Are Mastectomies on the Rise? A 13-Year Trend Analysis of the Selection of Mastectomy Versus Breast Conservation Therapy in 5865 Patients

Frailty and Malnutrition in Surgical Outcomes of Elderly Breast Cancer Patients

INTRODUCTION

We evaluate the impact of frailty and malnutrition on breast cancer surgery outcomes in older adults using the ACS 5-factor modified frailty index (MFI) and Global Leadership Initiative on Malnutrition (GLIM) definition.

METHODS

Single institution retrospective review of a prospective database of the older adult (>60 years old) breast cancer surgery patients (2000-2016); cases stratified into groups as per MFI (0-2) and GLIM. Characteristics, 90-day post-op events, and 5-year follow-up data were analyzed to report survival and complication outcomes.

RESULTS

Among 436 patients at diagnosis, 213 (48.9%) were >80 years old. 377 (86.5%) were alive at 5 years. 274 (62.8%) had MFI > 0, and 69 (15.8%) had malnutrition. Patients ≥ 80, MFI > 0, and PR-negative tumors had worse 5-year survival. There was no survival difference in patients >80 with/without malnutrition (HR = 1.01, p = 0.971), and there was no difference in mastectomy or lumpectomy (p = 0.560) between patients ≥ 80 or patients younger than 80; however, 94% of immediate reconstruction were in pts < 80. On multivariate regression, complications were associated with age < 80, readmission, MFI > 0, and history of HTN; serious complications were associated with age < 80, readmission, anticoagulation, and not receiving endocrine therapy.

CONCLUSION

MFI showed a significant predictive value for 5-year survival for patients ≥ 80 and should be part of the preoperative evaluation.

Prognosis of isolated locoregional recurrence after early breast cancer with immediate breast reconstruction surgery: a retrospective multi‑institutional study

BACKGROUND

The prognosis in patients with breast cancer with isolated locoregional recurrence (ILRR) without simultaneous distant metastases after immediate breast reconstruction (IBR) remains unknown. We aimed to investigate the prognosis in this patient population.

METHODS

This multi-institutional retrospective observational study evaluated 3295 patients with primary breast cancer who underwent IBR at 12 Japanese medical facilities between January 1, 2008 and December 31, 2016. The outcome measures were the prognostic factors for ILRR after IBR, 5-year distant metastasis-free interval (DMFI), and 5-year overall survival (OS).

RESULTS

Mastectomy or skin-sparing mastectomy was performed in 3295 patients. ILRR occurred in 70 patients, and the median observation period from ILRR diagnosis was 39.3 months. Of the 70 patients, 9 (12.9%) had axillary lymph node recurrence (ALNR) at the time of ILRR diagnosis. The 5-year DMFI and OS rates after ILRR were 92.4% and 91.2%, respectively. Pathological lymph node metastasis at primary surgery (P = 0.041) and ALNR (P = 0.022) at ILRR were significantly associated with DMFI in the univariate analysis. ALNR was the only independent prognostic factor in the multivariate analysis (P = 0.041). Post-mastectomy radiation therapy (PMRT; P = 0.022) and ALNR (P = 0.043) were significantly associated with OS in the univariate analysis, and both PMRT (P = 0.010) and ALNR (P = 0.028) were independent prognostic factors in the multivariate analysis for OS.

CONCLUSIONS

Although patients with breast cancer who had ILRR after IBR have favorable prognosis, ALNR may lead to poor prognosis. To the best of our knowledge, this study is the first to report the prognosis of these patients.

Locoregional Management of Multiple Ipsilateral Breast Cancers: A Review

The incidence of preoperatively diagnosed multiple ipsilateral breast cancer (MIBC) is increasing due to improved sensitivity of screening and preoperative staging modalities including digital breast tomosynthesis (3D breast mammography) and magnetic resonance imaging (MRI). The surgical management of MIBC remains controversial. Many surgeons continue to recommend mastectomy due to high local recurrence rates in patients with MIBC undergoing breast conservation therapy reported in historic, retrospective studies. More recent retrospective studies report acceptable rates of local recurrence. Yet concerns persist due to a paucity of prospective data regarding recurrence as well as concerns for margin positivity, cosmetic outcomes and the feasibility of adequate and safe delivery of radiation following breast conserving surgery. Breast conservation has emerged as the preferred surgical strategy for eligible patients with unifocal disease. Benefits include improved quality of life, body image and sexual function and lower surgical complication rates. A recent prospective clinical trial has corroborated a large body of retrospective data confirming the safety of breast conserving therapy and adjuvant radiation in women with MIBC with good oncologic control, low rates of conversion to mastectomy and satisfactory patient-reported cosmetic outcomes. With the current rise in MIBC diagnoses, it is imperative that surgeons understand the existent evidence in order to guide shared decision-making conversations with patients diagnosed with MIBC. This comprehensive review synthesizes the best available data and offers current recommendations for management of both the primary sites of disease as well as management of the axilla in patients with MIBC.

Epidemiology and prognostic nomogram for invasive breast cancer aged 85 years and older in the USA

The available data on epidemiology and prognostic factors of female patients with breast cancer aged 85 years and older in the USA are limited, especially regarding molecular-level heterogeneity. Relevant data were extracted from the surveillance, epidemiology, and end-result database. The incidence rate and the annual prevalence rate were determined. The annual percent change (APC) of incidence was measured to determine the gradual trends or changes in rates. A visual nomogram was constructed to predict the 3-year overall survival (OS). The Kaplan-Meier method and log-rank test were performed for survival analysis. In total, 18,137 female patients with invasive breast cancer aged 85 years and older were included. Among these patients, patients with HR+/HER2- accounted for 68.7%, followed by HR-/HER2- (9.3%), HR+/HER2+ (7.4%), and HR-/HER2+ (3.1%). The overall incidence rate among this population was 181.82 (95% CI 179.18-184.49) per 100,000 women. This decreased from 184.73 to 177.71 per 100,000 women from 2010 to 2019, with an APC of - 1.0 (95% CI - 1.8 to - 0.1, P = 0.036). The incidence rate varied across receptor subtypes and races and was higher in patients with HR+/HER2- or the black population. The most common treatment regime was breast-conserving surgery. Approximately 29.2% of all patients were categorized as receiving no treatment. A nomogram for predicting 3-year overall survival was constructed, with a consistency index of 0.71. Furthermore, the calibration curves showed consistency. In this study, we have presented the epidemiological data of invasive breast cancer in females aged 85 years and older in the USA. The developed predictive nomogram can effectively identify patients with poor survival.

A Multi-Center Retrospective Observational Analysis of Three-Year Experience of Our Protocol for Prevention and Monitoring of Surgical Site Infections in Implant-Based Breast Reconstruction

BACKGROUND

With the rise in the mastectomy rate, the number of patients who choose to undergo postmastectomy reconstruction has been increasing, and implant-based procedures are the most performed methods for postmastectomy breast reconstruction. Among the possible complications, the most feared is the loss of reconstruction. It can be related to several reasons, but one of the most common is infection of the implant, which can lead to prolonged antibiotic treatment, undesired additional surgical procedures, increased incidence of capsular contracture, and unsatisfactory aesthetics results, with a huge psychological impact on patients.

AIMS

The primary intent of this study is to analyze the status of infection rates at our institution and evaluate the effectiveness of our prevention protocol since its introduction. Secondly, we compared data of the surgical site infections (SSIs) after implant-based breast reconstruction at Trieste Hospital, where the protocol has been employed since 2020, and in another center, where plastic surgeons of our team are involved, with different prevention procedures.

METHODS AND RESULTS

We enrolled 396 female patients, who underwent implant-based breast reconstruction, using definitive mammary implants or breast tissue expanders, with or without ADM (acellular dermal matrix), both for breast cancer and risk-reducing surgery in BRCA1/2 patients. Patients treated at the Hospital of Trieste, with the use of the prevention protocol, were considered the experimental group (group 1), while patients treated in Gorizia by the same breast team with standardized best-practice rules, but without the use of the prevention protocol, were considered the control group (group 2). Infected patients were 5 in the first group (1.7%) and 8 in the second one (7.9%), with a global infection rate of 3.2%.

CONCLUSION

After the introduction of our prevention protocol, we faced a lower incidence of infection after breast surgery with implants or tissue expanders.

Survival pattern in male breast cancer: distinct from female breast cancer

Introduction

Male breast cancer (MBC) is a rare condition, and recent research has underscored notable distinctions between MBC and breast cancer in women. This study aimed to assess and contrast the long-term survival outcomes and disease patterns of MBC patients with those of their female counterparts.

Methods

We analyzed data from 113,845 patients diagnosed with breast cancer who had undergone curative surgery from the Korean Breast Cancer Registry (KBCR) between January 1990 and August 2014 in Seoul, Korea. The five-year overall survival was analyzed according to clinicopathological characteristics.

Results

Among 113,845 patients with breast cancer, 473 MBC cases were included. The median duration of follow-up was 72 months. The median age at diagnosis was 60 and 48 years for MBC and female breast cancer, respectively. Most male patients (92.6%) underwent total mastectomy, while 50.4% of female patients underwent breast-conserving surgery. Among MBC, 63.2% received chemotherapy, and 83.9% of hormone receptor-positive male patients received endocrine therapy. In survival analysis, MBC demonstrated distinct 5-year overall survival patterns compared with female breast cancer, according to age at diagnosis. In women with breast cancer, the younger age group (≤40 years) demonstrated worse 5-year overall survival than did the older age group (>40 years) (91.3% vs 92.7%, p <0.05). While in MBC, the younger age group (≤40 years) demonstrated better 5-year overall survival than did the older age group (>40 years) (97.4% vs 86.4%, p <0.05).

Discussion

In conclusion within this extensive cohort, we have revealed unique survival patterns in MBC that diverge from those observed in women with breast cancer. This study enhances our comprehension of MBC prognosis and can potentially shed light on unresolved questions, paving the way for future research in the realm of MBC.

Choosing breast-conserving therapy or mastectomy and subpectoral implant breast reconstruction: implications for pectoralis major function

BACKGROUND

An increasing number of women are choosing mastectomy and subpectoral implant (SI) breast reconstruction over breast-conserving therapy (BCT). It is unclear to what extent these procedures differ in their effect on the pectoralis major (PM). The purpose of this study was to assess the impact of choosing BCT or SI breast reconstruction on PM function.

METHODS

Ultrasound shear wave elastography images were acquired from the PM fiber regions and surface electromyography obtained activity from six shoulder muscles, while 14 BCT participants, 14 SI participants, and 14 age-matched controls remained at rest or generated submaximal shoulder torques.

RESULTS

BCT and SI participants were significantly weaker in shoulder adduction, while BCT participants were also weaker in internal and external rotation (all p ≤ 0.003). PM function was altered following either BCT or SI. In all treatment groups, the clavicular fiber region contributed primarily to flexion, and the sternocostal primarily contributed to adduction. However, healthy participants utilized the clavicular region more during adduction and the sternocostal region more during flexion when compared to BCT or SI participants (all p ≤ 0.049). The still intact clavicular region increased its contributions to flexion torques in SI participants compared to controls (p = 0.016). Finally, BCT and SI participants compensated for changes in PM function using synergistic shoulder musculature.

CONCLUSION

Both BCT and SI breast reconstruction result in significant long-term upper extremity strength deficits. Our results suggest changes to the underlying function of the PM and the adoption of unique but inadequate neuromuscular compensation strategies drive these deficits.

Near-Surface Dose Correlates With Moist Desquamation and Unplanned Reconstructive Surgery in Patients With Implant-Based Reconstruction Receiving Postmastectomy Radiation Therapy

Purpose

Postmastectomy radiation therapy (PMRT) reduces disease recurrence in appropriately selected patients but may compromise implant-based reconstruction. We investigated whether near-surface dose correlates with radiation-related toxic effects in these patients.

Methods and Materials

Patients receiving PMRT at a single institution from 2016 to 2019 were retrospectively reviewed. Patient demographics and treatment information were collected. Three near-surface structures were retrospectively generated, bound by the chest wall tangent beam as well as the skin surface and the skin-3 mm contour (SR3), skin surface and skin-5 mm contour (SR5), or skin-5 and skin-10 mm contours. Dosimetric analysis of these near-surface contours was performed in 2 Gy intervals. Univariate and multivariate analyses were used to identify predictors of moist desquamation, grade 2+ chest wall pain, use of opiate pain medication, unplanned reconstructive surgery, and implant failure. Logistic regression for each outcome and near-surface contour was performed for receiver-operator area under the curve (AUC) analysis and the Youden J Statistic was used to determine the optimal threshold for each dosimetric parameter.

Results

Of 126 patients reviewed, 109 met the study's eligibility criteria. Median follow-up was 2.3 years. Twenty-five patients (23%) underwent unplanned reconstructive surgery, and 10 (9.2%) experienced implant failure. Among clinical variables, low body mass index and history of smoking predicted unplanned surgery on univariate and multivariate analyses, and moist desquamation predicted grade 2+ chest wall pain. The top dosimetric parameters by AUC for moist desquamation, grade 2+ chest wall pain, use of opiates, unplanned reconstructive surgery, and implant failure were SR5 D10 cc (AUC = 0.701, optimal threshold 57.8 Gy, P < .001), SR3 D10 cc (AUC = 0.600, optimal threshold 56.8 Gy, P = .079), SR5 D10 cc (AUC = 0.642, optimal threshold 57.3 Gy, P = .041), SR3 V44 Gy (AUC = 0.711, optimal threshold 81%, P = .001), and SR3 V44 Gy (AUC = 0.688, optimal threshold 82%, P = .052), respectively.

Conclusions

Near-surface dose correlates with moist desquamation and unplanned reconstructive surgery after PMRT. Further evaluation of prospective optimization of dosimetric parameters related to SR3 and SR5 should be considered.

External Validation of the Breast Cancer Surgery Risk Calculator (BCSRc): A Predictive Model for Postoperative Complications

BACKGROUND

The breast cancer surgical risk calculator (BCSRc) is a prognostic tool that determines a breast cancer patient's unique risk of acute complications following each possible surgical intervention. When used in the preoperative setting, it can help to stratify patients with an increased complication risk and enhance the patient-physician informed decision-making process. The objective of this study was to externally validate the four models used in the BCSRc on a large cohort of patients who underwent breast cancer surgery.

METHODS

The BCSRc was developed by using a retrospective cohort from the National Surgical Quality Improvement Program database from 2005 to 2018. Four models were built by using logistic regression methods to predict the following composite outcomes: overall, infectious, hematologic, and internal organ complications. This study obtained a new cohort of patients from the National Surgical Quality Improvement Program by utilizing participant user files from 2019 to 2020. The area under the curve, brier score, and Hosmer-Lemeshow goodness of fit test measured model performance, accuracy, and calibration, respectively.

RESULTS

A total of 192,095 patients met inclusion criteria in the development of the BCSRc, and the validation cohort included 60,144 women. The area under the curve during external validation for each model was approximately 0.70. Accuracy, or Brier scores, were all between 0.04 and 0.003. Model calibration using the Hosmer-Lemeshow statistic found all p-values > 0.05. All of these model coefficients will be updated on the web-based BCSRc platform: www.breastcalc.org .

CONCLUSIONS

The BCSRc continues to show excellent external-validation measures. Collectively, this prognostic tool can enhance the decision-making process, help stratify patients with an increased complication risk, and improve expectant management.

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.

Efficacy and safety of PARP inhibitors in the treatment of BRCA-mutated breast cancer: an updated systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

Poly-ADP-ribose polymerase inhibitors (PARPis) have emerged as a new class of therapeutic agents for breast cancer patients with breast cancer susceptibility gene (BRCA) mutations. However, the efficacy and toxicity of PARPis have not been clearly established.

METHODS

This study comprehensively evaluated the efficacy and safety of PARPis in patients with BRCA-mutated breast cancer. Online databases were systematically searched, and six clinical trials were included. The primary endpoint of efficacy was progression-free survival (PFS), whereas the secondary endpoints were overall survival (OS) and objective response rate (ORR). Additionally, we assessed the safety of PARPis.

RESULTS

The results of the meta-analysis showed that PARPis can effectively improve the PFS and OS in patients compared with the control group. The pooled HR (PARPi vs control groups) was 0.63 (95% CI, 0.55 - 0.73) and 0.83 (95% CI, 0.73 to -0.95) for PFS and OS, respectively. In safety, PARPis demonstrated controllable adverse reactions. There were no significant differences in overall AEs or grade ≥3 AEs between the PARP inhibitor and control arms.

CONCLUSIONS

Our results confirm the efficacy and safety of PARPis in patients with BRCA-mutated breast cancer, and more specifically clarify the efficacy of PARPis alone or in combination with other chemotherapy drugs. [Figure: see text].

Breast Cancer Statistics, 2022

This article is the American Cancer Society's update on female breast cancer statistics in the United States, including population-based data on incidence, mortality, survival, and mammography screening. Breast cancer incidence rates have risen in most of the past four decades; during the most recent data years (2010-2019), the rate increased by 0.5% annually, largely driven by localized-stage and hormone receptor-positive disease. In contrast, breast cancer mortality rates have declined steadily since their peak in 1989, albeit at a slower pace in recent years (1.3% annually from 2011 to 2020) than in the previous decade (1.9% annually from 2002 to 2011). In total, the death rate dropped by 43% during 1989-2020, translating to 460,000 fewer breast cancer deaths during that time. The death rate declined similarly for women of all racial/ethnic groups except American Indians/Alaska Natives, among whom the rates were stable. However, despite a lower incidence rate in Black versus White women (127.8 vs. 133.7 per 100,000), the racial disparity in breast cancer mortality remained unwavering, with the death rate 40% higher in Black women overall (27.6 vs. 19.7 deaths per 100,000 in 2016-2020) and two-fold higher among adult women younger than 50 years (12.1 vs. 6.5 deaths per 100,000). Black women have the lowest 5-year relative survival of any racial/ethnic group for every molecular subtype and stage of disease (except stage I), with the largest Black-White gaps in absolute terms for hormone receptor-positive/human epidermal growth factor receptor 2-negative disease (88% vs. 96%), hormone receptor-negative/human epidermal growth factor receptor 2-positive disease (78% vs. 86%), and stage III disease (64% vs. 77%). Progress against breast cancer mortality could be accelerated by mitigating racial disparities through increased access to high-quality screening and treatment via nationwide Medicaid expansion and partnerships between community stakeholders, advocacy organizations, and health systems.

3D-printed bolus ensures the precise postmastectomy chest wall radiation therapy for breast cancer

Purpose

To investigate the values of a 3D-printed bolus ensuring the precise postmastectomy chest wall radiation therapy for breast cancer.

Methods and materials

In the preclinical study on the anthropomorphic phantom, the 3D-printed bolus was used for dosimetry and fitness evaluation. The dosimetric parameters of planning target volume (PTV) were assessed, including D_min, D_max, D_mean, D_95%, homogeneity index (HI), conformity index (CI), and organs at risk (OARs). The absolute percentage differences (|%diff|) between the theory and fact skin dose were also estimated, and the follow-up was conducted for potential skin side effects.

Results

In preclinical studies, a 3D-printed bolus can better ensure the radiation coverage of PTV (HI 0.05, CI 99.91%), the dose accuracy (|%diff| 0.99%), and skin fitness (mean air gap 1.01 mm). Of the 27 eligible patients, we evaluated the radiation dose parameter (median(min–max): D_min 4967(4789–5099) cGy, D_max 5447(5369–5589) cGy, D_mean 5236(5171–5323) cGy, D_95% 5053(4936–5156) cGy, HI 0.07 (0.06–0.17), and CI 99.94% (97.41%–100%)) and assessed the dose of OARs (ipsilateral lung: D_mean 1341(1208–1385) cGy, V₅ 48.06%(39.75%–48.97%), V₂₀ 24.55%(21.58%–26.93%), V₃₀ 18.40%(15.96%–19.16%); heart: D_mean 339(138–640) cGy, V₃₀ 1.10%(0%–6.14%), V₄₀ 0.38%(0%–4.39%); spinal cord PRV: D_max 639(389–898) cGy). The skin doses in vivo were D_theory 208.85(203.16–212.53) cGy, D_fact 209.53(204.14–214.42) cGy, and |%diff| 1.77% (0.89–2.94%). Of the 360 patients enrolled in the skin side effect follow-up study (including the above 27 patients), grade 1 was the most common toxicity (321, 89.2%), some of which progressing to grade 2 or grade 3 (32, 8.9% or 7, 1.9%); the radiotherapy interruption rate was 1.1%.

Conclusion

A 3D-printed bolus can guarantee the precise radiation dose on skin surface, good fitness to skin, and controllable acute skin toxicity, which possesses a great clinical application value in postmastectomy chest call radiation therapy for breast cancer.

Changes and challenges in sexual life experienced by the husbands of women with breast cancer: a qualitative study

BACKGROUND

Breast cancer (BC) in women can bring various problems to their marital and family life. Sexual life based on the experiences of the husbands of women diagnosed with BC has not been fully understood. Therefore, this research aimed to explore changes and challenges in sexual life experienced by the husbands of women diagnosed with BC.

METHODS

A qualitative research was carried out on 18 men whose wives had been diagnosed with BC at reproductive age. They were selected using purposeful sampling and were interviewed using in-depth semi-structured interviews. Collected data were analyzed using the conventional content analysis method.

RESULTS

'Sexual life suspension' was the main theme of this research. Also, 'unfulfilled sexual expectations', 'perceived barriers to satisfy sexual expectations', and 'efforts to adapt to sexual problems' were subthemes.

CONCLUSIONS

The husbands of women with BC need support to improve their sexual and marital relationships. Education and counseling about sexual life during the treatment of BC should be incorporated into the healthcare program.

Impact of Locoregional Treatment on Survival in Young Patients with Early-Stage Breast Cancer undergoing Upfront Surgery

BACKGROUND

Randomized, controlled trials comparing breast-conserving therapy (BCT) with mastectomy have demonstrated equivalent overall survival (OS), but recent observational studies have shown improved OS in patients undergoing BCT. These studies provide limited data on young patients who are traditionally offered mastectomy due to perceived higher disease risk. This study examines the OS in a contemporary series of young women with breast cancer undergoing upfront BCT compared with mastectomy.

METHODS

Women ≤40 years old with primary invasive T1-T2, N0-N1 breast cancer were identified from the National Cancer Database between 2006 and 2016. Patient cohorts were based according to locoregional treatment: BCT, mastectomy alone (Mx), and mastectomy with radiotherapy (Mx/RT). Kaplan-Meier method followed by Cox proportional-hazards regression with inverse probability of treatment weighting (IPTW) were performed to account for treatment selection bias effects in OS.

RESULTS

A total of 15,611 patients met the study criteria; 9,509 patients (60.9%) had BCT, 4,020 (25.8%) had Mx/RT, and 2,082 (13.3%) had Mx alone. The median follow-up was 4.6 years (interquartile range [IQR] 3.0-6.4). After IPTW-adjustment, the 5-year OS was similar for BCT (95%), Mx (95%), and Mx/RT (94%), and there was no significant difference in OS in Mx (hazard ratio [HR] = 1.16, 95% confidence interval [CI] 0.90-1.51) and Mx/RT (HR = 1.08, 95% CI 0.88-1.34) compared with BCT. Mx/RT was associated with decreased survival in patients with pT2N0 (HR = 1.78, 95% CI 1.12-2.84).

CONCLUSIONS

Among young patients with early-stage breast cancer, overall survival was equivalent regardless of surgical approach. Breast-conserving therapy remains a safe option in young women despite the clinical tendency to offer upfront mastectomy in young patients.

Analysis of a Trend Reversal in US Lumpectomy Rates From 2005 Through 2017 Using 3 Nationwide Data Sets

Importance

Rates of lumpectomy for breast cancer management in the United States previously declined in favor of more aggressive surgical options, such as mastectomy and contralateral prophylactic mastectomy (CPM).

Objective

To evaluate longitudinal trends in the rates of lumpectomy and mastectomy, including unilateral mastectomy vs CPM rates, and to determine characteristics associated with current surgical practice using 3 national data sets.

Design and Setting

Data from the National Surgical Quality Improvement Program (NSQIP), Surveillance, Epidemiology, and End Results (SEER) program, and National Cancer Database (NCDB) were examined to evaluate trends in lumpectomy and mastectomy rates from 2005 through 2017. Mastectomy rates were also evaluated with a focus on CPM. Longitudinal trends were analyzed using the Cochran-Armitage test for trend. Multivariate logistic regression models were performed on the NCDB data set to identify predictors of lumpectomy and CPM.

Results

A study sample of 3 467 645 female surgical breast cancer patients was analyzed. Lumpectomy rates reached a nadir between 2010 and 2013, with a significant increase thereafter. Conversely, in comparison with lumpectomy rates, overall mastectomy rates declined significantly starting in 2013. Cochran-Armitage trend tests demonstrated an annual decrease in lumpectomy rates of 1.31% (95% CI, 1.30%-1.32%), 0.07% (95% CI, 0.01%-0.12%), and 0.15% (95% CI, 0.15%-0.16%) for NSQIP, SEER, and NCDB, respectively, from 2005 to 2013 (P < .001, P = .01, and P < .001, respectively). From 2013 to 2017, the annual increase in lumpectomy rates was 0.96% (95% CI, 0.95%-0.98%), 1.60% (95% CI, 1.59%-1.62%), and 1.66% (95% CI, 1.65%-1.67%) for NSQIP, SEER, and NCDB, respectively (all P < .001). Comparisons of specific mastectomy types showed that unilateral mastectomy and CPM rates stabilized after 2013, with unilateral mastectomy rates remaining higher than CPM rates throughout the entire time period.

Conclusions

This observational longitudinal analysis indicated a trend reversal with an increase in lumpectomy rates since 2013 and an associated decline in mastectomies. The steady increase in CPM rates from 2005 to 2013 has since stabilized. The reasons for the recent reversal in trends are likely multifactorial. Further qualitative and quantitative research is required to understand the factors driving these recent practice changes and their associations with patient-reported outcomes.

Trends in surgical treatment of early-stage breast cancer reveal decreasing mastectomy use between 2003 and 2016 by age, race, and rurality

PURPOSE

To examine trends in the surgical treatment of breast cancer by age, rurality, and among Black women in a populous, racially diverse, state in the Southeastern United States of America.

METHODS

We identified women diagnosed with localized or regional breast cancer between 2003 and 2016 in the North Carolina Central Cancer Registry (n = 86,776). Using Joinpoint regression we evaluated the average annual percentage change in proportion of women treated with mastectomy versus breast-conserving surgery overall, by age group, among Black women, and for women residing in rural areas.

RESULTS

Overall, the rate of mastectomy usage in the population declined 2.5% per year between 2003 and 2016 (95% CI - 3.2, - 1.7). Over this same time interval, breast-conserving surgery increased by 1.6% per year (95% CI 0.9, 2.2). These temporal trends in surgery were also observed among Black women and rural residing women. Trends in surgery type varied by age group: mastectomy declined over time among women > 50 years, but not among women aged 18-49 at diagnosis.

DISCUSSION

In contrast to national studies that reported increasing use of mastectomy, we found declining mastectomy rates in the early 2000s in a Southern US state with a racially and geographically diverse population. These decreasing trends were consistent among key subgroups affected by cancer inequities, including Black and White rural women.

Racial Disparities in Survival of Breast Cancer Patients After Surgery

Introduction

The racial disparities of opportunity to receive the appropriate intervention and lower insurance coverage may result in survival disparities in different races. This study aims to provide a perspective on racial disparities in the survival of breast cancer patients after surgery.

Methods

Through data from the Surveillance, Epidemiology, and End Results (SEER) program, this study estimated the survival of breast cancer patients of different races from 1998 to 2017. Inverse probability weighting (IPW) was utilized to adjust the imbalanced clinicopathological features of patients of different races.

Results

This study analyzed 214,965 breast cancer patients after surgery. Among them, 130,746 patients received BCS, and the remaining 84,219 breast cancer patients underwent mastectomy. Although Asian or Pacific Islander (API) patients after surgery showed higher survival benefit than that of white patients in the primary data, after adjusting for age at diagnosis, luminal subtype, grade, T stage, and N stage in different races, white individuals had the longest period of survival was higher than that of the minority groups in BCS group [breast cancer-specific survival (BCSS): HR_Whitevs.API = 0.402, HR_{Whitevs.Black} = 0.132; P < 0.001; overall survival (OS): HR_Whitevs.API = 0.689, HR_{Whitevs.Black} = 0.254; all P < 0.001] and mastectomy group (BCSS: HR_Whitevs.API = 0.325, HR_{Whitevs.Black} = 0.128; P < 0.001; OS: HR_Whitevs.API = 0.481, HR_{Whitevs.Black} = 0.206; all P < 0.001)

Conclusions

We first identified that the survival benefit of the minority group after surgery was lower than that of white individuals, regardless of tumor chrematistics and surgery types.

Trends in surgery and adjuvant treatment for early-stage breast cancer: a population-based study in Queensland, Australia

PURPOSE

Our aim was to describe variations in the treatment of early-stage breast cancer and to examine factors associated with disease-specific survival (DSS).

METHODS

The study used linked data for 24,190 women with a T1 (≤ 20 mm) breast cancer who underwent surgery from 2005 to 2019. Multivariate logistic regression was used to model predictors of receiving breast-conserving surgery (BCS) compared to mastectomy and a multinomial model was used to examine factors associated with type(s) of treatment received.

RESULTS

Overall, 70.3% had BCS, with a reduced likelihood of BCS observed for younger women (p < 0.001), rural residence, (p < 0.001), socioeconomic disadvantage (p = 0.004), higher tumour grade (p < 0.001) and surgery in a public versus private hospital (p < 0.001). Compared to women who received BCS and radiation therapy (RT), those having mastectomy alone or mastectomy plus RT were more likely to be younger (p < 0.001), live in a rural area (p < 0.001), have higher-grade tumours (p < 0.001) and positive lymph nodes (p < 0.001). Overall 5-year survival was 95.3% and breast cancer-specific survival was 98.3%. Highest survival was observed for women having BCS and RT and lowest for those having mastectomy and RT (p < 0.001).

CONCLUSION

Our results indicate some variation in the management of early-stage breast cancer. Lower rates of BCS were observed for rural and disadvantaged women and for those treated in a public or low-volume hospital. Whilst survival was high for this cohort, differences in tumour biology likely explain the differences in survival according to treatment type.

Large and diffuse ductal carcinoma in situ: potentially lethal subtypes of "preinvasive" disease

PURPOSE

Trials for DCIS have not explored whether outcomes for patients with large disease burden requiring mastectomy are comparable to those of patients with lumpectomy-amenable disease. We aim to identify whether patients with DCIS larger than 5 cm and diffuse-type DCIS differ in breast cancer mortality (BCM) from patients with disease less than 5 cm.

METHODS

Patients diagnosed with DCIS in the SEER program were assessed to identify factors prognostic of breast-cancer-specific survival using competing risks regression.

RESULTS

44,849 patients met criteria for the cumulative incidence estimate. On competing risks cumulative incidence approximation, the 10-year estimate for BCM for each group was 1.3%, 1.3%, 2.3%, and 5.1%, respectively, and the difference among groups was significant (p = 0.017). On competing risks regression of patients with known covariates, both diffuse-type disease and disease larger than 5 cm (hazard ratio [HR] = 6.2 and 1.7, p = 0.013 and p = 0.042, respectively) were associated with increased risk of BCM. After matching, DCIS > 5 cm and diffuse disease were associated with increased BCM relative to disease < 5 cm (HR = 1.69, p = 0.04). Among patients undergoing mastectomy for disease larger than 5 cm or diffuse disease, the 10-year cumulative incidence for BCM was 0.5% among patients undergoing bilateral mastectomy and 2.4% for patients undergoing unilateral mastectomy.

CONCLUSION

Patients with large and diffuse DCIS represent uncommon but poorly studied DCIS subgroups with worse prognoses than patients with disease smaller than 5 cm. Further studies are needed to elucidate the appropriate treatment for these patients.

An empirical study on quality of life and related factors of Pakistani breast cancer survivors

A comprehensive understanding of the quality of life (QoL) is essential to establish long-term survivor care plans. The present study was aimed at the assessment of QoL of BC survivors with special emphasis on post-treatment physical, emotional, social, and spiritual challenges. We have assessed the QoL of 250 female BC survivors of all age groups through demographic factors. Volunteer BC survivors were registered in the present study who had got treatment from the Institute of Nuclear Medicine and Oncology (INMOL) hospital and Mayo hospital Lahore. An informed consent form was signed by each participant. The physical, psychological, and spiritual well-being was evaluated by a questionnaire filled with the help of respondents. The average age of BC survivors was 52 ± 7.8 years. Most of them (83%) complained of fatigue during daily life activities, 75.1% body pain or headache, 77.1% had problems with appetite, 63.2% reported weight loss, 77.1% had sleep problems, and 90.5% were feeling general weakness. Only 16.2% were satisfied with their physical health and 2% were not satisfied with their medication. Psychologically, 74.4% were feeling different levels of anxiety, only 10% of them were hoping to achieve a desired life. Age group 21 to 40 years reported better physical health, those with 40-50 years of age and family history of BC have shown better mental strength. The physical and psychological health of survivors from rural areas was comparatively better than those from urban areas. The BC survivor women have to face several physical, psychological and social challenges. The majorities of them complain of anxiety, body pain, fatigue, sleep problems, general weakness, and fear about the future. Our findings suggest the need for psychological support, physical activity a comprehensive post-diagnosis and post-treatment physical and mental health assistance plan for all BC survivors. Implications for Cancer Survivors. Survivors of breast cancer experience various challenges including anxiety, sleep problems, body pain, fatigue, and fear about the future. The psychological, physical and social factors make a great difference in their quality of life.

Determinants of Breast-Conserving Therapy in Early-Stage Breast Cancer Patients: A Nationwide Study

INTRODUCTION

Evidence from previous studies and treatment guidelines suggested that breast-conserving therapy (BCT) is the treatment of choice for early-stage breast cancer. However, in the last decades, surgeons have noticed a high percentage of mastectomies done in this population. The aim of this study is to explore the factors associated with not choosing BCT among eligible patients with early-stage breast cancer.

MATERIALS AND METHODS

This study uses a retrospective cohort design. Demographic and clinical characteristics derived from The Taiwan Cancer Registry Database, the National Health Insurance Database and the Death File Database from January 1, 2004 to December 31, 2014. Patients were followed until December 31, 2015. To explore the associated factors related to BCT, we used univariate and multivariate logistic regression analysis.

RESULTS

A total sample of 25,967 stage I breast cancer patients was included. Among them, 12,191 underwent BCT and 13,776 underwent mastectomy as their primary treatment. The logistic regression analysis reveals that age, pay-for-performance (P4P) program participation, number of affected lymph nodes, tumor size and location, were determinants of BCT. Interestingly enough, histological type did not reach the significance level.

CONCLUSION

This study shows that personal and clinical characteristics influence the treatment choice in stage 1 breast cancer patients.

Changes in Korean National Healthcare Insurance Policy and Breast Cancer Surgery Trend in Korea

BACKGROUND

Since April 2015, the Korean National Health Insurance (NHI) has reimbursed breast cancer patients, approximately 50% of the cost of the breast reconstruction (BR) procedure. We aimed to investigate NHI reimbursement policy influence on the rate of immediate BR (IBR) following total mastectomy (TM).

METHODS

We retrospectively analyzed breast cancer data between April 2011 and June 2016. We divided patients who underwent IBR following TM for primary breast cancer into "uninsured" and "insured" groups using their NHI statuses at the time of surgery. Univariate analyses determined the insurance influence on the decision to undergo IBR.

RESULTS

Of 2,897 breast cancer patients, fewer uninsured patients (n = 625) underwent IBR compared with those insured (n = 325) (30.0% vs. 39.8%, P < 0.001). Uninsured patients were younger than those insured (median age [range], 43 [38-48] vs. 45 [40-50] years; P < 0.001). Pathologic breast cancer stage did not differ between the groups (P = 0.383). More insured patients underwent neoadjuvant chemotherapy (P = 0.011), adjuvant radiotherapy (P < 0.001), and IBR with tissue expander insertion (P = 0.005) compared with those uninsured.

CONCLUSION

IBR rate in patients undergoing TM increased after NHI reimbursement.

Comparing the effect of distance to treatment facility on reconstruction and breast conservation therapy for early-stage invasive ductal carcinoma between the nation and the mountain region

BACKGROUND

Our objective is to evaluate the effect of distance to facility on the use of breast conservation therapy and reconstruction for early stage breast cancer.

METHODS

Utilizing the National Cancer Database, we identified females, age <65, with Stage I invasive ductal carcinoma from 2004 to 2015. Using logistic regression, we compared radiation, mastectomy, and reconstruction treatment patterns. A subgroup analysis was performed within the mountain region (MR).

RESULTS

Nationwide, there are decreasing odds of radiation, increasing odds of mastectomy, and increasing odds of reconstruction. Patients living farther were less likely to receive radiation, more likely to undergo mastectomy, with no effect on reconstruction. Within the MR, patients living farther from their facility were less likely to receive radiation, more likely to undergo mastectomy, however, they were less likely to undergo reconstruction.

CONCLUSIONS

Nationwide and within the MR, patients living farther from their facility are less likely to receive radiation and more likely to undergo mastectomy. There is a disparity between the MR and the nation in use of reconstruction for this population.

Recurrence rates and long-term survival factors in young women with breast cancer

Objectives:

To evaluate the factors related to breast cancer (BC) recurrence as well as survival in women ≤40 years old.

Methods:

This is a retrospective medical record review of women aged ≤40 years diagnosed with BC stages I to III between January 2009 and June 2017 at King Abdulaziz University Hospital (KAUH), Jeddah, Saudi Arabia. Demographic data collected included patients’ initial presentation (including age and date of diagnosis), imaging studies, tumor characteristics, type of surgery, systemic therapy (if any) received, and site of first recurrence. Data was analyzed to assess recurrence rate, disease-free survival (DFS), and overall survival (OS), and determine associated factors. Descriptive statistics were used to calculate the mean, median, standard deviation, and quartiles. Chi-square test was performed to test the association between 2 variables. Kaplan-Meier analyses were performed to assess survival distribution.

Results:

A total of 117 patients were included for analysis. Median follow-up was 16 months (range 0 to 99). Five-year DFS 57% and OS was 89%. Adjuvant chemotherapy was associated with a better DFS (hazard ratio of 0.204; 95% confidence interval, 0.050 to 0.832; p=0.027). Higher tumor, node, metastasis stage was significantly associated with worse DFS (p=0.034). Fewer postoperative follow-up visits significantly predicted recurrence (p=0.003).

Conclusion:

We found a high risk of BC recurrence among patients at our institution. Higher cancer stage, nonuse adjuvant chemotherapy, and low follow-up rate were significant predictive factors for recurrence.

Factors Associated With Surgical Modality Following Neoadjuvant Chemotherapy in Patients with Breast Cancer

BACKGROUND

The breast-conserving surgery (BCS) rate for patients with breast cancer in China is much lower than that in Europe and the United States. This study aimed to identify factors affecting the choice of surgical modality following neoadjuvant chemotherapy (NAC) in patients with breast cancer in northwest China.

PATIENTS AND METHODS

Patients who underwent mastectomy or BCS after NAC for invasive breast cancer from January 2013 to December 2017 were enrolled in the study. Single-factor and multivariate logistic regression analyses were applied to identify the association between the type of surgery and demographic characteristics or clinical pathological factors of patients.

RESULTS

This study enrolled 916 patients. Among them, 191 patients (20.9%) and 725 patients (79.1%) underwent BCS and mastectomy, respectively. Patients with high education were less likely to undergo mastectomy compared with patients with less education (P < .001; odds ratio [OR] = 0.50; 95% confidence interval [CI], 0.35-0.71). Patients with cT3 tumors were nearly six times more likely to undergo mastectomy compared with patients with cT1 tumors (P = .003; OR = 5.74; 95% CI, 2.07-15.97). Moreover, patients older than 50 years of age (P < .001; OR = 2.84; 95% CI, = 1.93-4.16) were more likely to be offered mastectomy. No association between the type of surgery and pathological complete response (P = .351) was observed.

CONCLUSION

Pretreatment clinical disease size remains a strong predictor of surgical management, whereas response to NAC appeared to play no role in the surgical decision, suggesting that the potential surgical benefits of NAC may be still under-recogonized in northwest China.

Neuromuscular compensation strategies adopted at the shoulder following bilateral subpectoral implant breast reconstruction

Immediate two-stage subpectoral implant breast reconstruction after mastectomy requires the surgical disinsertion of the sternocostal fiber region of the pectoralis major (PM). The disinsertion of the PM would need increased contributions from intact shoulder musculature to generate shoulder torques. This study aimed to identify neuromuscular compensation strategies adopted by subpectoral implant breast reconstruction patients using novel muscle synergy analyses. Fourteen patients treated bilaterally with subpectoral implant breast reconstruction (>2.5 years post-reconstruction) were compared to ten healthy controls. Surface electromyography was obtained from sixteen shoulder muscles as participants generated eight three-dimensional (3D) shoulder torques in five two-dimensional arm postures bilaterally. Non-negative matrix factorization revealed the muscle synergies utilized by each experimental group on the dominant and non-dominant limbs, and the normalized similarity index assessed group differences in overall synergy structure. Bilateral subpectoral implant patients exhibited similar shoulder strength to healthy controls on the dominant and non-dominant arms. Our results suggest that 3D shoulder torque is driven by three shoulder muscle synergies in both healthy participants and subpectoral implant patients. Two out of three synergies were more similar than is expected by chance between the groups on the non-dominant arm, whereas only one synergy is more similar than is expected by chance on the dominant arm. While bilateral shoulder strength is maintained following bilateral subpectoral implant breast reconstruction, a closer analysis of the muscle synergy patterns underlying 3D shoulder torque generation reveals that subpectoral implant patients adopt compensatory neuromuscular strategies only with the dominant arm.

Women Could Avoid Axillary Lymph Node Dissection by Choosing Breast-Conserving Therapy Instead of Mastectomy

BACKGROUND

The ACOSOG Z0011 trial showed that completion axillary lymph node dissection (cALND) can be safely omitted for some patients with T1-2 clinically node-negative breast cancer with one to two involved sentinel lymph nodes (SLNs) treated with breast-conserving therapy (BCT). There is little evidence for the safety of omitting cALND for mastectomy-treated patients. Consequently, cALND is often recommended for sentinel node-positive patients treated with mastectomy. The aim of this study is to determine the proportion of patients who could avoid cALND by choosing BCT instead of mastectomy at a tertiary cancer center.

PATIENTS AND METHODS

All T1-2 clinically node-negative breast cancer patients treated with BCT or mastectomy between 2012 and 2017 with metastases in the SLN(s) were selected from a prospectively maintained database. Clinical factors and outcomes were evaluated between the two groups. Differences were compared using Wilcoxon rank-sum test, chi-square test or Fisher's exact test as appropriate. Significance was set at the 0.05 level for all analyses.

RESULTS

A total of 306 patients were included, 199 (65.0%) of whom were treated with BCT and 107 (35.0%) with mastectomy. Patients treated with mastectomy were more often treated with cALND compared with those treated with BCT (71.0% versus 26.6%, p < 0.0001). Overall, 52 of the mastectomy patients (68.4%) could have avoided cALND if they had chosen BCT.

CONCLUSIONS

Patients treated with mastectomy are more likely to receive cALND than those treated with BCT. Axillary management should be addressed during discussion of primary tumor therapy, and cALND may be avoided when patients choose BCT instead of mastectomy.

Applications of 3D printing in breast cancer management

Three-dimensional (3D) printing is a method by which two-dimensional (2D) virtual data is converted to 3D objects by depositing various raw materials into successive layers. Even though the technology was invented almost 40 years ago, a rapid expansion in medical applications of 3D printing has only been observed in the last few years. 3D printing has been applied in almost every subspecialty of medicine for pre-surgical planning, production of patient-specific surgical devices, simulation, and training. While there are multiple review articles describing utilization of 3D printing in various disciplines, there is paucity of literature addressing applications of 3D printing in breast cancer management. Herein, we review the current applications of 3D printing in breast cancer management and discuss the potential impact on future practices.

Study protocol: a pilot quasi-experimental trial of tele-rehabilitation and tele-drain care post-mastectomy

Background

Breast cancer is the leading cancer affecting women in Singapore. Its survivors commonly experience decline in physical function and quality of life post-mastectomy, due to their upper limb morbidity and wound issues. Rehabilitation can address the aforementioned issues. When rehabilitation is accessible and easy to adhere, it can optimize recovery.

Home-based tele-rehabilitation guided by healthcare professionals and self-managed by patients can potentially optimize the patients’ adherence to rehabilitation and recovery. With that in mind, a team of breast cancer specialists (oncologists, nurses, and therapists) in Singapore has developed one of the first tele-rehabilitation systems for local women undergoing a unilateral mastectomy. To our knowledge, no such systems have been evaluated or proven effective as a treatment option among local breast cancer patients with acute disabilities.

Methods

This is a pilot quasi-experimental trial that aims to evaluate the feasibility of tele-rehabilitation and tele-drain care compared to usual care. Up to 40 patients (20 per group) will be recruited for this trial. They will be assigned to an intervention group that receives rehabilitation via a tele-rehabilitation system or a control group that receives rehabilitation in person at their clinic. The primary outcome of this trial is rehabilitation participation (i.e., the time spent on rehabilitation). The secondary outcomes are upper extremity functioning, perceived health, and quality of life.

Discussion

As part of this pilot trial, patients who opt in for the tele-rehabilitation will be asked to share their experience with and thoughts on the tele-rehabilitation system. With the evidence obtained from the tele-rehabilitation patients of this trial, we will be able to improve the current system for our future trial. Further, our additional data on rehabilitation participation, physical function, and quality of life will help us design a sufficiently powered future main trial.

Trial registration

The trial was approved by the National Healthcare Group’s Domain Specific Review Board (#2019/00283) and registered with www.ClinicalTrials.gov (#NCT04269967) in February 2020.

Laterality and Patient-Reported Outcomes following Autologous Breast Reconstruction with Free Abdominal Tissue: An 8-Year Examination of BREAST-Q Data

BACKGROUND

Despite the rise in rates of contralateral prophylactic mastectomy, few studies have used patient-reported outcomes to assess satisfaction between unilateral and bilateral breast reconstruction with autologous tissue. The purpose of this study was to investigate patient satisfaction and quality of life following autologous reconstruction to determine whether differences exist between unilateral and bilateral reconstructions to better guide clinical decision-making.

METHODS

The current study examined prospectively collected BREAST-Q results following abdominal free flap breast reconstruction procedures performed at a tertiary academic medical center from 2009 to 2017. The reconstruction module of the BREAST-Q was used to assess outcomes between laterality groups (unilateral versus bilateral) at 1 year, 2 years, 3 years, and more than 3 years.

RESULTS

Overall, 405 patients who underwent autologous breast reconstruction completed the BREAST-Q. Cross-sectional analysis at 1 year, 2 years, and 3 years revealed similar satisfaction scores between groups; however, bilateral reconstruction patients demonstrated higher satisfaction scores at more than 3 years (p = 0.04). Bilateral reconstruction patients reported lower scores of abdominal well-being at 1 year, 2 years, and more than 3 years (p = 0.01, p = 0.03, and p = 0.01, respectively).

CONCLUSIONS

These results suggest that satisfaction with breasts does not differ with the laterality of the autologous reconstruction up to 3 years postoperatively but may diverge thereafter. Bilateral reconstruction patients, however, have lower satisfaction with the abdominal donor site. These data can be used in preoperative counseling, informed consent, and expectations management in patients considering contralateral prophylactic mastectomy.

Implementing a breast cancer patient decision aid: Process evaluation using medical files and the patients' perspective

Objective

Although patient decision aids (PtDAs) have been shown to improve shared decision‐making, integration into clinical care pathways remains limited. This study investigated, among other outcomes, the uptake of the PtDA by professionals and the uptake as perceived by patients.

Methods

We performed a process evaluation among four breast cancer care teams that had been exposed to a multifaceted implementation strategy. Data were gathered by auditing patient files using a standardised data extraction sheet and conducting telephone interviews with patients using a structured interview guide. We analysed the data by using descriptive statistics.

Results

We found that the implementation strategies, including advice on how and when to present the PtDA to the patient, were followed for 14% of the included patients (N = 84); 92% of the patients reported to have received a login code for the web‐based PtDA, while 67% logged in and used the PtDA at home. An important factor influencing the use was the clinician promoting it when delivering the PtDA (OR 9.95 95% CI 3.03–37.72).

Discussion

The implementation strategies were followed in 14% of the patients, and a high delivery of the PtDA was achieved. Redesigning the care pathway and providing personal instruction on using PtDAs seem crucial.

Immediate Breast Reconstruction after mastectomy with polyurethane implants versus textured implants: A retrospective study with focus on capsular contracture

BACKGROUND

Capsular contracture (CC) is the most common complication following Immediate Breast Reconstruction (IBR) with breast implants. Different implant surfaces were developed aiming to reduce the incidence of CC. We evaluated the incidence and degree of CC after Direct-to-Implant (DTI) IBR with insertion of textured (TE) or polyurethane (PU) covered implants.

METHODS

A retrospective review of consecutive patients treated at our Institution with mastectomy and one-stage IBR and implant reconstruction between 2013 and 2018, with or without post mastectomy radiation therapy (PMRT), was conducted. Immediate breast reconstruction was performed by implanting 186 PU covered implants and 172 TE implants.

RESULTS

Three-hundred-twelve women underwent 358 DTI IBR with PU or TE implants, were analyzed with a median follow-up time of 2.3 years (range 1.0-3.0). The overall rate of CC Baker grade III and IV was 11.8% (95%CI: 8.4-16.3), while, after PU and TE implant placement it was 8.1% (95% CI: 4.1-15.7) and 15.8% (95% CI: 4.1-15.7) [p = 0.009]), respectively. Irradiated breasts developed CC more frequently rather than non-irradiated breasts (HR = 12.5, p < 0.001), and the relative risk was higher in the TE group compared with the PU group (HR = 0.3, p = 0.003).

CONCLUSIONS

After mastectomy and one-stage IBR, the use of PU covered implants is associated with a lower incidence of CC compared to TE implants. This advantage is amplified several folds for patients who necessitate PMRT. Footnote: Capsular contracture (CC); Immediate Breast Reconstruction (IBR); Directto- Implant (DTI); Textured (TE); Polyurethane (PU); Post mastectomy radiation therapy (PMRT); Nipple Sparing mastectomy (NSM).

Exploring the Effect of Post-mastectomy complications on 5-year survival

BACKGROUND

Ramifications of postoperative complications on long-term survival after mastectomy are uncertain.

METHODS

Overall complications (Clavien-Dindo Grades I-IIIB) and wound complications were analyzed using the Kaplan-Meier method for impact on 5-year overall (OS) and disease-free survival (DFS).

RESULTS

A total of 378 patients underwent mastectomy alone (157, 41%) or mastectomy with reconstruction (221, 59%) for Stage I-III disease with a median follow-up of 5 years. Postoperative complications occurred in 186 patients (49%), requiring non-surgical (I/II = 83, 22%) or surgical (IIIa/IIIb = 103, 27%) management. Wound complications occurred in 140 patients (37%). Reconstruction was associated with a higher rate of complication (P < 0.001). Postoperative complications after mastectomy (with or without reconstruction) did not significantly affect OS or DFS. Wound complications also showed no significant effect on OS or DFS following mastectomy alone, or mastectomy with reconstruction.

CONCLUSIONS

Postoperative complications after mastectomy, with or without reconstruction, bear no significant impact on 5-year survival.

Postmastectomy Reconstruction is Associated with Improved Survival in Patients with Invasive Breast Cancer: A Single-institution Study

Breast reconstruction after mastectomy positively affects psychosocial well-being; however, the influence of reconstruction on cancer outcomes is unknown. The objective of our study was to compare survival in reconstructed versus nonreconstructed patients after mastectomy. All consecutive female patients diagnosed with invasive breast cancer and treated with mastectomy between 2002 and 2011 were identified from our single-institution database. All cancer operations were performed by two surgeons. Survival was calculated using the Kaplan-Meier method and compared using the log-rank test. To identify the effect of reconstruction on survival, a multivariate Cox regression analysis was performed. Of 474 patients treated, 340 (71.7%) underwent breast reconstruction. At a mean follow-up 3.3 years, reconstructed patients had a longer 5-year survival (91 vs 74%, P < 0.001). After controlling for age, race, payer source, cancer stage, triple negative status, and receipt of radiation or chemotherapy, reconstructed patients maintained a survival advantage over nonreconstructed patients (hazard ratio, 0.47; 95% confidence interval, 0.25 to 0.88; P = 0.02). Patients with breast cancer who undergo reconstruction have longer survival than nonreconstructed patients. The explanation for this finding may be related to improved psychosocial qualities of life versus possible antitumorigenic effects of implants.

Breast-Specific Sensuality and Appearance Satisfaction: Comparison of Breast-Conserving Surgery and Nipple-Sparing Mastectomy

BACKGROUND

We demonstrated previously that lumpectomy (L) patients reported higher appearance satisfaction, appreciation of a pleasurable breast caress, and persistence of the breast during intimacy than mastectomy with reconstruction, which we used to describe breast-specific sensuality. Our current objective was to compare breast-specific sensuality between L and nipple-sparing mastectomy (NSM).

DESIGN

An anonymous, cross-sectional survey was distributed to breast cancer survivors between 2014 and 2016. Eligible patients underwent operation between 2000 and 2014, were adults older than 18 years, English-speaking, and at least one year into the post-operative period. Demographic characteristics, treatment details, Female Sexual Function Index metrics, and investigator-generated questions about appearance satisfaction and breast-specific sensuality were collected.

RESULTS

Of the 600 women who participated, 585 surveys were eligible. Surgical modality was reported as L by 406 (69.4%), mastectomy alone by 50 (8.5%), and mastectomy with reconstruction by 129 (22.1%). Nipple-preservation data were available for 47 of 129 mastectomy with reconstruction patients (36.4%), with 21 NSM and 26 non-nipple-sparing mastectomy patients. Favorable postoperative appearance satisfaction was reported by 76.2% of L and 71.4% of NSM (p = 0.039). Lumpectomy patients reported feeling more comfortable being seen undressed than NSM patients (82.4% vs 71.4%; p = 0.0003). The chest remained a part of intimacy for 65.4% of L patients vs 42.9% of NSM patients (p = 0.0009). A pleasurable breast caress was reported more frequently by L patients than NSM patients (66.2% vs 20%; p ≤ 0.0001). The breast caress was unpleasant for 40% of NSM patients, nearly 4-fold higher than L patients (11.3%; p < 0.0001).

CONCLUSIONS

NSM patients were significantly less satisfied with appearance, less comfortable being seen undressed, had decreased persistence of breast intimacy, and experienced a less pleasurable breast caress than L patients. Counseling patients about these findings will empower informed decision making, optimize expectations, and can enhance postoperative satisfaction.

Health-related quality of life following breast reconstruction compared to total mastectomy and breast-conserving surgery among breast cancer survivors: a systematic review and meta-analysis

The present review evaluated health-related quality of life (HR-QoL) outcomes in surgical breast cancer survivors who received breast reconstruction (BR), breast-conservation surgery (BCS) or mastectomy (M), and whether HR-QoL domains across generic and disease/surgery-specific questionnaires are compatible. Six electronic databases were searched for appropriate observational studies. Standardized scores for different HR-QoL domains in the BR, BCS, and M treatment groups were extracted from each study for the purpose of a meta-analysis. Using Stata version 14.0, a random-effects meta-analysis model was adopted for each outcome variable to estimate the effect size, 95% CI-confidence intervals, and statistical significance. Sixteen of the 18 eligible studies with BR (n = 1474) and BCS (n = 2612) or M (n = 1458) groups were included in the meta-analysis. The BR group exhibited a better physical health (k = 12; 0.1, 95% CI 0.04, 0.24) and body image (k = 12; 0.50, 95% CI 0.10, 0.89) than the M group. However, the two groups exhibited comparable social health (k = 13; 0.1, 95% CI -0.07, 0.37), emotional health (k = 13; -0.08, 95% CI - 0.41, 0.25), global health (k = 7; 0.1, 95% CI - 0.01, 0.27), and sexual health (k =11; 0.2, 95% CI - 0.02,0.57). There was no clear evidence of the superiority of BR to BCS for all the six domains. These results suggest that HR-QoL outcomes in BR and BCS groups are better than the M group. Therefore, women opting for BR or BCS are likely to report fairly better HR-QoL outcomes than M. However, due to the significant heterogeneity observed in most BR versus BCS outcomes, developing a unified questionnaire incorporating both breast/surgery-specific and generic HR-QoL domains is warranted.

Shikonin and 4-hydroxytamoxifen synergistically inhibit the proliferation of breast cancer cells through activating apoptosis signaling pathway in vitro and in vivo

Background

Tamoxifen (TAM) is a cell type-specific anti-estrogen and is applied to improve the survival of patients with estrogen receptor positive (ER +) breast cancer. However, long-term TAM use can induce serious drug resistance, leading to breast cancer recurrence and death in patients. Further, it is almost useless among patients with estrogen receptor negative (ER −) breast cancer. Shikonin (SK) is a natural product broadly explored in cancer therapy. Some studies have demonstrated the combined treatment of SK and clinical anticancer drugs including TAM on various tumors. However, the combined effect of SK and 4-hydroxytamoxifen (4-OHT) on ER- breast cancer is not known. The current study aimed to assess the combination effects of SK and 4-OHT on human breast cancer cells, MCF-7 (ER +) and MDA-MB-435S (ER −), in vitro and in vivo and to investigate the underlying mechanisms.

Methods

CCK-8 assays and flow cytometry were conducted to determine the cell viability and apoptotic profiles of human breast cancer cell lines (MCF-7 and MDA-MB-435S) treated with SK, 4-OHT, and the combination. ROS and JC-1 assays were used to determine ROS level and mitochondrial membrane potential. Western blot analysis was performed to investigate proteins that are associated with apoptosis. Haematoxylin & Eosin (HE) staining was used to detect the tumor and kidney morphology of mice. TUNEL and immunohistochemical staining were performed to detect Ki67 expression level and cell apoptotic profile in tumor tissues.

Results

SK and 4-OHT synergistically inhibited MCF-7 and MDA-MB-435S cell proliferation and promoted apoptosis by reducing mitochondrial membrane potential and increasing the intracellular ROS level. The combination of SK and 4-OHT activated the mitochondrial-dependent apoptosis and the death receptor pathways, significantly regulating the PI3K/AKT/Caspase 9 signaling pathway. Compared with SK and 4-OHT alone, the combination of SK and 4-OHT could better inhibit tumor growth in mice.

Conclusion

The combination of SK and 4-OHT shows highly efficient anticancer effects on breast cancer therapy. SK may be a promising candidate as an adjuvant to 4-OHT for breast cancer treatments, especially for ER- breast cancer.

Contralateral prophylactic mastectomy in breast cancer: what to discuss with patients

Introduction: The contralateral prophylactic mastectomy (CPM) rate in the U.S. has been steadily increasing. This is of particular concern because many women who undergo this procedure are candidates for breast-conserving surgery.Areas covered: CPM's medical benefit is related to the risk of contralateral cancer development and whether CPM provides a survival benefit. Contralateral cancer rates have decreased, and CPM does not provide a survival benefit. Other potential benefits of the procedure may be improved quality of life; these data are reviewed. Research efforts have been undertaken to better understand the decision-making process of patients who consider, and ultimately undergo, this procedure.Expert opinion: Decisional traits, personal values, the desire for peace of mind, and the desire to obtain breast symmetry are important factors that drive a woman's decision to undergo CPM. Additionally, many patients lack the knowledge on how different types of breast surgery impact outcomes. To improve the shared decision-making process, a stepwise approach to address possible misconceptions, and clarify the real risks/benefits of this procedure should be utilized. A clear recommendation (for/against) should be made for every patient with newly diagnosed breast cancer who considers CPM. Communication tools to assist patients and surgeons in this process are sorely needed.

Determinants of receiving immediate breast reconstruction: An analysis of patient characteristics at a tertiary care center in the US

BACKGROUND

Breast reconstruction is an option for women undergoing mastectomy for breast cancer. Previous studies have reported underutilization of reconstructive surgery. This study aims to examine the role demographic, clinical and socio-economic factors may have on patients' decisions to undergo breast reconstruction.

METHODS

We analyzed data from our institutional database. Using multivariable and multinomial logistic regression, we compared breast cancer patients who had undergone mastectomy-only to those who had immediate breast reconstruction (overall and by type of reconstruction).

RESULTS

We analyzed data on 1459 women who underwent mastectomy during the period 2003-2015. Of these, 475 (32.6%) underwent mastectomy-only and 984 (67.4%) also underwent immediate breast reconstruction. After adjusting for potential confounders, older age (OR = 0.18, 95%CI:0.08-0.40), Asian race (OR = 0.29, 95%CI:0.19-0.45), bilateral mastectomy (OR = 0.71, 95%CI:0.56-0.90), and higher stage of disease (OR = 0.44, 95%CI:0.26-0.74) were independent risk factors for not receiving immediate breast reconstruction. Furthermore, patients with Medicare or Medicaid insurance were less likely than patients with private insurance to receive an autologous reconstruction. There was no evidence for changes over time in the way socio-demographic and clinical factors were related to receiving immediate breast reconstruction after mastectomy.

CONCLUSIONS

Clinical characteristics, sociodemographic factors like age, race and insurance coverage affect the decision for reconstructive surgery following mastectomy.

The Effect of the Breast Cancer Provider Discussion Law on Breast Reconstruction Rates in New York State

BACKGROUND

New York State passed the Breast Cancer Provider Discussion Law in 2010, mandating discussion of insurance coverage for reconstruction and expedient plastic surgical referral, two significant factors found to affect reconstruction rates. This study examines the impact of this law.

METHODS

A retrospective cohort study of the New York State Planning and Research Cooperative System database to examine breast reconstruction rates 3 years before and 3 years after law enactment was performed. Difference-interrupted time series models were used to compare trends in the reconstruction rates by sociodemographic factors and provider types.

RESULTS

The study included 32,452 patients. The number of mastectomies decreased from 6479 in 2008 to 5235 in 2013; the rate of reconstruction increased from 49 percent in 2008 to 62 percent in 2013. This rise was seen across all median income brackets, races, and age groups. When comparing before to after law enactment, the increase in risk-adjusted reconstruction rates was significantly higher for African Americans and elderly patients, but the disparity in reconstruction rates did not change for other races, different income levels, or insurance types. Reconstruction rates were also not significantly different between those treated in various hospital settings.

CONCLUSIONS

The aim of the Breast Cancer Provider Discussion Law is to improve reconstruction rates through provider-driven patient education. The authors' data show significant change following law passage in African American and elderly populations, suggesting effectiveness of the law. The New York State Provider Discussion Law may provide a template for other states to model legislation geared toward patient-centered improvement of health outcomes.

Suppressing the metastatic properties of the breast cancer cells using STAT3 decoy oligodeoxynucleotides: A promising approach for eradication of cancer cells by differentiation therapy

Due to the presence of cancer stem cells (CSCs), breast cancer often relapsed after conventional therapies. Strategies that induce differentiation of CSCs will be helpful in eradication of tumor cells, so we designed an oligodeoxynucleotide (ODNs) for targeting of signal transducer and activator of transcription 3 (STAT3) transcription factor which is involved in stemness, and constitutively activated in triple-negative breast cancer. Molecular docking and electrophoretic mobility shift assay analysis showed that decoy ODN bound specifically to the DNA binding site of STAT3 protein. The prevalent uptake of Cy3-labeled ODNs is in the cytoplasm and the nucleus of MDA-MB-231 treated cells. STAT3 decoy ODNs treatment showed cell growth inhibition by decreasing cell viability (17%), increasing the percentage of arrested cells in G0/G1 phases (18%), and triggering apoptosis (29%). Migration and invasion potential decreased from 10.77 to 6.76 µm/hr, by wound closure rate, and migrated/invaded percentage by 26.4% and 15.4% in the transwell assays, respectively. CD44 protein expression level on the cell surface also decreased, while CD24 increased. Mammosphere formation efficiency reduced in terms of tumorsphere size by 47%, while the required time increased. Cells morphology was changed, and lipid droplets were accumulated in the cytoplasm compared to the control and scrambled groups, in all assays (repeated triplicate). Furthermore, the gene expression of all downstream targets significantly decreased owing to suppressing the STAT3 transcription factor. Overall, the results confirmed the antitumor effects of STAT3 decoy in MDA-MB-231 cells. Thus, it seems that STAT3 decoy ODNs might be considered as an auxiliary tool for breast cancer eradicating by the differentiation therapy approach.

Male breast cancer in the United States: Treatment patterns and prognostic factors in the 21st century

BACKGROUND

Male breast cancer (MBC) is a rare disease for which there is limited understanding of treatment patterns and prognostic factors.

METHODS

Men with TNM stage I to stage III breast cancer diagnosed between 2004 and 2014 in the National Cancer Data Base were included. Trends in treatment modalities were described using the average annual percentage change (AAPC) and estimated using Joinpoint software for the analysis of trends. Kaplan-Meier curves and the multivariate Cox proportional hazards regression model were used to compare survival between subgroups and to identify prognostic factors.

RESULTS

A total of 10,873 MBC cases were included, with a median age at diagnosis of 64 years. Breast-conserving surgery was performed in 24% of patients, and 70% of patients undergoing breast conservation received radiotherapy. Approximately 44% of patients received chemotherapy, and 62% of patients with estrogen receptor-positive disease received endocrine therapy. Oncotype DX was ordered in 35% of patients with lymph node-negative, estrogen receptor-positive/human epidermal growth factor receptor 2 (HER2)-negative tumors. During the study period, there was a significant increase in the rates of total mastectomy, contralateral prophylactic mastectomy, radiotherapy after breast conservation, ordering of Oncotype DX, and the use of endocrine therapy (P < .05). On multivariate analysis, factors found to be associated with worse overall survival were older age, black race, higher Charlson Comorbidity Index, high tumor grade and stage of disease, and undergoing total mastectomy. Residing in a higher income area; having progesterone receptor-positive tumors; and receipt of chemotherapy, radiotherapy, and endocrine therapy were associated with better overall survival.

CONCLUSIONS

Despite the lack of prospective randomized trials in patients with MBC, the results of the current study demonstrated that the treatment of this disease has evolved over the years. These findings further the understanding of the modern treatment and prognosis of MBC, and identify several areas for further research.

Long-Term Outcomes of Multiple-Wire Localizations for More Extensive Breast Cancer: Multiple-Wire Excision Does Not Increase Recurrence, Unplanned Imaging, or Biopsies

BACKGROUND

We previously reported that breast conservation was feasible for women with large or irregularly shaped breast cancers when tumor resection was guided by multiple localizing wires. We now report long-term outcomes of multiple-wire versus single-wire localized lumpectomies for breast cancer.

PATIENTS AND METHODS

We retrospectively reviewed wire-localized lumpectomies at our institution from May 2000 to November 2006. Rates of ipsilateral in-breast tumor recurrence, metastasis, and subsequent unplanned diagnostic imaging and biopsy were compared between multiple-wire and single-wire cohorts.

RESULTS

We identified 112 multiple-wire and 160 single-wire breast cancer lumpectomies that achieved clear margins. Median age was 64 years in the multiple-wire cohort and 57 years in the single-wire cohort. Mean lumpectomy volume was 75 mL in multiple-wire patients and 49 mL in single-wire patients (P = .003). Invasive tumor size, axillary node status, and use of radiation and systemic therapy were similar, but the multiple-wire group had more patients with ductal carcinoma-in-situ only (38% vs. 28%). At 108 months' median follow-up, there was no significant difference in local or distant recurrence rates between multiple-wire and single-wire cohorts. Six (5%) multiple-wire patients and 6 (4%) single-wire patients had local recurrences and 3 (3%) multiple-wire and 5 (3%) single-wire patients developed metastatic disease. Unplanned diagnostic imaging was required for 53 (47%) multiple-wire and 65 (41%) single-wire patients. Subsequent ipsilateral biopsy occurred in 15 (13%) multiple-wire and 19 (12%) single-wire patients.

CONCLUSION

Breast-conserving surgery with multiple localizing wires is a safe alternative to mastectomy for breast cancer patients with large mammographic lesions.

Breast cancer statistics, 2019

This article is the American Cancer Society's biennial update on female breast cancer statistics in the United States, including data on incidence, mortality, survival, and screening. Over the most recent 5-year period (2012-2016), the breast cancer incidence rate increased slightly by 0.3% per year, largely because of rising rates of local stage and hormone receptor-positive disease. In contrast, the breast cancer death rate continues to decline, dropping 40% from 1989 to 2017 and translating to 375,900 breast cancer deaths averted. Notably, the pace of the decline has slowed from an annual decrease of 1.9% during 1998 through 2011 to 1.3% during 2011 through 2017, largely driven by the trend in white women. Consequently, the black-white disparity in breast cancer mortality has remained stable since 2011 after widening over the past 3 decades. Nevertheless, the death rate remains 40% higher in blacks (28.4 vs 20.3 deaths per 100,000) despite a lower incidence rate (126.7 vs 130.8); this disparity is magnified among black women aged <50 years, who have a death rate double that of whites. In the most recent 5-year period (2013-2017), the death rate declined in Hispanics (2.1% per year), blacks (1.5%), whites (1.0%), and Asians/Pacific Islanders (0.8%) but was stable in American Indians/Alaska Natives. However, by state, breast cancer mortality rates are no longer declining in Nebraska overall; in Colorado and Wisconsin in black women; and in Nebraska, Texas, and Virginia in white women. Breast cancer was the leading cause of cancer death in women (surpassing lung cancer) in four Southern and two Midwestern states among blacks and in Utah among whites during 2016-2017. Declines in breast cancer mortality could be accelerated by expanding access to high-quality prevention, early detection, and treatment services to all women.

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.

The Impact of Margin Status on Breast Conservation Rates

BACKGROUND

Contemporary data indicate that breast conservation treatment (BCT) results in superior survival outcomes compared with mastectomy. However, positive margins after lumpectomy have implications for local control, and re-excisions are recommended to achieve negative margins. The need for reoperations after an initial attempt at BCT is associated with higher chance of conversion to mastectomy. Achieving negative margins at the first therapeutic surgical procedure is therefore critical to optimise BCT rates and survival outcomes.

METHODS

A compilation of scientific reports on BCT, margin status, rates of reoperation, and the impact on BCT rates was reviewed. Re-excision rates after initial lumpectomy is variable to a staggering degree and reported to be between 0 and 100%. High reoperation rates (ROR) are associated with higher likelihood of conversion to mastectomy, which may not confer favourable treatment outcomes. Although widely agreed that decreasing ROR is a desirable objective, there is controversy regarding the need for its urgent implementation as a quality metric. Critics of this cite challenges related to how this can be achieved and its attendant ramifications. On the other hand, without the appropriate incentive for quality improvement of surgical treatment of breast cancer, patients may be subject to poorer overall outcomes.

DISCUSSION

Techniques and approaches are discussed in this article to enable a reduction in positive margin status, and therefore ROR. The rationale for achieving ROR of 10-20% are explicated, as well as the impact this would have on BCT rates, which translates to better survival outcomes for women with breast cancer.

Cancer treatment and survivorship statistics, 2019

The number of cancer survivors continues to increase in the United States because of the growth and aging of the population as well as advances in early detection and treatment. To assist the public health community in better serving these individuals, the American Cancer Society and the National Cancer Institute collaborate every 3 years to estimate cancer prevalence in the United States using incidence and survival data from the Surveillance, Epidemiology, and End Results cancer registries; vital statistics from the Centers for Disease Control and Prevention's National Center for Health Statistics; and population projections from the US Census Bureau. Current treatment patterns based on information in the National Cancer Data Base are presented for the most prevalent cancer types. Cancer-related and treatment-related short-term, long-term, and late health effects are also briefly described. More than 16.9 million Americans (8.1 million males and 8.8 million females) with a history of cancer were alive on January 1, 2019; this number is projected to reach more than 22.1 million by January 1, 2030 based on the growth and aging of the population alone. The 3 most prevalent cancers in 2019 are prostate (3,650,030), colon and rectum (776,120), and melanoma of the skin (684,470) among males, and breast (3,861,520), uterine corpus (807,860), and colon and rectum (768,650) among females. More than one-half (56%) of survivors were diagnosed within the past 10 years, and almost two-thirds (64%) are aged 65 years or older. People with a history of cancer have unique medical and psychosocial needs that require proactive assessment and management by follow-up care providers. Although there are growing numbers of tools that can assist patients, caregivers, and clinicians in navigating the various phases of cancer survivorship, further evidence-based resources are needed to optimize care.

Patterns of Recurrence Among Higher-Risk Patients Receiving Daily External Beam Accelerated Partial-Breast Irradiation to 40 Gy in 10 Fractions

Purpose

The 2016 American Society for Radiation Oncology consensus guidelines for the use of accelerated partial-breast irradiation (APBI) define “suitable,” “cautionary,” and “unsuitable” populations for this adjuvant breast radiation therapy technique. We sought to determine whether patients in the cautionary group exhibited adverse outcomes after APBI compared with their suitable counterparts.

Methods and Materials

We identified 252 consecutively treated patients from a single institution with in situ or early-stage invasive breast cancer who underwent APBI between 2008 and 2017. Treatment technique was uniform throughout the population, consisting of 3-dimensional conformal radiation therapy to 40 Gy administered in 10 daily fractions.

Results

One hundred seventy-eight patients (70%) were classified as suitable, 69 (27%) as cautionary, and 5 (2.0%) as unsuitable. Because unsuitable patients were few and had no recurrences, they were excluded from analysis. At a median follow-up time of 3.9 years, 97.2% of patients were free of recurrence. Four patients (1.5% overall; 3 suitable and 1 cautionary) experienced ipsilateral in-breast recurrences, and 1 cautionary patient developed an ipsilateral regional recurrence in an axillary lymph node. There was no significant difference in the rate of ipsilateral breast recurrence (2.4% vs 1.0%) between cautionary and suitable groups.

Conclusions

Local recurrences are rare among guideline-defined cautionary patients with in situ or invasive breast cancer treated with APBI delivered via daily 3-dimensional conformal radiation therapy to 40 Gy. At a median follow-up of 3.9 years, no significant differences in local control were noted between cautionary and suitable patient groups. Further study is needed to characterize long-term disease outcomes among various risk groups.