; 16:16. [PMID: 25796377 DOI: 10.1007/s11864-015-0334-8] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Breast cancer (BC) under age 40 is a complex disease to manage due to the additionally fertility-related factors to be taken in consideration. More than 90% of young patients with BC are symptomatic. Women<40 years are more likely to develop BC with worse clinicopathological features and more aggressive subtype. This has been frequently associated with inferior outcomes. Recently, the prognostic significance of age<40 has been shown to differ according to the BC subtype, being associated with worst recurrence-free survival (RFS) and overall survival (OS) for luminal BC. The biology of BC<40 has also been explored through analysis of large genomic data set, and specific pathways overexpressed in these tumors have been identified which can lead to the development of targeted therapy in the future. A multidisciplinary tumor board should determine the optimal locoregional and systemic management strategies for every individual patient with BC before the start of any therapy including surgery. This applies to both early (early breast cancer (EBC)) and advanced (advanced breast cancer (ABC)) disease, before the start of any therapy. Mastectomy even in young patients confers no overall survival advantage when compared to breast-conserving treatment (BCT), followed by radiotherapy. Regarding axillary approach, indications are identical to other age groups. Young age is one of the most important risk factors for local recurrence after both breast-conserving surgery (BCS) and mastectomy, associated with a higher risk of distant metastasis and death. Radiation after BCS reduces local recurrence from 19.5 to 10.2% in BC patients 40 years and younger. The indications for and the choice of systemic treatment for invasive BC (both early and advanced disease) should not be based on age alone but driven by the biological characteristics of the individual tumor (including hormone receptor status, human epidermal growth factor receptor 2 (HER-2) status, grade, and proliferative activity), disease stage, and patient's comorbidities. Recommendations regarding the use of genomic profiles such as MammaPrint, Oncotype Dx, and Genomic grade index in young women are similar to the general BC population. Especially in the metastatic setting, patient preferences should always be taken into account, as the disease is incurable. The best strategy for these patients is the inclusion into well-designed, independent, prospective randomized clinical trials. Metastatic disease should always be biopsied whenever feasible for histological confirmation and reassessment of biology. Endocrine therapy is the preferred option for hormone receptor-positive disease (HR+ve), even in presence of visceral metastases, unless there is concern or proof of endocrine resistance or there is a need for rapid disease response and/or symptom control. Recommendations for chemotherapy (CT) should not differ from those for older patients with the same characteristics of the metastatic disease and its extent. Young age by itself should not be an indication to prescribe more intensive and combination CT regimens over the sequential use of monotherapy. Poly(ADP-ribose) polymerase inhibitors (PARP inhibitors) represent an important group of promising drugs in managing patients with breast cancer susceptibility gene (BRCA)-1- or BRCA-2-associated BC. Specific age-related side effects of systemic treatment (e.g., menopausal symptoms, change in body image, bone morbidity, cognitive function impairment, fertility damage, sexual dysfunction) and the social impact of diagnosis and treatment (job discrimination, taking care for children) should also be carefully addressed when planning systemic long-lasting therapy, such as endocrine therapy. Survivorship concerns for young women are different compared to older women, including issues of fertility, preservation, and pregnancy.
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Affiliation(s)
- D Ribnikar
- Medical Oncology Department, Institute of Oncology Ljubljana, Ljubljana, Slovenia
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19
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Tang LC, Jin X, Yang HY, He M, Chang H, Shao ZM, Di GH. Luminal B subtype: a key factor for the worse prognosis of young breast cancer patients in China. BMC Cancer 2015; 15:201. [PMID: 25885213 PMCID: PMC4389816 DOI: 10.1186/s12885-015-1207-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 03/17/2015] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The prognoses of young breast cancer patients are poor. The purpose of this study is to evaluate the different characteristics and prognoses among different subtypes of young breast cancer patients. METHODS The study included 1360 patients <40 years-old (y) and 3110 patients 40-50y with operable breast cancer in Shanghai Cancer Center, Fudan University. The characteristics, overall survival (OS) and disease-free survival (DFS) were compared. RESULTS The median follow-up was 54.1 months. More grade III tumors and more lymph-vascular invasions (P < 0.01) were presented in <40y group when compared with 40-50y group. More patients <40y presented with Luminal B (25.3% vs. 17.5%, P < 0.01) and triple negative (16.7% vs. 13.4%, P < 0.05) breast cancer while fewer had Luminal A tumor (48.5% vs. 59.2%, P < 0.01). Younger patients with tumors of both Luminal A and Luminal B types were at increased risk for worse DFS (P = 0.03, HR = 1.69, 95% CI = 1.05-2.72; P < 0.01, HR = 3.61, 95% CI = 2.50-5.22) when compared with the older patients. Patients <40y with Luminal B tumor had a two point five fold higher risk of death compared with older counterparts (P < 0.01, HR = 2.54, 95% CI = 1.35-4.79), however, a worse overall survival rate was not observed in the younger women with Luminal A breast cancer (P > 0.05). In multivariate analysis, Luminal B subtype was also a strong predictor of disease relapse (HR = 1.09, 95% CI = 1.01 to 1.19, P < 0.01) in younger patients with Luminal subtype tumors. CONCLUSION Characteristics of breast cancer suggested a more aggressive biology in Chinese patients with breast cancer diagnosed at young age. Luminal B subtype may have a negative effect on the prognosis of young patients in China which should be validated further.
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Affiliation(s)
- Li-Chen Tang
- Department of Breast Surgery, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China.
| | - Xi Jin
- Department of Breast Surgery, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China.
| | - Hai-Yuan Yang
- Department of Breast Surgery, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China.
| | - Min He
- Department of Breast Surgery, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China.
| | - Helena Chang
- Department of Surgery, Revlon/UCLA Breast Canter, David Geffen School of Medicine, Los Angeles, CA, USA.
| | - Zhi-Ming Shao
- Department of Breast Surgery, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China.
| | - Gen-Hong Di
- Department of Breast Surgery, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China.
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Age-specific risk of breast cancer in women with neurofibromatosis type 1. Br J Cancer 2015; 112:1546-8. [PMID: 25742481 PMCID: PMC4453683 DOI: 10.1038/bjc.2015.78] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Revised: 01/12/2015] [Accepted: 01/27/2015] [Indexed: 12/23/2022] Open
Abstract
Background: Young women with neurofibromatosis type 1 (NF1) are reported to have a higher risk of breast cancer than others, and this might have implications for screening programmes. Our aim was to calculate this risk. Methods: An all-England linked data set of hospital admissions and deaths was analysed to determine age-specific rates of breast cancer in women with NF1 and controls. Results: The age-specific excess risk of breast cancer, comparing the NF1 cohort with the control cohort, was elevated 6.5-fold (95% confidence interval 2.6–13.5) in women aged 30–39 years. There was a 4.4 (2.5–7.0) times higher risk among women aged 40–49. Conclusions: Women with NF1 develop breast cancer at younger ages than the general population.
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