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McLeod M, Leung K, Pramesh CS, Kingham P, Mutebi M, Torode J, Ilbawi A, Chakowa J, Sullivan R, Aggarwal A. Quality indicators in surgical oncology: systematic review of measures used to compare quality across hospitals. BJS Open 2024; 8:zrae009. [PMID: 38513280 PMCID: PMC10957165 DOI: 10.1093/bjsopen/zrae009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 11/16/2023] [Accepted: 12/17/2023] [Indexed: 03/23/2024] Open
Abstract
BACKGROUND Measurement and reporting of quality indicators at the hospital level has been shown to improve outcomes and support patient choice. Although there are many studies validating individual quality indicators, there has been no systematic approach to understanding what quality indicators exist for surgical oncology and no standardization for their use. The aim of this study was to review quality indicators used to assess variation in quality in surgical oncology care across hospitals or regions. It also sought to describe the aims of these studies and what, if any, feedback was offered to the analysed groups. METHODS A literature search was performed to identify studies published between 1 January 2000 and 23 October 2023 that applied surgical quality indicators to detect variation in cancer care at the hospital or regional level. RESULTS A total of 89 studies assessed 91 unique quality indicators that fell into the following Donabedian domains: process indicators (58; 64%); outcome indicators (26; 29%); structure indicators (6; 7%); and structure and outcome indicators (1; 1%). Purposes of evaluating variation included: identifying outliers (43; 48%); comparing centres with a benchmark (14; 16%); and supplying evidence of practice variation (29; 33%). Only 23 studies (26%) reported providing the results of their analyses back to those supplying data. CONCLUSION Comparisons of quality in surgical oncology within and among hospitals and regions have been undertaken in high-income countries. Quality indicators tended to be process measures and reporting focused on identifying outlying hospitals. Few studies offered feedback to data suppliers.
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Affiliation(s)
- Megan McLeod
- Department of Health Policy, London School of Economics and Political Science, London, UK
- Department of Otolaryngology—Head & Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kari Leung
- Department of Oncology, Guy’s & St Thomas’ NHS Trust, London, UK
| | - C S Pramesh
- Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Peter Kingham
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Miriam Mutebi
- Department of Surgery, Aga Khan University, Nairobi, Kenya
| | - Julie Torode
- Institute of Cancer Policy, Centre for Cancer, Society & Public Health, King’s College London, London, UK
| | - Andre Ilbawi
- Department of Universal Health Coverage, World Health Organization, Geneva, Switzerland
| | | | - Richard Sullivan
- Institute of Cancer Policy, Global Oncology Group, Centre for Cancer, Society & Public Health, King’s College London, London, UK
| | - Ajay Aggarwal
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Bundred JR, Michael S, Stuart B, Cutress RI, Beckmann K, Holleczek B, Dahlstrom JE, Gath J, Dodwell D, Bundred NJ. Margin status and survival outcomes after breast cancer conservation surgery: prospectively registered systematic review and meta-analysis. BMJ 2022; 378:e070346. [PMID: 36130770 PMCID: PMC9490551 DOI: 10.1136/bmj-2022-070346] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To determine if margin involvement is associated with distant recurrence and to determine the required margin to minimise both local recurrence and distant recurrence in early stage invasive breast cancer. DESIGN Prospectively registered systematic review and meta-analysis of literature. DATA SOURCES Medline (PubMed), Embase, and Proquest online databases. Unpublished data were sought from study authors. ELIGIBILITY CRITERIA Eligible studies reported on patients undergoing breast conserving surgery (for stages I-III breast cancer), allowed an estimation of outcomes in relation to margin status, and followed up patients for a minimum of 60 months. Patients with ductal carcinoma in situ only or treated with neoadjuvant chemotherapy or by mastectomy were excluded. Where applicable, margins were categorised as tumour on ink (involved), close margins (no tumour on ink but <2 mm), and negative margins (≥2 mm). RESULTS 68 studies from 1 January 1980 to 31 December 2021, comprising 112 140 patients with breast cancer, were included. Across all studies, 9.4% (95% confidence interval 6.8% to 12.8%) of patients had involved (tumour on ink) margins and 17.8% (13.0% to 23.9%) had tumour on ink or a close margin. The rate of distant recurrence was 25.4% (14.5% to 40.6%) in patients with tumour on ink, 8.4% (4.4% to 15.5%) in patients with tumour on ink or close, and 7.4% (3.9% to 13.6%) in patients with negative margins. Compared with negative margins, tumour on ink margins were associated with increased distant recurrence (hazard ratio 2.10, 95% confidence interval 1.65 to 2.69, P<0.001) and local recurrence (1.98, 1.66 to 2.36, P<0.001). Close margins were associated with increased distant recurrence (1.38, 1.13 to 1.69, P<0.001) and local recurrence (2.09, 1.39 to 3.13, P<0.001) compared with negative margins, after adjusting for receipt of adjuvant chemotherapy and radiotherapy. In five studies published since 2010, tumour on ink margins were associated with increased distant recurrence (2.41, 1.81 to 3.21, P<0.001) as were tumour on ink and close margins (1.44, 1.22 to 1.71, P<0.001) compared with negative margins. CONCLUSIONS Involved or close pathological margins after breast conserving surgery for early stage, invasive breast cancer are associated with increased distant recurrence and local recurrence. Surgeons should aim to achieve a minimum clear margin of at least 1 mm. On the basis of current evidence, international guidelines should be revised. SYSTEMATIC REVIEW REGISTRATION CRD42021232115.
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Affiliation(s)
- James R Bundred
- Leeds Institute of Molecular Medicine, University of Leeds, Leeds, UK
- Leeds Institute of Emergency Surgery, St James University Hospital, Leeds, UK
| | - Sarah Michael
- Manchester University NHS Foundation Trust, Wythenshawe, Manchester, UK
- Division of Cancer sciences, University of Manchester, Manchester, UK
| | - Beth Stuart
- Cancer Sciences, University of Southampton, Southampton, UK
| | - Ramsey I Cutress
- Cancer Sciences, University of Southampton, Southampton, UK
- University Hospital Southampton, Southampton, UK
| | - Kerri Beckmann
- Cancer Epidemiology and Population Health Research Group, University of South Australia, Adelaide, SA, Australia
| | - Bernd Holleczek
- Division of Clinical Epidemiology Aging Research, German Cancer Research Centre (DKFZ), Heidelberg, Germany
- Saarland Cancer Registry, Saarbrücken, Germany
| | - Jane E Dahlstrom
- ACT Pathology, Canberra Health Services and Australian National University Medical School, ACT, Australia
| | - Jacqui Gath
- Independent Cancer Patients' Voice, London, UK
| | - David Dodwell
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Nigel J Bundred
- Manchester University NHS Foundation Trust, Wythenshawe, Manchester, UK
- Division of Cancer sciences, University of Manchester, Manchester, UK
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Tan MP, Silva E. The case for breast-conservation treatment rates to be a quality metric. Curr Oncol 2020; 27:e442-e443. [PMID: 32905204 PMCID: PMC7467797 DOI: 10.3747/co.27.6539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We read the article titled “Mastectomy versus breastconservation therapy: an examination of how individual, clinicopathologic, and physician factors influence decision-making” by Gu et al. […]
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Affiliation(s)
- M P Tan
- MammoCare, 38 Irrawaddy Road, 06-21, 329563 Singapore,
- Department of Surgery, 986345 University of Nebraska Medical Center, Omaha, Nebraska 68198-63445 U.S.A.,
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Silva E, Tan M. The Impact of Margin Status on Breast Conservation Rates. Ann Surg Oncol 2019; 26:3931-3938. [PMID: 31482391 DOI: 10.1245/s10434-019-07641-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Contemporary data indicate that breast conservation treatment (BCT) results in superior survival outcomes compared with mastectomy. However, positive margins after lumpectomy have implications for local control, and re-excisions are recommended to achieve negative margins. The need for reoperations after an initial attempt at BCT is associated with higher chance of conversion to mastectomy. Achieving negative margins at the first therapeutic surgical procedure is therefore critical to optimise BCT rates and survival outcomes. METHODS A compilation of scientific reports on BCT, margin status, rates of reoperation, and the impact on BCT rates was reviewed. Re-excision rates after initial lumpectomy is variable to a staggering degree and reported to be between 0 and 100%. High reoperation rates (ROR) are associated with higher likelihood of conversion to mastectomy, which may not confer favourable treatment outcomes. Although widely agreed that decreasing ROR is a desirable objective, there is controversy regarding the need for its urgent implementation as a quality metric. Critics of this cite challenges related to how this can be achieved and its attendant ramifications. On the other hand, without the appropriate incentive for quality improvement of surgical treatment of breast cancer, patients may be subject to poorer overall outcomes. DISCUSSION Techniques and approaches are discussed in this article to enable a reduction in positive margin status, and therefore ROR. The rationale for achieving ROR of 10-20% are explicated, as well as the impact this would have on BCT rates, which translates to better survival outcomes for women with breast cancer.
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Affiliation(s)
- Edibaldo Silva
- Surgical Oncology, University of Nebraska Medical Center, Omaha, USA.
| | - Mona Tan
- MammoCare, Breast Surgery, Singapore, Singapore
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5
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Prognostic Impact of Breast-Conserving Therapy Versus Mastectomy of BRCA1/2 Mutation Carriers Compared With Noncarriers in a Consecutive Series of Young Breast Cancer Patients. Ann Surg 2019; 270:364-372. [DOI: 10.1097/sla.0000000000002804] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Holleczek B, Stegmaier C, Radosa JC, Solomayer EF, Brenner H. Risk of loco-regional recurrence and distant metastases of patients with invasive breast cancer up to ten years after diagnosis - results from a registry-based study from Germany. BMC Cancer 2019; 19:520. [PMID: 31146706 PMCID: PMC6543576 DOI: 10.1186/s12885-019-5710-5] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 05/14/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Population-based estimates of the long-term risk of loco-regional recurrence and distant metastases of breast cancer (BRC) patients are scant, as most published studies used hospital-based cohorts or participants of clinical trials. This work aims to extend available knowledge by providing population-based long-term estimates of the cumulative risk of BRC recurrence up to 10 years after diagnosis. METHODS Data from the population-based Saarland Cancer Registry were used and included 9359 female patients with primary invasive BRC diagnosed between 1999 and 2009. Estimates of the cumulative incidence (CI) of BRC recurrence were derived for patients who had received local surgery with free resection margins by type of recurrence and stratified by age, tumor characteristics and major treatment options, taking into account mortality from any cause as a competing risk. RESULTS The 10-year CI of BRC recurrence was 16%. For loco-regional recurrence and distant metastases alone it was 8 and 11%, respectively. The estimates showed substantial variation and were particularly increased if tumors were advanced (T1/2N+ 23%, T3/4N0 24%, T3/4N+ 34%), of high grade (23%), or of 'HER2/neu positive' (28%) or 'triple negative' subtype (23%), respectively. CONCLUSIONS The derived estimates reflect the risk of 'real world' patients and may therefore extend available knowledge. These data are thus of great relevance for clinicians, their patients and researchers. The study likewise demonstrated the usefulness of cancer registries for a population-based monitoring of the effectiveness of cancer care in terms of disease recurrence as a major treatment related outcome measure.
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Affiliation(s)
- Bernd Holleczek
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), INF 581, 69120, Heidelberg, Germany.
- Saarland Cancer Registry, Präsident Baltz-Straße 5, 66119, Saarbrücken, Germany.
| | - Christa Stegmaier
- Saarland Cancer Registry, Präsident Baltz-Straße 5, 66119, Saarbrücken, Germany
| | - Julia C Radosa
- Department of Gynecology and Obstetrics, Saarland University Hospital, Kirrberger Straße 100, 66421, Homburg/Saar, Germany
| | - Erich-Franz Solomayer
- Department of Gynecology and Obstetrics, Saarland University Hospital, Kirrberger Straße 100, 66421, Homburg/Saar, Germany
| | - Hermann Brenner
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), INF 581, 69120, Heidelberg, Germany
- Division of Preventive Oncology, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT), INF 460, 69120, Heidelberg, Germany
- German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), INF 280, 69120, Heidelberg, Germany
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7
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Tan MPC, Sitoh YY. Are breast conservation treatment rates optimized for Asian women with symptomatic malignancies? ANZ J Surg 2019; 89:529-535. [PMID: 30972960 DOI: 10.1111/ans.15084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 09/16/2018] [Accepted: 11/15/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Published data indicate that 20-40% of patients undergo breast conservation treatment (BCT) in Asia, which is below an indicative benchmark of 50%. With an increasing body of evidence suggesting that BCT might be associated with improved survival outcomes, it is exigent to increase BCT utilization. This study was therefore undertaken to evaluate BCT rates for women presenting with symptomatic breast cancer and potential for de-escalation of surgical treatment. METHODS All patients who presented with symptomatic tumours and underwent surgical treatment at the authors' healthcare facility between January 2009 and December 2011 were included in this retrospective study. Standard wide excision was performed to achieve clear margins and reasonable cosmetic outcomes for BCT-eligible patients. Oncoplastic techniques such as therapeutic mammoplasty or volume replacement with flaps were not employed. RESULTS A total of 116 women presented with symptomatic breast cancer. The majority (92.2%) were Asian. Mean age at diagnosis was 48.3 years and mean tumour size was 23.4 mm. Ninety-five patients (81.9%) underwent BCT. Of the 22 patients, 13 (59%) who underwent neoadjuvant chemotherapy had sufficient tumour size downstaging to successfully undergo BCT instead of mastectomy. CONCLUSION It is possible for more than 80% of Asian women with symptomatic breast malignancies to undergo BCT, with the appropriate use of neoadjuvant medical therapy and surgical techniques. As increasing data indicate improved survival with BCT, this should be offered as the treatment of choice.
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Affiliation(s)
| | - Yih Yiow Sitoh
- Clinical Medicine, Mount Elizabeth Novena Hospital, Singapore
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8
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Tan MP, Tot T. The sick lobe hypothesis, field cancerisation and the new era of precision breast surgery. Gland Surg 2018; 7:611-618. [PMID: 30687632 DOI: 10.21037/gs.2018.09.08] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Understanding the ductal anatomy of the breast provides insights into tumorigenesis, which in turn offers guidance on therapeutic decisions. In this regard, the sick lobe hypothesis, which states that cancer arises from genetically unstable cells through mutations acquired in utero, forms the basis of malignant transformation. These 'at risk' cells line the mammary ductal-lobular system of a single 'sick' lobe and when exposed to noxious events in the surrounding microenvironment, further genetic changes occur which completes conversion to malignancy, in certain defined patterns. This review explores how anatomy, pathology and genomics can merge, not only to guide optimum surgery, but also to provide a more comprehensive portal for precision medicine.
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Affiliation(s)
- Mona P Tan
- Department of Breast Surgical Oncology, MammoCare, Singapore, Singapore
| | - Tibor Tot
- Department of Pathology & Head, Pathology and Cytology Dalarna, County Hospital Falun, Falun, Sweden
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9
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Murugappan K, Saboo A, Kuo L, Ung O. Paradigm shift in the local treatment of breast cancer: mastectomy to breast conservation surgery. Gland Surg 2018; 7:506-519. [PMID: 30687624 PMCID: PMC6323252 DOI: 10.21037/gs.2018.09.01] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 09/03/2018] [Indexed: 01/16/2023]
Abstract
There have been fundamental changes in the approach to breast cancer management over the last century but the primary objective of achieving oncological safety remains unchanged. This evolution is highlighted with a summary of the key evidences in support of the oncological safety of breast conserving surgery (BCS) in early breast cancer (EBC) management. We will also discuss the increasingly pivotal role that neoadjuvant chemotherapy (NACT) may play, in the local treatment of EBC and locally advanced breast cancer (LABC) and the long-term surgical and oncological outcomes.
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Affiliation(s)
- Kowsi Murugappan
- Royal Brisbane Breast Surgery Unit, Department of General Surgery, RBWH, Brisbane, Australia
- University of Queensland, Brisbane, Australia
| | - Apoorva Saboo
- Royal Brisbane Breast Surgery Unit, Department of General Surgery, RBWH, Brisbane, Australia
| | - Lu Kuo
- University of Queensland, Brisbane, Australia
| | - Owen Ung
- Royal Brisbane Breast Surgery Unit, Department of General Surgery, RBWH, Brisbane, Australia
- University of Queensland, Brisbane, Australia
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Witteveen A, Otten JWM, Vliegen IMH, Siesling S, Timmer JB, IJzerman MJ. Risk-based breast cancer follow-up stratified by age. Cancer Med 2018; 7:5291-5298. [PMID: 30207076 PMCID: PMC6198239 DOI: 10.1002/cam4.1760] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 07/15/2018] [Accepted: 07/18/2018] [Indexed: 01/29/2023] Open
Abstract
Although personalization of cancer care is recommended, current follow‐up after the curative treatment of breast cancer is consensus‐based and not differentiated for base‐line risk. Every patient receives annual follow‐up for 5 years without taking into account the individual risk of recurrence. The aim of this study was to introduce personalized follow‐up schemes by stratifying for age. Using data from the Netherlands Cancer Registry of 37 230 patients with early breast cancer between 2003 and 2006, the risk of recurrence was determined for four age groups (<50, 50‐59, 60‐69, >70). Follow‐up was modeled with a discrete‐time partially observable Markov decision process. The decision to test for recurrences was made two times per year. Recurrences could be detected by mammography as well as by self‐detection. For all age groups, it was optimal to have more intensive follow‐up around the peak in recurrence risk in the second year after diagnosis. For the first age group (<50) with the highest risk, a slightly more intensive follow‐up with one extra visit was proposed compared to the current guideline recommendation. The other age groups were recommended less visits: four for ages 50‐59, three for 60‐69, and three for ≥70. With this model for risk‐based follow‐up, clinicians can make informed decisions and focus resources on patients with higher risk, while avoiding unnecessary and potentially harmful follow‐up visits for women with very low risks. The model can easily be extended to take into account more risk factors and provide even more personalized follow‐up schedules.
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Affiliation(s)
- Annemieke Witteveen
- Department of Health Technology and Services ResearchUniversity of TwenteEnschedeThe Netherlands
| | - Jan W. M. Otten
- Department of Stochastic Operations ResearchUniversity of TwenteEnschedeThe Netherlands
| | - Ingrid M. H. Vliegen
- Department of Industrial Engineering and Innovation SciencesEindhoven University of TechnologyEindhovenThe Netherlands
| | - Sabine Siesling
- Department of Health Technology and Services ResearchUniversity of TwenteEnschedeThe Netherlands
- Department of ResearchNetherlands Comprehensive Cancer Organisation (IKNL)UtrechtThe Netherlands
| | - Judith B. Timmer
- Department of Stochastic Operations ResearchUniversity of TwenteEnschedeThe Netherlands
| | - Maarten J. IJzerman
- Department of Health Technology and Services ResearchUniversity of TwenteEnschedeThe Netherlands
- Faculty of MedicineDentistry and Health SciencesSchool of Population and Global HealthUniversity of Melbourne and Victorian Comprehensive Cancer CentreMelbourneVictoriaAustralia
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Predictors for poor cosmetic outcome in patients with early stage breast cancer treated with breast conserving therapy: Results of the Young boost trial. Radiother Oncol 2018; 128:434-441. [DOI: 10.1016/j.radonc.2018.06.020] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 05/27/2018] [Accepted: 06/12/2018] [Indexed: 11/21/2022]
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Spronk I, Schellevis FG, Burgers JS, de Bock GH, Korevaar JC. Incidence of isolated local breast cancer recurrence and contralateral breast cancer: A systematic review. Breast 2018; 39:70-79. [PMID: 29621695 DOI: 10.1016/j.breast.2018.03.011] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 03/23/2018] [Accepted: 03/26/2018] [Indexed: 12/21/2022] Open
Abstract
An increasing number of women is surviving breast cancer and due to that at risk of developing an isolated ipsilateral breast tumor recurrence (IBTR) or a contralateral breast cancer (CBC). Patients' main concern is cancer recurrence. Patient counseling on breast cancer recurrence is challenging. In order to provide healthcare professionals and patients more guidance, a systematic literature review of the incidence of isolated IBTR and CBC in women diagnosed with early invasive breast cancer was performed. Medline, EMBASE and the Cochrane Library were searched from 2000 until October 2015. Multicenter studies reporting an IBTR or CBC rate in curatively treated adult females diagnosed with invasive breast cancer were included. The initial search yielded 6998 potentially relevant articles. Twenty were eligible for inclusion, representing 25 recurrence incidence rates. Both isolated IBTR and CBC incidence rates steadily increased with the length of follow-up, indicating that IBTR and CBC occur even more than 15 years after diagnosis. The annual incidence rate of isolated IBTR and CBC in women diagnosed with an early invasive breast cancer was 0.6% (range: 0.4-1.1%) and 0.5% (range: 0.2-0.7%), respectively. Analyzed data were lacking information about important risk factors and given treatment with regard to the incidence of recurrence, which hampers the prediction of patient tailored recurrence risks. The presented rates are therefore the best available estimates of isolated IBTR and CBC annual incidence rates based on the current literature. Healthcare professionals could use these rates in their communication with patients diagnosed with early invasive breast cancer.
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Affiliation(s)
- Inge Spronk
- NIVEL, Netherlands Institute for Health Services Research, P.O. Box 1568, 3500BN, Utrecht, The Netherlands.
| | - François G Schellevis
- NIVEL, Netherlands Institute for Health Services Research, P.O. Box 1568, 3500BN, Utrecht, The Netherlands; Department of General Practice & Elderly Care Medicine/ Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands.
| | - Jako S Burgers
- Dutch College of General Practitioners, P.O. Box 3231, 3502 GE, Utrecht, The Netherlands; School CAPHRI, Department Family Medicine, Universiteitssingel 40, 6229 ER, Maastricht University, Maastricht, The Netherlands.
| | - Geertruida H de Bock
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands.
| | - Joke C Korevaar
- NIVEL, Netherlands Institute for Health Services Research, P.O. Box 1568, 3500BN, Utrecht, The Netherlands.
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Tan MP, Silva E. Addressing the paradox of increasing mastectomy rates in an era of de-escalation of therapy: Communication strategies. Breast 2018; 38:136-143. [DOI: 10.1016/j.breast.2017.12.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Revised: 11/13/2017] [Accepted: 12/14/2017] [Indexed: 12/18/2022] Open
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Tan MP, Ong EM, Amy D, Tot T. Integrating anatomy, radiology, pathology, and surgery: An alternative approach in resecting multifocal and multicentric breast carcinoma. Breast J 2017; 23:663-669. [PMID: 28833864 DOI: 10.1111/tbj.12891] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Revised: 12/16/2016] [Accepted: 12/16/2016] [Indexed: 12/27/2022]
Abstract
The sick lobe hypothesis provides the basis for a lobar approach in radiology, pathology, and surgical treatment of breast cancer. This approach aims to remove the tumor together with the surrounding field of genetic aberrations. Detailed preoperative lobar imaging that properly maps the disease and assesses its extent guides the parenchymal resection. Integration of our knowledge of breast anatomy and pathology with the results of preoperative radiological mapping is critical in assessing the eligibility of patients with multifocal and/or multicentric breast cancer for breast conservation treatment. Through an appropriately selected incision, a multisegment resection of the diseased lobe(s) is performed, which leaves the residual parenchyma in a formation that allows dovetailing of one part into the other, like the way pieces of a jigsaw puzzle fit together. Detailed pathologic analysis of the surgical specimen provides valuable feedback to the radiologist, establishes the completeness of surgical intervention, and generates predictive information for therapeutic decisions. Our approach is a step in continuous search for ideal tailored therapy to avoid under or over-treatment of breast cancer patients.
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Affiliation(s)
| | - Eugene M Ong
- Diagnostic Radiology, Mount Elizabeth Novena Hospital, Singapore
| | | | - Tibor Tot
- Department of Pathology and Clinical Cytology, County Hospital Falun, Falun, Sweden
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Breast magnetic resonance imaging use in patients undergoing neoadjuvant chemotherapy is associated with less mastectomies in large ductal cancers but not in lobular cancers. Eur J Cancer 2017; 81:74-80. [PMID: 28618304 DOI: 10.1016/j.ejca.2017.05.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 03/29/2017] [Accepted: 05/05/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND To assess the impact of breast magnetic resonance imaging (MRI) use on surgical outcome per histological breast cancer subtype in patients treated with neoadjuvant chemotherapy. PATIENTS AND METHODS All patients aged 18-70 years who underwent neoadjuvant chemotherapy for stage I-III invasive breast cancer in the Netherlands in the years 2011-2013 were identified from the Netherlands Cancer Registry. Patients with cT4 tumours were excluded from the analysis. Use of breast MRI and impact on surgical treatment, resection margins and detection of contralateral breast cancer were analysed by multivariable analyses. RESULTS Breast MRI was performed in 2879 (83.9%) out of 3433 patients treated with neoadjuvant chemotherapy. Younger age (odds ratio [OR] 1.42; 95% confidence interval [CI] 1.17-1.71 for 18-50 years compared with 50-70 years), larger tumour stage (OR 1.46 [95% CI 1.15-1.86] for cT3, compared to cT1-2 tumours) and multifocality (OR 1.30; 95% CI 1.04-1.61, versus unifocality) were associated with increased breast MRI use. In ductal breast cancer, after stratification for cT-status, breast MRI use is associated with a significant lower OR for mastectomy as final surgery in cT3 tumours (OR 0.45, 95% CI 0.21-0.99). Resection margin involvement and detection of contralateral breast cancer were not associated with breast MRI use. CONCLUSION In patients treated with neoadjuvant chemotherapy, the use of breast MRI was associated with a reduced mastectomy rate, particularly in patients with large invasive ductal breast tumours but not in patients with lobular breast cancer.
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Oncoplastic to Onco-Aesthetic Surgery: A Movement toward Overtreatment? Arch Plast Surg 2017; 44:85-86. [PMID: 28194354 PMCID: PMC5300931 DOI: 10.5999/aps.2017.44.1.85] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Revised: 07/12/2016] [Accepted: 07/12/2016] [Indexed: 11/22/2022] Open
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Timbrell S, Al-Himdani S, Shaw O, Tan K, Morris J, Bundred N. Comparison of Local Recurrence After Simple and Skin-Sparing Mastectomy Performed in Patients with Ductal Carcinoma In Situ. Ann Surg Oncol 2016; 24:1071-1076. [PMID: 27837296 PMCID: PMC5339328 DOI: 10.1245/s10434-016-5673-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Indexed: 11/18/2022]
Abstract
Background The incidence of ductal carcinoma in situ (DCIS) is increasing with the use of screening mammography, and approximately 30% of all women diagnosed with DCIS are treated by mastectomy. There is increasing use of a skin-sparing mastectomy (SSM) approach to surgically excise DCIS as this facilitates immediate breast reconstruction. The rates of locoregional recurrence (LRR) after simple mastectomy performed for pure DCIS are historically reported as 1%; however, international data suggest that LRR after SSM may be higher. Methods To determine our rates of LRR and compare the effect of the type of mastectomy performed, we undertook a retrospective review of all patients who underwent a mastectomy for pure DCIS at our institution between 2000 and 2010. Results In total, 199 patients underwent a mastectomy for pure DCIS (with eight local recurrences), all of which were invasive ductal carcinoma. The recurrences all occurred after SSM, which was associated with a higher 5-year LRR of 5.9% (5/102) compared with 0% in the simple mastectomy group (0/97; p = 0.012), log-rank. Univariate analysis showed the two factors that predicted the risk of recurrence were a young age at mastectomy and close or involved margins. Conclusions These data highlight the importance of achieving clear margins, especially in young women with estrogen receptor-negative DCIS who have a higher risk of invasive recurrence. Women undergoing a mastectomy for DCIS should be counseled as to the importance of achieving clear margins and the potential increased need for further excision, post-mastectomy radiotherapy and post-reconstruction mammography in order to prevent LRR after SSM. Electronic supplementary material The online version of this article (doi:10.1245/s10434-016-5673-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Simon Timbrell
- Academic Surgery, University Hospital of South Manchester, Manchester, UK
| | - Sarah Al-Himdani
- Academic Surgery, University Hospital of South Manchester, Manchester, UK
| | - Oliver Shaw
- Academic Surgery, University Hospital of South Manchester, Manchester, UK
| | - Kian Tan
- Academic Surgery, University Hospital of South Manchester, Manchester, UK
| | - Julie Morris
- Academic Surgery, University Hospital of South Manchester, Manchester, UK
| | - Nigel Bundred
- Academic Surgery, University Hospital of South Manchester, Manchester, UK.
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Borrelli P, Donswijk ML, Stokkel MP, Teixeira SC, van Tinteren H, Rutgers EJT, Valdés Olmos RA. Contribution of SPECT/CT for sentinel node localization in patients with ipsilateral breast cancer relapse. Eur J Nucl Med Mol Imaging 2016; 44:630-637. [PMID: 27787592 PMCID: PMC5323474 DOI: 10.1007/s00259-016-3545-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 10/04/2016] [Indexed: 01/08/2023]
Abstract
Background In recent years repeat sentinel node (SN) biopsy has been proven to be feasible in local breast cancer recurrence (LBCR). However, in these patients SNs outside the ipsilateral axilla are frequently observed. This study evaluates the contribution of SPECT/CT for SN localization and surgical adjustment in LBCR patients. Methods SN biopsy was performed in 122 LBCR patients (median age 60.5 years, range 24–87), enrolled from August 2006 to July 2015. Median disease-free time lapse was 109.5 months (range 9–365). Axillary lymph node dissection (ALND) had previously been performed in 55 patients, SN biopsy in 44, both techniques in 13 and fine-needle aspiration in 10. Primary breast cancer treatment included radiotherapy in 104 patients (85.3 %) and chemotherapy in 40 (32.8 %). Preoperative lymphatic mapping, using planar scintigraphy (PS) and SPECT/CT included report of SN location according to lymph node territory. In case of a territorial PS-SPECT/CT mismatch, surgery was adjusted according to SPECT/CT findings. Results SPECT/CT SN visualization rate was higher than PS (53.3 % vs. 43.4 %, p n.s.) with, in total, 19 additional SN (118 vs. 99, p n.s.). PS-SPECT/CT territory mismatch, found in 60 % (39/65) of patients with SN visualization, led to surgical adjustment in 21.3 % (26/122) of patients. The SN procedure was finally performed in 104 patients resulting in a 65.7 % surgical retrieval rate with a total of 132 removed SNs (1.86/patient). SN metastases were found in 17/71 patients (23.9 %), in 16 of them (94 %) in ipsilateral basins outside the axilla or in the contralateral axilla. Conclusion Using SPECT/CT there is a trend to visualize more SNs in LBCR, providing at the same time important anatomical information to adjust intraoperative SN procedures. The addition of SPECT/CT to the standard imaging protocol may lead to better staging mainly in patients presenting drainage outside the ipsilateral axilla.
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Affiliation(s)
- Pablo Borrelli
- Department of Nuclear Medicine, The Netherlands Cancer Institute, Antoni Van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
- Nuclear Medicine, Medical Imaging Clinical Area, Hospital La Fe, Valencia, Spain
| | - Maarten L Donswijk
- Department of Nuclear Medicine, The Netherlands Cancer Institute, Antoni Van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Marcel P Stokkel
- Department of Nuclear Medicine, The Netherlands Cancer Institute, Antoni Van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Suzana C Teixeira
- Department of Nuclear Medicine, The Netherlands Cancer Institute, Antoni Van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Harm van Tinteren
- Department of Biometrics, The Netherlands Cancer Institute, Antoni Van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Emiel J Th Rutgers
- Department of Surgery, The Netherlands Cancer Institute, Antoni Van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Renato A Valdés Olmos
- Department of Nuclear Medicine, The Netherlands Cancer Institute, Antoni Van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.
- Nuclear Medicine Section and Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Centre, Leiden, The Netherlands.
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Tan MP. Mastectomy versus breast conservation treatment: is there a true survival difference? Breast Cancer Res Treat 2016; 158:601-3. [DOI: 10.1007/s10549-016-3903-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 07/05/2016] [Indexed: 12/01/2022]
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Prediction of margin involvement and local recurrence after skin-sparing and simple mastectomy. Eur J Surg Oncol 2016; 42:935-41. [DOI: 10.1016/j.ejso.2016.04.055] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Revised: 03/24/2016] [Accepted: 04/07/2016] [Indexed: 11/21/2022] Open
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Tan MP, Sitoh NY, Sitoh YY. Optimising Breast Conservation Treatment for Multifocal and Multicentric Breast Cancer: A Worthwhile Endeavour?: Reply. World J Surg 2016; 41:346-347. [PMID: 27272268 DOI: 10.1007/s00268-016-3590-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Mona P Tan
- MammoCare, Breast Surgery, Singapore, Singapore.
| | - Nadya Y Sitoh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yih Y Sitoh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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Tan MP. Is there an Ideal Breast Conservation Rate for the Treatment of Breast Cancer? Ann Surg Oncol 2016; 23:2825-31. [DOI: 10.1245/s10434-016-5267-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Indexed: 02/06/2023]
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Abstract
Breast conservation treatment (BCT) is the preferred modality of treatment for early breast cancer. However, a moderate proportion of women will develop deformity and those with tumours in the lower hemisphere of the breast pose a particular challenge. Here, a technique is described which allows acceptable cosmetic outcome in women with small or medium-sized breasts without the use of therapeutic mammoplasty or volume replacement with flaps.
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