Review of Factors Influencing Women's Choice of Mastectomy Versus Breast Conserving Therapy in Early Stage Breast Cancer: A Systematic Review

Long-term local control and cosmesis of perioperative interstitial brachytherapy for partial breast irradiation following breast-conserving surgery

PURPOSE

Multicatheter interstitial brachytherapy (MIB) is an established technique of partial breast irradiation (PBI). However, postoperative catheter implant is an invasive, inconvenient, and skillful procedure. In this study, local control and cosmesis of perioperative interstitial brachytherapy (PIB) by intraoperative catheter implant were evaluated by comparing with those of whole breast irradiation (WBI) following breast-conserving surgery (BCS).

METHODS

Between October 2007 and August 2019, consequent patients who underwent either PIB or WBI following BCS were included. In general, additional indications for PIB to WBI included age ≥ 40 years, tumor ≤ 3 cm, and pN0 or pNmi. WBI was initiated with a total dose of 50 Gy in 25 fractions, whereas PBI was delivered immediately following BCS at 32 Gy in eight fractions. Local recurrence (LR) was the primary endpoint, and subjective and objective cosmetic outcomes at 5 years using the Harvard Cosmesis Scale and BCCT.core software, respectively, were the secondary endpoints.

RESULTS

During the 10-year follow-up, the crude rate of LR was 3.8% (95% confidence interval [CI] 2.3-5.4) in 577 patients receiving PIB and 3.3% (95% CI 1.1-5.6) in 241 patients receiving WBI (P = 0.73). The 5- and 10-year LR-free survival rates in the PBI and WBI cohorts were 97.9% versus 97.9% and 95.4% versus 96.8%, respectively (P = 0.64). Multivariate analysis selected age < 50 years as an independent risk factor for LR. Excellent or good cosmesis in the PBI and WBI cohorts assessed by subjective and objective measures was 89.5% versus 84.5% (P = 0.26) and 83.7% versus 68.1% (P < 0.005), respectively.

CONCLUSIONS

Although this study was based on a retrospective chart review in a single institution, the largest series of data with a long follow-up suggested that acceptable local tumor control and cosmesis were achieved following PIB compared with WBI.

Racial and ethnic disparities in conversion to mastectomy following lumpectomy

PURPOSE

Advances in contemporary breast cancer care (e.g., early detection, increased use of preoperative chemotherapy, and updated SSO-ASTRO margin guidelines) have the collective potential to influence successful breast conservation. We evaluated contemporary trends in conversion to mastectomy (lumpectomy followed by definitive mastectomy) among women with breast cancer undergoing initial lumpectomy.

METHODS

Women with unilateral clinical stage 0-III breast cancer were identified from the National Cancer Database (2009-2019). Treatment sequence was categorized into surgery first or neoadjuvant chemotherapy (NACT) followed by surgery. We used a multivariable logistic regression model to calculate the predicted probability of conversion to mastectomy across diagnosis year and race and ethnicity, controlling for socio-demographic and clinical factors. We then calculated the relative change in conversion to mastectomy over time for each race and ethnic group.

RESULTS

The study included N = 1,543,702 women. Approximately 9.2% received NACT. Conversion to mastectomy differed significantly between those who underwent surgery first (10.6%) versus women who received NACT (6.1%, p < 0.0001). For those who underwent surgery first, success of breast conservation differed significantly by race/ethnicity. During the study period, White women had a relative decrease of 7.6% (95% CI - 10.58, - 4.59), while Black women had a relative increase of 8.9% (95% CI 1.53, 16.19) in predicted probability of conversion to mastectomy.

CONCLUSION

Over the past decade, Black women deemed candidates for initial lumpectomy were more likely to be converted to mastectomy when compared to White women. A greater understanding of contributing factors is needed to improve disparities in successful breast conservation.

Socioeconomic inequalities in waiting times for breast cancer surgery

Prompt access to cancer care is a policy priority in several OECD countries, because delayed access can exacerbate deleterious health outcomes. Access to care based on need remains a key pillar of publicly-funded health systems. This study tests for the presence of inequalities in waiting times by socioeconomic status for patients receiving breast cancer surgery (mastectomy or breast conserving surgery) in England using the Hospital Episode Statistics. We investigate separately the pre-COVID-19 period (April 2015-January 2020), and the COVID-19 period (February 2020-March 2022). We use linear regression models to study the association between waiting times and income deprivation measured at the patient's area of residence. We control for demographic factors, type and number of comorbidities, past emergency admissions and Healthcare Resource Groups, and supply-level factors through hospital fixed effects. In the pre-COVID-19 period, we do not find statistically significant associations between income deprivation in the patient's area of residence and waiting times for surgery. In the COVID-19 period, we find that patients living in the most deprived areas have longer waiting times by 0.7 days (given a mean waiting time of 20.6 days).

Dose constraints in breast cancer radiotherapy. A critical review

Radiotherapy plays an essential role in the treatment of breast cancer (BC). Recent advances in treatment technology and radiobiological knowledge have a major impact in BC patients with locoregional disease as the majority are now long-term survivors. Over the last three decades, intensity-modulated radiotherapy (IMRT), volumetric-modulated arc therapy (VMAT) and deep inspiration breath-hold (DIBH) techniques, together with the increasing adoption of moderately hypofractionated and ultra-hypofractionated treatment schedules as well as the possibility to offer partial breast radiotherapy to a well-defined patient subset have significantly changed radiotherapy for BC patients. As dose-volume constraints (DVCs) have to be adapted to these new treatment paradigms we have reviewed available evidence-based data concerning dose-constraints for the main organs at risk (OARs) that apply to the treatment of whole breast/chest wall radiotherapy, whole breast/chest wall radiotherapy including regional nodal irradiation (RNI) and partial breast irradiation (PBI), for the most relevant fractionation schedules that have been introduced recently. This narrative review provides a comprehensive summary that may help to harmonize treatment planning strategies.

Potential of MRI in Assessing Treatment Response After Neoadjuvant Radiation Therapy Treatment in Breast Cancer Patients: A Scoping Review

The objective of this scoping review is to evaluate the potential of Magnetic Resonance Imaging (MRI) and to determine which of the available MRI techniques reported in the literature are the most promising for assessing treatment response in breast cancer patients following neoadjuvant radiotherapy (NRT). Ovid Medline, Embase, CINAHL, and Cochrane databases were searched to identify relevant studies published from inception until March 13, 2023. After primary selection, 2 reviewers evaluated each study using a standardized data extraction template, guided by set inclusion and exclusion criteria. A total of 5 eligible studies were selected. The positive and negative predictive values for MRI predicting pathological complete response across the studies were 67% to 88% and 76% to 85%, respectively. MRI's potential in assessing postradiotherapy tumor sizes was greater for volume measurements than uni-dimensional longest diameter measurements; however, overestimation in surgical tumor sizes was observed. Apparent diffusion coefficient (ADC) values and Time to Enhance (TTE) was seen to increase post-NRT, with a notable difference between responders and nonresponders at 6 months, indicating a potential role in assessing treatment response. In conclusion, this review highlights tumor volume measurements, ADC, and TTE as promising MRI metrics for assessing treatment response post-NRT in breast cancer. However, further research with larger cohorts is needed to confirm their utility. If MRI can accurately identify responders from nonresponders to NRT, it could enable a more personalized and tailored treatment approach, potentially minimizing radiation therapy related toxicity and enhancing cosmetic outcomes.

The Role of Residential Segregation in Treatment and Outcomes of Ductal Carcinoma In Situ of the Breast

BACKGROUND

It remains unclear whether residential segregation impacts on clinical treatment and outcomes for ductal carcinoma in situ (DCIS), a nonobligate precursor to invasive breast cancer (IBC).

METHODS

This population-based retrospective cohort study included adult non-Hispanic White and Black women diagnosed with unilateral DCIS between January 1990 and December 2015, followed through December 2016, and identified from the Surveillance, Epidemiology, and End Results dataset. County-level racialized economic segregation was measured using the Index of Concentration at the Extremes. Multilevel logistic regression and Cox proportional hazards regression accounting for county-level clustering were used to estimate the ORs of local treatment and HRs of subsequent IBC and mortality.

RESULTS

Of 103,898 cases, mean age was 59.5 years, 12.5% were non-Hispanic Black, 87.5% were non-Hispanic White, 97.5% underwent surgery, 64.5% received radiotherapy following breast-conserving surgery (BCS), 7.1% developed IBC, and 18.6% died from all causes. Among women living in the least versus most privileged counties, we observed higher odds of receiving mastectomy [vs. BCS; OR = 1.51; 95% confidence interval (CI), 1.35-1.69; Ptrend < 0.001] and radiotherapy following BCS(OR = 1.27; 95% CI, 1.07-1.51; Ptrend < 0.01); the risk was higher in subsequent ipsilateral IBC (HR = 1.16; 95% CI, 1.02-1.32; Ptrend = 0.04), not in breast cancer-specific mortality (HR = 1.04; 95% CI, 0.88-1.23; Ptrend = 0.56).

CONCLUSIONS

The results provide evidence for disparities in clinical treatment for DCIS and prognostic outcomes among women in racially and economically segregated counties.

IMPACT

Our findings may inform geographically targeted multilevel interventions to reduce breast cancer burden and improve breast cancer care and equity.

Emotional Reactivity and Regulation Relate to Surgical Treatment Decision Making Among Newly Diagnosed Women With Breast Cancer

BACKGROUND

Despite bilateral mastectomy (BLM) for early-stage breast cancer (BC) showing no survival benefit and increased risk compared to breast conserving surgery, some patients still choose this treatment. This study examined whether emotion reactivity and regulation influence treatment decision making among newly diagnosed women with breast cancer.

METHODS

Cross-sectional survey data were analyzed as part of a larger study. Measures included the Contralateral Prophylactic Mastectomy (CPM) survey, PROMIS Anxiety scale, and Emotion Regulation Questionnaire (ERQ) Cognitive Reappraisal and Emotional Suppression subscales. Primary analysis included a logistic regression model predicting treatment choice (BLM vs. non-BLM).

RESULTS

Participants (N = 137) with unilateral BC (Stages 0-III) were divided between BLM (n = 66) versus breast conserving surgery (i.e., non-BLM, n = 71) treatment groups. Compared to the non-BLM group, the BLM group was younger, more likely to be partnered, and had a higher household income. Women with high levels of BC-specific worry were 3.6 times more likely to choose BLM compared to women with low levels of worry (OR = 3.09, 95% CI: 1.07-0.8.93). Those who used cognitive reappraisal were 10% less likely to choose BLM compared to women who did not use cognitive reappraisal (OR = 0.90, 95% CI: 0.82-0.99). There were no group differences in levels of generalized anxiety (OR = 0.93, 95% CI: 0.87-0.99) or emotional suppression (OR = 1.02, 95% CI: 0.90-1.16).

CONCLUSIONS

Findings suggest the choice of BLM may be due, in part, to negative emotional experiences after a BC diagnosis and lesser use of reappraisal to reframe cancer-related fears. These may be important targets of intervention to support women making BC treatment decisions.

Quality of life and its predictors among breast cancer patients treated with surgery-a retrospective minimum 3-year follow-up study

Aim

Quality of life (QoL) has been identified as an important indicator of positive outcomes among breast cancer (BC) survivors. However, the status and predictors of QoL in China remain unclear. This retrospective follow-up study aimed to examine the QoL levels among BC patients following surgery and to assess the influence of sociodemographic, clinical, and psychological factors on QoL.

Methods

An institution-based retrospective follow-up study was conducted among 714 BC patients who received surgery at the First Affiliated Hospital of Guangxi Medical University between January 2016 and December 2019. Our primary outcome measure was QoL, assessed using the European Organization for Research and Treatment of Cancer QoL Questionnaire Core 30 (EORTC QLQ-C30). Anxiety and depression were evaluated by the Self-Rating Anxiety Scale (SAS) and the Self-Rating Depression Scale (SDS), respectively. Data on the patient demographics and clinical were derived from medical records. Results are presented as means (SD), medians [Q1, Q3], or percentage (%). We used R 4.2.2 software to identify factors associated with QoL after BC surgery. AMOS 28.0 was used to construct a structural equation model (SEM) to predict QoL outcomes.

Results

The overall QoL score was 43.30 ± 4.77 (mean ± SD). Predictive factors were: surgery type, radiotherapy, anxiety, and depression (p<0.05). The results of the SEM indicated that anxiety and depression had a direct negative effect on QoL (effect value was -0.46, -0.84, respectively, p<0.05), radiotherapy had a direct positive effect on QoL (effect value was 0.71, p<0.05). The type of surgery (mastectomy) impacted QoL both directly and indirectly through its association with depression, with direct and indirect effect values of -0.96 and -0.66, respectively (p < 0.05).

Conclusion

The QoL of BC patients after surgery is generally moderate to low. Medical staff should prioritize early identification and rehabilitation management for patients experiencing anxiety, depression, radiotherapy, and mastectomy to enhance their QoL. Our findings provide a strong foundation for developing nursing intervention plans and assessment guidelines for practitioners caring for BC patients.

Performance of an AI-powered visualization software platform for precision surgery in breast cancer patients

Surgery remains the primary treatment modality in the management of early-stage invasive breast cancer. Artificial intelligence (AI)-powered visualization platforms offer the compelling potential to aid surgeons in evaluating the tumor's location and morphology within the breast and accordingly optimize their surgical approach. We sought to validate an AI platform that employs dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) to render three-dimensional (3D) representations of the tumor and 5 additional chest tissues, offering clear visualizations as well as functionalities for quantifying tumor morphology, tumor-to-landmark structure distances, excision volumes, and approximate surgical margins. This retrospective study assessed the visualization platform's performance on 100 cases with ground-truth labels vetted by 2 breast-specialized radiologists. We assessed features including automatic AI-generated clinical metrics (e.g., tumor dimensions) as well as visualization tools including convex hulls at desired margins around the tumor to help visualize lumpectomy volume. The statistical performance of the platform's automated features was robust and within the range of inter-radiologist variability. These detailed 3D tumor and surrounding multi-tissue depictions offer both qualitative and quantitative comprehension of cancer topology and may aid in formulating an optimal surgical approach for breast cancer treatment. We further establish the framework for broader data integration into the platform to enhance precision cancer care.

Magnetic resonance imaging-guided single-fraction preoperative radiotherapy for early-stage breast cancer (the RICE trial): feasibility study

BACKGROUND

Over the past decade, the adoption of screening programs, digital mammography, and magnetic resonance imaging (MRI) has increased early-stage breast cancer diagnosis rates. Mortality rates have decreased due to early detection and improved treatments, including personalized therapies. Accelerated partial-breast irradiation (APBI) is emerging as a convenient and effective treatment for some patients, with studies exploring its preoperative use. Preoperative APBI, especially with MRI guidance, offers improved tumor targeting and potentially reduced side effects. Magnetic Resonance Imaging-Guided Single-Fraction Pre-Operative Radiotherapy for Early-Stage Breast Cancer (RICE trial) aims to assess the feasibility and efficacy of MRI-guided single-dose radiotherapy (RT) for early-stage breast cancer.

METHODS

The RICE study is a prospective, single-arm study evaluating single-fraction preoperative, APBI treatment for patients with early-stage breast cancer using a magnetic resonance imaging linear accelerator (MRI linac). Eligible patients enrolled in this study will have a core biopsy to confirm estrogen receptor-positive and HER2-negative sub-type. RT planning will use a planning computed tomography (CT) co-registered with a MRI with the patient in either the supine or prone position. For the diagnostic workup, [18F] fluorodeoxyglucose positron emission tomography/CT ([18F] FDG PET/CT) and [18F] fluoroestradiol positron emission tomography/CT ([18F] FES PET/CT) will be performed prior to treatment. Thirty patients will receive a single ablative RT dose of 21 Gray to the tumor. Pre-treatment and post-treatment MRI scans will be acquired at baseline and 5 weeks post-RT respectively. Breast-conserving surgery will be scheduled for 6 weeks after APBI treatment using the MRI linac. The primary study endpoint is the successful administration of a single fraction of preoperative breast RT under the guidance of an MRI linac. Secondary endpoints include evaluating the utility of MRI, [18F] FDG PET/CT, and [18F] FES PET/CT as a non-invasive method for assessing treatment response in patients undergoing single-fraction preoperative APBI.

CONCLUSION

The RICE trial represents a significant step in breast cancer treatment, offering insights that could lead to treatment protocols with minimized RT appointments and enhanced patient outcomes.

TRIAL REGISTRATION

This trial is registered with the Australian New Zealand Clinical Trials Registry (ANZCTR). Registered 31st of May 2021.

REGISTRATION NUMBER

ACTRN12621000659808 .

Breast-Conserving Therapy Versus Postmastectomy Breast Reconstruction: Propensity Score-Matched Analysis

BACKGROUND

Although studies have compared patient-reported outcomes (PROs) after breast conserving-therapy (BCT) and postmastectomy breast reconstruction (PMBR), they often have been confounded by treatment or other factors that complicate a direct comparison. This study aimed to compare PROs after BCT and PMBR by using propensity score-matching analysis.

METHODS

Patients who underwent BCT or PMBR between 2010 and 2022 and completed the BREAST-Q were identified. Each BCT patient was matched to a PMBR patient using nearest-neighbor 1:1 matching with replacement for each BREAST-Q time point. Outcomes included all prospectively collected BREAST-Q domains preoperatively, at 6 months, and at 1, 2, and 3 years postoperatively. A 4-point difference was considered clinically meaningful.

RESULTS

For this study, 6215 patients (2501 BCT [40.2%] and 3714 PMBR [59.8%] patients) were eligible, and 2616 unique patients were matched. Preoperatively, 463 BCT and 463 PMBR patients were matched for analysis (6 months [443 matched pairs], 1 year [639 matched pairs], 2 years [421 matched pairs], 3 years [254 matched pairs]). At 6 months postoperatively, the BCT patients scored higher on all BREAST-Q domains than the PMBR patients (p < 0.05; differences > 4 points). At 1, 2, and 3 years, the patients who underwent BCT consistently had superior Satisfaction With Breasts, Psychosocial Well-Being, and Sexual Well-Being (p < 0.05), and the differences were clinically meaningful.

CONCLUSION

In this statistically powered study, the BCT patients reported higher quality of life than the PMBR patients in early assessment and also through 3 years of follow-up evaluation. Given the equivalency in survival and recurrence outcomes between BCT and PMBR, patients eligible for either surgery should be counseled regarding the superiority of BCT in terms of PROs.

Regional Variation in Deescalated Therapy in Older Adults With Early-Stage Breast Cancer

Importance

Although trial data support the omission of axillary surgery and radiation therapy (RT) in women aged 70 years or older with T1N0 hormone receptor-positive (HR+) breast cancer, potential overtreatment in older adults with frailty persists.

Objective

To determine how much geospatial variation in locoregional therapy may be attributed to region vs patient factors.

Design, Setting, and Participants

This retrospective cross-sectional study included women aged 70 years or older who were diagnosed with HR+/ERBB2-negative (ERBB2-) breast cancer from January 1, 2013, to December 31, 2017. Data came from Surveillance, Epidemiology, and End Results-Medicare. Hierarchical multivariable modeling was used to evaluate the variance in deescalated care attributable to 4 domains, ie, (1) random, (2) region (health service area [HSA]), (3) patient factors, and (4) unexplained. Patient factors included age, frailty (validated claims-based measure), Charlson Comorbidity Index (CCI), and socioeconomic status (Yost index). Analyses were performed from January to October 2023.

Exposure

HSA.

Main Outcomes and Measures

Deescalated care, defined as omission of axillary surgery, RT, or both. Standard therapy was defined as lumpectomy, axillary surgery, and RT or mastectomy with axillary surgery. Multivariable logistic regression was used to identify factors associated with deescalated care receipt.

Results

Of 9173 patients (mean [SD] age, 76.5 [5.2] years), 2363 (25.8%) were aged 80 years or older, 705 (7.7%) had frailty, and 419 (4.6%) had a CCI of 2 or greater. While 4499 (49.1%) underwent standard therapy, 4674 (50.9%) underwent deescalated therapy (1193 [13.0%] of the population omitted axillary surgery and 4342 [55.5%] of patients undergoing lumpectomy omitted RT). Of the total variance, random variation explained 27.3%, region/HSA explained 35.3%, patient factors explained 2.8%, and 34.5% was unexplained. In adjusted models, frailty and increased age were associated with a higher likelihood of undergoing deescalated therapy (frailty: odds ratio [OR], 1.70; 95% CI, 1.43-2.02; age, by 1-year increment: OR, 1.10; 95% CI, 1.09-1.11), but CCI was not. Patients in rural areas compared with those in urban areas (OR, 0.82; 95% CI, 0.68-0.99) and Asian and Pacific Islander patients compared with non-Hispanic White patients (OR, 0.68; 95% CI, 0.54-0.85) had a lower likelihood of undergoing deescalated therapy.

Conclusions and Relevance

In this retrospective cross-sectional study of women aged 70 years or older diagnosed with T1N0 HR+/ERBB2- breast cancer, region/HSA contributed more to the variation in deescalated therapy use than patient factors. Unexplained variation may be attributed to unmeasured characteristics, such as multidisciplinary environment and patient preference. Decision support efforts to address overtreatment should target regions with low rates of evidence-based deescalation.

Why do women with early breast cancer in Northern Sri Lanka undergo mastectomy? Decision-making and ways forward

BACKGROUND

Despite robust evidence confirming equivalent survival rates and better cosmetic outcomes with breast-conserving surgery (BCS) and radiotherapy compared to mastectomy, the rates of mastectomy among women with early breast cancer have not declined significantly in Sri Lanka. This study explores views on the surgical treatment of breast cancer among Northern Sri Lankan women who were eligible for BCS but underwent mastectomy.

METHODS

An exploratory descriptive qualitative study was carried out among 15 women who underwent mastectomy for early breast cancer. Patients who were referred to the Tellippalai Trail Cancer Hospital for adjuvant therapy after mastectomy and matched the study criteria were recruited. Data were collected through in-depth semi-structured interviews, which were transcribed in Tamil, translated into English, coded using QDA Miner Lite software, and analysed thematically.

RESULTS

Nine out of 15 participants were either not aware of breast-conserving surgery (BCS) as a treatment option or their eligibility for BCS at the time of mastectomy. According to participant narratives, the treating team had recommended mastectomy to most participants. While many opted for mastectomy believing that it was associated with lower rates of recurrence and spread compared to BCS, these beliefs were frequently reinforced by the treating team. The pros and cons of the two approaches had not been discussed before surgery with most participants. In the absence of information, family and friends weighed in on the decision to opt for mastectomy, ultimately resulting in feelings of loss and regret in most instances.

CONCLUSION

Most participants were not aware that they were eligible for BCS. These information gaps need to be urgently addressed for women to make informed decisions about their health.

Factors Influencing Surgical Choices in Breast Cancer Treatment in India: A Comparative Study of Breast-Conserving Surgery vs Mastectomy

Background Breast-conserving surgery (BCS) can make breast cancer treatment less disfiguring and more aesthetically acceptable for women. However, very few patients in India chose to undergo BCS surgery despite eligibility. Therefore, this study aims to explore the factors influencing the surgical choice in the treatment of breast cancer in India. Materials and methods This prospective study was conducted at a tertiary care hospital in Central India. Women having stage I/ II breast cancer diagnosis with a tumor size <5 cm were considered. A detailed self-designed questionnaire was used. A chi-square test with a significance level (p-value <0.05) was applied. Results Out of 40 females, 80% (n = 32) chose modified radical mastectomy (MRM), whereas 20% (n = 8) opted for BCS. The primary motivations to undergo MRM included concern about cancer recurrence (30%, n = 12), desire to avoid the adverse effects of radiation therapy (25%, n = 10), and fear of radiation therapy (20%, n = 8). Surgeons play a dominant role in determining surgical options, with 80% of MRM cases following the surgeon's recommendation. A significant association was observed between surgical options, education, economic status, locality, and family history (p<0.001). Changes in decision-making regarding the type of surgery after admission to the hospital were significant (p<0.001) after counseling. Conclusions The choice between breast conservation and mastectomy is influenced by sociodemographic factors, personal views, and surgeons' recommendations. Thus, these factors must be considered in preoperative counseling to help patients make informed choices.

Intraoperative radiotherapy: An alternative to whole-breast external beam radiotherapy in the management of highly selective breast cancer: A SEER database analysis

OBJECTIVE

This study aimed to verify if intraoperative radiotherapy (IORT) can achieve the same survival outcome as whole-breast external beam radiotherapy (EBRT) in early breast cancer after breast-conserving surgery (BCS), and to explore the suitable candidates that can safely receive IORT after BCS.

METHODS

Eligible post-BCS patients who received IORT or EBRT were included in the Surveillance, Epidemiology and End Results (SEER) database from 2010 to 2018. Risk factors that affected 5-year overall survival (OS) or breast cancer specific survival (BCSS) were identified by Cox proportional hazards regression analysis. Clinical characteristics, OS, and BCSS were comparatively analyzed between the two treatment modalities.

RESULTS

The survival analysis after propensity score matching confirmed that patients who received IORT (n = 2200) had a better 5-year OS than those who received EBRT (n = 2200) (p = 0.015). However, the two groups did not differ significantly in 5-year BCSS (p = 0.381). This feature persisted even after multivariate analyses that took into account numerous clinical characteristics. Although there was no significant difference in BCSS between different subgroups of patients treated with IORT or EBRT, patients over 55 years of age, with T1, N0, non-triple negative breast cancers, hormone receptor-positive, and histologic grade II showed a better OS after receiving IORT.

CONCLUSION

In low-risk, early-stage breast cancer, IORT was not inferior to EBRT considering 5-year BCSS and OS. Considering the equivalent clinical outcome but less radiotoxicity, IORT might be a reasonable alternative to EBRT in highly selective patients undergoing BCS.

A bibliometric worldview of breast-conserving surgery for breast cancer from 2013 to 2023

Over the last decade, significant advancements have been made in breast-conserving surgery (BCS) for breast cancer. However, there is a lack of analytical and descriptive investigations on the trajectory, essential research directions, current research scenario, pivotal investigative focuses, and forthcoming perspectives. The objective of this research is to provide a thorough update on the progress made in BCS for breast cancer over the preceding decade. Retrieved from the Web of Science database, the data span from January 1, 2013, to November 30, 2023. Utilizing a set of advanced analytical instruments, we conducted comprehensive bibliometric and visual analyses. The findings underscore the predominant influence of the USA, representing 35.77% of the overall publications and playing a pivotal role in shaping research within this field. Notable productivity was evident at various institutions, including the Memorial Sloan Kettering Cancer Center, the University of Texas MD Anderson Cancer Center, and the University of Toronto. Annals of Surgical Oncology contributed the most publications in this field. An examination of keywords indicated a change in the concentration of research attention, transitioning from molecular subtype, ultrasonography, and intraoperative aspects to SEER, male breast cancer, and adjuvant measures. By offering a comprehensive bibliometric assessment, this study enhances our understanding of BCS for breast cancer. Consequently, this benefits both experienced researchers and newcomers alike, providing prompt access to essential information and fostering the extraction of innovative concepts within this specific field.

Decision-making experiences related to mastectomy: A descriptive qualitative study

AIM

To obtain an in-depth understanding of women's decision-making experiences related to mastectomy.

DESIGN

A descriptive qualitative interview study.

METHODS

Individual semi-structured interviews were conducted face-to-face with 27 Chinese women with breast cancer who underwent mastectomy at two tertiary hospitals in mainland China between September 2020 and December 2021 after obtaining the appropriate ethical approvals. Interviews were conducted in Mandarin. Data were analysed using inductive content analysis.

RESULTS

Mean age of participants was 48 years (range 31-70). Most participants had low education, low monthly family income, had a partner and health insurance, had been diagnosed with early breast cancer, and had not undergone reconstructive surgery. Six categories related to decision-making experiences emerged: (1) Emotions affecting decision-making, (2) Information seeking for decision-making, (3) Beliefs about mastectomy and the breast, (4) Participation in decision-making, (5) People who influence decision-making, and (6) Post-decision reflection. Participants did not mention the role of nurses in their decision-making process for mastectomy.

CONCLUSIONS

This study adds valuable insights into the limited evidence on women's experience with decision-making about mastectomy from a Chinese perspective, which is important given the continuing high prevalence of mastectomy in many regions. Future studies from other countries and ethnic groups are recommended to gain diverse knowledge.

IMPACT

The findings of this study are useful for nurses and other healthcare professionals in the multidisciplinary team to better support women with breast cancer in their decision-making process regarding mastectomy. The findings could inform future interventions to support treatment decision-making and may be relevant to women living in similar socio-medical contexts to those in mainland China.

REPORTING METHOD

The study was reported following the Standards for Reporting Qualitative Research checklist.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

The influence of a previous implant-based breast reconstruction on postoperative sensation of the deep inferior epigastric artery perforator flap

BACKGROUND

Implants and DIEP flaps have different outcomes regarding postoperative breast sensation. When compared to the preoperative healthy breast, implant-based breast reconstruction (IBBR) negatively influences postoperative breast sensation. However, it is currently unknown whether a prior IBBR also influences postoperative sensation of a replacing DIEP flap. The goal of this cohort study is to evaluate the influence of an IBBR on the postoperative sensation of a replacing DIEP flap.

METHODS

Women were included if they received a DIEP flap reconstruction after mastectomy, with or without prior tissue expander (TE) and/or definitive breast implant. Sensation was measured at four intervals in 9 areas of the breast with Semmes-Weinstein monofilaments: T0 (preoperative, implant/no reconstruction), T1 (2-7 months postoperative, DIEP), T2 (± 12 months postoperative, DIEP), Tmax (maximum follow-up, DIEP). Linear mixed-effects models were used to investigate the relationship between an implant/TE prior to the DIEP flap and recovery of breast sensation.

RESULTS

142 women comprising 206 breasts were included. 48 (23.3%) breasts did, and 158 (76.7%) breasts did not have a TE/IBBR prior to their DIEP. No statistically significant or clinically relevant relationships were found between a prior implant/TE and recovery of DIEP flap breast sensation for the flap skin, native skin, or total breast skin at T1, T2, or Tmax. There were also no relationships found after adjustment for the confounders radiation therapy, BMI, diabetes, age, flap weight, follow-up, and nerve coaptation.

CONCLUSIONS

An implant/TE prior to a DIEP flap does not influence the recovery of postoperative breast sensation of the DIEP flap.

Screening chest wall ultrasound in the mastectomy patient

BACKGROUND

While there are clear guidelines regarding chest wall ultrasound in the symptomatic patient, there is conflicting evidence regarding the use of ultrasound in the screening of women post-mastectomy.

OBJECTIVE

To assess the utility of screening chest wall ultrasound after mastectomy and to assess features of detected malignancies.

METHODS

This IRB approved, retrospective study evaluates screening US examinations of the chest wall after mastectomy. Asymptomatic women presenting for screening chest wall ultrasound from January 2016 through May 2017 were included. Cases of known active malignancy were excluded. All patients had at least one year of clinical or imaging follow-up. 43 exams (8.5 %) were performed with a history of contralateral malignancy, 465 exams (91.3 %) were performed with a history of ipsilateral malignancy, and one exam (0.2 %) was performed in a patient with bilateral prophylactic mastectomy.

RESULTS

During the 17-month period, there were 509 screening US in 389 mastectomy patients. 504 (99.0 %) exams were negative/benign. Five exams (1.0 %) were considered suspicious, with recommendation for biopsy, which was performed. Out of 509 exams, 3 (0.6 %) yielded benign results, while 2 (0.39 %) revealed recurrent malignancy, with a 95 % confidence interval (exact binomial) of 0.05 % to 1.41 % for screening ultrasound. Both patients who recurred had previously recurred, and both had initial cancer of lobular histology.

CONCLUSION

Of 509 chest wall screening US exams performed in mastectomy, 2 malignancies were detected, and each patient had history of invasive lobular carcinoma and at least one prior recurrence prior to this study, suggesting benefit of screening ultrasound in these populations.

Traditional Clinicopathological Biomarkers Still Determine Disease-Free and Overall Survival in Invasive Breast Cancer Patients: A Pilot Study

Background: Molecular classification, tumor diameter, Ki67 expression, and brachytherapy administration still act as the most potent potential predictors of breast cancer recurrence and overall survival. Methods: Over the period of 23 months, we included in the study 92 invasive breast cancer (IBrC) patients initially diagnosed at the Clinical Ward of Breast Cancer and Reconstructive Surgery, Oncology Center in Bydgoszcz, Poland. The probability of disease-free survival (DFS) and overall survival (OS) in relation to potential prognostic factors for the patients were determined using a Kaplan-Meier analysis, and univariate and multivariate Cox regression analyses evaluated the predictive factors of IBrC patients. The investigation of the potential prognostic model's accuracy was analyzed using the ROC curve. Results: Patients with tumor size < 2 cm, Ki67 expression < 20%, luminal-A molecular subtype, and extra-dose brachytherapy boost administration displayed the most favorable prognosis according to breast cancer disease-free survival and overall survival. The estimated 5 year probability of DFS and OS rates in women with tumor diameter < 2 cm were 89% and 90%, respectively. In tumor diameter > 2 cm, the estimated 5 year probability of DFS was 73% and OS was 76%. Interestingly, the tumor diameter of 1.6 cm with a specificity of 60.5% and a sensitivity of 75% occurred as the best threshold point to differentiate patients with cancer recurrence from those without cancer progression. Conclusions: Our study provides essential information on the clinicopathological profile and future outcomes of early stage IBrC patients. Furthermore, the tumor diameter cut-off value of 1.6 cm discriminating between disease recurrence and those without disease progression patients represents an innovative direction for further research.

The factors involved in surgical decision-making in younger women diagnosed with breast cancer in Aotearoa New Zealand: A qualitative analysis

Women diagnosed with breast cancer must make important surgical decisions. The decision-making process for younger women is complex, with this group more likely to have an advanced diagnosis and life-stage considerations that can impact on treatment. This study investigated the decision-making process of women aged <50 years who had undergone breast cancer surgery within the preceding 12 months in Aotearoa New Zealand. Twelve women participated in semi-structured qualitative interviews to explore the factors that influenced treatment decisions. Thematic analysis resulted in three themes. Fear was the main concept identified as the primary influence on initial decision-making. Good quality shared decision-making between patient and clinician was found to provide essential support during the diagnosis to treatment period. In addition, women expressed a need for multi-modal presentation of medical information and more material reflecting younger women. These findings inform provision for younger women making surgical decisions when diagnosed with breast cancer.

Racial/ethnic disparities in the association between patient care experiences and receipt of initial surgical breast cancer care: findings from SEER-CAHPS

PURPOSE

We determined whether racial/ethnic differences in patient experiences with care influence timeliness and type of initial surgical breast cancer treatment for a sample of female Medicare cancer patients.

METHODS

We conducted a retrospective cohort study using the linked Epidemiology and End Results-Consumer Assessment of Healthcare Providers and Systems (SEER-CAHPS) dataset. The outcomes were: (1) time-to-initial surgical treatment, and (2) type of treatment [breast conserving surgery (BCS) vs. mastectomy]. The indicators were reports of four types of patient experiences with care including doctor communication, getting care quickly, getting needed care, and getting needed Rx. Interaction terms in each multivariable logistic model examined if the associations varied by race/ethnicity.

RESULTS

Of the 2069 patients, 84.6% were White, 7.6% Black and 7.8% Hispanic. After adjusting for potential confounders, non-Hispanic Black patients who provided excellent reports of their ability to get needed prescriptions had lower odds of receiving surgery within 2-months of diagnosis, compared to NH-Whites who provided less than excellent reports (aOR: 0.29, 95% CI 0.09-0.98). There were no differences based on 1-month or 3-month thresholds. We found no other statistically significant effect of race/ethnicity. As to type of surgery, among NH Blacks, excellent reports of getting care quickly were associated with higher odds of receiving BCS versus mastectomy (aOR: 2.82, 95% CI 1.16-6.85) compared to NH Whites with less than excellent reports. We found no other statistically significant differences by race/ethnicity.

CONCLUSION

Experiences with care are measurable and modifiable factors that can be used to assess and improve aspects of patient-centered care. Improvements in patient care experiences of older adults with cancer, particularly among minorities, may help to eliminate racial/ethnic disparities in timeliness and type of surgical treatment.

Association of clinicopathologic variables and patient preference with the choice of surgical treatment for early-stage breast cancer: A registry-based study

INTRODUCTION

Observational studies suggest that breast conserving surgery (BCS) and radiotherapy (RT) offers superior survival compared to mastectomy. The aim was to compare patient and tumour characteristics in women with invasive breast cancer ≤30 mm treated with either BCS or mastectomy, and to explore the underlying reason for choosing mastectomy.

METHODS

Women registered with breast cancer ≤30 mm and ≤4 positive axillary lymph nodes in the Swedish National Breast Cancer Register 2013-2016 were included. Logistic regression analyses were performed to assess the association of tumour and patient characteristics with receiving a mastectomy vs. BCS.

RESULTS

Of 1860 breast cancers in 1825 women, 1346 were treated by BCS and 514 by mastectomy. Adjuvant RT was given to 1309 women (97.1 %) after BCS and 146 (27.6 %) after mastectomy. Variables associated with receiving a mastectomy vs. BCS included clinical detection (Odds Ratio (OR) 4.15 (95 % Confidence Interval (CI) 3.35-5.14)) and clinical stage (T2 vs. T1 (OR 3.68 (95 % CI 2.90-4.68)), N1 vs. N0 (OR 2.02 (95 % CI 1.38-2.96)). Women receiving mastectomy more often had oestrogen receptor negative, HER2 positive tumours of higher histological grade. The most common reported reason for mastectomy was large or multifocal tumours (53.5 %), followed by patient preference (34.5 %).

CONCLUSION

Choice of surgery is strongly associated with key prognostic factors among women undergoing BCS with RT compared to mastectomy. Failure to control for all relevant confounders may bias results in outcome studies in favour of BCS.

Racial disparities in surgical outcomes after mastectomy in 223 000 female breast cancer patients: a retrospective cohort study

BACKGROUND

Breast cancer mortality and treatment differ across racial groups. It remains unclear whether such disparities are also reflected in perioperative outcomes of breast cancer patients undergoing mastectomy.

STUDY DESIGN

The authors reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2008-2021) to identify female patients who underwent mastectomy for oncological purposes. The outcomes were stratified by five racial groups (white, Black/African American, Asian, American Indian/Alaska Native, and Native Hawaiian/Pacific Islander) and included 30-day mortality, reoperation, readmission, surgical and medical complications, and non-home discharge.

RESULTS

The study population included 222 947 patients, 68% ( n =151 522) of whom were white, 11% ( n =23 987) Black/African American, 5% ( n =11 217) Asian, 0.5% ( n =1198) American Indian/Alaska Native, and 0.5% ( n =1018) Native Hawaiian/Pacific Islander. While 136 690 (61%) patients underwent partial mastectomy, 54 490 (24%) and 31 767 (14%) women received simple and radical mastectomy, respectively. Overall, adverse events occurred in 17 222 (7.7%) patients, the largest portion of which were surgical complications ( n =7246; 3.3%). Multivariable analysis revealed that being of Asian race was protective against perioperative complications [odds ratio (OR)=0.71; P <0.001], whereas American Indian/Alaska Native women were most vulnerable to the complication occurrence (OR=1.41; P <0.001). Black/African American patients had a significantly lower risk of medical (OR=0.59; P <0.001) and surgical complications (OR=0.60; P <0.001) after partial and radical mastectomy, respectively, their likelihood of readmission (OR=1.14; P =0.045) following partial mastectomy was significantly increased.

CONCLUSION

The authors identified American Indian/Alaska Native women as particularly vulnerable to complications following mastectomy. Asian patients experienced the lowest rate of complications in the perioperative period. The authors' analyses revealed comparable confounder-adjusted outcomes following partial and complete mastectomy between Black and white races. Their findings call for care equalization in the field of breast cancer surgery.

Key factors in the decision-making process for mastectomy alone or breast reconstruction: A qualitative analysis

Breast cancer is the most common cancer to affect New Zealand women. Women diagnosed face several decisions regarding surgical treatment, including whether to undergo lumpectomy, mastectomy, or breast reconstruction. Reconstructive surgery adds an additional layer of complexity, with several reconstructive options, each associated with differing surgical and recovery times. Furthermore, surgical decisions are often made under time-pressure and significant diagnostic distress, therefore provision of good information to support decision-making is crucial to adequately inform women of their options. We interviewed 24 women who had undergone breast surgery within the preceding 12 months to assess the key factors leading to their decision to opt for their chosen surgical procedure. Interviews revealed that decision-making was complex and involved multiple factors. Women were ultimately confronted with assessing feminine identity versus survival. Whether opting for breast reconstruction or not, women were fearful of what surgery would involve and how their reconstructed breast or mastectomy scar might look following surgery. Shared decision-making between patient and clinician can mitigate this fear and provide women with a sense of autonomy over their health decisions. Provision of visual depictions of surgical outcomes was not routinely provided to those interviewed but was expressed as important to help women manage surgical expectations. Therefore our findings support the multi-modal presentation of diagnostic and treatment information to support decision-making. Likewise, women reported feeling unsupported in their decision not to undergo breast reconstruction, suggesting a need to develop resources to provide women with positive discussions about 'going flat'.

Universal Germline-Genetic Testing for Breast Cancer: Implementation in a Rural Practice and Impact on Shared Decision-Making

BACKGROUND

Whereas the National Comprehensive Cancer Network (NCCN) criteria restrict germline-genetic testing (GGT) to a subset of breast cancer (BC) patients, the American Society of Breast Surgeons recommends universal GGT. Although the yield of pathogenic germline variants (PGV) in unselected BC patients has been studied, the practicality and utility of incorporating universal GGT into routine cancer care in community and rural settings is understudied. This study reports real-world implementation of universal GGT for patients with breast cancer and genetics-informed, treatment decision-making in a rural, community practice with limited resources.

METHODS

From 2019 to 2022, all patients with breast cancer at a small, rural hospital were offered GGT, using a genetics-extender model. Statistical analyses included Fisher's exact test, t-tests, and calculation of odds ratios. Significance was set at p < 0.05.

RESULTS

Of 210 patients with breast cancer who were offered GGT, 192 (91.4%) underwent testing with 104 (54.2%) in-criteria (IC) and 88 (45.8%) out-of-criteria (OOC) with NCCN guidelines. Pathogenic germline variants were identified in 25 patients (13.0%), with PGV frequencies of 15 of 104 (14.4%) in IC and ten of 88 (11.4%) in OOC patients (p = 0.495). GGT informed treatment for 129 of 185 (69.7%) patients.

CONCLUSIONS

Universal GGT was successfully implemented in a rural, community practice with > 90% uptake. Treatment was enhanced or de-escalated in those with and without clinically actionable PGVs, respectively. Universal GGT for patients with breast cancer is feasible within rural populations, enabling optimization of clinical care to patients' genetic profile, and may reduce unnecessary healthcare, resource utilization.

Better survival was found in patients treated with breast-conserving surgery compared with mastectomy in malignant phyllodes tumor of the breast

Malignant phyllodes tumor of the breast (MPTB) is a rare type of breast cancer. The prognosis between breast-conserving surgery (BCS) and mastectomy remains unclear in MPTB. Therefore, long-term survival was investigated between BCS and mastectomy in MPTB via the Surveillance, Epidemiology, and End Results (SEER) database. MPTB patients with T1-2/N0 stage between 2000 and 2015 from SEER database were retrospectively reviewed. Prognosis between different surgical approaches was assessed by Kaplan-Meier curves and Cox proportional hazards analysis. A total of 795 patients were enrolled with a median follow-up of 126 months. BCS was associated with significantly increased 10-year overall survival (OS) (89.2% vs. 81.1%, p = 0.002) and breast cancer-specific survival (BCSS) (95.2% vs. 90%, p = 0.004) compared with mastectomy. Multivariate analysis showed better OS (HR = 0.587, 95% CI 0.406-0.850, p = 0.005) and BCSS (HR = 0.463, 95%CI 0.267-0.804, p = 0.006) in the BCS group than the mastectomy group. After 1:1 propensity score matching (PSM), improved 10-year OS (89.2% vs.81%, p = 0.023) and BCSS (95.8% vs. 90.1%, p = 0.033) were observed in BCS compared with mastectomy. This study found the survival benefit of BCS over mastectomy in patients with early-stage MPTB. BCS should be recommended as a priority in MPTB patients when both surgical approaches are feasible.

Patient values in breast cancer surgical decision-making - The WhySurg study

BACKGROUND

The objective of this study was to describe patient values and personality traits associated with breast surgery choice for patients with breast cancer.

METHODS

A survey based on qualitative patient interviews and the Big-Five personality trait profile was distributed to Love Research Army volunteers aged 18-70 years old who underwent breast cancer surgery from 2009 to 2020. Multivariable logistic regression analysis was used to determine independent patient values and personality traits for the choice of breast-conserving surgery (BCS), unilateral mastectomy (UM) and bilateral mastectomy (BM).

RESULTS

1497 participants completed the survey. Open-mindedness was associated with UM and sociability was associated with BM. A majority of patients prioritized cancer outcomes. Compared to BM patients, BCS and UM patients were significantly more likely to choose values associated with maintaining their self-image, optimizing surgical recovery, and following their doctor's recommendation.

CONCLUSIONS

Other values besides cancer outcomes differentiate patient surgical choice for BCS or mastectomy.

The percentage of unnecessary mastectomy due to false size prediction using preoperative ultrasonography and MRI in breast cancer patients who underwent neoadjuvant chemotherapy: a prospective cohort study

BACKGROUND

Imaging-estimated tumour extent after neoadjuvant chemotherapy tends to be discordant with the pathological extent. The authors aimed to prospectively determine the proportion of decisions regarding total mastectomy for potential breast-conserving surgery candidates owing to false size prediction with imaging in neoadjuvant chemotherapy and non-neoadjuvant chemotherapy patients.

MATERIALS AND METHODS

The authors prospectively enroled clinical stage II or III breast cancer patients who are scheduled for total mastectomy between 2018 and 2021. This study was conducted at Seoul National University Hospital at South Korea. Before surgery, each surgeon recorded the hypothetical maximum tumour size at which the surgeon would have been able to attempt breast-conserving surgery if the patient had actually less than the size of the tumour at that location in the breast. After surgery, the hypothetical maximum tumour size was compared with the final pathologic total extent of the tumour, including invasive and in situ cancers.

RESULTS

Among the 360 enroled patients, 130 underwent neoadjuvant chemotherapy, and 230 did not undergo neoadjuvant chemotherapy. Of the total of each group, 47.7% in the neoadjuvant chemotherapy group and 21.3% in the non-neoadjuvant chemotherapy group had a smaller pathologic tumour extent than the pre-recorded hypothetical maximum tumour size (P<0.001). Further analyses were conducted for the neoadjuvant chemotherapy group. The proportions of total mastectomy with false size prediction were higher in HER2-positive (63.3%) and triple-negative (57.6%) patients compared with ER-positive/HER2-negative (25.0%) patients (P<0.001). Both magnetic resonance imaging-pathology and ultrasonography-pathology size discrepancies were significantly associated with false decisions for total mastectomy (both P<0.001). Without magnetic resonance imaging, the false decision may be reduced by 21.5%.

CONCLUSION

A total of 47.7% of patients who received total mastectomy after neoadjuvant chemotherapy were breast-conserving surgery eligible, which was significantly higher than that of non-neoadjuvant chemotherapy patients. Magnetic resonance imaging contributed the most to false size predictions.

Mastectomy patterns among older women with early invasive breast cancer in England and Wales: A population-based cohort study

INTRODUCTION

Older women with early invasive breast cancer (EIBC) are more likely to receive a mastectomy compared with younger women. This study assessed factors associated with receiving a mastectomy among older women with EIBC, with a particular focus on comorbidity and frailty.

MATERIALS AND METHODS

Women diagnosed with EIBC (stages I-IIIa) aged ≥50 years from 2014 to 2019 in English and Welsh NHS organisations who received breast surgery were identified from cancer registration datasets linked to routine hospital data. Separate multivariable logistic regression models explored factors associated with mastectomy use, within each tumour stage (T1-T3). For each tumour stage, risk-adjusted rates of mastectomy were calculated for each NHS organisation and displayed using funnel plots.

RESULTS

We included 106,952 women with EIBC: 23.4% received a mastectomy as their first breast cancer surgery. Receipt of mastectomy was more common among patients with a higher tumour stage (T1: 12.3%; T2: 37.6%; T3: 77.5%), and mastectomy use increased with age within each tumour stage category (50-59 vs 80 + years: 11.8% vs 26.3% for T1; 31.5% vs 56.9% for T2; 73.4% vs 90.3% for T3). Results from a multivariable regression model showed that more severe frailty was associated with mastectomy use for women with T1 (p = 0.002) or T2 (p = 0.003) tumours, but may not be for women with T3 tumours (p = 0.041). There was no association between comorbidity and mastectomy use after accounting for frailty (all p > 0.1). Adjusting for clinical and patient factors only slightly reduced the association between age and mastectomy use. Variation in mastectomy use between NHS organisations was greatest for women with T2 EIBC (unadjusted range: 17.7% to 68.4%).

DISCUSSION

Older women with EIBC are more commonly treated with mastectomy. This could not be explained by tumour characteristics or physical fitness, raising questions about whether surgical decision-making inconsistently incorporates information on patient fitness and functional age.

Association of Race, Ethnicity, Insurance, and Language and Rate of Breast-Conserving Therapy Among Women With Nonmetastatic Breast Cancer at an Urban, Safety-Net Hospital

INTRODUCTION

Breast-conserving therapy (BCT), specifically breast-conserving surgery (BCS) and adjuvant radiation, provides an equivalent alternative to mastectomy for eligible patients. However, previous studies have shown that BCT is underused in the United States, particularly among marginalized demographic groups. In this study, we examine the association between race, ethnicity, insurance, and language and rate of BCS among patients treated at an academic, safety-net hospital.

MATERIALS AND METHODS

We conducted a retrospective cohort study of 520 women with nonmetastatic breast cancer diagnosed and treated at an academic, safety-net hospital (2009-2014). We assessed eligibility for BCT and then differences in the rate of BCT among eligible patients by race, ethnicity, insurance, and language. Reasons for not undergoing BCT were documented.

RESULTS

Median age was 60 y; 55.9% were non-White, 31.9% were non-English-speaking, 15.6% were Hispanic, and 47.4% were Medicaid/uninsured. Three hundred seventy one (86.3%) underwent BCS; within this group, 324 (87.3%) completed adjuvant radiation. Among patients undergoing mastectomy, 30 patients (36.7%) were eligible for BCT; within this group, reasons for mastectomy included patient preference (n = 28) and to avoid possible re-excision or adjuvant radiation in patients with significant comorbidities (n = 2). Eligibility for BCT varied by ethnicity (Hispanic [100%], Non-Hispanic [92%], P = 0.02), but not race, language, or insurance. Among eligible patients, rate of BCS varied by age (<50 y [84.9%], ≥50 y [92.9%], P = 0.01) and ethnicity (Hispanic [98.5%], Non-Hispanic [91.3%], P = 0.04), but not race, language, or insurance.

CONCLUSIONS

At our safety-net hospital, the rate of BCS among eligible patients did not vary by race, language, or insurance. Excluding two highly comorbid patients, all patients who underwent mastectomy despite being eligible for BCT were counseled regarding BCS and expressed a preference for mastectomy. Further research is needed to understand the value of BCT in the treatment of breast cancer, to ensure informed decision-making, address potential misconceptions regarding BCT, and advance equitable care for all patients.

Computational mechanobiology model evaluating healing of postoperative cavities following breast-conserving surgery

Breast cancer is the most commonly diagnosed cancer type worldwide. Given high survivorship, increased focus has been placed on long-term treatment outcomes and patient quality of life. While breast-conserving surgery (BCS) is the preferred treatment strategy for early-stage breast cancer, anticipated healing and breast deformation (cosmetic) outcomes weigh heavily on surgeon and patient selection between BCS and more aggressive mastectomy procedures. Unfortunately, surgical outcomes following BCS are difficult to predict, owing to the complexity of the tissue repair process and significant patient-to-patient variability. To overcome this challenge, we developed a predictive computational mechanobiological model that simulates breast healing and deformation following BCS. The coupled biochemical-biomechanical model incorporates multi-scale cell and tissue mechanics, including collagen deposition and remodeling, collagen-dependent cell migration and contractility, and tissue plastic deformation. Available human clinical data evaluating cavity contraction and histopathological data from an experimental porcine lumpectomy study were used for model calibration. The computational model was successfully fit to data by optimizing biochemical and mechanobiological parameters through Gaussian process surrogates. The calibrated model was then applied to define key mechanobiological parameters and relationships influencing healing and breast deformation outcomes. Variability in patient characteristics including cavity-to-breast volume percentage and breast composition were further evaluated to determine effects on cavity contraction and breast cosmetic outcomes, with simulation outcomes aligning well with previously reported human studies. The proposed model has the potential to assist surgeons and their patients in developing and discussing individualized treatment plans that lead to more satisfying post-surgical outcomes and improved quality of life.

Receipt of mastectomy and adjuvant radiotherapy following breast conserving surgery (BCS) in New Zealand women with BCS-eligible breast cancer, 2010-2015: an observational study focusing on ethnic differences

BACKGROUND

Women with early breast cancer who meet guideline-based criteria should be offered breast conserving surgery (BCS) with adjuvant radiotherapy as an alternative to mastectomy. New Zealand (NZ) has documented ethnic disparities in screening access and in breast cancer treatment pathways. This study aimed to determine whether, among BCS-eligible women, rates of receipt of mastectomy or radiotherapy differed by ethnicity and other factors.

METHODS

The study assessed management of women with early breast cancer (ductal carcinoma in situ [DCIS] and invasive stages I-IIIA) registered between 2010 and 2015, extracted from the recently consolidated New Zealand Breast Cancer Registry (now Te Rēhita Mate Ūtaetae NZBCF National Breast Cancer Register). Specific criteria were applied to determine women eligible for BCS. Uni- and multivariable analyses were undertaken to examine differences by demographic and clinicopathological factors with a primary focus on ethnicity (Māori, Pacific, Asian, and Other; the latter is defined as NZ European, Other European, and Middle Eastern Latin American and African).

RESULTS

Overall 22.2% of 5520 BCS-eligible women were treated with mastectomy, and 91.1% of 3807 women who undertook BCS received adjuvant radiotherapy (93.5% for invasive cancer, and 78.3% for DCIS). Asian ethnicity was associated with a higher mastectomy rate in the invasive cancer group (OR 2.18; 95%CI 1.72-2.75), compared to Other ethnicity, along with older age, symptomatic diagnosis, advanced stage, larger tumour, HER2-positive, and hormone receptor-negative groups. Pacific ethnicity was associated with a lower adjuvant radiotherapy rate, compared to Other ethnicity, in both invasive and DCIS groups, along with older age, symptomatic diagnosis, and lower grade tumour in the invasive group. Both mastectomy and adjuvant radiotherapy rates decreased over time. For those who did not receive radiotherapy, non-referral by a clinician was the most common documented reason (8%), followed by patient decline after being referred (5%).

CONCLUSION

Rates of radiotherapy use are high by international standards. Further research is required to understand differences by ethnicity in both rates of mastectomy and lower rates of radiotherapy after BCS for Pacific women, and the reasons for non-referral by clinicians.

Surgeon Factors Influencing Breast Surgery Outcomes: A Scoping Review to Define the Modern Breast Surgical Oncologist

BACKGROUND

Modern breast surgical oncology incorporates many aspects of care including preoperative workup, surgical management, and multidisciplinary collaboration to achieve favorable oncologic outcomes and high patient satisfaction. However, there is variability in surgical practice and outcomes. This review aims to identify modifiable surgeon factors influencing breast surgery outcomes and provide a definition of the modern breast surgical oncologist.

METHODS

A systematic literature search with additional backward citation searching was conducted. Studies describing modifiable surgeon factors with associated breast surgery outcomes such as rates of breast conservation, sentinel node biopsy, re-excision, complications, acceptable esthetic outcome, and disease-free and overall survival were included. Surgeon factors were categorized for qualitative analysis.

RESULTS

A total of 91 studies met inclusion criteria describing both modifiable surgeon factor and outcome data. Four key surgeon factors associated with improved breast surgery outcomes were identified: surgical volume (45 studies), use of oncoplastic techniques (41 studies), sub-specialization in breast surgery or surgical oncology (9 studies), and participation in professional development activities (5 studies).

CONCLUSIONS

On the basis of the literature review, the modern breast surgical oncologist has a moderate- to high-volume breast surgery practice, understands the use and application of oncoplastic breast surgery, engages in additional training opportunities, maintains memberships in relevant societies, and remains up to date on key literature. Surgeons practicing in breast surgical oncology can target these modifiable factors for professional development and quality improvement.

Time interval between breast cancer diagnosis and surgery is associated with disease outcome

Time interval between breast cancer (BC) diagnosis and surgery is of concern to patients and clinicians, but its impact on survival remains unclear. We identified 5130 BC patients receiving surgery between 2009 and 2017 from the Shanghai Jiaotong University Breast Cancer Database (SJTU-BCDB), and divided as Ruijin cohort and SJTU cohort. All participants were divided into three groups according to the interval between diagnosis and surgery: ≤ 1 week, 1-2 weeks, and > 2 weeks. Among 3144 patients of Ruijin cohort, the estimated 5-year breast cancer-free interval (BCFI) rates for the ≤ 1 week, 1-2 weeks and > 2 weeks groups were 91.8%, 87.5%, and 84.0% (P = 0.088), and the estimated 5-year overall survival (OS) rates were 95.6%, 89.6%, and 91.5% (P = 0.002). Multivariate analysis showed that patients with a TTS > 2 weeks had significantly lower BCFI (HR = 1.80, 95%CI 1.05-3.11, P = 0.034) and OS (HR = 2.07, 95% CI 1.04-4.13, P = 0.038) rates than patients with a TTS ≤ 1 week. Among 5130 patients when combining Ruijin cohort with SJTU cohort, the estimated 5-year BCFI rates for the ≤ 1 week, 1-2 weeks, and > 2 weeks groups were 91.0%, 87.9%, and 78.9%, and the estimated 5-year OS rates for the ≤ 1 week, 1-2 weeks, and > 2 weeks groups were 95.8%, 90.6%, and 91.5%, both with a significantly p value < 0.001. Our findings demonstrated the prolonged time to surgery (more than 2 weeks) after BC diagnosis was associated with poor disease outcomes, suggesting that efforts to early initiate treatment after diagnosis need to be pursued where possible to improve survival.

Biomarkers in Breast Cancer: An Old Story with a New End

Breast cancer is the second most frequent cancer in the world. It is a heterogeneous disease and the leading cause of cancer mortality in women. Advances in molecular technologies allowed for the identification of new and more specifics biomarkers for breast cancer diagnosis, prognosis, and risk prediction, enabling personalized treatments, improving therapy, and preventing overtreatment, undertreatment, and incorrect treatment. Several breast cancer biomarkers have been identified and, along with traditional biomarkers, they can assist physicians throughout treatment plan and increase therapy success. Despite the need of more data to improve specificity and determine the real clinical utility of some biomarkers, others are already established and can be used as a guide to make treatment decisions. In this review, we summarize the available traditional, novel, and potential biomarkers while also including gene expression profiles, breast cancer single-cell and polyploid giant cancer cells. We hope to help physicians understand tumor specific characteristics and support decision-making in patient-personalized clinical management, consequently improving treatment outcome.

Geriatric Radiation Oncology: What We Know and What Can We Do Better?

Elderly patients represent a growing subgroup of cancer patients for whom the role of radiation therapy is poorly defined. Older patients are still clearly underrepresented in clinical trials, resulting in very limited high-level evidence. Moreover, elderly patients are less likely to receive radiation therapy in similar clinical scenarios compared to younger patients. However, there is no clear evidence for a generally reduced radiation tolerance with increasing age. Modern radiation techniques have clearly reduced acute and late side effects, thus extending the boundaries of the possible regarding treatment intensity in elderly or frail patients. Hypofractionated regimens have further decreased the socioeconomic burden of radiation treatments by reducing the overall treatment time. The current review aims at summarizing the existing data for the use of radiation therapy or chemoradiation in elderly patients focusing on the main cancer types. It provides an overview of treatment tolerability and outcomes with current standard radiation therapy regimens, including possible predictive factors in the elderly population. Strategies for patient selection for standard or tailored radiation therapy approaches based on age, performance score or comorbidity, including the use of prediction tests or geriatric assessments, are discussed. Current and future possibilities for improvements of routine care and creation of high-level evidence in elderly patients receiving radiation therapy are highlighted.

Computational Mechanobiology Model Evaluating Healing of Postoperative Cavities Following Breast-Conserving Surgery

Breast cancer is the most commonly diagnosed cancer type worldwide. Given high survivorship, increased focus has been placed on long-term treatment outcomes and patient quality of life. While breast-conserving surgery (BCS) is the preferred treatment strategy for early-stage breast cancer, anticipated healing and breast deformation (cosmetic) outcomes weigh heavily on surgeon and patient selection between BCS and more aggressive mastectomy procedures. Unfortunately, surgical outcomes following BCS are difficult to predict, owing to the complexity of the tissue repair process and significant patient-to-patient variability. To overcome this challenge, we developed a predictive computational mechanobiological model that simulates breast healing and deformation following BCS. The coupled biochemical-biomechanical model incorporates multi-scale cell and tissue mechanics, including collagen deposition and remodeling, collagen-dependent cell migration and contractility, and tissue plastic deformation. Available human clinical data evaluating cavity contraction and histopathological data from an experimental porcine lumpectomy study were used for model calibration. The computational model was successfully fit to data by optimizing biochemical and mechanobiological parameters through the Gaussian Process. The calibrated model was then applied to define key mechanobiological parameters and relationships influencing healing and breast deformation outcomes. Variability in patient characteristics including cavity-to-breast volume percentage and breast composition were further evaluated to determine effects on cavity contraction and breast cosmetic outcomes, with simulation outcomes aligning well with previously reported human studies. The proposed model has the potential to assist surgeons and their patients in developing and discussing individualized treatment plans that lead to more satisfying post-surgical outcomes and improved quality of life.

Disparate Utilization of Breast Conservation Therapy in the Surgical Management of Early-Stage Breast Cancer

BACKGROUND

Despite evidence suggesting oncologic equipoise of breast conservation therapy (BCT) for early-stage (stages I and II) breast cancer, mastectomy is still widely utilized.

PATIENTS AND METHODS

The 2004-2015 National Cancer Database was used to tabulate all adult women receiving mastectomy or BCT for early-stage breast cancer. Multivariable regression was used to evaluate factors associated with utilization of BCT, relative to mastectomy.

RESULTS

Of 1,079,057 women meeting study criteria, 57.4% underwent BCT. BCT patients were older and more commonly White, compared to mastectomy. They were more commonly privately insured, in the highest income quartile, and treated at metropolitan, nonacademic institutions. After adjustment, increasing age (AOR 1.01/year), Black race (AOR 1.21, Ref: White), and care at a community hospital (AOR 1.08, Ref: Academic; all P< .05) were associated with increased odds of undergoing BCT. Conversely, Asian or Pacific Islander (AAPI) race (AOR 0.74), Medicare (AOR 0.89) or Medicaid (AOR 0.95) coverage, and being in the lowest (AOR 0.95) and second lowest (AOR 0.98, all P< .05) income quartiles were associated with reduced odds of undergoing BCT. Finally, increasing tumor size (AOR 0.97, P< .05) was associated with decreased adjusted odds of undergoing BCT.

CONCLUSION

Our results suggest persistent socioeconomic and racial disparities in BCT utilization for early-stage breast cancer. Directed strategies should be implemented in order to reduce treatment inequality in this patient population.

Breast Conservative Surgery for Breast Cancer: Indian Surgeon's Preferences and Factors Influencing Them

Background

It is well established that disease-free survival and overall survival after breast conservation surgery (BCS) followed by radiotherapy are equivalent to that after mastectomy. However, in Asian countries, the rate of BCS continues to remain low. The cause may be multifactorial including the patient's choice, availability and accessibility of infrastructure, and surgeon's choice. We aimed to elucidate the Indian surgeons' perspective while choosing between BCS and mastectomy, in women oncologically eligible for BCS.

Methods

We conducted a survey-based cross-sectional study in January-February 2021. Indian surgeons with general surgical or specialised oncosurgical training, who consented to participate were included in the study. Multinomial logistic regression was performed to assess the effect of study variables on offering mastectomy or BCS.

Results

A total of 347 responses were included. The mean age of the participants was 43 ± 11 years. Sixty-three of the surgeons were in the 25-44 years age group with the majority (80%) being males. 66.4% of surgeons 'almost always' offered BCS to oncologically eligible patients. Surgeons who had undergone specialised training in oncosurgery or breast conservation surgery were 35 times more likely to offer BCS (p < 0.01). Surgeons working in hospitals with in-house radiation oncology facilities were 9 times more likely to offer BCS (p < 0.05). Surgeons' years of practice, age, sex and hospital setting did not influence the surgery offered.

Conclusion

Two-thirds of Indian surgeons preferred BCS over mastectomy. Lack of radiotherapy facilities and specialised surgical training were deterrents to offering BCS to eligible women.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13193-022-01601-y.

Recent Advances in Optimizing Radiation Therapy Decisions in Early Invasive Breast Cancer

Adjuvant whole breast irradiation after breast-conserving surgery is a well-established treatment standard for early invasive breast cancer. Screening, early diagnosis, refinement in surgical techniques, the knowledge of new and specific molecular prognostic factors, and now the standard use of more effective neo/adjuvant systemic therapies have proven instrumental in reducing the rates of locoregional relapses. This underscores the need for reliably identifying women with such low-risk disease burdens in whom elimination of radiation from the treatment plan would not compromise oncological safety. This review summarizes the current evidence for radiation de-intensification strategies and details ongoing prospective clinical trials investigating the omission of adjuvant whole breast irradiation in molecularly defined low-risk breast cancers and related evidence supporting the potential for radiation de-escalation in HER2+ and triple-negative clinical subtypes. Furthermore, we discuss the current evidence for the de-escalation of regional nodal irradiation after neoadjuvant chemotherapy. Finally, we also detail the current knowledge of the clinical value of stromal tumor-infiltrating lymphocytes and liquid-based biomarkers as prognostic factors for locoregional relapse.

A large single-center prospective study to investigate the factors influencing the choice of breast-conserving surgery versus mastectomy in Chinese women with early breast cancer

BACKGROUND

Compared to mastectomy, breast-conserving surgery (BCS) provides the same survival rate and a higher quality of life for patients with early breast cancer (EBC). However, Chinese women with EBC are known to have a low BCS rate. A large prospective cohort study was conducted to investigate the factors influencing the choice of BCS in this population.

METHODS

In 2017, all women with unilateral EBC and eligible for BCS at our institution were enrolled. Before surgery, the patient's trust in the surgeon and her perceived strength of the surgeon's recommendation of BCS were measured through an in-person interview and validated ad hoc questionnaire. Multivariate logistic regressions on BCS procedure vs. mastectomy were used to estimate the odds ratio (OR).

RESULTS

One thousand one hundred thirty-six patients enrolled at analysis had an average age of 51.8 and tumor size of 2.4 cm. 19.9% of patients had BCS. The "strong" level of trust in the surgeon was significantly associated with BCS with an OR of 2.944 (p<0.001) when compared to the "average or under" trust. The "strong" and "moderate" strengths in surgeon recommendation for BCS were also found to be significantly associated with the BCS procedure with ORs of 12.376 (p <0.001) and 1.757 (p =0.040), respectively, compared to the "neutral or dissuaded" strength.

CONCLUSIONS

Stronger trust in surgeons and BCS recommendation by surgeons are associated with a higher rate of BCS in Chinese women with EBC. Interventional trials are needed to confirm this finding.

Locoregional relapse after sparing mastectomies and immediate reconstruction in women with breast cancer

INTRODUCTION

In recent years, cultural changes in today's society and improved risk assessment have increased the indication for mastectomies in women with breast cancer. Various studies have confirmed the oncological safety of sparing mastectomies and immediate reconstruction. The objective of this study is to analyze the incidence of locoregional relapses of this procedure and its impact on reconstruction and overall survival.

PATIENTS AND METHODS

Prospective study of patients with breast carcinoma who underwent a sparing mastectomy and immediate reconstruction. Locoregional relapses and their treatment and their impact on survival were analyzed.

RESULTS

The study group is made up of 271 women with breast carcinoma treated with a skin-sparing mastectomy and immediate reconstruction. The mean follow-up was 7.98 years and during the same 18 locoregional relapses (6.6%) were diagnosed: 72.2% in the mastectomy flap and 27.8% lymph node. There were no significant differences in the pathological characteristics of the primary tumor between patients with and without locoregional relapse, although the percentage of women with hormone-sensitive tumors was higher in the group without relapse. Patients with lymph node relapse had larger tumors (80% T2-T3) and 60% had axillary metastases at diagnosis, compared to 7.7% of women with skin relapse (p = 0.047). All patients operated on for locoregional relapse preserved their reconstruction. The incidence of metastases and deaths was significantly higher in patients with a relapse, causing a non-significant decrease in overall survival.

CONCLUSION

Locoregional relapses are a rare event in women with a sparing mastectomy and immediate reconstruction. Most patients with locoregional relapse can preserve their initial reconstruction through local resection of the tumor and adjuvant and / or neoadjuvant therapies.

Cosmetic Results and Side Effects of Accelerated Partial-Breast Irradiation Versus Whole-Breast Irradiation for Low-Risk Invasive Carcinoma of the Breast: The Randomized Phase III IRMA Trial

PURPOSE

The results in terms of side effects vary among the published accelerated partial-breast irradiation (APBI) studies. Here, we report the 5-year results for cosmetic outcomes and toxicity of the IRMA trial.

METHODS

We ran this randomized phase III trial in 35 centers. Women with stage I-IIA breast cancer treated with breast-conserving surgery, age ≥ 49 years, were randomly assigned 1:1 to receive either whole-breast irradiation (WBI) or external beam radiation therapy APBI (38.5 Gy/10 fraction twice daily). Patients and investigators were not masked to treatment allocation. The primary end point was ipsilateral breast tumor recurrence. We hereby present the analysis of the secondary outcomes, cosmesis, and normal tissue toxicity. All side effects were graded with the Radiation Therapy Oncology Group/European Organisation for Research and Treatment of Cancer Radiation Morbidity Scoring Schema. Analysis was performed with both intention-to-treat and as-treated approaches.

RESULTS

Between March 2007 and March 2019, 3,309 patients were randomly assigned to 1,657 WBI and 1,652 APBI; 3,225 patients comprised the intention-to-treat population (1,623 WBI and 1,602 APBI). At a median follow-up of 5.6 (interquartile range, 4.0-8.4) years, adverse cosmesis in the APBI patients was higher than that in the WBI patients at 3 years (12.7% v 9.2%; P = .009) and at 5 years (14% v 9.8%; P = .012). Late soft tissue toxicity (grade ≥ 3: 2.8% APBI v 1% WBI, P < .0001) and late bone toxicity (grade ≥ 3: 1.1% APBI v 0% WBI, P < .0001) were significantly higher in the APBI arm. There were no significant differences in late skin and lung toxicities.

CONCLUSION

External beam radiation therapy-APBI with a twice-daily IRMA schedule was associated with increased rates of late moderate soft tissue and bone toxicities, with a slight decrease in patient-reported cosmetic outcomes at 5 years when compared with WBI, although overall toxicity was in an acceptable range.

The role of tumor phenotype in the surgical treatment of early-stage breast cancer

BACKGROUND

We investigated whether tumor phenotype influences surgical decision-making, and how that may impact overall survival (OS) for early-stage breast cancer.

METHODS

Women aged 18-69 with cT0-2/cN0/cM0 breast cancer in the National Cancer Database (2010-2017) were included. A generalized logistic model was used to identify factors associated with surgery type. A Kaplan-Meier curve was used to visualize unadjusted OS, and the log-rank test was used to test for differences in OS between surgery types.

RESULTS

Of 597,149 patients, 58% underwent lumpectomy with radiation (BCT), 25% unilateral mastectomy (UM), and 17% bilateral mastectomy (BM). After adjustment, HER2+ and triple-negative (TN) tumors were less likely to undergo UM than BCT, versus hormone receptor-positive tumors (OR = 0.881, 95% CI = 0.860-0.903; OR = 0.485, 95% CI = 0.470-0.501). UM and BM had worse 5-year OS versus BCT (UM: 0.926, vs BM: 0.952, vs BCT: 0.960).

CONCLUSIONS

BCT is increasingly used to treat HER2+ and TN tumors. More extensive surgery is not associated with better survival outcomes, regardless of tumor phenotype.

Socioeconomic Disparities in Neoadjuvant Chemotherapy for Early-Stage Breast Cancer

Background

Neoadjuvant chemotherapy (NCT) is often used for patients with early-stage breast cancer. Disparities in the use of NCT based on clinical, demographic, and socioeconomic factors have not been evaluated.

Methods

Data from the National Cancer Database was analyzed for patients with T1-2, N0-1 breast cancer from 2006 to 2015. Univariate and multivariate analysis determined which factors predicted for the receipt of NCT.

Results

We found 159 946 eligible patients. Factors associated with receipt of NCT included T2 vs. T1 disease, N1 vs. N0, and treatment at an academic facility. Race itself was not significant; however, a higher level of education amongst Black populations correlated with the receipt of NCT.

Discussion

Clinical factors are the greatest determinants for receipt of NCT in early-stage breast cancer. Disparities exist that cannot be explained by race alone; socioeconomic and demographic factors are important. Cancer care should be evaluated in the context of the intersectionality of these health determinants.

Distance to radiation therapy facility influences surgery type among older women with early‐stage breast cancer

BACKGROUND

Breast-conserving surgery plus radiation (BCT) yields equivalent or better survival than mastectomy for early-stage breast cancer (ESBC) women. However, nationwide mastectomy trends increased in recent decades, attracting studies on underlying causes. Prior research identified that long distance to the radiation treatment facility (RTF) was associated with mastectomy. Still, it is unclear whether such association applies to young and old ESBC women comparably. We sought to delineate such impacts by age.

METHODS

Women diagnosed with stages 0-II breast cancer in 2013-2017 receiving either BCT or mastectomy were identified from the Louisiana Tumor Registry. We assessed the association of surgery (mastectomy vs. BCT) with the distance to the nearest or nearest accessible RTFs using multivariable logistic regression adjusting the socio-demographic and tumor characteristics. The nearest accessible RTF was determined based on patients' health insurance. For Medicaid, uninsured, and unknown insurance patients, the nearest accessible RTF is the nearest RTF owned by the government. The interaction effect of age and distance was evaluated as well.

RESULTS

Of 11,604 patients, 46.7% received mastectomy. Compared with distance ≤5 miles to the nearest RTF, those with distance ≥40 miles or 15-40 miles had higher odds of mastectomy (adjusted (adj) OR = 1.39, 95% CI = 1.07-1.82; adj OR = 1.17, 95% CI = 1.02-1.34). To the nearest accessible RTF, the adj ORs were 1.25 (95% CI = 1.03-1.51) and 1.19 (95% CI = 1.04-1.35), respectively. Age-stratified analysis showed the significant association (p < 0.05) only presented among women aged ≥65, but not those aged <65 years.

CONCLUSION

Distance to the nearest or nearest accessible RTF influences the surgery choice, especially among women in Louisiana ≥65 years with ESBC. Further understanding of factors leading to the decision for mastectomy in this age group is needed.

Yield of Surveillance Imaging After Mastectomy With or Without Reconstruction for Patients With Prior Breast Cancer: A Systematic Review and Meta-analysis

IMPORTANCE

A discrepancy on current guidelines and clinical practice exists regarding routine imaging surveillance after mastectomy, mainly regarding the lack of adequate evidence for imaging in this setting.

OBJECTIVE

To investigate the usefulness of imaging surveillance in terms of cancer detection and interval cancer rates after mastectomy with or without reconstruction for patients with prior breast cancer.

DATA SOURCES

A comprehensive literature search was conducted in 3 electronic databases-PubMed, ISI Web of Science, and Scopus-without year restriction. References from relevant reviews and eligible studies were also manually searched.

STUDY SELECTION

Eligible studies were defined as those conducting surveillance imaging (mammography, ultrasonography, or magnetic resonance imaging [MRI]) of patients with prior breast cancer after mastectomy with or without reconstruction that presented adequate data to calculate cancer detection rates for each surveillance method.

DATA EXTRACTION AND SYNTHESIS

Independent data extraction by 2 investigators with consensus on discrepant results was performed. A quality assessment of studies was performed using the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies-2) template. The generalized linear mixed model framework with both fixed-effects and random-effects models was used to meta-analyze the proportion of cases across studies including 3 variables: surveillance method, reconstruction after mastectomy, and surveillance measure.

MAIN OUTCOMES AND MEASURES

Three outcome measures were calculated for each eligible study and each surveillance imaging method within studies: overall cancer detection (defined as ipsilateral cancer, both palpable and nonpalpable) rate per 1000 examinations, clinically occult (nonpalpable) cancer detection rate per 1000 examinations, and interval cancer rate per 1000 examinations.

RESULTS

In total, 16 studies were eligible for the meta-analysis. The pooled overall cancer detection rates per 1000 examinations were 1.86 (95% CI, 1.05-3.30) for mammography, 2.66 (95% CI, 1.48-4.76) for ultrasonography, and 5.17 (95% CI, 1.49-17.75) for MRI. For mastectomy without reconstruction, the rate of clinically occult (nonpalpable) cancer per 1000 examinations (2.96; 95% CI, 1.38-6.32) and the interval cancer rate per 1000 examinations (3.73; 95% CI, 0.84-3.98) were lower than the overall cancer detection rate (including both palpable and nonpalpable lesions) per 1000 examinations (6.41; 95% CI, 3.09-13.25) across all imaging modalities. The interval cancer rate per 1000 examinations for mastectomy with reconstruction (3.73; 95% CI, 0.41-2.73) was comparable to the pooled cancer detection rate per 1000 examinations (4.73; 95% CI, 2.32-9.63) across all imaging modalities. In all clinical scenarios and imaging modalities, lower rates of clinically occult cancer compared with cancer detection rates were observed.

CONCLUSIONS AND RELEVANCE

Lower detection rates of clinically occult-compared with overall-cancer across all 3 imaging modalities challenge the use of imaging surveillance after mastectomy, with or without reconstruction. Findings suggest that imaging surveillance in this context is unnecessary in clinical practice, at least until further studies demonstrate otherwise. Future studies should consider using the clinically occult cancer detection rate as a more clinically relevant measure in this setting.