The importance of local control in the conservative treatment of breast cancer

Estimating survival in patients with operable skeletal metastases: an application of a bayesian belief network

Background

Accurate estimations of life expectancy are important in the management of patients with metastatic cancer affecting the extremities, and help set patient, family, and physician expectations. Clinically, the decision whether to operate on patients with skeletal metastases, as well as the choice of surgical procedure, are predicated on an individual patient's estimated survival. Currently, there are no reliable methods for estimating survival in this patient population. Bayesian classification, which includes Bayesian belief network (BBN) modeling, is a statistical method that explores conditional, probabilistic relationships between variables to estimate the likelihood of an outcome using observed data. Thus, BBN models are being used with increasing frequency in a variety of diagnoses to codify complex clinical data into prognostic models. The purpose of this study was to determine the feasibility of developing Bayesian classifiers to estimate survival in patients undergoing surgery for metastases of the axial and appendicular skeleton.

Methods

We searched an institution-owned patient management database for all patients who underwent surgery for skeletal metastases between 1999 and 2003. We then developed and trained a machine-learned BBN model to estimate survival in months using candidate features based on historical data. Ten-fold cross-validation and receiver operating characteristic (ROC) curve analysis were performed to evaluate the BNN model's accuracy and robustness.

Results

A total of 189 consecutive patients were included. First-degree predictors of survival differed between the 3-month and 12-month models. Following cross validation, the area under the ROC curve was 0.85 (95% CI: 0.80–0.93) for 3-month probability of survival and 0.83 (95% CI: 0.77–0.90) for 12-month probability of survival.

Conclusions

A robust, accurate, probabilistic naïve BBN model was successfully developed using observed clinical data to estimate individualized survival in patients with operable skeletal metastases. This method warrants further development and must be externally validated in other patient populations.

Frozen section analysis for intraoperative margin assessment during breast-conserving surgery results in low rates of re-excision and local recurrence

BACKGROUND

Negative surgical margins minimize the risk of local recurrence after breast-conserving surgery. Intraoperative frozen section analysis (FSA) is one method for margin evaluation. We retrospectively analyzed records of patients who received breast-conserving therapy with intraoperative FSA of the lumpectomy cavity to assess re-excision rates and local control.

METHODS

Records were retrospectively reviewed for individuals who underwent breast-conserving surgery for ductal carcinoma in situ (DCIS) or invasive carcinoma between 1993 and 2003. Inclusion criteria were a minimum of 2 years follow-up and intact tumor at the time of operation. The major outcome measure was local recurrence. The Kaplan-Meier test was used to evaluate local recurrence rates between groups.

RESULTS

290 subjects with an average age of 57.2 years (range 27-89) underwent 292 lumpectomies with FSA. 11.3% had DCIS, 73.3% had infiltrating ductal, 5.8% had infiltrating lobular, and 9.6% exhibited other forms of invasive carcinoma. 70 subjects underwent additional resection at the time of breast surgery, 16 underwent subsequent re-excision, and 17 underwent subsequent mastectomy. At a median follow-up of 53.4 months (range 5.8-137.8), there were six local recurrences (2.74%) in patients who had breast-conserving procedures and two local recurrences in patients who underwent mastectomy. There were no statistically significant associations among local recurrence rate, tumor size, nodal status, or overall stage. Local recurrences were higher in patients with DCIS compared with invasive carcinoma, and tumors >2cm.

CONCLUSIONS

Intraoperative FSA allows resection of suspicious or positive margins at the time of lumpectomy and results in low rates of local recurrence and re-excision. The low local recurrence rate reported here is comparable to those reported with other margin assessment techniques.

Radiation therapy and patient age in the survival from early-stage breast cancer

PURPOSE

To analyze the use of radiation therapy following local excision of invasive localized breast cancer and subsequent survival by 5-year age category.

METHODS

Data for 27, 399 women diagnosed with localized stage of breast cancer and treated with local excision surgery from 1983 through 1992 were collected and provided by the national Surveillance, Epidemiology, and End Results (SEER) program. Use of radiation therapy was analyzed by race, ethnic background, geographic location, and age at diagnosis. Survival for women treated with local excision plus radiation therapy was compared to that of women treated with local excision alone for each 5-year age category.

RESULTS

Subjects in older age groups were significantly less likely (p < 0.001) to receive radiation following local excision compared to younger age groups. Statistically significant survival advantages were conferred on women receiving radiation therapy in each 5-year age category from age 35 to 84 years (ranging from p = 0.02 to p < 0.0001).

CONCLUSION

While the use of radiation therapy following local excision of early-stage breast tumors drops significantly in older age groups, women aged 35-84 years receiving radiation therapy had significant reductions in mortality. These results did not appear to be influenced by the presence of mortal comorbid conditions. These results strongly suggest the need to consider carefully patient characteristics other than age in deciding the course of treatment for early-stage breast cancer.

Detection of eIF4E gene amplification in breast cancer by competitive PCR

BACKGROUND

Initiation factor eIF4E binds to mRNA as the initial step for protein translation. Overexpression of the eIF4E oncoprotein has been found in breast cancer but not in benign breast tissue. The objective of this study is to determine if eIF4E oncoprotein overexpression is associated with eIF4E gene amplification in breast cancer using Western blots and competitive polymerase chain reaction (PCR).

METHODS

Unknown concentrations of DNA extracted from breast specimens were amplified by PCR using a set of primers spanning intron 2/exon 3 of the eIF4E gene. In the same PCR tube, an internal control consisting of a known concentration of an eIF4E DNA template with 20-base pair (bp) deletion was used as the competitive reference standard (CRS) for competitive PCR. Gel electrophoresis of the PCR products was performed and the bands quantified by densitometry. eIF4E gene amplification was then determined relative to a nonamplified gene (gastrin). Using an anti-eIF4E rabbit antibody, Western blots were performed on benign and malignant breast specimens. Quantification was accomplished by developing blots with a color assay using nitro blue tetrazolium (NBT) and 5-bromo-4-chloro-3-indolyl phosphate (BCIP), scanned and analyzed by densitometry.

RESULTS

Twenty-two breast specimens (14 cancer, 8 control) from patients were examined for eIF4E gene amplification and oncoprotein expression. In all fourteen specimens from stage I-III breast cancer patients, eIF4E overexpression was detected at 3- to 30-fold ( 16.71 +/- 7.83) elevations. Similarly, all 14 specimens demonstrated eIF4E gene amplification by competitive PCR (3.69 +/- 1.27). In the eight benign breast specimens examined, all were negative for eIF4E overexpression and gene amplification.

CONCLUSIONS

Overexpression of eIF4E was associated with eIF4E gene amplification in breast cancer specimens. No overexpression or gene amplification was detected in benign breast tissues. eIF4E gene amplification may be one mechanism for eIF4E oncoprotein overexpression.

The impact of radiation on early breast carcinoma survival. A Bayesian analysis

BACKGROUND

A Bayesian statistical approach was used to examine the effect of local control on survival of patients with early breast carcinoma.

METHODS

The effect of radiation on overall survival was examined in the four published randomized trials on conservation surgery with or without radiation: the Uppsala-Orebro, Canadian, NSABP-B06, and Milan III trials. Classical and Bayesian statistical approaches were used to evaluate the effect of sample size and follow-up on the results.

RESULTS

Combined 5-year survival results of patients with negative lymph nodes and surgical margins in the Uppsala-Orebro, Canadian, and NSABP-B06 trials indicated a 79% probability of a positive benefit with the addition of radiation and a 9.6% relative reduction in the annual mortality rate in favor of the irradiated patients. For the same subgroup of patients in the NSABP-B06 trial, the probability of a positive benefit with radiation increased from 65% at 5 years to 87% at 10 years, and is reflected in the change of the relative reduction in annual mortality from 8.2% at 5 years to 17.5% at 10 years. For all patients who accepted randomized treatment in the NSABP-B06 trial, the probability of a positive survival benefit with radiation was 80%, 98%, and 91% at 5, 10, and 12 years, respectively, with corresponding relative reductions in the annual mortality rates of 12.8%, 20.5%, and 15.2%.

CONCLUSIONS

The addition of radiation to lumpectomy offers a small but important survival advantage, even in patients with negative surgical margins and lymph nodes. Because locoregional control and breast preservation are significantly improved with radiation, even a small survival advantage substantiates the importance of radiation in the treatment of patients with early breast carcinoma.