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Yoshida M, Yoshimura RI, Notake R, Shinjo H, Miyaura K, Kuwayama T, Kawanaka T, Shien T, Yoshio K, Shiga T, Kaneyasu Y, Nakagawa T, Kubota K, Nakamura S, Itami J. Feasibility of accelerated partial breast irradiation with strut-adjusted volume implant brachytherapy in Japan focusing on dosimetry and acute toxicity: a Japanese multi-institutional prospective study. Breast Cancer 2024; 31:75-83. [PMID: 37865624 DOI: 10.1007/s12282-023-01513-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 10/07/2023] [Indexed: 10/23/2023]
Abstract
BACKGROUND A Japanese multi-institutional prospective study was initiated to investigate the effectiveness and safety of accelerated partial breast irradiation (APBI) using strut-adjusted volume implant (SAVI) brachytherapy, with subjects registered between 2016 and 2021. Herein, we report the preliminary results on the feasibility of this treatment modality in Japan, focusing on the registration process, dosimetry, and acute toxicities. PATIENTS AND METHODS Primary registration was conducted before breast-conserving surgery (BCS) and the eligibility criteria included the following: age ≥ 40 years, tumor unifocal and unicentric, ≤ 3 cm in diameter, cN0M0, proven ductal, mucinous, tubular, medullary, or lobular carcinoma by needle biopsy. Secondary registration was conducted after BCS had been performed leaving a cavity for device implantation and pathological evaluations, and the eligibility criteria were as follows: negative surgical margin, tumor ≤ 3 cm in diameter on gross pathological examination, histologically confirmed ductal, mucinous, tubular medullary, colloid, or lobular carcinoma, pN0, L0V0, no extensive ductal component, no initiation of chemotherapy within 2 weeks of the brachytherapy APBI planning with SAVI was performed for the patients successfully entered in the study by the secondary registration process, and the treatment was administered at the dose of 34 Gy in 10 fractions administered twice daily. RESULTS Between 2016 and 2021, 64 women were enrolled in the study through primary registration, of which 19 were excluded from the secondary registration process, and in one, it was deemed impossible to comply with the dose constraints established during treatment planning. After the exclusion of these latter 20 patients, we treated the remaining 44 patients by APBI with SAVI. The dose constraints could be adhered to in all the patients, but re-planning was necessitated in 3 patients because of applicator movement during the treatment period. Grade 2 acute toxicities were observed in 18% of all patients, but more severe acute toxicities than Grade 2 were not observed in any of the patients. CONCLUSION APBI with SAVI brachytherapy is feasible in Japan from the aspects of compliance with dose constraints and frequency of acute toxicities.
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Affiliation(s)
- Masahiro Yoshida
- Department of Radiation Therapeutics and Oncology, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan
- Department of Radiology, Toho University Ohashi Medical Center, 2-22-36 Ohashi, Meguro-ku, Tokyo, Japan
| | - Ryo-Ichi Yoshimura
- Department of Radiation Therapeutics and Oncology, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan.
| | - Ryoichi Notake
- Radiology Center, Tokyo Medical and Dental University Hospital, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan
| | - Hidenori Shinjo
- Division of Radiation Oncology, Department of Radiology, Showa University, 1-5-8 Hatanodai Shinagawa-ku, Tokyo, Japan
| | - Kazunori Miyaura
- Division of Radiation Oncology, Department of Radiology, Showa University, 1-5-8 Hatanodai Shinagawa-ku, Tokyo, Japan
| | - Takashi Kuwayama
- Division of Breast Surgical Oncology, Department of Surgery, Showa University, 1-5-8 Hatanodai Shinagawa-ku, Tokyo, Japan
| | - Takashi Kawanaka
- Department of Radiology and Radiation Oncology, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima, Japan
| | - Tadahiko Shien
- Department of Breast and Endocrine Surgery, Okayama University, 2-5-1 Shikata-cho, Kita-ku, Okayama-shi, Okayama, Japan
| | - Kotaro Yoshio
- Department of Proton Beam Therapy, Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata-cho, Kita-ku, Okayama City, Okayama, Japan
| | - Toshiko Shiga
- Department of Radiology, Kansai Medical University Medical Center, 10-15 Fumizono-cho, Moriguchi, Osaka, Japan
| | - Yuko Kaneyasu
- Department of Radiation Oncology, National Hospital Organization Fukuyama Medical Center, 4-14-17 Okinogami-cho, Fukuyama, Hiroshima, Japan
| | - Tsuyoshi Nakagawa
- Department of Breast Surgery, Tokyo Medical and Dental University Hospital, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan
| | - Kazunori Kubota
- Department of Radiology, Dokkyo Medical University Saitama Medical Center, Minamikoshigaya 2-1-50, Koshigaya, Saitama, Japan
| | - Seigo Nakamura
- Division of Breast Surgical Oncology, Department of Surgery, Showa University, 1-5-8 Hatanodai Shinagawa-ku, Tokyo, Japan
| | - Jun Itami
- ShinMatsudo Accuracy Radiation Therapy Center, ShinMatsudo Central General Hospital, Matsudo 1-380, Matsudo City, Chiba, Japan
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Rego IB, Coelho S, Semedo PM, Cavaco-Silva J, Teixeira L, Sousa S, Reis J, Dinis R, Schmitt F, Afonso N, Fougo JL, Pavão F, Baptista Leite R, Costa L. 360 Health Analysis (H360)-A Comparison of Key Performance Indicators in Breast Cancer Management across Health Institution Settings in Portugal. Curr Oncol 2023; 30:6041-6065. [PMID: 37504311 PMCID: PMC10378695 DOI: 10.3390/curroncol30070451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 06/02/2023] [Accepted: 06/14/2023] [Indexed: 07/29/2023] Open
Abstract
BACKGROUND The increased focus on quality indicators (QIs) and the use of clinical registries in real-world cancer studies have increased compliance with therapeutic standards and patient survival. The European Society of Breast Cancer Specialists (EUSOMA) established QIs to assess compliance with current standards in breast cancer care. METHODS This retrospective study is part of H360 Health Analysis and aims to describe compliance with EUSOMA QIs in breast cancer management in different hospital settings (public vs. private; general hospitals vs. oncology centers). A set of key performance indicators (KPIs) was selected based on EUSOMA and previously identified QIs. Secondary data were retrieved from patients' clinical records. Compliance with target KPIs in different disease stages was compared with minimum and target EUSOMA standards. RESULTS A total of 259 patient records were assessed. In stages I, II, and III, 18 KPIs met target EUSOMA standards, 5 met minimum standards, and 8 failed to meet minimum standards. Compliance with KPIs varied according to the type of hospital (particularly regarding diagnosis) and disease stage. Although small differences were found in KPI compliance among institutions, several statistical differences were found among treatment KPIs according to disease stage, particularly in stage III. CONCLUSIONS This study represents the first assessment of the quality of breast cancer care in different hospital settings in Portugal and shows that, although most QIs meet EUSOMA standards, there is room for improvement. Differences have been found across institutions, particularly between oncology centers and general hospitals, in diagnosis and compliance with KPIs among disease stages. Stage III showed the greatest variability in compliance with treatment KPIs, probably related to the lower specificity of the guidelines in this disease stage.
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Affiliation(s)
- Inês Brandão Rego
- Institute of Health Sciences, Universidade Católica Portuguesa, Palma de Cima, 1649-023 Lisboa, Portugal
- Hospital de São João, Centro Hospitalar Universitário de São João, 4200-319 Porto, Portugal
| | - Sara Coelho
- Institute of Health Sciences, Universidade Católica Portuguesa, Palma de Cima, 1649-023 Lisboa, Portugal
- Instituto Português de Oncologia do Porto Francisco Gentil EPE, 4200-072 Porto, Portugal
| | - Patrícia Miguel Semedo
- Institute of Health Sciences, Universidade Católica Portuguesa, Palma de Cima, 1649-023 Lisboa, Portugal
- Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, 1649-028 Lisboa, Portugal
- Instituto de Medicina Molecular-João Lobo Antunes, Faculdade de Medicina da Universidade de Lisboa, 1649-028 Lisboa, Portugal
| | - Joana Cavaco-Silva
- Institute of Health Sciences, Universidade Católica Portuguesa, Palma de Cima, 1649-023 Lisboa, Portugal
- ScienceCircle-Scientific and Biomedical Consulting, 1600-369 Lisboa, Portugal
| | - Laetitia Teixeira
- Institute of Health Sciences, Universidade Católica Portuguesa, Palma de Cima, 1649-023 Lisboa, Portugal
- Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, 4050-313 Porto, Portugal
| | - Susana Sousa
- Institute of Health Sciences, Universidade Católica Portuguesa, Palma de Cima, 1649-023 Lisboa, Portugal
- Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, 4050-313 Porto, Portugal
| | - Joana Reis
- Hospital de São João, Centro Hospitalar Universitário de São João, 4200-319 Porto, Portugal
| | - Rui Dinis
- Hospital do Espírito Santo de Évora, 7000-811 Évora, Portugal
| | - Fernando Schmitt
- Faculdade de Medicina da Universidade do Porto, 4200-319 Porto, Portugal
| | - Noémia Afonso
- Centro Hospitalar de Vila Nova de Gaia e Espinho, 4400-129 Vila Nova de Gaia, Portugal
| | - José Luís Fougo
- Faculdade de Medicina da Universidade do Porto, 4200-319 Porto, Portugal
- Centro de Mama, Centro Hospitalar Universitário de São João, 4200-319 Porto, Portugal
| | - Francisco Pavão
- Institute of Health Sciences, Universidade Católica Portuguesa, Palma de Cima, 1649-023 Lisboa, Portugal
| | - Ricardo Baptista Leite
- Institute of Health Sciences, Universidade Católica Portuguesa, Palma de Cima, 1649-023 Lisboa, Portugal
- Faculty of Health, Medicine and Life Sciences, Maastricht University, 6211 LK Maastricht, The Netherlands
| | - Luís Costa
- Institute of Health Sciences, Universidade Católica Portuguesa, Palma de Cima, 1649-023 Lisboa, Portugal
- Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, 1649-028 Lisboa, Portugal
- Instituto de Medicina Molecular-João Lobo Antunes, Faculdade de Medicina da Universidade de Lisboa, 1649-028 Lisboa, Portugal
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Meduri B, Baldissera A, Iotti C, Scheijmans LJEE, Stam MR, Parisi S, Boersma LJ, Ammendolia I, Koiter E, Valli M, Scandolaro L, Busz D, Stenfert Kroese MC, Ciabatti S, Giacobazzi P, Ruggieri MP, Engelen A, Munafò T, Westenberg AH, Verhoeven K, Vicini R, D'Amico R, Lohr F, Bertoni F, Poortmans P, Frezza GP. Cosmetic Results and Side Effects of Accelerated Partial-Breast Irradiation Versus Whole-Breast Irradiation for Low-Risk Invasive Carcinoma of the Breast: The Randomized Phase III IRMA Trial. J Clin Oncol 2023; 41:2201-2210. [PMID: 36623246 DOI: 10.1200/jco.22.01485] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
PURPOSE The results in terms of side effects vary among the published accelerated partial-breast irradiation (APBI) studies. Here, we report the 5-year results for cosmetic outcomes and toxicity of the IRMA trial. METHODS We ran this randomized phase III trial in 35 centers. Women with stage I-IIA breast cancer treated with breast-conserving surgery, age ≥ 49 years, were randomly assigned 1:1 to receive either whole-breast irradiation (WBI) or external beam radiation therapy APBI (38.5 Gy/10 fraction twice daily). Patients and investigators were not masked to treatment allocation. The primary end point was ipsilateral breast tumor recurrence. We hereby present the analysis of the secondary outcomes, cosmesis, and normal tissue toxicity. All side effects were graded with the Radiation Therapy Oncology Group/European Organisation for Research and Treatment of Cancer Radiation Morbidity Scoring Schema. Analysis was performed with both intention-to-treat and as-treated approaches. RESULTS Between March 2007 and March 2019, 3,309 patients were randomly assigned to 1,657 WBI and 1,652 APBI; 3,225 patients comprised the intention-to-treat population (1,623 WBI and 1,602 APBI). At a median follow-up of 5.6 (interquartile range, 4.0-8.4) years, adverse cosmesis in the APBI patients was higher than that in the WBI patients at 3 years (12.7% v 9.2%; P = .009) and at 5 years (14% v 9.8%; P = .012). Late soft tissue toxicity (grade ≥ 3: 2.8% APBI v 1% WBI, P < .0001) and late bone toxicity (grade ≥ 3: 1.1% APBI v 0% WBI, P < .0001) were significantly higher in the APBI arm. There were no significant differences in late skin and lung toxicities. CONCLUSION External beam radiation therapy-APBI with a twice-daily IRMA schedule was associated with increased rates of late moderate soft tissue and bone toxicities, with a slight decrease in patient-reported cosmetic outcomes at 5 years when compared with WBI, although overall toxicity was in an acceptable range.
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Affiliation(s)
- Bruno Meduri
- Department of Radiation Oncology, University Hospital of Modena, Modena, Italy
| | - Antonella Baldissera
- Department of Radiation Oncology, Bellaria Hospital-AUSL Bologna, Bologna, Italy
| | - Cinzia Iotti
- Department of Radiation Oncology, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | | | | | - Salvatore Parisi
- Department of Radiation Oncology, Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Liesbeth J Boersma
- Department of Radiation Oncology (Maastro), Maastricht University Medical Centre+-GROW School for Oncology and Reproduction, Maastricht, the Netherlands
| | - Ilario Ammendolia
- Department of Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Eveline Koiter
- Department of Radiation Oncology, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Mariacarla Valli
- Department of Radiation Oncology, IOSI (Oncology Institute of Italian Switzerland), Bellinzona, Switzerland
| | - Luciano Scandolaro
- Department of Radiation Oncology, Presidio Ospedaliero S.Anna-ASST Lariana, San Fermo della Battaglia-Como, Italy
| | - Dianne Busz
- Department of Radiation Oncology, University of Groningen-University Medical Center Groningen, Groningen, the Netherlands
| | | | - Selena Ciabatti
- Department of Radiation Oncology, Bellaria Hospital-AUSL Bologna, Bologna, Italy
| | - Patrizia Giacobazzi
- Department of Radiation Oncology, University Hospital of Modena, Modena, Italy
| | - Maria P Ruggieri
- Department of Radiation Oncology, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Antoine Engelen
- Department of Radiation Oncology, Instituut Verbeeten, Tilburg, the Netherlands
| | - Tindara Munafò
- Department of Radiation Oncology, Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | | | - Karolien Verhoeven
- Department of Radiation Oncology (Maastro), Maastricht University Medical Centre+-GROW School for Oncology and Reproduction, Maastricht, the Netherlands
| | - Roberto Vicini
- Department of Methodological and Statistical Support for Clinical Research, University Hospital of Modena, Modena, Italy
| | - Roberto D'Amico
- Department of Methodological and Statistical Support for Clinical Research, University Hospital of Modena, Modena, Italy.,Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Frank Lohr
- Department of Radiation Oncology, University Hospital of Modena, Modena, Italy
| | - Filippo Bertoni
- Department of Radiation Oncology, University Hospital of Modena, Modena, Italy
| | - Philip Poortmans
- Department of Radiation Oncology, Iridium Netwerk, Wilrijk-Antwerp, Belgium.,Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk-Antwerp, Belgium
| | - Giovanni P Frezza
- Department of Radiation Oncology, Bellaria Hospital-AUSL Bologna, Bologna, Italy
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Mackenzie P, Vajdic C, Delaney G, Comans T, Morris L, Agar M, Gabriel G, Barton M. Radiotherapy utilisation rates for patients with cancer as a function of age: A systematic review. J Geriatr Oncol 2022; 14:101387. [PMID: 36272958 DOI: 10.1016/j.jgo.2022.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 09/16/2022] [Accepted: 10/05/2022] [Indexed: 11/05/2022]
Abstract
INTRODUCTION There is an increasing incidence of cancer in older people, but limited data on radiotherapy uptake, and in particular, radiotherapy utilisation (RTU) rates. The RTU rate for older adults with cancer may be lower than recommended due to lower tolerance for radiotherapy as well as additional comorbidities, reduced life expectancy and travel for treatment. Radiotherapy use must be aligned with best available, age-specific evidence to ensure older adults with cancer receive optimal benefit without harms. MATERIALS AND METHODS A systematic review was conducted to synthesise the published data on the actual RTU rate for patients with cancer as a function of age. MEDLINE and EMBASE were systematically searched to identify relevant population-based and hospital-based cohort studies on radiotherapy utilisation for all age groups, published in English, from 1 January 1990 to 1 July 2020. We focused on the following common cancers in older adults for which radiotherapy is recommended: breast, prostate, lung, rectal cancer, glioblastoma multiforme (GBM), and cervical cancer. Age-specific radiotherapy utilisation data were extracted and analysed as a narrative synthesis. RESULTS From 2606 studies screened, 75 cohort and population-based studies were identified with age-specific radiotherapy utilisation data. The total number of patients in the 75 studies was 4,792,138. The RTU rate decreased with increasing age for all tumour sites analysed, except for patients receiving curative radiotherapy as definitive treatment for prostate or cervical cancer. This reduction with increasing age was demonstrated in both palliative and curative settings. DISCUSSION There is a global reduction in radiotherapy utilisation with increasing age for most tumour sites. The reduction in delivery of radiotherapy warrants further examination and evidence-based guidelines specific to this population.
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Roberson ML, Nichols HB, Olshan AF, Wheeler SB, Reeder-Hayes KE, Robinson WR. Trends in surgical treatment of early-stage breast cancer reveal decreasing mastectomy use between 2003 and 2016 by age, race, and rurality. Breast Cancer Res Treat 2022; 193:445-454. [PMID: 35286524 PMCID: PMC9098687 DOI: 10.1007/s10549-022-06564-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 03/03/2022] [Indexed: 11/02/2022]
Abstract
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.
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Affiliation(s)
- Mya L Roberson
- Department of Health Policy, Vanderbilt University School of Medicine, 2525 West End Ave, Suite 1200, Nashville, TN, 37203, USA.
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Hazel B Nichols
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Andrew F Olshan
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Stephanie B Wheeler
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Division of Hematology-Oncology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Katherine E Reeder-Hayes
- Division of Hematology-Oncology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Division of Hematology-Oncology, Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Whitney R Robinson
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC, USA
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6
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Ciérvide R, Montero Á, Potdevin G, García J, Aranda MG, Álvarez B, Rossi K, López M, Hernando O, Valero J, Sánchez E, Chen X, Alonso R, Letón PF, Rubio C. 5-year results of accelerated partial breast irradiation (APBI) with SBRT (stereotactic body radiation therapy) and exactrac adaptive gating (Novalis ®) for very early breast cancer patients: was it all worth it? Clin Transl Oncol 2021; 23:2358-2367. [PMID: 34043153 DOI: 10.1007/s12094-021-02636-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 05/05/2021] [Indexed: 12/25/2022]
Abstract
PURPOSE To explore the feasibility of image-guided and respiratory-gated Stereotactic Body Radiation Therapy (SBRT) for Accelerated Partial Breast Irradiation (APBI) in patients with very early breast cancer. MATERIAL AND METHODS Selected patients with early breast carcinoma after breast-conserving surgery were enrolled in this phase II trial. A fiducial marker was percutaneously placed close to surgical bed and five external fiducials were set on the skin. A CT scan for planning was acquired at free breathing. The treatment was planned and DVH were assessed according to international recommendations. Prescription dose was 30 Gy in five consecutive fractions of 6 Gy. A 6MV monoenergetic LINAC (linear accelerator) that combines stereoscopic X-ray imaging system and ExacTrac Adaptive Gating technique was used. PTV (planning target volume) intrafraction motion was controlled and PTV was irradiated in a selected gated area of the respiratory cycle. Shifts for a correct, gated set-up were calculated and automatically applied. RESULTS Between April 2013 and October 2015, a total of 23 patients were included. The median tumor size was 12 mm. The mean PTV volume was 114 cc. The mean ipsilateral lung V9 Gy was 2.2% and for left-sided breast cancers, the volume of the heart receiving 1.5 Gy was 11.5%. Maximum skin dose was 30.8 Gy. Acute toxicity was grade1 in all the patients and 100% experienced excellent/good breast cosmesis outcomes. With a median follow-up of 66 months (range 8-99 months) local-relapse-free-survival reaches 100%. One patient developed a second breast cancer outside the treated quadrant after 25.1 months. CONCLUSION APBI with SBRT and ExacTrac Adaptive Gating System was feasible. The acute and late toxicities were almost null and cosmesis was excellent. We also found that the margins of 5 mm applied from CTV to PTV were sufficient to compensate for geometric uncertainties.
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MESH Headings
- Breast Neoplasms/diagnostic imaging
- Breast Neoplasms/pathology
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/diagnostic imaging
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/radiotherapy
- Carcinoma, Ductal, Breast/surgery
- Disease-Free Survival
- Dose Fractionation, Radiation
- Feasibility Studies
- Female
- Fiducial Markers
- Heart/radiation effects
- Humans
- Lung/radiation effects
- Mastectomy, Segmental
- Middle Aged
- Organ Motion
- Organs at Risk/radiation effects
- Postoperative Care/methods
- Prospective Studies
- Radiosurgery/instrumentation
- Radiosurgery/methods
- Respiration
- Skin/radiation effects
- Time Factors
- Tomography, X-Ray Computed
- Tumor Burden
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Affiliation(s)
- R Ciérvide
- Department of Radiation Oncology, U.H. Sanchinarro. HM Hospitales, Calle Oña, 10, 28050, Madrid, Spain.
| | - Á Montero
- Department of Radiation Oncology, U.H. Sanchinarro. HM Hospitales, Calle Oña, 10, 28050, Madrid, Spain
| | - G Potdevin
- Department of Radiation Oncology, Fundación Valle del Lili, Cali, Colombia
| | - J García
- Department of Radiation Oncology, U.H. Puerta del Sur. HM Hospitales, Madrid, Spain
| | - M G Aranda
- Department of Radiation Oncology, U.H. Sanchinarro. HM Hospitales, Calle Oña, 10, 28050, Madrid, Spain
| | - B Álvarez
- Department of Radiation Oncology, U.H. Sanchinarro. HM Hospitales, Calle Oña, 10, 28050, Madrid, Spain
| | - K Rossi
- Department of Radiation Oncology, U.H. Sanchinarro. HM Hospitales, Calle Oña, 10, 28050, Madrid, Spain
| | - M López
- Department of Radiation Oncology, U.H. Sanchinarro. HM Hospitales, Calle Oña, 10, 28050, Madrid, Spain
| | - O Hernando
- Department of Radiation Oncology, U.H. Puerta del Sur. HM Hospitales, Madrid, Spain
| | - J Valero
- Department of Radiation Oncology, U.H. Sanchinarro. HM Hospitales, Calle Oña, 10, 28050, Madrid, Spain
| | - E Sánchez
- Department of Radiation Oncology, U.H. Sanchinarro. HM Hospitales, Calle Oña, 10, 28050, Madrid, Spain
| | - X Chen
- Department of Radiation Oncology, U.H. Puerta del Sur. HM Hospitales, Madrid, Spain
| | - R Alonso
- Department of Radiation Oncology, U.H. Puerta del Sur. HM Hospitales, Madrid, Spain
| | - P F Letón
- Department of Radiation Oncology, U.H. Sanchinarro. HM Hospitales, Calle Oña, 10, 28050, Madrid, Spain
- Department of Radiation Oncology, U.H. Puerta del Sur. HM Hospitales, Madrid, Spain
| | - C Rubio
- Department of Radiation Oncology, U.H. Sanchinarro. HM Hospitales, Calle Oña, 10, 28050, Madrid, Spain
- Department of Radiation Oncology, U.H. Puerta del Sur. HM Hospitales, Madrid, Spain
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Gupta A, Jhawar SR, Sayan M, Yehia ZA, Haffty BG, Yu JB, Wang SY. Cost-Effectiveness of Adjuvant Treatment for Ductal Carcinoma In Situ. J Clin Oncol 2021; 39:2386-2396. [PMID: 34019456 PMCID: PMC10166354 DOI: 10.1200/jco.21.00831] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Ductal carcinoma in situ (DCIS) accounts for 20% of breast cancer cases in the United States and is potentially overtreated, leading to high expenditures and low-value care. We conducted a cost-effectiveness analysis evaluating all adjuvant treatment strategies for DCIS. METHODS A Markov model was created with six competing treatment strategies: observation, tamoxifen (TAM) alone, aromatase inhibitor (AI) alone, radiation treatment (RT) alone, RT + TAM, and RT + AI. Baseline recurrence rates were modeled using the NSABP B17 and RTOG 9804 trials for standard-risk and good-risk DCIS, respectively. Relative risk reductions and adverse event rates for each treatment strategy were derived from meta-analyses of large randomized trials. We used a willingness-to-pay threshold of $100,000 in US dollars/quality-adjusted life-year and a lifetime horizon for two cohorts of women, age 40 and 60 years. Comprehensive sensitivity analyses evaluated the robustness of base-case results. RESULTS RT alone was cost-effective for patients with standard-risk DCIS, and observation was cost-effective for patients with good-risk DCIS, across both age groups. Strategies including TAM or AI resulted in fewer quality-adjusted life-years than observation, because of the prolonged decrement in quality of life outweighing the modest benefit in ipsilateral risk reduction. In sensitivity analysis, RT alone was cost-effective for age 40, good-risk patients when ipsilateral risk reduction matched that of the RTOG 9804 trial, there was minimal increased risk of contralateral breast secondary malignancy, or there was strong patient willingness to pursue RT. CONCLUSION Our findings suggest that cost-effective and clinically optimal treatment strategies are RT alone for standard-risk DCIS and observation for good-risk DCIS, with personalization on the basis of patient age and preference for RT. Hormonal therapy is likely suboptimal for most patients with DCIS.
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Affiliation(s)
- Apar Gupta
- Columbia University Herbert Irving Comprehensive Cancer Center, New York, NY
| | - Sachin R Jhawar
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Mutlay Sayan
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Zeinab A Yehia
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Bruce G Haffty
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - James B Yu
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, CT.,Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT
| | - Shi-Yi Wang
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, CT.,Yale School of Public Health, New Haven, CT
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8
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Mackenzie P, Vajdic C, Delaney G, Gabriel G, Agar M, Comans T, Barton M. Factors affecting radiotherapy utilisation in geriatric oncology patients in NSW, Australia. Tech Innov Patient Support Radiat Oncol 2021; 16:17-23. [PMID: 33385070 PMCID: PMC7769853 DOI: 10.1016/j.tipsro.2020.09.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 09/14/2020] [Accepted: 09/16/2020] [Indexed: 12/26/2022] Open
Abstract
Background and Purpose Large non-age-specific radiotherapy utilisation rate (RTU) studies have demonstrated that actual RTU is below the optimal recommended utilisation rate for both curative and palliative intent radiotherapy indications. The optimal utilisation rate for the geriatric oncology cohort of patients has not yet been determined. The purpose of this research was to examine the actual RTU for patients treated in New South Wales (NSW), Australia as a function of increasing age, and the relationship between RTU and tumour site, travelling distance and socio-economic status. Materials & Methods NSW Central Cancer Registry data (2009-2011) were linked to the NSW Radiotherapy Dataset (2009-2012). RTU was calculated for patients aged <80 years and ≥80 years. RTU was defined as the proportion of patients receiving at least a single course of radiotherapy within 12 months of a cancer diagnosis. Results 110,645 patients were diagnosed with cancer, of whom 27,721 received at least one course of radiotherapy. The overall RTU was 25%. RTU for patients aged <80 years was 28% compared to 14% for patients aged 80+ years (p < 0.001). On both univariate and multivariate analysis, increasing age, residential address in disadvantaged socioeconomic areas and increasing distance to the nearest radiotherapy department were associated with a reduction in RTU. Conclusion Geriatric oncology patients are less likely to receive radiotherapy than their younger counterparts. Some of the reduction in RTU may be justifiable on the basis of limited life expectancy and co-morbidity. Further research is required to determine the co-morbidity adjusted optimal RTU in older patients.
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Affiliation(s)
- Penny Mackenzie
- St Andrew's Hospital, Icon Cancer Care, Toowoomba, QLD, Australia.,Collaboration for Cancer Outcomes Research and Evaluation, Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | | | - Geoff Delaney
- Collaboration for Cancer Outcomes Research and Evaluation, Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - Gabriel Gabriel
- Collaboration for Cancer Outcomes Research and Evaluation, Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - Meera Agar
- University of Technology, Sydney, Australia
| | | | - Michael Barton
- Collaboration for Cancer Outcomes Research and Evaluation, Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
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9
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Long-term Impact of CALGB 9343 on Radiation Utilization. J Surg Res 2020; 256:577-583. [PMID: 32805580 DOI: 10.1016/j.jss.2020.07.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 07/07/2020] [Accepted: 07/11/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND The results of the Cancer and Leukemia Group B (CALGB) 9343 trial showed that radiation therapy (RT) did not improve survival for women older than 70 y with early-stage estrogen receptor + breast cancer treated with breast conserving surgery and adjuvant endocrine therapy. In 2005, guidelines were modified to allow for RT omission; however, minimal change in clinical practice has occurred. The aim of this study was to determine if CALGB long-term follow-up data have affected RT utilization, and to characterize the population still receiving RT after breast conserving surgery. METHODS The Surveillance, Epidemiology, and End Results-Medicare database was used to identify women diagnosed with early-stage breast cancer from 2004 to 2015 who matched the CALGB 9343 inclusion criteria. Multivariate logistic regression was carried out to identify the factors that affect the receipt of radiation therapy. We also plotted the overall use of RT over time juxtaposed with the temporal trends of CALGB 9343 clinical trial data, guideline recommendations, and publishing of long-term survival data. RESULTS The study cohort included 25,723 Medicare beneficiaries, of whom 20,328 (79%) received RT and 5395 (21%) did not receive RT. In a multivariate model, the frequency of RT omission increased over time, with those diagnosed in year 2015 being 2.72 times more likely to omit RT compared with those diagnosed in 2004 (95% confidence interval 2.31-3.19). CONCLUSIONS This study investigated the impact of long-term CALGB 9343 data on clinical practice. The results of this study support results from previous studies, extend the dates of analysis, and indicate that after long-term follow-up of CALGB 9343 data, RT was less used, but overall trends did not dramatically decrease.
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10
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Tamburelli F, Maggiorotto F, Marchiò C, Balmativola D, Magistris A, Kubatzki F, Sgandurra P, Di Virgilio MR, Regge D, Montemurro F, Gatti M, Sapino A, Ponzone R. Reoperation rate after breast conserving surgery as quality indicator in breast cancer treatment: A reappraisal. Breast 2020; 53:181-188. [PMID: 32841804 PMCID: PMC7451417 DOI: 10.1016/j.breast.2020.07.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 07/04/2020] [Accepted: 07/28/2020] [Indexed: 12/15/2022] Open
Abstract
Aim To analyse the role of repeated breast surgery (RBS) after breast conserving surgery (BCS) as a quality indicator in a consecutive series of breast cancer patients. Methods Data from 1233 breast cancer patients submitted to BCS from 2015 to 2019 were reviewed. The influence of several variables on RBS rate (182/1232; 14.8%) was examined. Univariate and multivariate analyses were conducted to look for significant associations with the risk of RBS. Results Surgical workload, BCS rate and clinicopathological variables were consistent over the study period, while RBS rate decreased after the introduction of shaving of cavity margins (from 17.9% to 9.5%). Tumor persistence at RBS was higher for mastectomy vs. re-excision (87.3% vs. 37.8%; p = 0.05), inconclusive vs. positive diagnostic biopsy (48.2% vs. 69.4%; p = 0.003), ductal carcinoma in situ vs. invasive carcinoma (69.0% vs. 51.3%; p = 0.046) and lower after neoadjuvant therapy (14.3% vs. 57.8%; p = 0.044). Several clinicopathological variables were associated with the risk of RBS, but only multifocality [Odds Ratio (OR): 1.8; p = 0.009], microcalcifications (OR: 2.0, p = 0.000), neoadjuvant therapy (OR: 0.4; p = 0.014), pathological intraoperative assessment (OR: 0.6; p = 0.010) and shaving of cavity margins (OR: 0.3; p = 0.000) retained independent value at multivariate analysis. Conclusions RBS rate can be reduced by shaving of cavity margins. Current standards for RBS should not be made more stringent due to the existence of non-actionable risk factors. The value of RBS as a quality indicator should be scrutinzed. Some breast cancer patients need a reoperation for incomplete tumor excision after breast conserving surgery. Reoperation rates show wide variations (10%–50%) among different Countries. Shaving of cavity margins may reduce the reoperation rate, but non-invasive and multicentric lesiona are non-actionable risk factors The value of reoperation rate as a quality indicator of breast cancer surgery is questionable.
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Affiliation(s)
- Francesca Tamburelli
- Gynecological Oncology Unit, Candiolo Cancer Institute, FPO - IRCCS, Strada Provinciale 142 Km 3.95, 10060, Candiolo, Italy
| | - Furio Maggiorotto
- Gynecological Oncology Unit, Candiolo Cancer Institute, FPO - IRCCS, Strada Provinciale 142 Km 3.95, 10060, Candiolo, Italy
| | - Caterina Marchiò
- Pathology Unit, Candiolo Cancer Institute, FPO - IRCCS, Strada Provinciale 142 Km 3.95, 10060, Candiolo, Italy; Department of Medical Sciences, University of Turin, 10126, Turin, Italy
| | - Davide Balmativola
- Pathology Unit, Candiolo Cancer Institute, FPO - IRCCS, Strada Provinciale 142 Km 3.95, 10060, Candiolo, Italy
| | - Alessandra Magistris
- Gynecological Oncology Unit, Candiolo Cancer Institute, FPO - IRCCS, Strada Provinciale 142 Km 3.95, 10060, Candiolo, Italy
| | - Franziska Kubatzki
- Gynecological Oncology Unit, Candiolo Cancer Institute, FPO - IRCCS, Strada Provinciale 142 Km 3.95, 10060, Candiolo, Italy
| | - Paola Sgandurra
- Gynecological Oncology Unit, Candiolo Cancer Institute, FPO - IRCCS, Strada Provinciale 142 Km 3.95, 10060, Candiolo, Italy
| | - Maria Rosaria Di Virgilio
- Radiology Unit, Candiolo Cancer Institute, FPO - IRCCS, Strada Provinciale 142 Km 3.95, 10060, Candiolo, Italy
| | - Daniele Regge
- Department of Surgical Sciences, University of Turin, 10124, Turin, Italy; Radiology Unit, Candiolo Cancer Institute, FPO - IRCCS, Strada Provinciale 142 Km 3.95, 10060, Candiolo, Italy
| | - Filippo Montemurro
- Multidisciplinary Outpatient Oncology Clinic, Candiolo Cancer Institute, FPO - IRCCS, Strada Provinciale 142 Km 3.95, 10060, Candiolo, Italy
| | - Marco Gatti
- Radiotherapy Unit, Candiolo Candiolo Cancer Institute, FPO - IRCCS, Strada Provinciale 142 Km 3.95, 10060, Candiolo, Italy
| | - Anna Sapino
- Pathology Unit, Candiolo Cancer Institute, FPO - IRCCS, Strada Provinciale 142 Km 3.95, 10060, Candiolo, Italy; Department of Medical Sciences, University of Turin, 10126, Turin, Italy
| | - Riccardo Ponzone
- Gynecological Oncology Unit, Candiolo Cancer Institute, FPO - IRCCS, Strada Provinciale 142 Km 3.95, 10060, Candiolo, Italy.
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11
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Tamburelli F, Ponzone R. The Value of Repeated Breast Surgery as a Quality Indicator in Breast Cancer Care. Ann Surg Oncol 2020; 28:340-352. [PMID: 32524463 DOI: 10.1245/s10434-020-08704-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Indexed: 02/06/2023]
Abstract
Breast-conserving surgery, a major achievement in surgical oncology, has allowed an increasing number of breast cancer patients to avoid the mutilation of mastectomy. However, mastectomy still is performed in certain circumstances although breast-conserving surgery would be equally safe. Many reasons, including patients' and surgeons' personal motivations, influence the decision-making process before the final choice between breast preservation and mastectomy. The importance of quality measurement and reporting in medicine is increasingly recognized, and breast surgery is no exception. The substantial variability of re-excision rates for positive surgical margins after a first attempt at breast-conserving surgery suggests that improvement is possible. Therefore, the re-excision rate has been proposed as a quality metric for assessing and comparing the performance of different institutions. Indeed, re-excision rates can be reduced by actionable factors such as accurate preoperative local staging, localization of occult lesions, and intraoperative assessment of the oriented specimen. However, equally important non-actionable risk factors pertaining the biology, detectability, and resectability of the tumor also should be taken into account. Therefore, if the re-excision rate has to be used as a performance indicator of breast surgical care, critical interpretation of results with accurate case-mix adjustment are mandatory, and reasonable targets must be appropriately set so that surgeons treating patients at higher risk of positive margins are not unduly penalized.
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Affiliation(s)
- Francesca Tamburelli
- Gynecological Oncology Unit, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Italy
| | - Riccardo Ponzone
- Gynecological Oncology Unit, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Italy.
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12
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Siotos C, Lagiou P, Cheah MA, Bello RJ, Orfanos P, Payne RM, Broderick KP, Aliu O, Habibi M, Cooney CM, Naska A, Rosson GD. Determinants of receiving immediate breast reconstruction: An analysis of patient characteristics at a tertiary care center in the US. Surg Oncol 2020; 34:1-6. [PMID: 32103789 DOI: 10.1016/j.suronc.2020.02.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 01/14/2020] [Accepted: 02/14/2020] [Indexed: 10/25/2022]
Abstract
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.
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Affiliation(s)
- Charalampos Siotos
- Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, National and Kapodistrian University of Athens, Mikras Asias 75, Athens, 115 27, Greece; Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, 601 N. Caroline Street, Baltimore, 21287, Maryland, USA, 21287.
| | - Pagona Lagiou
- Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, National and Kapodistrian University of Athens, Mikras Asias 75, Athens, 115 27, Greece
| | - Michael A Cheah
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, 601 N. Caroline Street, Baltimore, 21287, Maryland, USA, 21287
| | - Ricardo J Bello
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, 601 N. Caroline Street, Baltimore, 21287, Maryland, USA, 21287; Department of Surgery, Johns Hopkins Hospital, 601 N. Caroline Street, Baltimore, 21287, Maryland, USA, 21287
| | - Phillipos Orfanos
- Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, National and Kapodistrian University of Athens, Mikras Asias 75, Athens, 115 27, Greece
| | - Rachael M Payne
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, 601 N. Caroline Street, Baltimore, 21287, Maryland, USA, 21287
| | - Kristen P Broderick
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, 601 N. Caroline Street, Baltimore, 21287, Maryland, USA, 21287
| | - Oluseyi Aliu
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, 601 N. Caroline Street, Baltimore, 21287, Maryland, USA, 21287
| | - Mehran Habibi
- Department of Surgery, Johns Hopkins Hospital, 601 N. Caroline Street, Baltimore, 21287, Maryland, USA, 21287
| | - Carisa M Cooney
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, 601 N. Caroline Street, Baltimore, 21287, Maryland, USA, 21287
| | - Androniki Naska
- Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, National and Kapodistrian University of Athens, Mikras Asias 75, Athens, 115 27, Greece
| | - Gedge D Rosson
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, 601 N. Caroline Street, Baltimore, 21287, Maryland, USA, 21287
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13
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Compliance with clinical guidelines for breast cancer management: A population-based study of quality-of-care indicators in France. PLoS One 2019; 14:e0224275. [PMID: 31644603 PMCID: PMC6808419 DOI: 10.1371/journal.pone.0224275] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 10/09/2019] [Indexed: 12/09/2022] Open
Abstract
Background The European Society of Breast Cancer Specialists (EUSOMA), which aims to standardize the quality of patient care in Europe, has defined quality indicators (QIs) for breast cancer (BC) care to assess compliance to current care standards. These QIs are a useful tool to evaluate care organizations. Only population-based studies are able to assess health system performance in “real-life” situations. This population-based study aimed to describe compliance with several EUSOMA QIs overall and according to patient and organizational factors in France. Methods 1 560 adult women with primary invasive non-metastatic BC diagnosed in 2012 were randomly selected among all incident BC from 16 French geographical areas covered by cancer registries. Twelve EUSOMA QIs were selected regarding diagnosis, treatment and staging. Results The minimum standard as proposed by EUSOMA was met for nine QIs related to pre-operative definitive diagnosis, multidisciplinary discussion and treatment (single surgery, breast conserving surgery (BCS) for small BC (<3cm), radiotherapy after BCS or mastectomy for regional BC (pN≥2a), hormonotherapy, adjuvant chemotherapy and trastuzumab). Low compliance was observed for sentinel lymph node biopsy (SLNB) and staging imaging. Adherence to guidelines was usually lower in older patients and in patients with comorbidities. Multidisciplinary discussion was positively related to adherence to guidelines for diagnosis, staging practices (SNLB, imaging) and systemic treatments. Compliance also varied by area of residence and by place of first treatment. Conclusion This study provides the first current, comprehensive overview of BC quality care at a population level in France. The guidelines were correctly applied in percentage satisfying the EUSOMA standards for the diagnosis and treatment of BC, although staging practices (SLNB, imaging) can be improved. These results highlight the need for continuous measurement of adherence to guidelines to improve BC care.
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14
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Manyam B, Shah C, Julian T, Vicini F. Partial-Breast Irradiation: Review of Modern Trials. CURRENT BREAST CANCER REPORTS 2019. [DOI: 10.1007/s12609-019-00326-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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15
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Bazan JG, Fisher JL, Park KU, Marcus EA, Bittoni MA, White JR. Assessing the Impact of CALGB 9343 on Surgical Trends in Elderly-Women With Stage I ER+ Breast Cancer: A SEER-Based Analysis. Front Oncol 2019; 9:621. [PMID: 31338334 PMCID: PMC6629892 DOI: 10.3389/fonc.2019.00621] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 06/24/2019] [Indexed: 01/11/2023] Open
Abstract
Purpose: Lumpectomy (L) and breast radiotherapy (RT) results in equivalent outcomes in comparison to mastectomy (M) for early-stage breast cancer (BC) based on randomized controlled trials (RCT). Since 2004, RCT support that L without RT yields equivalent survival and acceptable local-regional outcomes in women ≥70-years old with T1N0 hormone-sensitive (ER+) BC on endocrine therapy. Based on this, we hypothesized that M rates should decrease substantially after 2004 in this low-risk elderly population. Methods: We used the Surveillance Epidemiology and End Results registry data to conduct this study. We included women with T1N0 ER+ BC from 2000 to 2014. We compared M rates in women diagnosed from 2000 to 2004 vs. 2005–2012 using the Chi-Square test. Logistic regression analyses was performed to examine demographic/clinical factors associated with mastectomy. Results: 67,506 women met the study criteria. In elderly Stage I ER+ BC, the M rate decreased by 6.3%: 29.0% before 2004 to 22.7% after 2004 (p < 0.0001). M rates remained higher in elderly non-Hispanic black (NHB, 27.1%, p < 0.0001), non-Hispanic Asian-Pacific-Islander (NHAPI, 30.1%, p < 0.0001), and Hispanics (24.4%, p = 0.0004) vs. non-Hispanic White (NHW, 21.5%). Treatment in the modern cohort was associated with decreased odds of mastectomy (OR = 0.71, 95% CI 0.68-0.74, p < 0.0001) while NH-API race was associated with the highest increased odds of mastectomy (OR = 1.65, 95% 1.53-1.78, p < 0.0001). In the modern cohort specifically (2005–2014), Hispanic women (OR = 1.12, p = 0.014), NHB women (OR = 1.21, p < 0.0001), and NHAPI women (OR = 1.73, p < 0.0001) all had higher odds of undergoing mastectomy relative to NHW women after adjusting for all other patient and tumor related factors. Conclusions: In elderly patients with stage I, ER+ BC, M rates have decreased modestly since 2004. These trends are driven mostly be decreases in the M rate in NHW women, but M rates remain ~25% in Hispanic, NHB, and NHAPI women. Further research is needed to identify why M, which is associated with higher cost and morbidity than L alone, has not changed substantially in elderly, low-risk BC.
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Affiliation(s)
- Jose G Bazan
- Department of Radiation Oncology, Arthur G. James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, United States
| | - James L Fisher
- Division of Clinical Epidemiology, College of Public Health, The Ohio State University, Columbus, OH, United States
| | - Ko Un Park
- Division of Surgical Oncology, Department of Surgery, Arthur G. James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, United States
| | - Elizabeth A Marcus
- Division of Breast Oncology, Department of Surgery, John H. Stroger, Jr. Hospital, Chicago, IL, United States
| | - Marisa A Bittoni
- Division of Thoracic Oncology, Arthur G. James Comprehensive Cancer Center, Columbus, OH, United States
| | - Julia R White
- Department of Radiation Oncology, Arthur G. James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, United States
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16
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Guidolin K, Lock M, Vogt K, McClure JA, Winick-Ng J, Vinden C, Brackstone M. Appropriate treatment receipt after breast-conserving surgery. ACTA ACUST UNITED AC 2019; 25:e545-e552. [PMID: 30607122 DOI: 10.3747/co.25.4117] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Breast-conserving surgery (bcs) and radiation therapy (rt) are the standard of care for early breast cancer, although some women receive ipsilateral mastectomy or adjuvant tamoxifen, both of which can be appropriate alternatives to rt. Objectives of the present study were to determine the proportion of women who are treated appropriately after bcs and to identify factors associated with non-receipt of rt. Methods This retrospective cohort study used Ontario data linked at the Institute for Clinical and Evaluative Sciences to examine 33,718 patients who received bcs during 2004-2010. Primary outcome was rt receipt. The ipsilateral mastectomy rate and patient, surgeon, and setting variables were measured. Results Of the study patients, 86.1% received either rt or completion mastectomy; in the cohort less than 70 years of age, 90.8% received rt or completion mastectomy. Among patients less than 70 years of age, 3 risk factors for non-receipt of rt were identified: age less than 46 years, treatment in a non-academic institution, and earlier year of initial bcs. Additionally, in the overall cohort, rt non-receipt was associated with high comorbidity, more than 40 km to the cancer centre, income quintile, and breast care specialization. Conclusions In Ontario, 90.8% of patients less than 70 years of age are appropriately treated for early breast cancer; approximately 1 in 10 do not receive rt or completion mastectomy. Based on those findings, women less than 46 years of age might be at increased risk of recurrence and death because of incomplete treatment. It also appears that academic centres more effectively treat breast cancer; however, breast cancer care appears to be improving over time in Ontario.
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Affiliation(s)
- K Guidolin
- Department of Surgery, University of Toronto, Toronto
| | - M Lock
- Schulich School of Medicine and Dentistry, Western University, London.,London Health Sciences Centre, London
| | - K Vogt
- Schulich School of Medicine and Dentistry, Western University, London.,London Health Sciences Centre, London
| | - J A McClure
- Institute for Clinical Evaluative Sciences, London, ON
| | - J Winick-Ng
- Institute for Clinical Evaluative Sciences, London, ON
| | - C Vinden
- Schulich School of Medicine and Dentistry, Western University, London.,London Health Sciences Centre, London.,Institute for Clinical Evaluative Sciences, London, ON
| | - M Brackstone
- Schulich School of Medicine and Dentistry, Western University, London.,London Health Sciences Centre, London
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17
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Regional diagnostic rates, treatments, and outcomes among patients with invasive ductal carcinoma. J Surg Res 2018; 229:114-121. [PMID: 29936977 DOI: 10.1016/j.jss.2018.03.067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 03/12/2018] [Accepted: 03/28/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND The association between regional breast cancer diagnostic rates, treatments, and outcomes is unclear. We sought to investigate the management and survival of women with invasive ductal carcinoma (IDC) from geographic regions with variable rates of diagnosis. METHODS Data on women diagnosed with IDC years 2009-2010 were obtained from the Surveillance, Epidemiology, and End Results database. Patients were divided into quartiles based on the IDC diagnostic rate within their county of residence. Chi-square and one-way analysis of variance (ANOVA) analyses tested the association between patient and clinical characteristics and the diagnostic rate quartiles. Cox regression analyses compared survival between the quartiles. RESULTS Among the 83,375 patients included, the mean age was 60.8 y and 70.9% were white. Patients residing in counties with the highest diagnostic rates were more frequently white, employed, educated, and wealthier and more often received adjuvant radiation following both partial mastectomy for localized disease and complete mastectomy for advanced disease compared to patients in counties with the lowest diagnostic rates. The highest diagnostic rate quartile had 10% decreased odds of death compared to the lower quartile (hazard ratio: 0.897; 95% confidence interval: 0.832-0.966). However, after adjustment for socioeconomic variables, survival was comparable (hazard ratio: 0.916; 95% confidence interval: 0.835-1.003). CONCLUSIONS Regional variation in IDC diagnostic rates is associated with differences in socioeconomic status, grade, stage, and treatment. Patients from regions with the highest rates of diagnosis may have improved access to evidence-based care and resultant superior survival. Enhancing access to care may improve outcomes of patients residing in regions where breast cancer is diagnosed less frequently.
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Gupta A, Ohri N, Haffty BG. Hypofractionated radiation treatment in the management of breast cancer. Expert Rev Anticancer Ther 2018; 18:793-803. [PMID: 29902386 DOI: 10.1080/14737140.2018.1489245] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION The standard treatment for early-stage breast cancer is breast conservation therapy, consisting of breast conserving surgery followed by adjuvant radiation treatment (RT). Conventionally-fractionated whole breast irradiation (CF-WBI) has been the standard RT regimen, but recently shorter courses of hypofractionated whole breast irradiation (HF-WBI) have been advocated for patient convenience and reduction in healthcare costs and resources. Areas covered: This review covers the major randomized European and Canadian trials comparing HF-WBI to CF-WBI with long-term follow-up, as well as additional recently closed randomized trials that further seek to define the applicability of HF-WBI in clinical practice. Randomized data is summarized in terms of clinical utility and for a variety of clinical applications. Recently published consensus guidelines and practical implementation of HF-WBI including its broader effect on the healthcare system are reviewed. Finally, an assessment of the emerging evidence in support of hypofractionation for locally advanced disease is presented. Expert commentary: HF-WBI has replaced CF-WBI as the accepted standard of care in most women with early-stage breast cancer who do not require regional nodal irradiation. Early data supports the continued study of hypofractionation in the locally advanced setting, however broad adoption awaits longer follow-up and additional data from ongoing clinical trials.
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Affiliation(s)
- Apar Gupta
- a Department of Radiation Oncology , Rutgers Cancer Institute of New Jersey , New Brunswick , NJ , USA
| | - Nisha Ohri
- a Department of Radiation Oncology , Rutgers Cancer Institute of New Jersey , New Brunswick , NJ , USA
| | - Bruce G Haffty
- a Department of Radiation Oncology , Rutgers Cancer Institute of New Jersey , New Brunswick , NJ , USA
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Evaluating Candidacy for Hypofractionated Radiation Therapy, Accelerated Partial Breast Irradiation, and Endocrine Therapy After Breast Conserving Surgery. Am J Clin Oncol 2018; 41:526-531. [DOI: 10.1097/coc.0000000000000332] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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20
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Accelerated partial breast irradiation in a single 18 Gy fraction with high-dose-rate brachytherapy: preliminary results. J Contemp Brachytherapy 2018; 10:58-63. [PMID: 29619057 PMCID: PMC5881592 DOI: 10.5114/jcb.2018.73994] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 01/22/2018] [Indexed: 11/17/2022] Open
Abstract
Purpose To evaluate the feasibility of acute and chronic toxicity in patients suitable for accelerated partial breast irradiation (APBI) in a single 18 Gy fraction with multicatheter high-dose-rate (HDR) brachytherapy, as well as cosmetic and oncological outcomes. Material and methods Between September 2014 and March 2016, twenty consecutive patients with low-risk invasive and ductal carcinoma in situ were treated with interstitial multicatheter HDR brachytherapy in a single 18 Gy fraction. Results Median age was 63.5 years (range, 51-79). Acute toxicity was observed in seven patients, while the pain during following days and hematoma were seen in four patients. With a median follow-up of 24 months, late toxicity was found in one patient with fat necrosis g2 and fibrosis g2 in another patient. The overall survival (OS) and locoregional control (LC) was 100%. Disease-free survival (DFS) and distant control was 95%. Good to excellent cosmetic outcomes were noted in 80% of patients and fair in 4 patients (20%). Conclusions This is the first report in the medical literature that focuses on feasibility and acute and chronic toxicity, with a median follow-up of 24 months (range, 20-40). The protocol is viable and convenient. However, a longer follow-up is needed to know chronic toxicity and oncologic outcomes.
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Wang S, Ma X, Hong X, Cheng Y, Tian Y, Zhao S, Liu W, Tang Y, Zhao R, Song L, Teng Z, Lu G. Adjuvant Photothermal Therapy Inhibits Local Recurrences after Breast-Conserving Surgery with Little Skin Damage. ACS NANO 2018; 12:662-670. [PMID: 29271636 DOI: 10.1021/acsnano.7b07757] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Adjuvant treatments following breast-conserving surgery (BCS) are essential to reduce the risk of local recurrences in patients with breast cancer. However, current adjuvant treatments are based on ionizing radiation, which brings radiation-induced damage and amplifies the risk of death. Here we explore the feasibility of using non-ionizing light to induce photothermal therapy as an adjuvant treatment to BCS. In an orthotopic breast cancer mice model, we demonstrate that adjuvant photothermal therapy (aPTT) decreases the incidence of local recurrences after BCS with no expense of cosmetic outcome. In comparison with conventional photothermal therapy, the technique used in aPTT provides more uniformly distributed light energy and less risk of skin burns and local recurrences. Overall, this work represents a departure from the traditional concept of using PTT as an alternative to surgery and reveals the potential of using PTT as an alternative to adjuvant radiation therapy, which is valuable especially for patients susceptible to radiation damage.
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Affiliation(s)
- Shouju Wang
- Department of Medical Imaging, Jinling Hospital, School of Medicine, Nanjing University , Nanjing 210002, P. R. China
- State Key Laboratory of Analytical Chemistry for Life Science, School of Chemistry and Chemical Engineering, Nanjing University , Nanjing 210093, P. R. China
| | - Xingqun Ma
- The Affiliated Bayi Hospital of Nanjing University of Chinese Medicine , Nanjing 210002, P. R. China
| | - Xuhao Hong
- Department of Physics, Nanjing University , Nanjing 210000, P. R. China
| | - Yingxia Cheng
- The Affiliated Bayi Hospital of Nanjing University of Chinese Medicine , Nanjing 210002, P. R. China
| | - Ying Tian
- Department of Medical Imaging, Jinling Hospital, School of Medicine, Nanjing University , Nanjing 210002, P. R. China
| | - Shuang Zhao
- Department of Medical Imaging, Jinling Hospital, School of Medicine, Nanjing University , Nanjing 210002, P. R. China
| | - Wenfei Liu
- Department of Medical Imaging, Jinling Hospital, School of Medicine, Nanjing University , Nanjing 210002, P. R. China
| | - Yuxia Tang
- Department of Medical Imaging, Jinling Hospital, School of Medicine, Nanjing University , Nanjing 210002, P. R. China
| | - Ruizhi Zhao
- Department of Physics, Nanjing University , Nanjing 210000, P. R. China
| | - Liang Song
- Research Laboratory for Biomedical Optics and Molecular Imaging, Shenzhen Key Laboratory for Molecular Imaging, Institute of Biomedical and Health Engineering, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences , Shenzhen 518055, P. R. China
| | - Zhaogang Teng
- Department of Medical Imaging, Jinling Hospital, School of Medicine, Nanjing University , Nanjing 210002, P. R. China
- State Key Laboratory of Analytical Chemistry for Life Science, School of Chemistry and Chemical Engineering, Nanjing University , Nanjing 210093, P. R. China
| | - Guangming Lu
- Department of Medical Imaging, Jinling Hospital, School of Medicine, Nanjing University , Nanjing 210002, P. R. China
- State Key Laboratory of Analytical Chemistry for Life Science, School of Chemistry and Chemical Engineering, Nanjing University , Nanjing 210093, P. R. China
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Cont NT, Maggiorotto F, Martincich L, Rivolin A, Kubatzki F, Sgandurra P, Marocco F, Magistris A, Gatti M, Balmativola D, Montemurro F, Sapino A, Ponzone R. Primary tumor location predicts the site of local relapse after nipple-areola complex (NAC) sparing mastectomy. Breast Cancer Res Treat 2017; 165:85-95. [PMID: 28553683 DOI: 10.1007/s10549-017-4312-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Accepted: 05/23/2017] [Indexed: 01/06/2023]
Abstract
PURPOSE To assess the oncological safety of nipple-areola complex (NAC) sparing mastectomy in breast cancer patients. METHODS From 2010 to 2015, 518 breast cancer patients were submitted to NAC sparing mastectomy. Breast MRI and intraoperative assessment of the subareolar (SD) and proximal (ND) nipple ducts were performed to predict NAC involvement. Significant associations between pre- and postoperative variables with SD/ND involvement and with the risk of local recurrence were retrospectively investigated. RESULTS SD/ND were involved in 26.1% of the cases. Final pathology of SD/ND was predicted by tumor-NAC distance at MRI and intraoperative pathology with 75 and 93% accuracy, respectively. NAC involvement was more frequent in case of positive ND than positive SD (68.3 vs. 38.3%; p = 0.003). Fourteen (2.7%) local relapses developed over a mean follow-up of 33 months. Ki-67 ≥25% (p = 0.002) and high tumor grade (p = 0.027) correlated with local recurrence. Most relapses developed in the subcutaneous tissue of the quadrant where the primary tumor was located (12/14; 85.7%). No local relapses occurred in patients who received post-mastectomy radiotherapy as compared to patients who did not, although they had a higher rate of positive surgical margins (40.5 vs. 16.2%; p = 0.000). CONCLUSIONS NAC involvement can be predicted by MRI and intraoperative pathology of ND/SD. Local recurrences after NAC sparing mastectomy almost invariably develop in the same quadrant where the primary tumor was located and in highly proliferative tumors.
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Affiliation(s)
- Nicoletta Tomasi Cont
- Gynecological Oncology, Candiolo Cancer Institute-FPO, IRCCS, Str. Prov. 142, km 3.95, I-10060, Candiolo (Turin), Italy
| | - Furio Maggiorotto
- Gynecological Oncology, Candiolo Cancer Institute-FPO, IRCCS, Str. Prov. 142, km 3.95, I-10060, Candiolo (Turin), Italy
| | - Laura Martincich
- Radiology, Candiolo Cancer Institute-FPO, IRCCS, Candiolo (Turin), Italy
| | - Alessandro Rivolin
- Gynecological Oncology, Candiolo Cancer Institute-FPO, IRCCS, Str. Prov. 142, km 3.95, I-10060, Candiolo (Turin), Italy
| | - Franziska Kubatzki
- Gynecological Oncology, Candiolo Cancer Institute-FPO, IRCCS, Str. Prov. 142, km 3.95, I-10060, Candiolo (Turin), Italy
| | - Paola Sgandurra
- Gynecological Oncology, Candiolo Cancer Institute-FPO, IRCCS, Str. Prov. 142, km 3.95, I-10060, Candiolo (Turin), Italy
| | - Francesco Marocco
- Gynecological Oncology, Candiolo Cancer Institute-FPO, IRCCS, Str. Prov. 142, km 3.95, I-10060, Candiolo (Turin), Italy
| | - Alessandra Magistris
- Gynecological Oncology, Candiolo Cancer Institute-FPO, IRCCS, Str. Prov. 142, km 3.95, I-10060, Candiolo (Turin), Italy
| | - Marco Gatti
- Radiation Therapy, Candiolo Cancer Institute-FPO, IRCCS, Candiolo (Turin), Italy
| | - Davide Balmativola
- Pathology, Candiolo Cancer Institute-FPO, IRCCS, Candiolo (Turin), Italy
| | - Filippo Montemurro
- Investigative Clinical Oncology, Candiolo Cancer Institute-FPO, IRCCS, Candiolo (Turin), Italy
| | - Anna Sapino
- Pathology, Candiolo Cancer Institute-FPO, IRCCS, Candiolo (Turin), Italy
| | - Riccardo Ponzone
- Gynecological Oncology, Candiolo Cancer Institute-FPO, IRCCS, Str. Prov. 142, km 3.95, I-10060, Candiolo (Turin), Italy.
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Vaz-Luis I, Lin NU, Keating NL, Barry WT, Winer EP, Freedman RA. Factors Associated with Early Mortality Among Patients with De Novo Metastatic Breast Cancer: A Population-Based Study. Oncologist 2017; 22:386-393. [PMID: 28242790 DOI: 10.1634/theoncologist.2016-0369] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 10/28/2016] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Although improvements in survival have been achieved for patients with metastatic breast cancer, some patients experience early death after diagnosis. PATIENTS AND METHODS Using Surveillance, Epidemiology, and End Results data, we identified 26,538 patients with de novo metastatic breast cancer diagnosed between January 1, 2000 and June 30, 2011. We evaluated time trends for deaths at 1 and 6 months after diagnosis. We then restricted the cohort to patients diagnosed between 2010 and 2011 (n = 3,317), when human epidermal growth factor receptor 2 was routinely collected, and examined factors associated with early death. RESULTS In 2000, 15.9% of patients died within 1 month of diagnosis and 33.2% within 6 months. In 2011, the proportion of women dying within 1 month decreased to 13.4% and 26.3% within 6 months (p < .001). Older age and uninsured status were associated with early death (at both time points, age ≥70 [versus age <40] had >8.5 higher odds of dying, and uninsured [versus insured] patients had >2.5 higher odds of death). In addition, in some subgroups (e.g., no insurance and triple negative disease), more than half of patients died within 6 months. Region was also associated with early death. CONCLUSION Although we observed improvements in the proportion of patients experiencing early death, one quarter of patients with de novo metastatic disease diagnosed in 2011 died within 6 months of diagnosis. In addition to tumor factors and older age, geography and uninsured status were associated with early death. Our findings highlight the need for focused interventions for metastatic patients at highest risk for poor outcomes. The Oncologist 2017;22:386-393 IMPLICATIONS FOR PRACTICE: With nearly one quarter of patients in our dataset diagnosed in 2011 dying within 6 months of diagnosis, our findings highlight the persistent and critical need of further characterization and identification of patients who are risk for poor outcomes in order to optimize care, impact change, and improve outcomes for all women with metastatic breast cancer. Our data also emphasize the need for interventions among those at highest risk for early death. These interventions would likely promote immediate referral for clinical trial participation, early palliative care referrals, and additional supportive services, optimizing equitable patient access to cancer treatment and care.
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Affiliation(s)
- Ines Vaz-Luis
- Departments of Medical Oncology
- Department of Medical Oncology, Institute Gustave Roussy, Villejuif, France
| | | | - Nancy L Keating
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - William T Barry
- Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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LeMasters TJ, Madhavan SS, Sambamoorthi U, Vyas AM. Disparities in the Initial Local Treatment of Older Women with Early-Stage Breast Cancer: A Population-Based Study. J Womens Health (Larchmt) 2017; 26:735-744. [PMID: 28170302 DOI: 10.1089/jwh.2015.5639] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Although breast cancer is most prevalent among older women, the majority are diagnosed at an early stage. When diagnosed at an early stage, women have the option of breast-conserving surgery (BCS) plus radiation therapy (RT) or mastectomy for the treatment of early-stage breast cancer (ESBC). Omission of RT when receiving BCS increases the risk for recurrence and poor survival. Yet, a small subset of older women may omit RT after BCS. This study examines the current patterns of local treatment for ESBC among older women. METHODS This study conducted a retrospective observational analysis using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked dataset of women age ≥66 diagnosed with stage I-II breast cancer in 2003-2009. SEER-Medicare data was additionally linked with data from the Area Resource File (ARF) to examine the association between area-level healthcare resources and treatment. Two logistic regression models were used to estimate how study factors were associated with receiving (1) BCS versus BCS+RT and (2) Mastectomy versus BCS+RT. A stratified analysis was also conducted among women aged <70 years. RESULTS Among 45,924 patients, 55% received BCS+RT, 23% received mastectomy, and 22% received BCS only. Women of increasing age, comorbidity, primary care provider visits, stage II disease, and nonwhite race were more likely to have mastectomy or BCS only, than BCS+RT. Women diagnosed in 2004-2006, treated by an oncology surgeon, residing in metro areas, areas of greater education and income, were less likely to receive mastectomy or BCS only, than BCS+RT. While women aged <70 years were more likely to receive BCS+RT, socioeconomic and physician specialties were associated with receiving BCS only. CONCLUSIONS Over half of older women with ESBC initially receive BCS+RT. The likelihood for mastectomy and BCS only increases with age, comorbidity, and vulnerable socio-demographic characteristics. Findings demonstrate continued treatment disparities among certain vulnerable populations.
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Affiliation(s)
- Traci J LeMasters
- Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University , Morgantown, West Virginia
| | - Suresh S Madhavan
- Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University , Morgantown, West Virginia
| | - Usha Sambamoorthi
- Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University , Morgantown, West Virginia
| | - Ami M Vyas
- Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University , Morgantown, West Virginia
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Grover S, Nurkic S, Diener-West M, Showalter SL. Survival after Breast-Conserving Surgery with Whole Breast or Partial Breast Irradiation in Women with Early Stage Breast Cancer: A SEER Data-base Analysis. Breast J 2016; 23:292-298. [PMID: 27988987 DOI: 10.1111/tbj.12729] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Randomized clinical trials have demonstrated equivalency in survival outcomes for early stage breast cancer patients treated with either mastectomy or breast-conserving surgery (BCS) with radiation. Recent, state-level data confirm comparable survival outcomes. Using Surveillance Epidemiology and End Research (SEER) data, we sought to evaluate survival outcomes among patients with early stage breast cancer treated with mastectomy, BCS with whole breast irradiation (BCS + WBI), or BCS with accelerated partial breast irradiation (BCS + APBI). Data on women 50 years or older diagnosed with a node negative invasive breast cancer (≤3 cm in size) between 1995 and 2009 were extracted from the SEER data base. Women treated with mastectomy alone or BCS with radiation were eligible for analysis. Kaplan-Meier estimates and Cox proportional hazard models were used to compare overall survival (OS) and cancer-specific survival (CSS) among the treatment groups. 150,171 women fulfilled inclusion criteria. OS was significantly improved among women treated with BCS and WBI or BCS and APBI compared to mastectomy alone. Adjusted hazard ratios for death in BCS with WBI or APBI (versus mastectomy alone) were 0.73 (95% CI: 0.71, 0.76) and 0.68 (95% CI: 0.58, 0.79), respectively. Adjusted CSS was also significantly improved in patients treated with BCS and WBI (HR 0.80, 95% CI: 0.76, 0.85) as compared to mastectomy. BCS with radiation (WBI or APBI) was associated with significantly improved OS and CSS, versus mastectomy alone. These results support the use of BCS with WBI or APBI (in well selected patients) for the treatment of breast cancer.
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Affiliation(s)
- Surbhi Grover
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sommer Nurkic
- Department of Radiation Oncology, University of Florida, Baltimore, Maryland
| | - Marie Diener-West
- Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Shayna L Showalter
- Department of Surgery, University of Virginia, Charlottesville, Virginia
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LeMasters T, Madhavan SS, Sambamoorthi U. Comparison of the Initial Loco-Regional Treatment Received for Early-Stage Breast Cancer between Elderly Women in Appalachia and a United States - Based Population: Good and Bad News. GLOBAL JOURNAL OF BREAST CANCER RESEARCH 2016; 4:10-19. [PMID: 27517039 DOI: 10.20941/2309-4419.2016.04.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Breast conserving surgery (BCS) followed by radiation therapy (RT) (BCS+RT) is as effective for long-term survival of invasive early-stage breast cancer (ESBC) as mastectomy, and is the local treatment option selected by the majority of women with ESBC. Women of older age and vulnerable socio-demographic characteristics are at greater risk for receiving substandard (BCS only) and non-preferred treatments (mastectomy), such as populations of women from the Appalachian region of United States. METHODS Using a retrospective cohort study design, we identified 26,106 patients from the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked dataset and 811 patients from the West Virginia Cancer Registry (WVCR)-Medicare dataset age ≥ 66 diagnosed from 2003 to 2006 with stage I-II breast cancer. Multivariable logistic regression models estimated type of initial treatment received between WVCR-Medicare and SEER-Medicare patients, and the association with type of treatment. RESULTS Overall, women in WV were 0.82 (95% CI 0.68-0.99) and 0.70 (95% CI 0.58-0.84) times less likely to have mastectomy or BCS only vs. BCS+RT, than those in SEER regions. Women in WV of increasing age, greater comorbidity, stage II disease, and non-white race were more likely to have mastectomy or BCS only vs. BCS+RT, whereas, those residing in areas of higher income, higher education, and metro status were less likely, than similarly characterized women from SEER regions. CONCLUSIONS Findings from this study suggest that the magnitude of disparities in breast cancer treatment between groups of women with more and less resources are even greater in the Appalachian region, than they are among US populations. Improving access to oncology treatment services, as well as, the implementation of patient navigation programs are needed to improve patterns of initial treatment for ESBC among at-risk populations.
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Affiliation(s)
- Traci LeMasters
- Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University, USA
| | - S Suresh Madhavan
- Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University, USA
| | - Usha Sambamoorthi
- Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University, USA
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Do Socioeconomic Factors and Race Determine the Likelihood of Breast-Conserving Surgery? Clin Breast Cancer 2016; 16:e93-7. [DOI: 10.1016/j.clbc.2016.05.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2015] [Revised: 02/18/2016] [Accepted: 05/09/2016] [Indexed: 11/20/2022]
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Konski A, Yu JB, Freedman G, Harrison LB, Johnstone PAS. Radiation Oncology Practice: Adjusting to a New Reimbursement Model. J Oncol Pract 2016; 12:e576-83. [PMID: 27006359 DOI: 10.1200/jop.2015.007385] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Use of hypofractionation is increasing in radiation oncology because of several factors. The effects of increasing hypofractionation use on departments and staff currently based on fee-for-service models are not well studied. METHODS We modeled the effects of moving to hypofractionation for prostate, breast, and lung cancer and palliative treatments in a typical-sized hospital-based radiation oncology department. Year 2015 relative value unit (RVU) data were used to determine changes in reimbursement. The change in number of fractions was used to model the effects on machine volume, staff time, and workforce predictions. RESULTS The per-case marginal reduction in technical revenue was $1,777, $4,297, $9,041, and $9,498 for palliative and breast, prostate, and lung cancer cases, respectively. The physician reduction per case in RVUs was 5.22, 10.44, 43.02, and 43.02 respectively. A department could anticipate an annual reduction in technical revenue of $540,661 and a reduction in workflow of approximately five patients or 1 to 1.5 hours per day from a hypofractionation rate of 40%. CONCLUSION The move to hypofractionation in the United States will lead to increased pressures on departments to address budget shortfalls resulting from the decrease in per-patient revenue. This may be done through a combination of an increase in patient volume, recognition of the increased skill sets required to deliver hypofractionated radiotherapy, delay in capital purchases, and/or reduction in staff. In a value-based environment, these evolutions should improve the value proposition of radiation oncology over a fee-for-service model.
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Affiliation(s)
- Andre Konski
- Perelman School of Medicine, University of Pennsylvania; Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA; Yale University School of Medicine, New Haven Hospital, New Haven, CT; and Moffitt Cancer Center, Tampa, FL
| | - James B Yu
- Perelman School of Medicine, University of Pennsylvania; Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA; Yale University School of Medicine, New Haven Hospital, New Haven, CT; and Moffitt Cancer Center, Tampa, FL
| | - Gary Freedman
- Perelman School of Medicine, University of Pennsylvania; Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA; Yale University School of Medicine, New Haven Hospital, New Haven, CT; and Moffitt Cancer Center, Tampa, FL
| | - Louis B Harrison
- Perelman School of Medicine, University of Pennsylvania; Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA; Yale University School of Medicine, New Haven Hospital, New Haven, CT; and Moffitt Cancer Center, Tampa, FL
| | - Peter A S Johnstone
- Perelman School of Medicine, University of Pennsylvania; Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA; Yale University School of Medicine, New Haven Hospital, New Haven, CT; and Moffitt Cancer Center, Tampa, FL
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Trends in the use of mastectomy in women with small node-negative breast cancer treated at US academic centers. Breast Cancer Res Treat 2016; 155:569-78. [PMID: 26868124 DOI: 10.1007/s10549-016-3707-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 02/05/2016] [Indexed: 10/22/2022]
Abstract
Breast-conserving surgery (BCS) provides equivalent survival outcomes to unilateral mastectomy. There is no survival advantage to bilateral mastectomy in average risk breast cancer. Among a cohort of breast cancer patients expected to be candidates for BCS, we examined choice of surgery and factors associated with it. A prospective cohort study of unilateral clinical Stage I breast cancer patients treated at National Comprehensive Cancer Network centers from 2000 to 2009 was performed. The proportion of patients who initially underwent mastectomy versus BCS and time to definitive surgery and chemotherapy were examined. Of 10,249 patients, 23 % underwent mastectomy as an initial surgery. No decline in the use of mastectomy as initial surgery was found. There was significant institutional variation, with rates of initial mastectomy ranging from 14 to 30 % (adjusted odds ratio: 0.42-1.38). Tumor characteristics were associated with surgical option, but with small absolute differences. Of those who received initial mastectomy, 22 % had bilateral mastectomy, with an increase over time (2000:13 % vs. 2009:30 %) and substantial institutional variation (11-34 %). Women treated with initial mastectomy had longer median times from diagnosis to complete definitive surgery (6 vs. 4 weeks) and to start of adjuvant chemotherapy (12 vs. 11 weeks). Among Stage I breast cancer, the overall use of mastectomy did not change significantly over 10 years; however, an increasing proportion of women with unilateral cancer had bilateral mastectomy, and there was wide variation in type of surgery by institution. Further studies to assess reasons for the observed wide variation are warranted.
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Shirvani SM, Jiang J, Likhacheva A, Hoffman KE, Shaitelman SF, Caudle A, Buchholz TA, Giordano SH, Smith BD. Trends in Local Therapy Utilization and Cost for Early-Stage Breast Cancer in Older Women: Implications for Payment and Policy Reform. Int J Radiat Oncol Biol Phys 2016; 95:605-16. [PMID: 27034179 DOI: 10.1016/j.ijrobp.2016.01.059] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 01/16/2016] [Accepted: 01/29/2016] [Indexed: 02/07/2023]
Abstract
PURPOSE Older women with early-stage disease constitute the most rapidly growing breast cancer demographic, yet it is not known which local therapy strategies are most favored by this population in the current era. Understanding utilization trends and cost of local therapy is important for informing the design of bundled payment models as payers migrate away from fee-for-service models. We therefore used the Surveillance, Epidemiology, and End Results Medicare database to determine patterns of care and costs for local therapy among older women with breast cancer. METHODS AND MATERIALS Treatment strategy and covariables were determined in 55,327 women age ≥66 with Tis-T2N0-1M0 breast cancer who underwent local therapy between 2000 and 2008. Trends in local therapy were characterized using Joinpoint. Polychotomous logistic regression determined predictors of local therapy. The median aggregate cost over the first 24 months after diagnosis was determined from Medicare claims through 2010 and reported in 2014 dollars. RESULTS The median age was 75. Local therapy distribution was as follows: 27,896 (50.3%) lumpectomy with external beam radiation, 18,356 (33.1%) mastectomy alone, 6159 (11.1%) lumpectomy alone, 1488 (2.7%) mastectomy with reconstruction, and 1455 (2.6%) lumpectomy with brachytherapy. Mastectomy alone declined from 39.0% in 2000 to 28.2% in 2008, and the use of breast conserving local therapies rose from 58.7% to 68.2%. Mastectomy with reconstruction was more common among the youngest, healthiest patients, whereas mastectomy alone was more common among patients living in rural low-income regions. By 2008, the costs were $36,749 for lumpectomy with brachytherapy, $35,030 for mastectomy with reconstruction, $31,388 for lumpectomy with external beam radiation, $21,993 for mastectomy alone, and $19,287 for lumpectomy alone. CONCLUSIONS The use of mastectomy alone in older women declined in favor of breast conserving strategies between 2000 and 2008. Using these cost estimates, price points for local therapy bundles can be constructed to incentivize the treatment strategies that confer the highest value.
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Affiliation(s)
- Shervin M Shirvani
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Radiation Oncology, Banner MD Anderson Cancer Center, Gilbert, Arizona
| | - Jing Jiang
- Department of Health Services Research, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Anna Likhacheva
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Radiation Oncology, Banner MD Anderson Cancer Center, Gilbert, Arizona
| | - Karen E Hoffman
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Simona F Shaitelman
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Abigail Caudle
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Thomas A Buchholz
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sharon H Giordano
- Department of Health Services Research, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Benjamin D Smith
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Health Services Research, University of Texas MD Anderson Cancer Center, Houston, Texas.
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Strnad V, Ott OJ, Hildebrandt G, Kauer-Dorner D, Knauerhase H, Major T, Lyczek J, Guinot JL, Dunst J, Gutierrez Miguelez C, Slampa P, Allgäuer M, Lössl K, Polat B, Kovács G, Fischedick AR, Wendt TG, Fietkau R, Hindemith M, Resch A, Kulik A, Arribas L, Niehoff P, Guedea F, Schlamann A, Pötter R, Gall C, Malzer M, Uter W, Polgár C. 5-year results of accelerated partial breast irradiation using sole interstitial multicatheter brachytherapy versus whole-breast irradiation with boost after breast-conserving surgery for low-risk invasive and in-situ carcinoma of the female breast: a randomised, phase 3, non-inferiority trial. Lancet 2016; 387:229-38. [PMID: 26494415 DOI: 10.1016/s0140-6736(15)00471-7] [Citation(s) in RCA: 474] [Impact Index Per Article: 59.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND In a phase 3, randomised, non-inferiority trial, accelerated partial breast irradiation (APBI) for patients with stage 0, I, and IIA breast cancer who underwent breast-conserving treatment was compared with whole-breast irradiation. Here, we present 5-year follow-up results. METHODS We did a phase 3, randomised, non-inferiority trial at 16 hospitals and medical centres in seven European countries. 1184 patients with low-risk invasive and ductal carcinoma in situ treated with breast-conserving surgery were centrally randomised to either whole-breast irradiation or APBI using multicatheter brachytherapy. The primary endpoint was local recurrence. Analysis was done according to treatment received. This trial is registered with ClinicalTrials.gov, number NCT00402519. FINDINGS Between April 20, 2004, and July 30, 2009, 551 patients had whole-breast irradiation with tumour-bed boost and 633 patients received APBI using interstitial multicatheter brachytherapy. At 5-year follow-up, nine patients treated with APBI and five patients receiving whole-breast irradiation had a local recurrence; the cumulative incidence of local recurrence was 1.44% (95% CI 0.51-2.38) with APBI and 0.92% (0.12-1.73) with whole-breast irradiation (difference 0.52%, 95% CI -0.72 to 1.75; p=0.42). No grade 4 late side-effects were reported. The 5-year risk of grade 2-3 late side-effects to the skin was 3.2% with APBI versus 5.7% with whole-breast irradiation (p=0.08), and 5-year risk of grade 2-3 subcutaneous tissue late side-effects was 7.6% versus 6.3% (p=0.53). The risk of severe (grade 3) fibrosis at 5 years was 0.2% with whole-breast irradiation and 0% with APBI (p=0.46). INTERPRETATION The difference between treatments was below the relevance margin of 3 percentage points. Therefore, adjuvant APBI using multicatheter brachytherapy after breast-conserving surgery in patients with early breast cancer is not inferior to adjuvant whole-breast irradiation with respect to 5-year local control, disease-free survival, and overall survival. FUNDING German Cancer Aid.
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Affiliation(s)
- Vratislav Strnad
- Department of Radiation Oncology, University Hospital Erlangen, Erlangen, Germany.
| | - Oliver J Ott
- Department of Radiation Oncology, University Hospital Erlangen, Erlangen, Germany
| | - Guido Hildebrandt
- Department of Radiation Oncology, University Hospital Leipzig, Leipzig, Germany; Department of Radiation Oncology, University Hospital Rostock, Rostock, Germany
| | | | - Hellen Knauerhase
- Department of Radiation Oncology, University Hospital Rostock, Rostock, Germany
| | - Tibor Major
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary
| | - Jaroslaw Lyczek
- Brachytherapy Department, Centrum Onkologii-Instytut im Marii Skłodowskej, Warsaw, Poland; Podkarpacki Hospital Cancer Center Brzozów, Brzozów, Poland
| | - Jose Luis Guinot
- Department of Radiation Oncology, Valencian Institute of Oncology, Valencia, Spain
| | - Jürgen Dunst
- Department of Radiation Oncology, University Hospital Kiel, Germany
| | | | - Pavel Slampa
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
| | - Michael Allgäuer
- Department of Radiation Oncology, Hospital Barmherzige Brüder Regensburg, Regensburg, Germany
| | - Kristina Lössl
- Department of Radiation Oncology, University Hospital Bern, Inselspital, Bern, Switzerland
| | - Bülent Polat
- Department of Radiation Oncology, University Hospital Würzburg, Würzburg, Germany
| | - György Kovács
- Interdisciplinary Brachytherapy Unit, University of Lübeck/UKSH Campus Lübeck, Lübeck, Germany
| | | | - Thomas G Wendt
- Department of Radiation Oncology, University Hospital Jena, Jena, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, University Hospital Erlangen, Erlangen, Germany; Department of Radiation Oncology, University Hospital Rostock, Rostock, Germany
| | - Marion Hindemith
- Department of Radiation Oncology, University Hospital Leipzig, Leipzig, Germany
| | - Alexandra Resch
- Department of Radiation Oncology, University Hospital AKH Wien, Vienna, Austria
| | - Anna Kulik
- Brachytherapy Department, Centrum Onkologii-Instytut im Marii Skłodowskej, Warsaw, Poland
| | - Leo Arribas
- Department of Radiation Oncology, Valencian Institute of Oncology, Valencia, Spain
| | - Peter Niehoff
- Department of Radiation Oncology, University Hospital Kiel, Germany; Department of Radiotherapy, Municipal Hospital Cologne, University Witten-Herdecke, Witten, Germany
| | - Fernando Guedea
- Department of Radiation Oncology, Catalan Institute of Oncology, Barcelona, Spain
| | - Annika Schlamann
- Department of Radiation Oncology, University Hospital Leipzig, Leipzig, Germany
| | - Richard Pötter
- Department of Radiation Oncology, University Hospital AKH Wien, Vienna, Austria
| | - Christine Gall
- Department of Medical Informatics, Biometry and Epidemiology, University Erlangen-Nuremberg, Erlangen, Germany
| | - Martina Malzer
- Department of Medical Informatics, Biometry and Epidemiology, University Erlangen-Nuremberg, Erlangen, Germany
| | - Wolfgang Uter
- Department of Medical Informatics, Biometry and Epidemiology, University Erlangen-Nuremberg, Erlangen, Germany
| | - Csaba Polgár
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary
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Recommendations from GEC ESTRO Breast Cancer Working Group (I): Target definition and target delineation for accelerated or boost Partial Breast Irradiation using multicatheter interstitial brachytherapy after breast conserving closed cavity surgery. Radiother Oncol 2015; 115:342-8. [DOI: 10.1016/j.radonc.2015.06.010] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 06/08/2015] [Accepted: 06/08/2015] [Indexed: 11/18/2022]
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Yu JI, Choi DH, Huh SJ, Park W, Nam SJ, Kim SW, Lee JE, Kil WH, Im YH, Ahn JS, Park YH. Proportion and clinical outcomes of postoperative radiotherapy omission after breast-conserving surgery in women with breast cancer. J Breast Cancer 2015; 18:50-6. [PMID: 25834611 PMCID: PMC4381123 DOI: 10.4048/jbc.2015.18.1.50] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 01/16/2015] [Indexed: 01/16/2023] Open
Abstract
PURPOSE The present study was conducted to investigate the proportion and clinical outcomes of breast cancer patients who did not receive postoperative radiotherapy (PORT) after breast-conserving surgery (BCS). METHODS This retrospective study included all breast cancer patients received curative BCS without PORT between 2003 and 2013. In the PORT omission group, characteristics and local recurrence differences were compared between the recommended group and the refused group. To compare the local recurrence-free survival (LRFS) of the PORT omission group and the control group who received PORT, subjects were selected by using the pooled data of patients treated between 1994 and 2007. RESULTS During the study period, 96 patients did not receive PORT among a total of 6,680 patients who underwent BCS. Therefore, the overall rate of PORT omission was 1.4%. Among the 96 patients, 20 were recommended for PORT omission (recommended group) and 76 refused PORT (refused group). The median follow-up period of all study participants was 19.3 months (range, 0.3-115.1 months). Patients in the recommended group were older (p=0.004), were more likely to be postmenopausal (p=0.013), and had more number of positive prognostic factors compared with the refused group. Overall, 12 cases of disease recurrence, including 11 cases of local recurrence, developed in the PORT-refused group. The LRFS of the PORT-omission group was significantly inferior to that of patients who received PORT after BCS (p<0.001). In the PORT-omission group, significant favorable prognostic factors for LRFS were having histologic grade 1 or 2 disease (p=0.023), having no axillary lymph node metastasis (p=0.039), receiving adjuvant endocrine therapy (p=0.046), and being in the recommended group (p=0.026). CONCLUSION The rate of PORT omission in the present study is very low among women who underwent surgery compared to that of other studies worldwide. PORT omission is significantly related to a high local recurrence rate.
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Affiliation(s)
- Jeong Il Yu
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Doo Ho Choi
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Jae Huh
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Won Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seok Jin Nam
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seok Won Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Eon Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Won Ho Kil
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young-Hyuck Im
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin Seok Ahn
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yeon Hee Park
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Youssef OZ, Azim HA. Understanding the factors associated with the surgical management of early breast cancer. Gland Surg 2014; 2:4-6. [PMID: 25083449 DOI: 10.3978/j.issn.2227-684x.2013.01.02] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2012] [Accepted: 01/21/2013] [Indexed: 11/14/2022]
Affiliation(s)
- Omar Z Youssef
- 1 Department of Surgical Oncology, National Cancer Institute, Cairo University, Cairo, Egypt ; 2 Department of Medicine, BrEAST Data Centre, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Hatem A Azim
- 1 Department of Surgical Oncology, National Cancer Institute, Cairo University, Cairo, Egypt ; 2 Department of Medicine, BrEAST Data Centre, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
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Garcia-Etienne CA, Tomatis M, Heil J, Danaei M, Rageth CJ, Marotti L, Rosselli Del Turco M, Ponti A. Fluctuating mastectomy rates across time and geography. Ann Surg Oncol 2013; 20:2114-6. [PMID: 23640480 DOI: 10.1245/s10434-013-2982-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
In 2009, 2 single-institution studies from the United States reported increasing mastectomy rates during the last decade. We have recently reported unilateral mastectomy trends from a European database and demonstrated a significant trend of decreasing mastectomy rates from 38.1 % in 2005 to 13.1 % in 2010. A recent study from the SEER registry in the United States confirmed a previously reported decrease in mastectomy rates from 40.1 % in year 2000 to 35.6 % in 2005, but showed a statistically significant increase in mastectomy rates up to 38.4 % in 2008. This report provides evidence that mastectomy trends may be in opposite directions in different geographical areas. The sharpest increase in mastectomy rates across all ages in the recent SEER study occurs right after year 2005, which interestingly corresponds with the time of publication of the meta-analysis by the EBCTCG that highlighted the importance of local control in breast cancer. The coincident timing raises the question of whether this evidence may have indirectly triggered an increase in mastectomy rates in the United States that would partially explain the observed trend, and more importantly, of whether an increase would be justified on this basis. Multiple factors influence the proportion between mastectomy and breast conservation, so it may be unreasonable to think of an optimal cutoff. There is not necessarily a right or wrong direction for mastectomy trends, but aiming to determine explanations for these differences may help provide a clearer insight of the decision-making process involved in the surgical management of breast cancer.
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Moo TA, Choi L, Culpepper C, Olcese C, Heerdt A, Sclafani L, King TA, Reiner AS, Patil S, Brogi E, Morrow M, Van Zee KJ. Impact of margin assessment method on positive margin rate and total volume excised. Ann Surg Oncol 2013; 21:86-92. [PMID: 24046114 DOI: 10.1245/s10434-013-3257-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND For breast-conserving surgery, the method of margin assessment that most frequently achieves negative margins without increasing the volume of tissue excised is uncertain. We examined our institutional experience with three different margin assessment methods used by six experienced breast surgeons. METHODS Patients undergoing breast-conserving surgery for invasive carcinoma during July to December of a representative year during which each method was performed (perpendicular, 2003; tangential, 2004; cavity shave, 2011) were included. The effect of margin method on the positive margin rate at first excision and the total volume excised to achieve negative margins were evaluated by multivariable analysis, by surgeon, and by tumor size and presence of extensive intraductal component (EIC). RESULTS A total of 555 patients were identified, as follows: perpendicular, 140; tangential, 124; and cavity shave, 291. The tangential method had a higher rate of positive margins at first excision than the perpendicular and cavity-shave methods (49, 15, 11 %, respectively; p < 0.0001). Median volumes to achieve negative margins were similar (55 ml perpendicular; 64 ml tangential; 62 ml cavity shave; p = 0.24). Four of six surgeons had the lowest rate of positive margins with the cavity-shave method, which was significant when compared to the tangential method (p < 0.0001) but not the perpendicular method (p = 0.37). The volume excised by the three methods varied by surgeon (p < 0.0001). The perpendicular method was optimal for T1 tumors without EIC; the cavity-shave method tended to be superior for T2-T3 tumors and/or EIC. CONCLUSIONS Although the cavity-shave method may decrease the rates of positive margins, its effect on volume is variable among surgeons and may result in an increase in the total volume excised for some surgeons and for small tumors without EIC.
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Affiliation(s)
- Tracy-Ann Moo
- Breast Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
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