Early breast cancer in the older woman

Assessment of low-cost surgical metallic clip placement for tumor localization in BIRDAS VI breast cancer patients undergoing neoadjuvant chemotherapy

Background

Neoadjunvant chemotherapy has become a challenging connotation for both surgeons and radiologists due to the high clinical response up to dramatic pathological complete response (pCR) that may hinder proper localization of any residual tumoral tissue. So the radiopaque markers implantation at the tumor bed became a reliable and recommended method for tumor localization before surgical intervention or NAC. Many types of commercial clips and markers are available; however they are relatively of high cost and represent a considerable burden on the governments and the heath institute that made the researchers study cheaper alternatives as standard titanium based cholecystectomy surgical clips for tumor localization.

Results

The study was conducted on 45 patients where 57 clips were inserted corresponding to number of lesions found in the total number of the patients. The response to Neoadjunvant chemotherapy was recorded and showed that 6 patients (about 13.3%) had complete radiological response after NAC, while 27 patients (60%) had regressive course after the treatment. The low cost surgical clips were evaluated by using sono-mammography and magnetic resonance imaging, and complications that occurred were recorded. Our study showed that in only 2 patients (3.5%) there was difficulty in clip visualization by Ultrasound during post-treatment follow up. In 45 patients, all the inserted clips (100%) were well visualized as small signal void on MRI at both T1WIs and T2WIs sequences, and the primary malignancy was easily visualized on both MRI and sono-mammography not interfering with the image interpretation and judgment. As regards the reported complications, our results revealed that in only 2 patients (3.5%) there was evidence of positive clip migration, while only 2 patients (3.5%) developed hematoma during the procedure as shown by ultrasound, Also 4 patients (7%) complained of pain only shortly after clip insertion. No other significant complications like infection or heat sensation developed either during the procedure or during MRI. The total price of the surgical clips was calculated with average cost of the needle about 10 US$ equivalent to 170 LE Egyptian pounds and the clip about 1.3 US$ or 20 Egyptian pounds, which is considered of lower cost when compared to the commercial breast markers of different companies with an estimated price range for clip = 75–200 US$ (average 90 US$). So insertion of surgical clips saved about 1135 Egyptian pounds equivalent to 73–75 US$ per clip placement.

Conclusion

We concluded from our study that the use of breast markers are mandatory before NAC where Surgical clips can safely substitute the commercial tissue markers as tumor localizers as they are effective, safe, well tolerated, easily visualized on imaging and do not interfere with assessment of the treatment response, with no evidence of complications and are of low cost compared with the commercial breast clips.

Addressing Misinformation About the Canadian Breast Screening Guidelines

Screening mammography has been shown to reduce breast cancer mortality by 41% in screened women ages 40-69 years. There is misinformation about breast screening and the Canadian breast screening guidelines. This can decrease confidence in screening mammography and can lead to suboptimal recommendations. We review some of this misinformation to help radiologists and referring physicians navigate the varied international and provincial guidelines. We address the ages to start and stop breast screening. We explore how these recommendations may vary for specific populations such as patients who are at increased risk, transgender patients and minorities. We identify who would benefit from supplemental screening and review the available supplemental screening modalities including ultrasound, MRI, contrast-enhanced mammography and others. We describe emerging technologies including the potential use of artificial intelligence for breast screening. We provide background on why screening policies vary across the country between provinces and territories. This review is intended to help radiologists and referring physicians understand and navigate the varied international and provincial recommendations and guidelines and make the best recommendations for their patients.

Adjuvant Treatment of Elderly Breast Cancer Patients: Offer the Best Chances of Cure

Background

Breast cancer remains the most common cancer in women and a leading cause of death. Elderly people have a higher incidence of breast cancer since it increases with age. Furthermore, the extended life expectancy and advances in imaging techniques have led to an increased number of cases. Guidelines concerning the management of this specific age group are rare, mainly due to underrepresentation of seniors in clinical trials. Moreover, increased frailty, comorbidities, and a poor performance status make it complex to determine the best therapeutic approach.

Summary

In this review, we attempt to summarize the current literature and aim to provide specific approaches and recommendations for prompt diagnosis, treatment, and management of breast cancer in the elderly.

Key Messages

The establishment of applicable protocols is imperative and efforts are being made in this direction. A careful geriatric assessment and adequate consultation should be the standard of care and patient's preferences should always be considered.

Classification of mammographic breast density and its correlation with BI-RADS in elder women using machine learning approach

INTRODUCTION

Mammographic breast density (MBD) is a known risk factor for breast cancer and older women have higher incidence rates of breast cancer occurrence. The Breast Imaging Reporting and Data System (BI-RADS) is a commonly used MBD classification tool for mammogram reporting. However, they have limitations since there are reading inconsistencies between different radiologists with the visual assessment of breast density.

METHODS

Digitised film-screen mammographic images were extracted from the Digital Database for Screening Mammography (DDSM). A machine learning project was developed using commercially available software with several predictive models applied to classify different amount of MBD on mammograms into different density groups. The effectiveness of different predictive models used in classifying the mammograms were tested by receiver operator characteristics (ROC) curve with comparison to the gold standard of BI-RADS classification.

RESULTS

Three predictive models, Decision Tree (Tree), Support Vector Model (SVM) and k-Nearest Neighbour (kNN) showed high AUC values of 0.801, 0.805 and 0.810 respectively. High AUC values for the three predictive models indicates that the accuracy of the model is approaching that of the BI-RADS method.

DISCUSSION

Our machine learning project showed to have capabilities to be potentially used in the clinical settings to help categorise mammograms into extremely dense breasts (BI-RADS Group A) from entirely fatty breasts (BI-RADS Group D).

CONCLUSION

Findings from the present study suggest that the machine learning method is potentially useful to quantify the amount of MBD in mammograms.

Practical consensus recommendations regarding the management of hormone receptor positive early breast cancer in elderly women

Breast cancer is a leading cause of death among women, and its incidence increases with age. Currently the treatment of breast cancer in older patients is almost identical to their younger counterparts. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at these practical consensus recommendations for the benefit of community oncologists regarding the management of early breast cancer specifically in elderly women.

Could lymph node evaluation be eliminated in nearly 50% of women with early stage ER/PR positive breast cancer?

BACKGROUND

The Society of Surgical Oncology introduced guidance discouraging routine axillary staging in women 70 years or older with invasive, clinically node negative, hormone-receptor positive breast cancer. Due to concerns this could result in patients missing necessary treatment, researchers from the Mayo Clinic developed a rule to distinguish between those at low/high-risk of having positive nodes. The purpose of this study was to validate the Mayo Clinic rule in women of all ages.

METHODS

A retrospective review was conducted on patients seen in one breast surgeon's practice from January 1, 2006 through March 1, 2018. The Mayo Clinic rule was applied, and accuracy was evaluated.

RESULTS

Utilizing the Mayo Clinic rule, 46.8% (n = 289) of women met low-risk criteria. Unexpected positive lymph nodes in low-risk women was 10.0% (n = 29), which was similar to the Mayo Clinic study finding (7.8%, P = 0.167).

CONCLUSIONS

These data suggest the Mayo Clinic rule is reproducible. Nearly 50% of women with hormone receptor positive breast cancer could avoid axillary staging, but about 10% will have unexpected positive lymph nodes.

Effectiveness of Population-Based Service Screening with Mammography for Women Aged 70-74 Years in Sweden

BACKGROUND

Consensus has been reached on the effectiveness of inviting women aged 50 to 69 years to mammography screening, but for older women, the evidence is scarce. The aim of this study was to estimate the marginal effectiveness of inviting women to mammography screening with an upper age limit of 74 years versus stopping at age 69 using data from the Swedish service-screening program.

METHODS

A cohort design was used to compare the breast cancer mortality in the period 1986 to 2012 between geographic areas and periods where women were invited to screening up to the age of 74 years (study group) with those where women were invited up to age 69 (control group). The study group and the control group were compared using the incidence-based breast cancer mortality rate ratio where only breast cancer deaths in cases diagnosed at 70 to 74 years of age were counted.

RESULTS

After 20 years of follow-up, there were 1,040 and 1,173 breast cancer deaths in the study and the control group, respectively. The breast cancer mortality rate ratio for women invited up to age 74 versus women invited up to age 69 was 0.80 [95% confidence interval (CI): 0.75-0.85] after bias adjustments. The corresponding rate ratio for participating women was 0.73 (95% CI: 0.66-0.81).

CONCLUSIONS

Continuing to screen women up to 74 years of age is effective compared with stopping screening at 69 years.

IMPACT

This large long-term study will add to the knowledge of the effect of mammography screening for women 70 to 74 years.

Age-related disparities in older women with breast cancer

Improvements in breast cancer (BC) mortality rates have not been seen in the older adult community, and the fact that older adults are more likely to die from their cancer than younger women establishes a major health disparity. Studies have identified that despite typically presenting with more favorable histology, older women present with more advanced disease, which may be related in part to delayed diagnosis. This is supported by examination of screening practices in older adults. Older women have a worse prognosis than younger women in both early stage disease, and more advanced and metastatic disease. Focus on the treatment of older adults has often concentrated on avoiding overtreatment, but in fact undertreatment may be one reason for the age-related differences in outcomes, and treatments need to be individualized for every older adult, and take into account patient preferences and functional status and not chronologic age alone. Given the aging population in the US, identifying methods to improve early diagnosis in this population and identify additional factors will be important to reducing this age-related disparity.

Inflammation, immunosuppressive microenvironment and breast cancer: opportunities for cancer prevention and therapy

Breast cancer is the most commonly diagnosed malignancy and a leading cause of cancer-related death in women worldwide. It also exhibits pronounced racial disparities in terms of incidence and clinical outcomes. There has been a growing interest in research community to better understand the role of the microenvironment in cancer. Several lines of evidence have highlighted the significance of chronic inflammation at the local and/or systemic level in breast tumor pathobiology. Inflammation can influence breast cancer progression, metastasis and therapeutic outcome by establishing a tumor supportive immune microenvironment. These processes are mediated through a variety of cytokines and hormones that exert their biological actions either locally or distantly via systemic circulation. Targeting of immune and inflammatory pathways has met tremendous success in some cancers underscoring the importance of research to further our understanding of these systems in breast cancer. This knowledge can be helpful not only in the development of novel prevention and therapeutic strategies, but also help in better prediction of therapeutic responses in patients. This review summarizes some of the significant findings on the role of inflammation in breast cancer to gain collective molecular and mechanistic insights. We also discuss ongoing efforts and future outlook to exploit the existing knowledge for improved breast cancer management.

The role of radiotherapy in metaplastic breast cancer: a propensity score-matched analysis of the SEER database

BACKGROUND

Only few studies, with small patient cohorts, have evaluated the effect of radiotherapy (RT) for metaplastic breast cancer (MBC). Hence, it is important to investigate the role of RT in MBC survival using a large population-database.

METHODS

A retrospective cohort study using the Surveillance, Epidemiology, and End Results (SEER) from 1973 to 2015 was performed. We compared MBC patients with or without RT for overall survival (OS) and breast cancer-specific survival (BCSS) using univariate and multivariate Cox proportional hazard regressions before and after propensity score matching (PSM).

RESULTS

From a total of 2267 patients diagnosed with MBC between 1998 and 2015, 1086 (47.9%) received RT. In the multivariate analysis before PSM, RT provided a better OS (HR 0.73; 95% CI 0.61-0.88; p = 0.001) and BCSS (HR 0.71; 95% CI 0.58-0.88; p = 0.002). Multivariate analyses after PSM (n = 1066) confirmed that patients receiving RT (n = 506) survived longer than those without RT (OS, HR 0.64; 95% CI 0.51-0.80; p < 0.001 and BCSS, HR 0.64; 95% CI 0.50-0.83; p = 0.001). A longer OS was observed when RT was given to older patients (p = 0.001) and in case of large tumor size (p = 0.002). Intriguingly, patients with N0 stage showed better OS after RT (HR 0.69, P = 0.012).

CONCLUSIONS

Our findings support the beneficial effect of RT for MBC patients. In particular, older patients or with large tumor size have a greater survival benefit from RT. In conclusion, we have assessed the importance of the use of RT in MBC as survival factor and this could lead to the development of guidelines for this rare sub-type of tumors.

Overall survival of elderly patients with breast cancer is not related to breast-cancer specific survival: A single institution experience in Japan

BACKGROUND

As the aging population grows, the number of elderly breast cancer patients has rapidly increased especially in Japan; a suitable treatment for elderly patients, considering chronic comorbidities and treatment tolerance, is urgently needed.

METHODS

In this retrospective study, 286 elderly breast cancer patients were investigated. Tumor characteristics and survival outcome were compared between 70-79-year-old and ≥ 80-year-old groups. Disease-free survival, overall survival, and breast cancer-specific survival were compared, and the effect of variables was analyzed statistically. For resectable cases, prognoses were compared based on treatment (standard therapy or undertreated).

RESULTS

Tumor characteristics were similar between groups, but the Ki-67 labeling index tended to be higher in older patients. Elderly patients with resectable cancer tended to be undertreated. During the median 59-month follow-up period, overall survival was significantly worse in the ≥80-year-old than in the 70-79-year-old group (p < 0.001), but disease-free and breast cancer-specific survivals were equivalent. Recurrence or death event hazard rates tended to be lower in patients receiving standard treatment.

CONCLUSIONS

Standard multidisciplinary treatment for breast cancer prevents recurrence and metastasis and tends to extend breast cancer-specific survival even in elderly patients.

Comorbid conditions and health-related quality of life in long-term cancer survivors-associations with demographic and medical characteristics

PURPOSE

Our study provides a detailed overview of comorbid conditions and health-related quality of life of long-term cancer survivors and analyses the impact of demographic, disease- and treatment-related characteristics.

METHODS

We present data obtained from 1000 survivors across mixed tumour entities 5 and 10 years after cancer diagnosis in a cross-sectional study. We analyse the prevalence of physical symptoms and health conditions via self-report and health-related quality of life using the EORTC QLQ-C30 in comparison to gender- and age-matched reference values of the general population.

RESULTS

Cancer survivors reported on average 5 comorbidities; 23% had 7 or more comorbid conditions. Cancer survivors reported higher physical symptom burden than the population-especially fatigue, insomnia and pain. Type and prevalence of long-term and late effects differ with disease-related factors (e.g. cancer type, treatment) and characteristics of the patient. Cancer survivors also reported lower quality of life than the population, especially in everyday activities, social life, psychological well-being and financial difficulties. There was a positive association between high quality of life and a low level of morbidity.

CONCLUSIONS

The specific knowledge about physical long-term consequences for the individual types of cancer could raise awareness in health care professionals for high-risk patients and help to develop adequate prevention and survivorship-programs.

IMPLICATIONS FOR CANCER SURVIVORS

Limitations in the mental health area underlines the importance of psycho-oncological survivorship-care-plans, which go beyond the time of rehabilitation. Special attention should be given to the financial situation of patients in long-term follow-up care.

The Relationship of Age and Postoperative Pain in Women after Surgery for Breast Cancer

BACKGROUND

In the past, elderly women with breast cancer were not offered surgery because of beliefs that they would experience serious complications from comorbidities and increased chronological age. Today the decision to offer surgery is based on a woman's fitness rather than her age.

OBJECTIVE

The purpose of this study is to compare the experience of postoperative nausea and vomiting (PONV), anxiety, and reported pain levels in women who represent four different age groups after breast cancer surgery. This study employed a prospective comparative design. A large women's hospital which houses a Comprehensive Breast Care Program. Women diagnosed with early stage breast cancer and scheduled for surgical resection.

METHODS

Postoperative pain was measured in the postanesthesia care unit using an 11-point verbal pain scale, PONV was measured categorically, and if present, severity of nausea was assessed. Anxiety was measured preoperatively by the short-form Profile of Mood States.

FINDINGS

A total of 97 women aged 37-78 participated in this study. Overall, 35% of all women experienced PONV; only two women (18%) in the highest age range (70-79) experienced PONV, yet they reported significantly more pain than women in the other age groups. Understanding the difference in postoperative symptoms experienced by older woman after surgery for breast cancer will support the development of age-specific strategies.

Management of Cancer in the Older Age Person: An Approach to Complex Medical Decisions

The management of cancer in older aged people is becoming a common problem due to the aging of the population. There are many variables determining the complex situation that are interconnected. Some of them can be assessed, such as risk of mortality and risk of treatment complications, but many others are still unknown, such as the course of disease, the host-related factors that influence cancer aggressiveness, and the phenotype heralding risk of permanent treatment-related damage.This article presents a dynamic and personalized approach to older people with cancer based on our experience on aging, cancer, and their biological interactions. Also, novel treatments and management approaches to older individuals, based on their functional age and their social and emotional needs, are thoughtfully explored here. The Oncologist 2017;22:335-342 IMPLICATIONS FOR PRACTICE: The goal of this article is to suggest a practical approach to complexity, a clinical situation becoming increasingly common with the aging of the population. Beginning with the analysis of two clinical cases, the authors offer an algorithm for approaching cancer in the older person that involves the assessment of life expectancy without cancer, the risk that cancer might compromise a patient's survival, function, or quality of life, and the potential benefits and risks of the treatments based on a clinical evaluation. The authors then review possible laboratory assessment of functional age and the importance of rapid-learning databases in the study of cancer and age.

High expression levels of miR-21 and miR-210 predict unfavorable survival in breast cancer: a systemic review and meta-analysis

BACKGROUND

MicroRNAs (miRNAs) have been emerging as valuable prognostic biomarkers of breast cancer. We therefore summarized recent research into miRNAs involved in human breast cancer and, further, completed a meta-analysis to predict the role of specific miRNAs in the survival of breast cancer patients.

METHODS

Studies were identified by searching PubMed, Embase and Web of Science. Descriptive characteristics for studies were described, and an additional meta-analysis for specific miRNAs was performed. Pooled hazard ratios (HRs) and their corresponding 95% confidence intervals (CIs) were calculated.

RESULTS

A total of 41 articles including 27 types of miRNAs were found regarding prognostic biomarkers for breast cancer survival, of which, micRNA-21 (miR-21) was the most-studied specific miRNA that appeared repeatedly among the selected classifiers. For the studies evaluating miR-21's association with clinical outcomes, the median HR in the studies was 2.32 (interquartile range [IQR] = 1.04-3.40), and the pooled HR suggested that high expression of miR-21 has a negative impact on overall survival (OS; HR = 1.46, 95% CI, 1.25-1.70; p<0.05) and disease/recurrence-free survival in breast cancer (HR = 1.49, 95% CI, 1.17-1.90; p<0.01). We also found that higher expression levels of miR-210 significantly predicted poorer outcome, with median HR in the reported studies of 4.07 (IQR = 1.54-4.43) and a pooled HR of 2.94 (95% CI, 2.08-4.17; p<0.05).

CONCLUSIONS

These results indicate that miRNAs show promising associations with prognosis in breast cancer. Moreover, specific miRNAs such as miR-21 and miR-210 can predict poor survival rates in breast cancer patients.

High expression of miR-210 predicts poor survival in patients with breast cancer: a meta-analysis

BACKGROUND

Many microRNAs (miRNAs) exhibit altered expression levels in cancers, and they may be considered as valuable prognostic biomarkers for cancers. Here we aimed to summarize the recent advances in miR-210 involvement in human breast cancer and analyze the predicting role of miR-210 for survival.

METHODS

A meta-analysis was performed by searching PubMed, Cochrane Library, and Science Direct databases. Data were extracted from studies comparing survival in patients with breast cancer having higher expression of miR-210 with those having lower expression. Pooled hazard ratios (HRs) and 95% confidence intervals (CI) were calculated.

RESULTS

A total of 511 cases of breast cancer were involved for this global meta-analysis. For post-operational survival, the HR of higher miR-210 expression in breast cancer tissue was 3.39 (95% CI: 2.04-5.63, P<0.05), which could significantly predict poorer survival.

CONCLUSIONS

High expression of miR-210 might predict poor survival in patients with breast cancer.