Second primary cancers of the breast: incidence and risk factors

Personalizing Decision-Making for Patients Choosing Contralateral Prophylactic Mastectomy: A Utility Analysis of Genetic Factors and the Relative Risk of Breast Cancer

Introduction

There has been an increasing trend of patients with breast cancer electing to undergo contralateral prophylactic mastectomy (CPM), despite the lack of evidence showing long-term survival benefit. We aim to quantify the tiered amount of genetic and surgical complication risk deemed necessary to justify CPM.

Methods

A review of breast cancer-affiliated genetic mutations and morbidity rates of breast cancer surgery from a single institution was compiled. A survey using a utility analysis was created. Severity of breast cancer genetic risk and morbidity risk warranting CPM was quantified and evaluated.

Results

A total of 143 surveys were submitted by women of the general population. Data analysis confirmed previous predictions that at a hypothetical increased risk of contralateral breast cancer (CBC), about twice the proportion of women will elect CPM. With over 10 times the baseline risk and no surgical complications, 98.6% of women chose CPM. There was a decrease in affirmative responses with increasing morbidity. This decrease was least prominent at higher genetic risk, illustrating that when women are at a higher risk of CBC, the surgical morbidity rate has less of an impact on their decision for CPM.

Conclusion

At increased risk of CBC, women are likely to elect for CPM. We anticipate that these findings will encourage the growing use of personalized medicine, with the potential to tailor breast cancer treatment plans for each patient's personal genetic profile.

Assessing the additional surgical risk of contralateral prophylactic mastectomy and immediate breast implant reconstruction

INTRODUCTION

There has been a sharp rise in the rate of contralateral prophylactic mastectomy over the last decade, despite the low incidence of new primary cancers predicted for the contralateral breast. This study compares the postoperative complication rates between the diseased breast treated with mastectomy and the contralateral breast that underwent prophylactic mastectomy, followed by immediate bilateral breast implant reconstruction. We hypothesized that there will be no difference in postoperative outcomes between prophylactic and diseased groups, as the surgical approach would be comparable.

METHODS

After IRB approval, a retrospective chart review identified consecutive unilateral breast cancer patients who underwent bilateral mastectomy and immediate breast reconstruction between May 2008 and May 2018 at a tertiary academic medical center. A paired sample t-test and a penalized logic regression model were constructed to identify relationships between breast laterality and outcomes.

RESULTS

A total of 1117 patients with unilateral breast cancer who underwent bilateral mastectomy and immediate breast implant reconstruction were identified. Rates of capsular contracture and infection were significantly greater in the diseased breast, while rates of revision were significantly greater in the contralateral prophylactic breast. There were no statistically significant differences between breasts in rates of explant, skin flap necrosis or hematoma. When adjusted for confounding variables, a higher infection rate was observed in the diseased breast.

CONCLUSION

This study detected significant differences in postoperative complication rates between the diseased and prophylactic breasts following bilateral mastectomy and immediate breast implant reconstruction. Postoperative complications occurred more frequently in the diseased breast compared with low rates of complications in the contralateral prophylactic breast. This information is helpful for preoperative decision making, as surgeons and patients carefully weigh the additional risks of contralateral prophylactic procedure.

Two-Staged Implant-Based Breast Reconstruction: A Long-Term Outcome Study in a Young Population

Background and objectives: Differences in patient anatomy and physiology exist between young and older patients undergoing breast reconstruction after mastectomy. Breast cancer has been described as being more aggressive, more likely to receive radiation, contralateral mastectomy, as well as bilateral reconstruction in young patients. Our purpose is to report long-term experience on two-staged implant-based breast reconstruction (IBR) in young females, with complication sub-analysis based on obesity and adjuvant radiation. Materials and Methods: Retrospective chart review of all consecutive young patients who underwent two-staged IBR at our institution, between 2000 and 2016, was performed. Patients between 15 and 40 years old with least 1-year follow-up were included. Univariate logistic regression models and receiver operating characteristic (ROC) curves were created. Results: Overall 594 breasts met our inclusion criteria. The mean age was 34 years, and the median follow-up was 29.6 months. Final IBR was achieved in 98% of breasts. Overall, 12% of breasts had complications, leading to explantations of 5% of the devices. Adjuvant radiation was followed by higher rates of total device explantations (p = 0.003), while obese patients had higher rates of total complications (p < 0.001). For each point increase in BMI, the odds of developing complications increased 8.1% (p < 0.001); the cutoff BMI to predict higher complications was 24.81 kg/m². Conclusions: This population demonstrates high successful IBR completion and low explantation rates. These data suggest that obese women and those with planned adjuvant radiation deserve special counseling about their higher risk of complications.

Synchronous bilateral breast cancer patients submitted to conservative treatment and brachytherapy - The experience of a service

Introduction

The incidence of breast carcinoma (BC) has increased in the last years. Between 2 and 12% of patients diagnosed with BC will develop bilateral breast carcinoma (BBC). The treatment of these carcinomas is more aggressive than unilateral BC.

Purpose

To perform a retrospective qualitative analysis of BBC patients whose treatment has included brachytherapy (BT) and to present a revised literature on this issue.

Material and methods

The cases of BBC whose treatment included brachytherapy were revised. The literature on this issue was refreshed.

Results

Five women, aged between 54 and 78 at the time of the diagnosis, submitted to conservative surgery followed by external radiotherapy (RT) with boost of BT or exclusive BT (APBI), in the IPO-P BT Service between 2003 and 2016.

Discussion

The patients with BBC have slightly higher rates of local recurrences, mostly in the tumor bed, where there is a higher risk of local recurrence. Patients treated with BT had lower rates of recurrences than those treated with photons and electrons.

Conclusions

BBC represents a complex challenge for doctors, because in some cases there is a tendency to use more aggressive treatments and, at the same time, it is not easy to achieve the timing for the correct treatment.

Clinicopathological Profile and Treatment Outcomes of Bilateral Breast Cancer: A Study from Tertiary Cancer Center in South India

Background: Bilateral breast cancer (BBC) is a rare clinical entity with limited data regarding clinicopathological aspects and treatment guidelines. Materials and Methods: This was an observational study of patients diagnosed with BBC from August 2012 to July 2014. Synchronous breast cancers (SBCs) was defined as two tumors diagnosed within an interval of 6 months and metachronous breast cancer (MBC) as second cancer diagnosed after 6 months. Results: Out of 750 breast cancer patients seen during a 2-year period, 35 had BBC. Ten patients were diagnosed as SBC whereas 25 patients as MBC. Among patients with MBC, the average time for development of contralateral breast cancer was 5 years. In 8 patients, the contralateral breast cancer was detected mammography whereas rest 27 patients were detected by clinical breast examination. At a median follow-up of 24 months, 23 (66%) patients were disease free, 9 (26%) patients had disease relapse, and 3 (8%) patients succumbed to the progressive disease. Conclusions: Every patient with breast cancer should be regularly followed up with clinical breast examination at a more frequent interval. The role of frequent clinical breast examination appears more than mammography especially beyond 5 years for early detection of contralateral breast cancer.

An Analysis of the Decisions Made for Contralateral Prophylactic Mastectomy and Breast Reconstruction

BACKGROUND

Little is known about the role breast reconstruction plays in decisions made for contralateral prophylactic mastectomy. This study explores factors critical to patient medical decision-making for contralateral prophylactic mastectomy and reconstruction among women with early stage, unilateral breast cancer.

METHODS

A mixed methods approach was used to gain an understanding of patients' choices and experiences. Patients with stage 0 to III unilateral breast cancer who underwent reconstruction were recruited, and semistructured interviews were conducted. Patient-reported outcomes were evaluated using the Concerns About Recurrence Scale and the BREAST-Q.

RESULTS

Thirty patients were enrolled; 13 (43 percent) underwent unilateral mastectomy and 17 (57 percent) underwent contralateral prophylactic mastectomy. Three broad categories emerged from patient interviews: medical decision-making, quality of life after mastectomy, and breast reconstruction expectations. Patients who chose contralateral prophylactic mastectomy made the decision for mastectomy based primarily on worry about recurrence. Quality of life after mastectomy was characterized by relief of worry, especially in patients who chose contralateral prophylactic mastectomy [n = 14 (82.4 percent)]. Patients' desires for symmetry, although not the primary reason for contralateral prophylactic mastectomy, played a role in supporting decisions made. Levels of worry after treatment were similar in both groups (72.7 percent). Patients with contralateral prophylactic mastectomy had higher mean scores for satisfaction with breast (82.4 versus 70.6) and satisfaction with outcome (89.9 versus 75.2).

CONCLUSIONS

The choice for contralateral prophylactic mastectomy is greatly influenced by fear of recurrence, with desires for symmetry playing a secondary role in decisions made.

A model for individualized risk prediction of contralateral breast cancer

PURPOSE

Patients diagnosed with invasive breast cancer (BC) or ductal carcinoma in situ are increasingly choosing to undergo contralateral prophylactic mastectomy (CPM) to reduce their risk of contralateral BC (CBC). This is a particularly disturbing trend as a large proportion of these CPMs are believed to be medically unnecessary. Many BC patients tend to substantially overestimate their CBC risk. Thus, there is a pressing need to educate patients effectively on their CBC risk. We develop a CBC risk prediction model to aid physicians in this task.

METHODS

We used data from two sources: Breast Cancer Surveillance Consortium and Surveillance, Epidemiology, and End Results to build the model. The model building steps are similar to those used in developing the BC risk assessment tool (popularly known as Gail model) for counseling women on their BC risk. Our model, named CBCRisk, is exclusively designed for counseling women diagnosed with unilateral BC on the risk of developing CBC.

RESULTS

We identified eight factors to be significantly associated with CBC-age at first BC diagnosis, anti-estrogen therapy, family history of BC, high-risk pre-neoplasia status, estrogen receptor status, breast density, type of first BC, and age at first birth. Combining the relative risk estimates with the relevant hazard rates, CBCRisk projects absolute risk of developing CBC over a given period.

CONCLUSIONS

By providing individualized CBC risk estimates, CBCRisk may help in counseling of BC patients. In turn, this may potentially help alleviate the rate of medically unnecessary CPMs.

Body mass index, weight change, and risk of second primary breast cancer in the WECARE study: influence of estrogen receptor status of the first breast cancer

Studies examining the relationship between body mass index (BMI) and risk of contralateral breast cancer (CBC) have reported mixed findings. We previously showed that obese postmenopausal women with estrogen receptor (ER)‐negative breast cancer have a fivefold higher risk of CBC compared with normal weight women. In the current analysis, we reexamined this relationship in the expanded Women's Environmental Cancer and Radiation Epidemiology (WECARE) Study, focusing on the impact of menopausal status and ER status of the first breast cancer. The WECARE Study is a population‐based case–control study of young women with CBC (cases, N = 1386) and with unilateral breast cancer (controls, N = 2045). Rate ratios (RR) and 95% confidence intervals (CI) were calculated to assess the relationship between BMI and risk of CBC stratified by menopausal and ER status. Positive associations with obesity and weight gain were limited to women who became postmenopausal following their first primary breast cancer. Among those with an ER‐negative first breast cancer, obesity (vs. normal weight) at first diagnosis was associated with an increased risk of CBC (RR = 1.9, 95% CI: 1.02, 3.4). Also, weight gain of ≥10 kg after first diagnosis was associated with an almost twofold increased risk of CBC (RR = 1.9, 95% CI: 0.99, 3.8). These results suggest that women with an ER‐negative first primary cancer who are obese at first primary diagnosis or who experience a large weight gain afterward may benefit from heightened surveillance. Future studies are needed to address the impact of weight loss interventions on risk of CBC.

Trends and concepts in post-mastectomy breast reconstruction

A number of factors have contributed to a paradigm shift in US post-mastectomy breast reconstruction. The increasing numbers of contralateral prophylactic mastectomies strongly correlated to a rise in implant-based reconstructions. Autologous reconstruction, however, has faced a number of barriers including technically complicated perforator flaps and declining reimbursements. As such, a market concentration has developed within high volume microsurgical centers. As more patients receive radiation, the timing and method of reconstruction has become a controversial topic. J. Surg. Oncol. 2016;113:891-894. © 2016 Wiley Periodicals, Inc.

A paradigm shift in U.S. breast reconstruction: Part 2. The influence of changing mastectomy patterns on reconstructive rate and method

BACKGROUND

The aims of the current study were to (1) measure trends in the type of mastectomy performed, (2) evaluate sociodemographic/hospital characteristics of patients undergoing contralateral prophylactic mastectomy versus unilateral mastectomies, and (3) analyze reconstruction rates and method used following different mastectomy types.

METHODS

Mastectomies from 1998 to 2008 were analyzed using the Nationwide Inpatient Sample database. Mastectomies (n = 178,603) were classified as either unilateral, contralateral prophylactic, or bilateral prophylactic. Reconstructive procedures were categorized into either implant or autologous. Longitudinal trends were analyzed with Poisson regression and sociodemographic/hospital variables were analyzed with logistic regression.

RESULTS

Unilateral mastectomies decreased 2 percent per year, whereas contralateral and bilateral prophylactic mastectomies increased significantly by 15 and 12 percent per year, respectively (p < 0.01). Independent predictors for contralateral prophylactic mastectomy (compared with unilateral mastectomy) were patients younger than 39 years, Caucasian and Hispanic race, private insurance carriers, treated in teaching hospitals, and from South and Midwest regions. Contralateral prophylactic mastectomy is the only group with increased reconstruction rates throughout the study period (p < 0.01). Although implant use increased for all mastectomy types, it remains greater in bilateral and contralateral prophylactic mastectomy.

CONCLUSIONS

There is increasing use of bilateral mastectomies in the United States, particularly in patients with unilateral cancer. Although implant use has increased for all mastectomy types, they are used most commonly following bilateral and contralateral prophylactic mastectomies. Changing mastectomy patterns are one factor underlying the paradigm shift away from autologous tissue to implant-based reconstruction.

Early-onset breast cancer: what do we know about the risk factors?: A Countercurrents Series

If a woman develops invasive breast cancer in the left breast at age 30, the probability of her developing breast cancer in the right breast by age 40 is about 5% (0.5% per year) 1.[...]

Body mass index and risk of second primary breast cancer: the WECARE Study

The identification of potentially modifiable risk factors, such as body size, could allow for interventions that could help reduce the burden of contralateral breast cancer (CBC) among breast cancer survivors. Studies examining the relationship between body mass index (BMI) and CBC have yielded mixed results. From the population-based, case-control, Women's Environmental, Cancer and Radiation Epidemiology (WECARE) Study, we included 511 women with CBC (cases) and 999 women with unilateral breast cancer (controls) who had never used postmenopausal hormone therapy. Rate ratios (RR) and 95% confidence intervals (CI) were used to assess the relationship between BMI and CBC risk. No associations between BMI at first diagnosis or weight-change between first diagnosis and date of CBC diagnosis (or corresponding date in matched controls) and CBC risk were seen. However, obese (BMI ≥ 30 kg/m(2)) postmenopausal women with estrogen receptor (ER)-negative first primary tumors (n = 12 cases and 9 controls) were at an increased risk of CBC compared with normal weight women (BMI < 25 kg/m(2)) (n = 43 cases and 98 controls) (RR = 5.64 (95% CI 1.76, 18.1)). No association between BMI and CBC risk was seen in premenopausal or postmenopausal women with ER-positive first primaries. Overall, BMI is not associated with CBC risk in this population of young breast cancer survivors. Our finding of an over five-fold higher risk of CBC in a small subgroup of obese postmenopausal women with an ER-negative first primary breast cancer is based on limited numbers and requires confirmation in a larger study.

Breast cancer in women under age 40 years: treatment by total mastectomy and reconstruction

INTRODUCTION

Breast cancer in women under 40 years of age is rare, accounting for approximately 5% of cases. The disease tends to be more aggressive in younger women. Younger age has been shown to be an independent predictive of breast reconstruction after total mastectomy. Treatment by total mastectomy and reconstruction is examined in relation to patient age.

METHODS

A retrospective review of all breast cancer patients treated by total mastectomy and reconstruction between 2005 and 2009 was performed by querying a prospective database.

RESULTS

A total of 671 patients underwent total mastectomy and reconstruction; of them, 106 (16%) aged <40 and 565 (84%) aged ≥40 years. Compared with older patients, the age <40 group was more likely to present with advanced breast cancer (P < 0.001), receive radiation (P = 0.006), undergo contralateral prophylactic mastectomy (P < 0.001) and bilateral reconstruction (P = 0.005), and undergo delayed reconstruction (P = 0.02). Transverse rectus abdominis musculocutaneous flap reconstruction was more common in the age ≥40 years (P = 0.03). Bilateral reconstruction was most commonly performed with tissue expansion regardless of patient age.

CONCLUSIONS

Breast reconstruction in women less than 40 years of age is influenced by advanced tumor stage and the necessity for adjuvant radiation therapy as well as an increased use of contralateral prophylactic mastectomy.

Occult malignancy in patients undergoing contralateral prophylactic mastectomy

OBJECTIVE

To identify factors that predict for occult malignancy or high-risk lesions (HRL) in the contralateral breast among women undergoing contralateral prophylactic mastectomy (CPM).

BACKGROUND

A growing number of women are choosing to undergo CPM, yet the benefit of this procedure for the average woman with breast cancer remains uncertain. The identification of reliable predictors of occult malignancy or HRL in the contralateral breast may aid in selecting patients most likely to benefit from CPM.

METHODS

Patients undergoing mastectomy with CPM for their first diagnosis of unilateral stage 0 to III breast cancer were retrospectively identified (1997-2005). Univariate and multivariate logistic regression was used to identify factors predictive of HRL and/or occult contralateral breast cancer (CBC).

RESULTS

Among 2965 patients, 407 (13%) underwent CPM. Occult CBC was identified in 24 (6%) patients, and 114 (28%) had an HRL. On univariate analysis, multifocality/multicentricity of the index cancer was the only factor associated with occult malignancy in the CPM (OR 2.88, P = 0.04). On multivariate analysis, patient age and progesterone receptor positivity of the index cancer were associated with finding either malignancy or a HRL in the CPM.

CONCLUSIONS

The diagnosis of multifocality/multicentricity invasive index cancer was associated with occult malignancy in the CPM; however, lack of standardized definitions and differences in pathologic evaluation limit the application of this finding in the preoperative setting. Until reliable predictors for occult disease are identified, the low rates of occult CBC do not support the use of CPM in average-risk women with newly diagnosed breast cancer.

Risk factors for metachronous contralateral breast cancer suggest two aetiological pathways

Although many studies show an increased risk of metachronous contralateral breast cancer (CBC) in women with a positive family history and young age at diagnosis of the initial breast cancer, the aetiological pathways are still enigmatic. In a cohort of 8478 primary breast cancer patients diagnosed between 1975 and 2006, 558 cases of metachronous CBC were identified. Using multivariate Cox proportional hazards models, we analysed risk factors assessed at the time of the first primary tumour, including patient demographics, tumour characteristics and treatment among 4681 breast cancer patients for whom data on key variables were available. The analysis was performed separately in patients who developed CBC without and with prior recurrence(s). Risk of CBC without prior recurrent disease was increased by a positive family history [adjusted relative risk (RR) 2.8 (95% confidence interval (CI) 1.4-5.5)]; and decreased by endocrine treatment [RR 0.6 (95% CI 0.4-1.0)]. We found an increased risk of CBC with prior recurrent disease with younger age [RR 1.2 (95% CI 1.4-3.0)]; positive family history [RR 2.1 (95%CI 0.8-5.0)]; and extensive lymph node involvement [RR 2.0 (95% CI 1.2-3.6)]. Our results suggest that nodal status of the primary tumour may be as important a risk factor as family history or age, which indicates a high susceptibility to breast cancer or an impaired host defence mechanism. It may also imply that some CBCs are metastases from the first primary tumour, particularly in patients who present with recurrent disease before CBC.

Clinical Management Factors Contribute to the Decision for Contralateral Prophylactic Mastectomy

Purpose

To determine whether increasing rates of contralateral prophylactic mastectomy (CPM) are due to recognition of risk factors for contralateral breast cancer (CBC) or treatment factors related to the index lesion.

Methods

From 1997 to 2005, 2,965 patients with stage 0 to III primary unilateral breast cancer underwent mastectomy at Memorial Sloan-Kettering Cancer Center. Patients who did and did not undergo CPM within 1 year of treatment for their index cancer were compared to identify independent predictors of CPM.

Results

The rate of CPM was 13.8% (n = 407), increasing from 6.7% in 1997 to 24.2% in 2005 (P < .0001). Patients with BRCA mutations or prior mantle radiation (n = 52) accounted for 13% of those having CPM. The rate of CPM by surgeon varied from 1% to 26%. Multivariate logistic regression adjusting for surgeon-identified white race (odds ratio [OR] = 3.3), immediate reconstruction (OR = 3.3), family history of breast cancer (OR = 2.9), magnetic resonance imaging (MRI) at diagnosis (OR = 2.8), age younger than 50 years (OR = 2.2), noninvasive histology (OR = 1.8), and prior attempt at breast conversation (OR = 1.7) to be independent predictors of CPM.

Conclusion

These data suggest that increasing use of CPM is not associated with increased recognition of patients at high risk for CBC. Treatment factors, such as immediate reconstruction, preoperative MRI, and unsuccessful attempts at breast conservation, are associated with increased rates of CPM. Efforts to optimize breast conservation, minimize unnecessary tests, and improve patient education about the low risk of CBC may help to curb this trend.

Breast cancer in young women

Although uncommon, breast cancer in young women is worthy of special attention due to the unique and complex issues that are raised. This article reviews specific challenges associated with the care of younger breast cancer patients, which include fertility preservation, management of inherited breast cancer syndromes, maintenance of bone health, secondary prevention, and attention to psychosocial issues.

Relation of risk of contralateral breast cancer to the interval since the first primary tumour

BACKGROUND

There is no consensus on how to separate contralateral breast cancer (CBC) occurring as distant spread of the primary breast cancer (BC) from an independent CBC.

METHODS

We used standardised incidence ratios (SIRs) to analyse the variations in the risk of CBC over time among 6629 women with BC diagnosed between 1954 and 1983. To explore the most appropriate cutoff to separate the two types of CBC, we analysed the deviance between models including different cutoff points as compared with the basal model with no cutoff date. We also performed a prognostic study through a Cox model.

RESULTS

The SIR was much higher during the first 2 years of follow-up than afterwards. The best cutoff appeared to be 2 years. The risk of early CBC was linked to tumour spread and the risk of late CBC was linked to age and to the size of the tumour. Radiotherapy was not selected by the model either for early or late CBC risk.

CONCLUSION

A clearer pattern of CBC risk might appear if studies used a similar cutoff time after the initial BC.

Patient and surgeon characteristics associated with increased use of contralateral prophylactic mastectomy in patients with breast cancer

INTRODUCTION

Patients with unilateral breast cancer have an increased risk of developing contralateral breast cancer. A recent population-based study demonstrated that the proportion of patients with unilateral breast cancer in the United States who underwent contralateral prophylactic mastectomy (CPM) has increased by 150% in recent years. The current study evaluated patients who underwent breast cancer surgery in a metropolitan-based hospital system to determine factors associated with CPM.

METHODS

We reviewed the records of all patients who underwent surgical treatment for breast cancer in 2006 and 2007 in a single health care system, which included six different hospitals. Exclusion criteria included preoperative diagnosis of bilateral disease, stage IV disease, and a history of previous breast cancer. We recorded patient, treatment, tumor, and surgeon characteristics. Multivariate logistic regression models were used to predict CPM use.

RESULTS

Of 571 eligible patients, 276 (48.3%) underwent breast-conserving surgery (BCS), 130 (22.8%) underwent unilateral mastectomy, and 165 (28.9%) underwent mastectomy and a CPM. Among mastectomy patients, 55.9% underwent CPM. Young age (<40 vs. >55 years), large tumor size (>5 vs. <2 cm), positive family history, lobular histology, multicentric disease, and surgeon gender (female) were independent predictors of increased CPM rates. Body mass index, tumor grade, estrogen receptor status, and preoperative breast magnetic resonance imaging were not associated with increased CPM rates.

CONCLUSIONS

Our study is the first to evaluate specific surgeon characteristics associated with CPM use. Prospective studies are needed to examine factors affecting patient decision-making to develop resources that may assist patients in this process.

Diagnostic and prognostic utility of molecular markers in synchronous bilateral breast carcinoma

Histologic criteria have a limited role in determining whether the synchronous bilateral breast carcinomas represent two primaries or a metastasis to the contralateral breast. We studied the molecular analysis of synchronous bilateral breast carcinoma and whether they are originating from a single or different clone. We examined 17 patients with breast carcinoma, including 12 patients with synchronous bilateral carcinomas and control group of 5 infiltrating ductal carcinomas with regional lymph node metastases. Mutations were quantitatively determined to detect loss of heterozygosity (LOH) and microsatellite size alterations for a broad panel of 15 markers, involving 10 chromosomes using polymerase chain reaction. The carcinomas were classified as de novo or metastasis based on three levels of concordance: (1) marker-affected tumors were considered concordant if 50% or more of the same markers were mutated, (2) same gene copy affected, and (3) temporal sequence of mutation acquisition. In synchronous bilateral breast carcinoma patients, molecular analysis showed discordant mutations in all cases, supporting the diagnosis of de novo bilateral primary breast carcinomas. In patients with lymph node metastases, the primary breast carcinoma and metastases shared the same mutations, revealing a metastatic lesion. In conclusion, the application of molecular technology may play an important role for the differential diagnosis of dual primary carcinomas vs a metastatic breast cancer to contralateral breast. In this study, synchronous bilateral breast cancers represent two independent primaries rather than metastatic events.

Increasing Use of Contralateral Prophylactic Mastectomy for Breast Cancer Patients: A Trend Toward More Aggressive Surgical Treatment

Purpose

Many patients with unilateral breast cancer choose contralateral prophylactic mastectomy to prevent cancer in the opposite breast. The purpose of our study was to determine the use and trends of contralateral prophylactic mastectomy in the United States.

Patients and Methods

We used the Surveillance, Epidemiology and End Results database to review the treatment of patients with unilateral breast cancer diagnosed from 1998 through 2003. We determined the rate of contralateral prophylactic mastectomy as a proportion of all surgically treated patients and as a proportion of all mastectomies.

Results

We identified 152,755 patients with stage I, II, or III breast cancer; 4,969 patients chose contralateral prophylactic mastectomy. The rate was 3.3% for all surgically treated patients; 7.7%, for patients undergoing mastectomy. The overall rate significantly increased from 1.8% in 1998 to 4.5% in 2003. Likewise, the contralateral prophylactic mastectomy rate for patients undergoing mastectomy significantly increased from 4.2% in 1998 to 11.0% in 2003. These increased rates applied to all cancer stages and continued to the end of our study period. Young patient age, non-Hispanic white race, lobular histology, and previous cancer diagnosis were associated with significantly higher rates. Large tumor size was associated with a higher overall rate, but with a lower rate for patients undergoing mastectomy.

Conclusion

The use of contralateral prophylactic mastectomy in the United States more than doubled within the recent 6-year period of our study. Prospective studies are needed to understand the decision-making processes that have led to more aggressive breast cancer surgery.

Breast cancer risk factors and second primary malignancies among women with breast cancer

PURPOSE

To examine the association between breast cancer risk factors and second primary cancers (independent diagnoses occurring at least 12 months after the initial breast cancer diagnosis) among breast cancer survivors.

METHODS

In this population-based study, cancer outcomes among breast cancer survivors first diagnosed during 1987-2000 were investigated. Invasive breast cancer cases were identified from the statewide tumor registry and interviewed regarding their pre-diagnosis risk factors, including reproductive and lifestyle characteristics, approximately 1 year after diagnosis. Data on second primary cancers (not recurrences) and deaths were obtained by linkage with tumor registry reports and death certificates through December 31, 2002. Hazard ratios (HR) were estimated using proportional hazards regression stratified by age and adjusted for stage and other factors.

RESULTS

Among the 10,953 breast cancer cases, 10.8% experienced a second cancer diagnosis within an average of 7 years (including 488 breast, 132 colorectal, 113 endometrial, and 36 ovarian cancers). Risk of a second primary breast cancer increased according to low parity (P = 0.002), older age at menopause (P = 0.08), greater body mass index (P = 0.003) and adult weight gain (P = 0.02), and a family history of breast cancer-particularly among women with 2 or more first-degree affected relatives (HR = 1.8, 95% CI: 1.1-2.9). Reduced risk of colorectal cancer after breast cancer was observed in relation to older ages at menarche (P = 0.05), younger age at menopause (P = 0.04), postmenopausal hormone use (HR = 0.4, 95% CI: 0.3-0.7), normal body mass index (P = 0.07), and infrequent alcohol consumption (P = 0.01). Second endometrial cancer risk was associated with increasing body mass index (P < 0.01) and adult weight gain (P = 0.03). Risk of second ovarian cancer appeared related to recent alcohol intake and family history of breast cancer. Women who reported consuming any alcohol appeared to have a 55% reduction in ovarian cancer risk (95% CI: 0.2-1.0) compared to non-drinkers, while having 2 or more first-degree relatives with breast cancer was associated with an increased risk of ovarian cancer (HR = 4.3, 95% CI: 1.3-14.6).

CONCLUSION

This study suggests that family history of breast cancer as well as potentially modifiable characteristics including body weight, alcohol intake, and postmenopausal hormone use may be associated with risk of a second cancer diagnosis among breast cancer cases.

Combined breast ductal lavage and ductal endoscopy for the evaluation of the high-risk breast: a feasibility study

BACKGROUND AND OBJECTIVES

Evaluation of the ductal epithelium of the breast at increased risk for breast cancer is needed to define the carcinogenic pathway, for risk assessment, and to improve selection of women for chemoprevention therapy. We studied the feasibility of combining breast ductal endoscopy with ductal lavage in the high-risk contralateral breast of women with ipsilateral breast cancer for the evaluation of high-risk ducts and acquisition of ductal epithelial cells for analysis.

METHODS

Breast ducts were studied by ductal lavage and ductal endoscopy, and epithelial cell content studied cytologically and quantitatively.

RESULTS

Twenty-five subjects and 44 ducts, including 22 (50.0%) which did not produce nipple aspirate fluid (NAF), were studied. Cellular atypia was present in five subjects. Ductal endoscopy was performed on 1 or more ducts in 24 subjects. Structural changes were noted in 63.6% of the ducts, most commonly fibrous stranding or bridging. Ductal sampling with endoscopic brush and coil sampling devices provided additional cellular samples of relatively pure ductal epithelial content (> or = 91% purity) in 8/11 subjects.

CONCLUSIONS

Breast ductal endoscopy combined with ductal lavage represents a feasible approach for characterizing the ducts and ductal epithelium of the high-risk breast, especially in a research setting.

High risk of contralateral breast carcinoma in women with hereditary/familial non-BRCA1/BRCA2 breast carcinoma

BACKGROUND

The objectives of the current study were to estimate the risk of developing contralateral breast carcinoma (CBC) among women with hereditary/familial non-BRCA1/BRCA2 breast carcinoma and to determine the factors that may predict their risk of CBC.

METHODS

The study sample consisted of all families (n = 217 families) that were referred between 1994-2001 to the Clinic of Cancer Genetics at the University Hospital of Umeå for suspected hereditary breast carcinoma. The study included all women in the 217 families who had carcinoma of the breast as their first primary invasive malignancy diagnosed between 1970-2001 in northern Sweden. Exclusion criteria were an estimated lifetime risk < 20%, BRCA1/BRCA2 mutation, noninvasive carcinoma (ductal or lobular carcinoma in situ), and bilateral breast carcinoma. In the final analysis, 204 women were included from 120 families.

RESULTS

The cumulative probability of developing CBC among women who had hereditary/familial non-BRCA1/BRCA2 breast carcinoma after 20 years was 27.3% (95% confidence interval, 15.0-37.8) compared with the expected risk (4.9%) among women in northern Sweden who had primary breast carcinoma. A significantly increased risk of CBC was associated with age younger than 50 years at the time of diagnosis of the first primary breast carcinoma (P = 0.006). Adjuvant hormone therapy reduced the risk of CBC (P = 0.036).

CONCLUSIONS

Women with hereditary/familial non-BRCA1/BRCA2 breast carcinoma had a high risk of developing CBC. This risk was attenuated further among women who were younger at the time of onset, who had a cumulative probability of developing CBC of nearly 40% after 15 years, which is similar to the estimated risk among BRCA1/BRCA2 mutation carriers. The results of this study emphasized the importance of genetic counseling for these women.

Incidence and risk factors associated with bilateral breast cancer in area with early age diagnosis but low incidence of primary breast cancer: analysis of 10-year longitudinal cohort in Taiwan

This study aims to examine the incidence and risk factors of bilateral breast cancer in area with low incidence rate. A total of 120 and 1902 women with bilateral and unilateral breast cancers were enrolled; various factors, including those concerning their medical history and life style, were extracted. Using Kaplan-Meier method, we calculate the cumulative incidence of contralateral breast cancer. The results show as follows. The cumulative incidences of contralateral breast cancer at 1, 3, 5 years after diagnosis of first breast cancer were 1.15, 1.94, and 2.97%, respectively. The statistically significant risk factors included menopause (Hazard Ratio (HR) =1.56, (1.00-2.42)), invasive lobular carcinoma (HR=2.98, (1.35-6.56)), receiving chemotherapy (HR=2.21, (1.43-3.42)) and/or radiotherapy (HR=3.32, (2.19-5.05) and a protective factor was tamoxifen therapy (HR=0.5 (0.34-0.74). Size of the second occurred tumour (2.97 cm) tended to be smaller than the first one (3.58 cm) with borderline statistical significance (p=0.0731). Comparing to the existing data on Western countries, we find a higher risk for developing contralateral breast cancer in Taiwan where a low incidence of first breast cancer rate with early age diagnosis is noted. It suggests that first primary breast tumour with early age of onset and lobular carcinoma are found more likely to develop bilateral breast cancers.

Breast-conserving therapy in patients with bilateral breast cancer: do today's treatment choices burn bridges for tomorrow?

PURPOSE

To determine how often initial treatment choices limit treatment options for subsequent breast cancer management in patients undergoing breast-conserving therapy (BCT), in particular with treatment of internal mammary nodes.

METHODS AND MATERIALS

Between January 1985 and June 2001, 464 women with pathologic Stage 0, I, and II (T0-2, N0-1) breast cancer underwent BCT at our institution. All 464 patients had computed tomography-based treatment planning. In patients with bilateral breast cancer, the planning computed tomography scans were used to determine the impact initial radiation therapy fields had on treatment options for subsequent contralateral breast cancer.

RESULTS

There were 500 breast cancers diagnosed in 464 patients. Thirty-six patients (8%) had bilateral breast cancer with 9 (2%) synchronous and 27 (6%) metachronous primaries. In 80 patients, the ipsilateral internal mammary nodes were explicitly treated. Initial breast cancer treatment choices impacted subsequent treatment decisions for the contralateral breast in only 2 of 464 patients (0.4%) in the study: 2 of 80 patients (2.5%) whose internal mammary nodes were treated, and 2 of 27 patients (7.4%) who developed metachronous bilateral breast cancer.

CONCLUSIONS

Initial BCT, including internal mammary node irradiation, rarely compromised future contralateral breast-conserving therapy.

Breast cancer: critical data analysis concludes that estrogens are not the cause, however lifestyle changes can alter risk rapidly

BACKGROUND

The theory that estrogens are causally associated with increased risk of breast cancer and the question of whether lifetime cumulative exposure is necessary are critically reviewed.

METHODS

Systematic search was made of published epidemiological and clinical data relating to estrogen concentrations at different times and situations, and of breast cancer incidence with age and after lifestyle changes.

RESULTS

Breast cancer incidence increases with age, although the rate of increase slows. Reproductive factors are known to affect risk, but data that do not fit the theory of estrogen causation include low estradiol levels and decline of estrogen excretion postmenopausally, rates in HRT-takers, absence of increased rate during or after pregnancy, and breast cancer in men. Breast cancer risk can be altered by external factors within a few years, as shown by studies in both Norway and England during World War II, by changing rates in migrant populations, and by the effect on rates of recent adiposity.

CONCLUSIONS

It is probable that estrogens act as promoters rather than being directly causal. Even as promoters, lifetime exposure to estrogens is not necessary. The cause is most probably a lifestyle factor, changes in which can rapidly alter risk. This has important implications in the search for a causative factor.

Contralateral Breast Cancer and Thromboembolic Events in African American Women Treated With Tamoxifen

BACKGROUND

Information about breast cancer treatment and prevention in African American women is scant, and recommendations for therapy from clinical trials for breast cancer are based primarily on data obtained from white women.

METHODS

We compared the effects of tamoxifen on risk of contralateral breast cancer and thromboembolic events in African American women and white women with a history of primary breast cancer. Data from 13 National Surgical Adjuvant Breast and Bowel Project clinical trials were pooled for analyses of time to contralateral breast cancer as a first event (eight trials and 10,619 patients) and of time to any thromboembolic phenomenon as a first event (all 13 trials and 20,878 patients). Risk factors for contralateral breast cancer and thromboembolic events among all women were determined using univariate proportional hazards models. (For each racial group, the rate of events associated with tamoxifen use was calculated as the ratio of the incidence rate with tamoxifen to that without tamoxifen.) Proportional hazards regression models were used to calculate 95% confidence intervals (CIs) and risk ratios. All statistical tests were two-sided.

RESULTS

Risk factors for contralateral breast cancer were body mass index (BMI) and lymph node positivity; those for thromboembolic events were BMI and age. In women of both ethnicities with estrogen receptor-positive breast cancer, those who took tamoxifen experienced a similar reduction in contralateral breast cancer (risk ratio for African American women = 0.74, 95% CI = 0.46 to 1.17, n = 690; risk ratio for white women = 0.76, 95% CI = 0.59 to 0.98, n = 9929; P = .92). Tamoxifen was also associated with an increase in thromboembolic events. The relative risk for thromboembolic events was higher in both African American and white women treated with tamoxifen and chemotherapy than in those who were treated with tamoxifen alone (risk ratio for African American women = 10.70, 95% CI = 5.94 to 19.28 versus 2.16, 95% CI = 1.26 to 3.71; n = 1842; risk ratio for white women = 15.49, 95% CI = 9.53 to 25.17 versus 3.13, 95% CI = 2.04 to 4.79, n = 19,036), and this effect was similar between the races (P = .10).

CONCLUSIONS

African American and white women appear to have the same risks of contralateral breast cancer and thromboembolic events in response to tamoxifen treatment.

Phenotypic similarities in bilateral breast cancer

Bilateral breast cancers that develop at similar times in an individual are likely to have been subjected to similar hormonal, environmental and genetic influences during tumourogenesis compared with metachronous tumours. As such, it is possible that tumour phenotype in synchronous bilateral breast cancer may display similar biological characteristics. The aim of this study was to identify phenotypic similarities between synchronous and metachronous bilateral breast cancers which may suggest a common origin. Thirty-three cases of synchronous and 46 cases of metachronous bilateral breast cancer that displayed similar tumour type were analysed for concordance in relation to various histological and immunohistochemical parameters. A higher level of concordance was demonstrated for synchronous cases with the highest level seen for oestrogen receptor. It is likely that this is related to similar tumourogenic pathways occurring at equivalent exposure times to various environmental and hormonal influences, although, in a proportion of cases, inherited genetic factors may play a role.

Biopathological profile of multiple synchronous homolateral and bilateral breast cancers

It still needs to be verified whether multiple syncronous homolateral and bilateral breast cancers represent intramammary spread of a single tumor or two or more separate neoplastic events. To clarify this problem, we studied the biopathological profile of 46 homolateral and 20 bilateral cases. The cancers were always surgically removed and processed at the same time. The expression of estrogen receptors (ER), progesterone receptors (PR), MIB 1, p53, and c-erbB-2 was determined. Computer-assisted image analysis (CAS 200) was used to evaluate ER, PR, MIB 1, and p53. The histological concordance was 95.6% in homolateral and 50% in bilateral cases. The immunophenotype profile of multiple homolateral neoplasms showed a concordance between 93.47% for ER and 78.26% for p53. The results were statistically significant for all parameters except for p53. In bilateral cancers, there was a significant statistical concordance for ER. These data strongly suggest that both mechanisms may exert an influence and, in particular, that in the majority of homolateral carcinomas, there may be intramammary spread of tumor cells. In multiple bilateral tumors, however, the great diversity of the histological aspects and the differences in the immunophenotype pattern suggest that the vast majority of these may constitute independent multiple events.

Cancer du sein bilatéral. Incidence et facteurs de risque

OBJECTIVE

To clarify, thanks to a retrospective study of 24 bilateral breast cancer cases, the frequency, the risk factors and the prognosis of bilateral breast cancers.

PATIENTS AND METHOD

Between 1984 and 1999, out of 506 patients treated for unilateral non-metastatic breast cancer at Gynecologic and Obstetric ward, at Maternity Souissi of Rabat, 24 cases of bilateral breast cancers were diagnosed. Our results were compared to those of the literature.

RESULTS

The frequency of bilateral breast cancers was 4.7% (24/506). In 87.5% of cases, these were metachronous cancers with a mean interval of 45 months (12-144 months). Patients under 40 at first cancer ran a fivefold superior risk than women more than 40 (P < 0.05). In cases of T3 or T4 tumors, the risk was 10-fold superior to that in smaller ones (P < 0.05).

DISCUSSION AND CONCLUSION

Significantly more first metachronous tumors were invasive adenocarcinoma cancers. Histologic type of first and second tumor was the same in all cases. The prognosis depends at once on the first and second cancer staging and the treatment must be done according to the same rules as in the first cancer.

The risk of a contralateral breast cancer among women diagnosed with ductal and lobular breast carcinoma in situ: data from the Connecticut Tumor Registry

BACKGROUND

Women diagnosed with breast carcinoma in situ are at increased risk for developing a contralateral breast cancer. The magnitude of this risk and the relationship between this risk and age, time since diagnosis, histologic subtype, and treatment for the first breast cancer is continuing to be defined.

METHODS

The risk of developing a contralateral breast cancer is examined among 4198 women diagnosed with breast carcinoma in situ and reported to the Connecticut Tumor Registry (CTR) between January 1, 1975 and March 14, 1998 using Kaplan-Meier estimation. A Cox proportional hazards model is used to assess the effect of surgical treatment, radiation therapy, age at diagnosis, race, histology, marital status, anatomic location within the breast, and time since diagnosis upon this risk.

RESULTS

The cumulative 5- and 10-year probabilities of being diagnosed with a contralateral breast cancer among women initially diagnosed with a ductal breast carcinoma in situ (DCIS) were 4.3% (95% confidence interval, 3.6-5.0%) and 6.8% (95% confidence interval, 5.5-8.2%), respectively. These risks are 3.35 times greater than those for women without a history of breast cancer but are similar to those for women diagnosed with non-metastatic invasive ductal carcinomas of the breast. The cumulative 5- and 10-year probabilities of being diagnosed with a contralateral breast cancer among women initially diagnosed with a lobular breast carcinoma in situ (LCIS) were 11.9% (95% confidence interval, 9.5-14.3%) and 13.9% (95% confidence interval, 11.0-16.8%), respectively.

CONCLUSIONS

Women diagnosed with LCIS were 2.6 (95% confidence interval, 2.0-3.4%) times more likely than women with DCIS to be diagnosed with a contralateral breast cancer within the first six months of the first breast primary. The risk of developing a contralateral breast cancer more than 6 months after the initial breast cancer was independent of surgical or radiation therapy, time since diagnosis, age at diagnosis, histology, race, marital status, or anatomic location of the cancer within the breast.

Epidemiologic and molecular risk factors for contralateral breast cancer among young women

Women diagnosed with a first breast cancer before the age of 45 years have a greater than 5.0-fold risk of developing a second primary contralateral breast cancer (CBC) than women in the general population have of developing a first breast cancer. Identifying epidemiologic or molecular factors that influence CBC risk could aid in the development of new strategies for the management of these patients. A total of 1285 participants in two case-control studies conducted in Seattle, Washington, who were 21-44 years of age when diagnosed with a first invasive breast carcinoma from 1983 to 1992, were followed through December 2001. Of them, 77 were diagnosed with CBC and 907 tumour tissues from first cancers were analysed. Women with body mass indices (BMIs) >/=30 kg m(-2) had a 2.6-fold greater risk (95% CI: 1.1-5.9) of CBC compared to women with BMIs </=19.9 kg m(-2). Women whose first tumour was c-erbB-2 positive had a 1.7-fold (95% CI: 1.0-3.0) excess CBC risk. Body mass index and c-erbB-2 expression may be risk factors for CBC in young women. Further observational studies are needed to confirm these findings and to evaluate whether testing for c-erbB-2 in this population may help identify those at high risk for CBC.

Histological grade, p53, HER2 and hormone receptor status of synchronous bilateral breast carcinoma

BACKGROUND AND OBJECTIVES

Histological grade and tumor biology remain important predictors of the clinical behavior of breast carcinomas. We analyzed the clinicopathological characteristics and tumor biology with regard to histological grade (HG), p53, HER2 and hormone receptor status to address this question.

PATIENTS AND METHODS

A consecutive series of 74 female synchronous bilateral breast carcinoma patients treated at the National Cancer Center Hospital were the primary source of these retrospective data. Clinicopathological background factors, histological grade and immunohistochemical staining for p53, HER2 and hormone receptor status, were analyzed.

RESULTS

Of 148 synchronous bilateral tumors, 102 were invasive ductal carcinoma (IDC). The others included 24 pure or predominant ductal carcinoma in situ (DCIS), 5 spindle cell carcinomas, 16 invasive lobular carcinomas and 1 squamous cell carcinoma. 128 cases (128/148: 89%) were HG 1 (72/148: 49%) or HG 2 (56/148: 38%). The positivity rates for p53, HER2, estrogen receptor (ER) and progesterone receptor (PR) were 9%(14/148), 18%(26/148), 64%(95/148) and 64%(95/148), respectively.

CONCLUSION

Our findings indicate that synchronous bilateral breast carcinomas showed a higher frequency of invasive lobular carcinoma, lower HG and higher rate of hormone receptor positivity than unilateral breast carcinomas.

Heritable breast cancer in twins

Known major mutations such as BRCA1/2 and TP53 only cause a small proportion of heritable breast cancers. Co-dominant genes of lower penetrance that regulate hormones have been thought responsible for most others. Incident breast cancer cases in the identical (monozygotic) twins of representative cases reflect the entire range of pertinent alleles, whether acting singly or in combination. Having reported the rate in twins and other relatives of cases to be high and nearly constant over age, we now examine the descriptive and histological characteristics of the concordant and discordant breast cancers occurring in 2310 affected pairs of monozygotic and fraternal (dizygotic) twins in relation to conventional expectations and hypotheses. Like other first-degree relatives, dizygotic co-twins of breast cancer cases are at higher than usual risk (standardised incidence ratio (SIR)=1.7, CI=1.1-2.6), but the additional cases among monozygotic co-twins of cases are much more numerous, both before and after menopause (SIR=4.4, CI=3.6-5.6), than the 100% genetic identity would predict. Monozygotic co-twin diagnoses following early proband cancers also occur more rapidly than expected (within 5 years, SIR=20.0, CI=7.5-53.3). Cases in concordant pairs represent heritable disease and are significantly more likely to be oestrogen receptor-positive than those of comparable age from discordant pairs. The increase in risk to the monozygotic co-twins of cases cannot be attributed to the common environment, to factors that cumulate with age, or to any aggregate of single autosomal dominant mutations. The genotype more plausibly consists of multiple co-existing susceptibility alleles acting through heightened susceptibility to hormones and/or defective tumour suppression. The resultant class of disease accounts for a larger proportion of all breast cancers than previously thought, with a rather high overall penetrance. Some of the biological characteristics differ from those of breast cancer generally.

Treatment guidelines and techniques in delivery of postmastectomy radiotherapy in management of operable breast cancer

Radiation therapy has been shown to statistically significantly reduce the risk of locoregional recurrence in high-risk patients with operable breast cancer following mastectomy and systemic therapy. Recent trials have also demonstrated a significant survival benefit following radiotherapy in high-risk patients. Therefore, it is important to identify the patients who could potentially derive that survival benefit and to not offer treatment to those patients who are not at increased risk for failure. Established risk factors that predict for increased rates of locoregional recurrence include axillary lymph node involvement and T3 (or T4) disease. While treatment-related factors, such as the extent of the axillary dissection and extent of lymph nodal positivity, also undoubtedly affect locoregional recurrence, additional studies are needed to define the magnitude of their risk. Locoregional patterns of failure have identified the chest wall and supraclavicular/infraclavicular regions to be the most common sites of locoregional failure following mastectomy, which justifies treatment to these regions. While long-term complications are uncommon following locoregional radiotherapy, careful treatment planning is critical to minimize cardiac (and pulmonary) toxicity.

Efficacy of Breast Conservation Therapy in Early Stage Bilateral Breast Cancer

The purpose of this study was to evaluate the outcome of patients with bilateral breast cancer as compared to unilateral breast cancer treated with breast conservation therapy. Sixty patients with bilateral breast cancer (BBC) and 1,080 unilateral breast cancer (UBC) patients treated with breast conservation therapy from 1977 to 1994 were analyzed for outcome. Of the 60 bilateral patients, 44 were metachronous bilateral breast cancer patients (MBBC) and 16 were synchronous bilateral breast cancer patients (SBBC). The majority of patients received lumpectomy, axillary node dissection, and localized radiation therapy. Median tumor size was 1.4 cm for BBC and 1.5 cm for UBC patients. Median total dose to the tumor bed was 60 Gy for both unilateral and bilateral patients. Of the 44 MBBC patients, 14 received breast conservation for both the first and second lesions, while 30 received breast conservation for only the second metachronous lesion. Thus 58 lesions in 44 patients were treated with breast conservation therapy. Of the SBBC patients, 13 of 16 patients received breast-conserving therapy for both breasts, while 3 received a mastectomy for the second synchronous primary. Median follow-up was 50 months for SBBC patients, 45 months for MBBC patients, and 52 months for UBC patients. Local control and survival were analyzed in patients with SBBC, MBBC, and UBC. The interval to development of local recurrence and survival were calculated from the time of development of the second breast lesion in patients with MBBC. No differences were found for survival and failure-free survival in patients with SBBC, MBBC, or UBC. Five-year overall survival by lifetable analysis was 76% for SBBC, 78% for MBBC, and 87% for UBC patients (p = 0.32 by log-rank analysis). The 5-year failure-free survival was 79% for SBBC, 73% for MBBC, and 85% for UBC patients (p = 0.28 by log-rank analysis). No significant differences were seen for median age, tumor size, pathologic node status, tamoxifen use, chemotherapy use, or median total radiation dose for SBBC, MBBC, or UBC patients. A significant difference was found in the incidence of family history of breast cancer in patients with unilateral versus bilateral breast cancer (p = 0.028 by chi-square analysis). However, there was no difference in outcome of patients by family history of breast cancer. The local control was identical in both BBC and UBC patients, with a local failure rate of 3%. Therefore, breast conservation therapy in local-regional, early stage breast cancer is a rational and efficacious treatment modality for patients with SBBC, MBBC, and UBC.

Diagnosis of metachronous contralateral breast cancer

The purpose of this study was to compare the characteristics of primary breast cancers (PBCs) and metachronous contralateral breast cancers (MCBCs). Between 1984 and 1996, 236 women treated with curative intent for PBC who developed a MCBC >6 months after initial diagnosis (without previous evidence of distant metastases) were retrospectively evaluated for clinical and pathologic characteristics and method of diagnosis of their tumors. There were more noninvasive cancers among the MCBCs than the PBCs (11.4% and 5.1%, respectively, p < 0.02). Among the invasive cancers, the mean size of the MCBCs was smaller than the PBCs (1.94 versus 2.55 cm, p < 0.001). MCBCs were more likely than PBCs to be mammographically detected (46.2% versus 19.9%, p < 0.001). Tumor size was correlated with the method of diagnosis. The mean tumor size was 1.39, 2.02, and 2.69 cm for mammogram-, physician-, and patient-detected tumors, respectively. Among patients having axillary lymph node dissections, mammogram- and physician-detected tumors were less likely to have lymph node metastases than patient-detected tumors (22.0% versus 41.2%, p < 0.005). Regular follow-up of breast cancer patients diagnoses MCBCs when they are smaller and less likely to have nodal metastases than PBCs mainly because of early mammographic detection.

Second cancers after conservative surgery and radiation for stages I-II breast cancer: identifying a subset of women at increased risk

PURPOSE

To assess the risk and patterns of second malignancy in a group of women treated with conservative surgery and radiation in a relatively contemporary manner for early-stage invasive breast cancer, and to identify a subgroup of these women at increased risk for a second cancer.

METHODS AND MATERIALS

From 1978 to 1994, 1,253 women with unilateral Stage I-II breast cancer underwent wide excision, axillary dissection, and radiation. The median follow-up was 8.9 years, with 446 patients followed for >or= 10 years. The median age was 55 years. Sixty-eight percent had T1 tumors and 74% were axillary-node negative. Radiation was directed to the breast only in 78%. Adjuvant therapy consisted of chemotherapy in 19%, tamoxifen in 19%, and both in 8%. Factors analyzed for their association with the cumulative incidence of all second malignancies, contralateral breast cancer, and non-breast cancer malignancy were: age, menopausal status, race, family history, obesity, smoking, tumor size, location, histology, pathologic nodal status, region(s) treated with radiation, and the use and type of adjuvant therapy.

RESULTS

One hundred seventy-six women developed a second malignancy (87 contralateral breast cancers at a median interval of 5.8 years, and 98 non-breast cancer malignancies at a median interval of 7.2 years). Nine women had both a contralateral breast cancer and non-breast cancer second malignancy. The 5- and 10-year cumulative incidences of a second malignancy were 5% and 16% for all cancers, 3% and 7% for contralateral breast cancer, 3% and 8%, for all second non-breast cancer malignancies, and 1% and 5%, respectively, for second non-breast cancer malignancies, excluding skin cancers. Patient age was a significant factor for contralateral breast cancer and non-breast cancer second malignancy. Young age was associated with an increased risk of contralateral breast cancer, while older age was associated with an increased the risk of a second non-breast cancer second malignancy. A positive family history increased the risk of contralateral breast cancer, but not non-breast cancer malignancies. The risk of a contralateral breast cancer increased as the number of affected relatives increased. Tamoxifen resulted in a nonsignificant decrease in contralateral breast cancer and an increase in non-breast cancer second malignancies. The 5-and 10-year cumulative incidences for leukemia and lung cancer were 0.08% and 0.2%, and 0.8% and 1%, respectively. There was no significant effect of chemotherapy or the regions treated with radiation on contralateral breast cancer or non-breast cancer second malignancy. The most common types of second non-breast cancer malignancies were skin cancers, followed by gynecologic malignancies (endometrial), and gastrointestinal malignancies (colorectal and pancreas).

CONCLUSION

The 10-years cumulative incidence of a second cancer in this study was 16%. Young age and family history predicted for an increased risk of contralateral breast cancer, and older age predicted for an increased risk of non-breast cancer malignancy. The majority of patients treated with conservative surgery and radiation with or without adjuvant systemic therapy will not develop a second cancer. Long-term follow-up is important to document the risk and patterns of second cancer, and knowledge of this risk and the patterns will influence surveillance and prevention strategies.

Mutations of the BRCA1 and BRCA2 genes in patients with bilateral breast cancer

Mutations of the BRCA1 or BRCA2 genes have been shown to strongly predispose towards the development of contralateral breast cancer in patients from large multi-case families. In order to test the hypothesis that BRCA1 and BRCA2 mutations are more frequent in patients with bilateral breast cancer, we have investigated a hospital-based series of 75 consecutive patients with bilateral breast cancer and a comparison group of 75 patients with unilateral breast cancer, pairwise matched by age and family history, for mutations in the BRCA1 and BRCA2 genes. Five frameshift deletions (517delGT in BRCA1; 4772delA, 5946delCT, 6174delT and 8138del5 in BRCA2) were identified in patients with bilateral disease. No further mutations, apart from polymorphisms and 3 rare unclassified variants, were found after scanning the whole BRCA1 and BRCA2 coding sequence. Three pathogenic BRCA1 mutations (Cys61Gly, 3814del5, 5382insC) were identified in the group of patients with unilateral breast cancer. The frequencies of common BRCA1 and BRCA2 missense variants were not different between the 2 groups. In summary, we did not find a significantly increased prevalence of BRCA1 and BRCA2 mutations in a hospital-based cohort of German patients with bilateral breast cancer. We conclude that bilaterality of breast cancer on its own is not strongly associated with BRCA1 and BRCA2 mutations when adjusted for age and family history. The high frequency of bilateral disease in multi-case breast cancer families may be due to a familial aggregation of additional susceptibility factors modifying the penetrance of BRCA1 and BRCA2 mutations.

Prognostic significance of synchronous and metachronous bilateral breast cancer

Women previously treated for primary operable breast cancer are at increased risk of developing cancer in the contralateral breast, but the clinical significance of this development is unclear. The purpose of this study was to assess the impact of synchronous bilateral breast cancer or the development of a metachronous contralateral breast primary on the prognosis. In a series of 3210 women age < or = 70 years treated between 1975 and 1995 for primary operable breast cancer, 106 were identified to have bilateral breast cancer. Of these women, 26 were noted to have synchronous bilateral breast primaries (0.8%), and 80 developed a contralateral breast cancer after treatment for an initial primary breast cancer. Using life-tables analysis, there was a significant difference in survival between women with unilateral breast cancer, those with synchronous bilateral breast cancers, and those with metachronous contralateral breast with survivals at 16 years of 53.8%, 42.4%, and 60.1%, respectively (p < 0.0001), from the date of the diagnosis of the first primary tumor. There was no difference in survival seen between the three groups when survival was calculated from the date of diagnosis of the second primary in cases of metachronous contralateral breast cancer (p = 0.31). When contralateral breast cancer was incorporated as a time-dependent covariate in a Cox multivariate model together with the three factors used to determine the Nottingham Prognostic Index (invasive tumor size, grade, and lymph node stage), contralateral breast cancer continued to be a significant prognostic determinant (p = 0.02). The survival of women with synchronous bilateral breast cancer or metachronous breast cancers diagnosed within 2 years of the original primary was worse than those with unilateral disease. However, the time duration to metachronous contralateral breast cancer did not have prognostic significance in a multivariate model compared with the prognostic features of the original primary.