Decision-Making in the Surgical Treatment of Breast Cancer: Factors Influencing Women's Choices for Mastectomy and Breast Conserving Surgery

Risk Factors for Skin Flap and Nipple-Areolar Necrosis in Patients Undergoing Nipple-Sparing Mastectomy With Deep Inferior Epigastric Perforator Flap Reconstruction

INTRODUCTION

Nipple-sparing mastectomy (NSM) with deep inferior epigastric perforator (DIEP) flap reconstruction is a surgical option for select patients with or at risk of breast cancer. However, post-operative skin flap and nipple-areolar complex (NAC) necrosis remain common complications. This study aimed to identify factors associated with necrosis in patients undergoing NSM with DIEP reconstruction.

METHODS

A retrospective cohort study was performed from 2015 to 2023. 74 variables were analyzed in patients undergoing NSM with DIEP. Patients were stratified into 3 groups based on post-operative skin/NAC necrosis: none, partial thickness, and full thickness. Comparative and descriptive statistics were performed via t-tests, ANOVA, and chi-squared tests.

RESULTS

34 women with 31 breast cancers met inclusion. 44% experienced necrosis: 15% partial thickness and 29% full thickness. The majority were white (85.3%) with mean age of 50 years (SD = 9.11). In patients with immediate DIEP reconstruction, hypoperfused areas identified by SPY angiography increased risk of necrosis (P = .012). Approximately 50% of both partial thickness and full thickness necrosis patients had concerns on SPY angiography. Former smokers in the full thickness necrosis group had more pack years than those without necrosis (9 vs .65 pack years, P = .035).

CONCLUSION

In patients receiving NSM with DIEP flap reconstruction, those with hypoperfusion on SPY angiography and longer smoking history had higher necrosis rates. This supports the continued used of SPY angiography and the role of pre-operative counseling in former smokers with increased pack years on their risk of necrosis and the role of preventative measures in the perioperative setting.

Racial/ethnic disparities in the association between patient care experiences and receipt of initial surgical breast cancer care: findings from SEER-CAHPS

PURPOSE

We determined whether racial/ethnic differences in patient experiences with care influence timeliness and type of initial surgical breast cancer treatment for a sample of female Medicare cancer patients.

METHODS

We conducted a retrospective cohort study using the linked Epidemiology and End Results-Consumer Assessment of Healthcare Providers and Systems (SEER-CAHPS) dataset. The outcomes were: (1) time-to-initial surgical treatment, and (2) type of treatment [breast conserving surgery (BCS) vs. mastectomy]. The indicators were reports of four types of patient experiences with care including doctor communication, getting care quickly, getting needed care, and getting needed Rx. Interaction terms in each multivariable logistic model examined if the associations varied by race/ethnicity.

RESULTS

Of the 2069 patients, 84.6% were White, 7.6% Black and 7.8% Hispanic. After adjusting for potential confounders, non-Hispanic Black patients who provided excellent reports of their ability to get needed prescriptions had lower odds of receiving surgery within 2-months of diagnosis, compared to NH-Whites who provided less than excellent reports (aOR: 0.29, 95% CI 0.09-0.98). There were no differences based on 1-month or 3-month thresholds. We found no other statistically significant effect of race/ethnicity. As to type of surgery, among NH Blacks, excellent reports of getting care quickly were associated with higher odds of receiving BCS versus mastectomy (aOR: 2.82, 95% CI 1.16-6.85) compared to NH Whites with less than excellent reports. We found no other statistically significant differences by race/ethnicity.

CONCLUSION

Experiences with care are measurable and modifiable factors that can be used to assess and improve aspects of patient-centered care. Improvements in patient care experiences of older adults with cancer, particularly among minorities, may help to eliminate racial/ethnic disparities in timeliness and type of surgical treatment.

Patient values in breast cancer surgical decision-making - The WhySurg study

BACKGROUND

The objective of this study was to describe patient values and personality traits associated with breast surgery choice for patients with breast cancer.

METHODS

A survey based on qualitative patient interviews and the Big-Five personality trait profile was distributed to Love Research Army volunteers aged 18-70 years old who underwent breast cancer surgery from 2009 to 2020. Multivariable logistic regression analysis was used to determine independent patient values and personality traits for the choice of breast-conserving surgery (BCS), unilateral mastectomy (UM) and bilateral mastectomy (BM).

RESULTS

1497 participants completed the survey. Open-mindedness was associated with UM and sociability was associated with BM. A majority of patients prioritized cancer outcomes. Compared to BM patients, BCS and UM patients were significantly more likely to choose values associated with maintaining their self-image, optimizing surgical recovery, and following their doctor's recommendation.

CONCLUSIONS

Other values besides cancer outcomes differentiate patient surgical choice for BCS or mastectomy.

"I don't know if I understood the whole process from the beginning": A photo-elicitation exploration of the experience of mastectomy and breast reconstruction decision making

Objectives

Policy and guidance assume that reconstruction following mastectomy will have physical and psychological benefits, however research has disputed whether this is always the case. This study aimed to explore mastectomy experiences and reconstruction decision making.

Methods

Semi-structured interviews about self-curated participant photographs of the breast cancer experience were analysed using interpretative phenomenological analysis (IPA).

Results

Three themes were developed: 'Life before mastectomy'; 'I don't know if I understood the whole process from the beginning'; and getting back to 'normal'.

Conclusions

Decisions regarding reconstruction were influenced by needs of others, and surgeons' communication and behaviour and negative experiences were prominent. Over time participants came to terms with physical and psychological impacts of mastectomy reporting re-finding themselves alongside acceptance of their post mastectomy bodies. However, many participants were living with the fear that their cancer may one day return. Communication skills training for healthcare professionals should be a priority to ensure decisions made result in the best possible outcomes for patients.

Innovation

Photo-elicitation is a novel research method enabling rich investigation of mastectomy experiences. Self-curation of images enables patient-led discussions about mastectomy experience and illustrates the importance of life context. Photographs may have value within clinical training to facilitate understanding of patient experiences.

Breast Conservative Surgery for Breast Cancer: Indian Surgeon's Preferences and Factors Influencing Them

Background

It is well established that disease-free survival and overall survival after breast conservation surgery (BCS) followed by radiotherapy are equivalent to that after mastectomy. However, in Asian countries, the rate of BCS continues to remain low. The cause may be multifactorial including the patient's choice, availability and accessibility of infrastructure, and surgeon's choice. We aimed to elucidate the Indian surgeons' perspective while choosing between BCS and mastectomy, in women oncologically eligible for BCS.

Methods

We conducted a survey-based cross-sectional study in January-February 2021. Indian surgeons with general surgical or specialised oncosurgical training, who consented to participate were included in the study. Multinomial logistic regression was performed to assess the effect of study variables on offering mastectomy or BCS.

Results

A total of 347 responses were included. The mean age of the participants was 43 ± 11 years. Sixty-three of the surgeons were in the 25-44 years age group with the majority (80%) being males. 66.4% of surgeons 'almost always' offered BCS to oncologically eligible patients. Surgeons who had undergone specialised training in oncosurgery or breast conservation surgery were 35 times more likely to offer BCS (p < 0.01). Surgeons working in hospitals with in-house radiation oncology facilities were 9 times more likely to offer BCS (p < 0.05). Surgeons' years of practice, age, sex and hospital setting did not influence the surgery offered.

Conclusion

Two-thirds of Indian surgeons preferred BCS over mastectomy. Lack of radiotherapy facilities and specialised surgical training were deterrents to offering BCS to eligible women.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13193-022-01601-y.

A large single-center prospective study to investigate the factors influencing the choice of breast-conserving surgery versus mastectomy in Chinese women with early breast cancer

BACKGROUND

Compared to mastectomy, breast-conserving surgery (BCS) provides the same survival rate and a higher quality of life for patients with early breast cancer (EBC). However, Chinese women with EBC are known to have a low BCS rate. A large prospective cohort study was conducted to investigate the factors influencing the choice of BCS in this population.

METHODS

In 2017, all women with unilateral EBC and eligible for BCS at our institution were enrolled. Before surgery, the patient's trust in the surgeon and her perceived strength of the surgeon's recommendation of BCS were measured through an in-person interview and validated ad hoc questionnaire. Multivariate logistic regressions on BCS procedure vs. mastectomy were used to estimate the odds ratio (OR).

RESULTS

One thousand one hundred thirty-six patients enrolled at analysis had an average age of 51.8 and tumor size of 2.4 cm. 19.9% of patients had BCS. The "strong" level of trust in the surgeon was significantly associated with BCS with an OR of 2.944 (p<0.001) when compared to the "average or under" trust. The "strong" and "moderate" strengths in surgeon recommendation for BCS were also found to be significantly associated with the BCS procedure with ORs of 12.376 (p <0.001) and 1.757 (p =0.040), respectively, compared to the "neutral or dissuaded" strength.

CONCLUSIONS

Stronger trust in surgeons and BCS recommendation by surgeons are associated with a higher rate of BCS in Chinese women with EBC. Interventional trials are needed to confirm this finding.

Breast Reconstruction Decision Aids Decrease Decisional Conflict and Improve Decisional Satisfaction: A Randomized Controlled Trial

BACKGROUND

Decision aids are useful adjuncts to clinical consultations for women considering breast reconstruction. This study compared the impact of two online decision aids, the Breast RECONstruction Decision Aid (BRECONDA) and the Alberta Health Services (AHS) decision aid, on decisional conflict, decisional satisfaction, and decisional regret.

METHODS

This randomized controlled trial included 60 women considering whether or not to undergo breast reconstruction. Two online decision aids, the AHS and the BRECONDA, were compared using randomized two-arm equal allocation. Participants responded to questionnaires at baseline, after the first and second consultations, and at 6 weeks and 6 months after deciding to, or not to, undergo reconstruction. Change in decisional conflict scores was compared between the BRECONDA and the AHS decision aid. Secondary outcomes included decisional regret and decisional satisfaction.

RESULTS

Both groups were similar in demographic, clinical, and behavioral characteristics. Women spent more time consulting the BRECONDA in comparison to women using the AHS decision aid (56.7 ± 53.8 minutes versus 28.4 ± 27.2 minutes; P < 0.05). Decisional conflict decreased (P < 0.05), and decisional satisfaction improved over time in both groups (P < 0.05). However, there were no differences based on the type of decision aid used (P > 0.05). Both decision aids had a similar reduction in decisional regret (P > 0.05).

CONCLUSIONS

Decision aids decrease decisional conflict and improve decisional satisfaction among women considering breast reconstruction. Physicians should therefore offer patients access to decision aids as an adjunct to breast reconstruction consultations to help patients make an informed decision.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, I.

Conventional standard-sized bra with prosthesis or patient's bra with customized hand-knitted external prosthesis after mastectomy: Mixed-methods evaluation of patients' preferences

INTRODUCTION

In breast cancer patients undergoing mastectomy without reconstruction, an external breast prosthesis could aid patients' recovery, improve body image and confidence by helping to regain a symmetrical chest appearance when dressed. However, external breast prosthesis preferences among Asian breast cancer patients were not widely studied. We aimed to compare patients' experience with the conventional commercially manufactured standard-sized (small, medium, large, extra-large) bra and prosthesis versus customized hand-knitted external breast prosthesis with patient's bra after unilateral mastectomy at a tertiary hospital. This is the first such study in Asian women, to our knowledge.

METHODS

In this prospective study, participants used the conventional bra-prosthesis followed by the customized one consecutively, each for at least 3 months before they were administered an identical questionnaire at 3 and 6 months respectively. The questionnaire assessed the patients' experience with the prosthesis on the aspects of comfort, body image and satisfaction etc. Patients were also invited for in-depth interviews.

RESULTS

Of 155 eligible patients, 148 patients participated with a response rate of 95.5%. 99 (67%) participants preferred the customized prosthesis, while 38 (25.7%) did not. 11 (7.4%) participants were undecided. Seventeen participants underwent in-depth interviews until data saturation on major qualitative themes was achieved. More patients experienced excessive sweating (p < 0.0001), greater discomfort (p = 0.0195) and higher rates of prosthesis dislodgement (p = 0.0269) with the conventional bra-prosthesis.

CONCLUSION

Customized external breast prostheses could be an alternative to the conventional ones for breast cancer patients with mastectomy, with additional benefits of less sweating, more comfort and less dislodgement perceived.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Receipt of breast conservation over mastectomy in Black women- does breast cancer subtype matter?

BACKGROUND

Breast conservation surgery (BCS) and mastectomy have equivalent survivability. However, perception of surgical benefit may be affected by breast cancer subtypes, impacting procedure choice. We evaluate surgical management among non-Hispanic Black (NHB) and White (NHW) breast cancer patients based on subtypes.

METHODS

Queried the National Cancer Database (NCDB) including BCS eligible women with T1 (<2cm) breast cancer between 2011 and 2016. We selected NHB and NHW women and evaluated differences in sociodemographic variables and treatment including surgery. To determine factors associated with receipt of BCS, a multivariable logistic regression analysis was performed adjusting for age, race, surgery type and breast cancer subtypes.

RESULTS

Analyzed 390,278 women with 89.7% NHW and 10.3% NHB, of mean age 63 years. 55.4% vs. 53.5% of NHW compared to NHB women had BCS (p<.001) as initial cancer therapy. Statistically significant differences between NHB and NHW in surgery were found on univariate analysis in all breast cancer subtypes except Luminal B. NHB women with TNBC and Luminal A subtypes were more likely to undergo BCS on multivariate analysis.

CONCLUSIONS

Significant differences are found in the surgical management of breast cancer with Black women more likely to receive BCS, less likely to undergo mastectomy compared to White counterparts even with TNBC or her-2+ subtypes. Understanding surgical decision making and how knowledge of subtype is applied deserves further study in women of diverse racial and ethnic groups.

The challenge of equipoise: qualitative interviews exploring the views of health professionals and women with multiple ipsilateral breast cancer on recruitment to a surgical randomised controlled feasibility trial

Background

A multicentre feasibility trial (MIAMI), comparing outcomes and quality of life of women with multiple ipsilateral breast cancer randomised to therapeutic mammoplasty or mastectomy, was conducted from September 2018 to March 2020. The MIAMI surgical trial aimed to investigate recruitment of sufficient numbers of women. Multidisciplinary teams at 10 breast care centres in the UK identified 190 with MIBC diagnosis; 20 were eligible for trial participation but after being approached only four patients were recruited. A nested qualitative study sought to understand the reasons for this lack of recruitment.

Methods

Interviews were conducted from November 2019 to September 2020 with 17 staff from eight hospital-based breast care centres that recruited and attempted to recruit to MIAMI; and seven patients from four centres, comprising all patients who were recruited to the trial and some who declined to take part. Interviews were audio-recorded, anonymised and analysed using thematic methods of building codes into themes and sub-themes using the process of constant comparison.

Results

Overarching themes of (1) influences on equipoise and recruitment and (2) effects of a lack of equipoise were generated. Within these themes, health professional themes described the barriers to recruitment as ‘the treatment landscape has changed’, ‘staff preferences and beliefs’ which influenced equipoise and patient advice; and how different the treatments were for patients. Patient themes of ‘altruism and timing of trial approach’, ‘influences from consultants and others’ and ‘diagnostic journey doubts’ all played a part in whether patients agreed to take part in the trial.

Conclusions

Barriers to recruiting to breast cancer surgical trials can be significant, especially where there are substantial differences between the treatments being offered and a lack of equipoise communicated by healthcare professionals to patients. Patients can become overwhelmed by numerous requests for participation in research trials and inappropriate timing of trial discussions. Alternative study designs to the gold standard randomised control trial for surgical interventions may be required to provide the high-quality evidence on which to base practice.

Trial registration

ISRCTN (ISRCTN17987569) registered on April 20, 2018, and ClinicalTrials.gov (NCT03514654).

Validity of breast cancer surgery treatment information in a state-based cancer registry

PURPOSE

Surgery is an important part of early stage breast cancer treatment that affects overall survival. Many studies of surgical treatment of breast cancer rely on data sources that condition on continuous insurance coverage or treatment at specified facilities and thus under-sample populations especially affected by cancer care inequities including the uninsured and rural populations. Statewide cancer registries contain data on first course of cancer treatment for all patients diagnosed with cancer but the accuracy of these data are uncertain.

METHODS

Patients diagnosed with stage I-III breast cancer between 2003 and 2016 were identified using the North Carolina Central Cancer Registry and linked to Medicaid, Medicare, and private insurance claims. We calculated the sensitivity, specificity, positive predictive value, negative predictive value, and Kappa statistics for receipt of surgery and type of surgery (breast conserving surgery or mastectomy) using the insurance claims as the presumed gold standard. Analyses were stratified by race, insurance type, and rurality.

RESULTS

Of 26,819 patients who met eligibility criteria, 23,125 were identified as having surgery in both the claims and registry for a sensitivity of 97.9% (95% CI 97.8%, 98.1%). There was also strong agreement for surgery type between the cancer registry and the insurance claims (Kappa: 0.91). Registry treatment data validity was lower for Medicaid insured patients than for Medicare and commercially insured patients.

CONCLUSIONS

Cancer registry treatment data reliably identified receipt and type of breast cancer surgery. Cancer registries are an important source of data for understanding cancer care in underrepresented populations.

Systematic Review of Breast-Q: A Tool to Evaluate Post-Mastectomy Breast Reconstruction

Purpose

The aim of this systematic review is to update and synthesize new evidence on BREAST-Q questionnaire’s ability to reflect patient-reported outcomes in women who have undergone breast reconstruction surgery (BRS) following mastectomy.

Methods

PubMed, Science Direct, Google Scholar, Cochrane CENTRAL, and Clincaltrial.gov were searched for relevant studies from January 2009 to September 2021. Any interventional or observational studies that used BREAST-Q to assess patient-reported outcomes in the assessment of BRS following mastectomy were included.

Results

A total of 42 studies were eligible for inclusion in the review. Three were randomized controlled trials and 39 were observational studies. Compared with pre-operative scores, there was an improvement in all BREAST-Q outcome domains following BRS including ‘satisfaction with breasts’, “satisfaction with outcome” “psychosocial”, “physical”, and “sexual wellbeing”. Sexual well-being had the lowest BREAST-Q score both pre-and post-operatively (37.8–80.0 and 39.0–78.0, respectively). Autologous BRS reports higher satisfaction and overall wellbeing compared to implant-based BRS. BREAST-Q has a higher and narrow internal consistency of 0.81 to 0.96 compared with other patient-reported outcome measures (PROMs; EORTC-QLQ, FACT-B, BR-23, BCTOS). The BREAST-Q questionnaire is the only PROM which allows patients to reflect on their care, surgical outcomes, and satisfaction collectively.

Conclusion

This review highlights the fact that BREAST-Q can effectively and reliably measure satisfaction and wellbeing of breast cancer patients after BRS. Comparatively, sexual wellbeing shows poorer outcomes following BRS and more longitudinal studies are necessary to understand the basis for these findings. Compared to other PROMs, BREAST-Q is reliable and specific to breast cancer surgery. Overall, BREAST-Q can help clinicians improve their quality of service, understand patient experiences, and may be used as an auditing tool for surgical outcomes.

Institutions Treating Breast Cancer Patients of a Low Socioeconomic Status Achieve Multidisciplinary Quality Standards at Lower Rates

BACKGROUND

The National Accreditation Program of Breast Centers (NAPBC) certifies institutions that provide quality breast care. Whereas low socioeconomic status (SES) has a negative impact on patient outcomes, it is unknown whether an institution's patient SES mix is associated with meeting NAPBC standards.

METHODS

All institutions submitting at least 100 breast cancer patients to the National Cancer Database (2006-2017) were ranked based on the patients' insurance status, income, and education. The 10% treating the largest proportion of low-SES patients were termed low-SES institutions (LSES). Patient cohorts were created based on the 2018 NAPBC standards. Uni- and multivariate comparisons of patient, tumor, and treatment factors were made to calculate adjusted odds of meeting each standard between low- and non-low-SES institutions.

RESULTS

The analysis included 1319 institutions. Both the LSES and non-LSES reached the benchmark rate of 50% lumpectomies (61.2 vs 62.9%; p < 0.001), but the unadjusted and adjusted rates of lumpectomy were lower in LSES. The rate for sentinel lymphadenectomy was lower for LSES (49.2 vs 53.7%; p < 0.001). Similarly, the unadjusted and adjusted rates of adjuvant chemotherapy and endocrine therapy were lower at LSES. Although the unadjusted rate of adjuvant radiation was higher at LSES, adjusted odds demonstrated that patients treated at LSES were less likely to undergo adjuvant radiation when appropriate.

CONCLUSIONS

Small but significant differences in achieving multidisciplinary standards for quality breast cancer care exist between LSES and non-LSES and may exacerbate disparities already faced by patients of low SES.

The relationship of self-acceptance with decision making duration in cancer patient to perform mastectomy

BACKGROUND

Cancer is a disease caused by abnormal growth of body cells that turn malignant and continue to grow uncontrollably. One of the treatments for breast cancer is mastectomy. The quickness of decision-making determines the survival rate of prognosis patients.

OBJECTIVE

This study aimed to determine the relationship of self-acceptance with decision-making duration in cancer patients to perform a mastectomy.

METHODS

An analytic observation method with cross-sectional design. The samples were taken by purposive sampling method with 50 samples of breast cancer patients. Data collected include age, last level of education, marital status, profession, stage of cancer during mastectomy, self-acceptance score, and decision-making duration to perform a mastectomy.

RESULTS

The data analyzed with the Kruskal-Wallis test. The test showed the relationship of self-acceptance (p = 0.027) with decision-making duration in breast cancer patients to perform a mastectomy.

CONCLUSION

In conclusion, there is a relationship of self-acceptance with decision-making duration in breast cancer patients to perform a mastectomy.

Young Women With Breast Cancer: Treatment, Care, and Nursing Implications

BACKGROUND

Young women with breast cancer (YWBC) are more likely to have aggressive disease, carry mutations for hereditary cancer genes, and experience higher mortality. They also may face reduced fertility because of the toxicity of chemotherapy.

OBJECTIVES

This article aims to present a review of YWBC treatments, sequelae of treatment, and psychosocial challenges.

METHODS

The authors performed a review of guideline-supported treatment options, patient resources, and nursing implications.

FINDINGS

Because of high-risk cancers and a lack of specific treatment guidelines, healthcare providers may consider aggressive treatments for younger patients. However, studies indicate that the foundation for treatment decisions for YWBC are best based on disease stage and National Comprehensive Cancer Network guidelines.

Breast surgery for young women with early-stage breast cancer: Mastectomy or breast-conserving therapy?

Whether breast-conserving therapy (BCT) should be chosen as a local treatment for young women with early-stage breast cancer is controversial. This study compared the survival benefits of BCT or mastectomy in young women under 40 with early-stage breast cancer and further explored age-stratified outcomes. This study investigated whether there is a survival benefit when young women undergo BCT compared with mastectomy.The characteristics and prognosis of white women under 40 with stage I-II breast cancer from 1988 to 2016 were analyzed using the Surveillance, Epidemiology, and End Results (SEER) database. These women were either treated with BCT or mastectomy. The log-rank test of the Kaplan-Meier survival curve and Cox proportional risk regression model were used to analyze the data and survival. The analysis was stratified by age (18-35 and 36-40 years).A total of 23,810 breast cancer patients were included, of whom 44.9% received BCT and 55.1% underwent mastectomy, with a median follow-up of 116 months. Patients undergoing mastectomy had a higher tumor burden and younger age. By the end of the 20th century, the proportion of BCT had grown from nearly 35% to approximately 60%, and then gradually fell to 35% into the 21st century. Compared with the mastectomy group, the BCT group had improved breast cancer-specific survival (BCSS) (hazard ratio [HR] 0.917; 95% CI, 0.846-0.995, P = .037) and overall survival (OS) (HR 0.925; 95% CI, 0.859-0.997, P = .041). In stratified analysis according to the different ages, the survival benefit of BCT was more pronounced in the slightly older (36-40 years) group while there was no significant survival difference in the younger group (18-35 years).In young women with early-stage breast cancer, BCT showed survival benefits that were at least no worse than mastectomy, and these benefits were even better in the 36 to 40 years age group. Young age may not be a contraindication for BCT.

Neoadjuvant and adjuvant end-points in health technology assessment in oncology

Health technology assessment (HTA) of clinical and economic value of a new intervention is an integral step in providing the access of patients to innovative cancer care and treatment. Overall survival (OS) is the preferred criterion for demonstrating the therapeutic efficacy in HTA given its direct clinical and patient relevance. However, with often long life expectancy of patients with early cancer, analysis of OS becomes less practical. Partially due to this reason, pathological complete response (pCR) and time-to-event end-points like disease-free survival are frequently incorporated into the pivotal clinical trials in the neoadjuvant and adjuvant settings. However, there exists a discrepancy between different national HTA bodies regarding the acknowledgement of patient relevance of these end-points. In this article, we analysed the perspectives of patients on different aspects of end-points used in clinical trials in early cancer. Gathered evidence strongly suggests that complete tumour eradication and reduced risk of recurrence provide important psychological benefits thus signifying that pCR and time-to-event end-points are directly relevant to patients. Additionally, we reviewed opinions on patient relevance of neoadjuvant and adjuvant therapy end-points adopted by HTA bodies during the recent evaluations. We found that improvements in end-points used in the adjuvant setting were commonly considered as valuable to patients. In contrast, opinions on patient relevance of neoadjuvant therapy end-points varied between the national HTA bodies. Universal acknowledgement of patient relevance of therapeutic end-points for early cancer by HTA bodies is necessary to balance the inequality in uptake of innovative therapies into national healthcare systems.

Neoadjuvant Endocrine Therapy Versus Neoadjuvant Chemotherapy in Node-Positive Invasive Lobular Carcinoma

BACKGROUND

Neoadjuvant chemotherapy (NACT) is often recommended for patients with node-positive invasive lobular carcinoma (ILC) despite unclear benefit in this largely hormone receptor-positive (HR+) group. We sought to compare overall survival (OS) between patients with node-positive ILC who received neoadjuvant endocrine therapy (NET) and those who received NACT.

METHODS

Women with cT1-4c, cN1-3 HR+ ILC in the National Cancer Data Base (2004-2014) who underwent surgery following neoadjuvant therapy were identified. Kaplan-Meier curves and Cox proportional hazards modeling were used to estimate unadjusted and adjusted overall survival (OS), respectively.

RESULTS

Of the 5942 patients in the cohort, 855 received NET and 5087 received NACT. NET recipients were older (70 vs. 54 years) and had more comorbidities (Charlson-Deyo score ≥ 1: 21.1% vs. 11.5%), lower cT classification (cT3-4: 44.2% vs. 51.0%), lower rates of mastectomy (72.5% vs. 82.2%), lower rates of pathologic complete response (0% vs. 2.5%), and lower rates of postlumpectomy (73.2% vs. 91.0%) and postmastectomy (60.0% vs. 80.8%) radiation versus NACT recipients (all p < 0.001). NACT recipients had higher unadjusted 10-year OS versus NET recipients (57.9% vs. 36.0%), but after adjustment, there was no significant difference in OS between the two groups (p = 0.10).

CONCLUSIONS

Patients with node-positive ILC who received NET presented with smaller tumors, older age, and greater burden of comorbidities versus NACT recipients but had similar adjusted OS. While there is evidence from clinical trials supporting efficacy of NET in HR+ breast cancer, our findings suggest the need for further, histology-specific investigation regarding the optimal inclusion and sequence of endocrine therapy and chemotherapy in ILC.

Increase in Superficial Dose in Whole-Breast Irradiation With Halcyon Straight-Through Linac Compared With Traditional C-arm Linac With Flattening Filter: In vivo Dosimetry and Planning Study

Purpose

Superficial dose is an important parameter in breast cancer radiation therapy. When treated with conventional linacs, bolus is commonly applied to improve target coverage near the surface while also managing the risk of severe skin reactions and negative cosmesis. With the introduction of modern linacs with 6X flattening filter free (FFF) photon beams, the effect on superficial dose and the need for bolus must be evaluated.

Methods and Materials

In vivo measurements of superficial dose were made with optically stimulated luminescence dosimeters on 11 breast cancer patients treated with the Halcyon 6X FFF linac (Varian Medical Systems, Palo Alto, CA). Additionally, measurements were made with the Halycon 6X FFF beam and a 6X beam with flattening filter (FF) delivered to an anthropomorphic phantom. A planning study was carried out in which 14 patients treated on the Halcyon were replanned with a conventional linac to determine the difference in superficial dose predicted by the treatment planning system. Measures were taken to increase the accuracy of the treatment planning system superficial dose.

Results

The use of the Halcyon 6X FFF beam led to higher superficial dose compared with 6X FF beams. The in vivo measurements show an average superficial dose of 83.8% ± 0.6%, which is an increase of approximately 10% compared with published measurements for a 6X FF linac. Comparison of superficial dose for 6X FF and 6X FFF beams in the phantom measurements show an increase from 70% ± 1.3% to 84% ± 1.3%, which is consistent with the in vivo measurements. The planning comparison shows an increase in V70%Rx from 62% ± 4.4% to 81% ± 2.2% for the superficial breast tissue for the Halcyon 6X FFF beam compared with a standard C-arm linac with FF.

Conclusions

The use of the Halcyon 6X FFF beam was associated with higher superficial dose which may obviate the use of bolus.

Striving to Do No Harm and Yet Respect Patient Autonomy: Plastic Surgeons' Perspectives of the Consultation for Breast Reconstruction with Women Who Have Early-Stage Breast Cancer

BACKGROUND

Rates of contralateral prophylactic mastectomy (CPM) have doubled over the last decade among women considered low risk for developing contralateral breast cancer. Despite the strong association between CPM and breast reconstruction, little is known about the clinical encounter between patients and plastic surgeons. A qualitative study was performed to understand how plastic surgeons describe their roles in the treatment decision-making process through their consultations with women who have unilateral early-stage breast cancer.

METHODS

Semi-structured interviews with Ontario plastic surgeons were conducted. An inductive and interpretive thematic approach was initially used to analyze the data. The four principles of biomedical ethics then served as the conceptual lens to interpret the findings.

RESULTS

The participants in this study were 18 plastic surgeons, and data saturation was reached. Four themes were identified: maintaining non-maleficence, supporting patient autonomy, delivering (un)equal health care, and providing care to enhance well-being. The ongoing push-pull between competing ethical principles was the overarching theme, specifically, striving to balance parallel responsibilities to do no harm while also respecting patients' rights to make their own healthcare decisions.

CONCLUSIONS

In this patient-centric climate, it is important to acknowledge that patients may value outcomes such as achieving greater peace of mind above other clinical factors and are willing to incur additional risks to achieve these goals. Shared decision-making will help to reveal the rationale underlying each individual's treatment choice, which in turn will allow physicians to appropriately weigh patient requests with the best available medical evidence when counseling women on decision-making for breast cancer care.

Mastectomy or Breast-Conserving Therapy: Which Factors Influence A Patient's Decision?

BACKGROUND

The choice between mastectomy and breast-conserving therapy (BCT) is a first step for patients with breast cancer who are confronting decisions about treatment.

OBJECTIVE

To identify the most important determinants in treatment decision making by patients with breast cancer.

METHODS

Between 2003 and 2013, a total of 5258 patients with breast cancer were recorded in Kaiser Permanente Northwest's cancer registry. Patients had similar clinical-pathologic profiles, education, and insurance coverage, and were managed by 1 surgical group. A total of 2604 patients with invasive breast cancer chose mastectomy or BCT as they met unambiguous criteria for equivalent outcomes with either option. We examined the influence of the patient's surgeon on patient preferences.

RESULTS

Our retrospective analyses examined a study population that had similar risk profiles (age, family history of breast cancer, T category on tumor-node-metastasis staging system, tumor size, physical examination findings), surgeons consulting on similar patient types, and managed by surgeons with similar surgical performance patterns (case volumes, reexcision rates, number of reoperations, and ability to meet patient's expectations). Patients who preferred mastectomy were strongly influenced by tumor size (p < 0.001) and abnormal physical examination findings (palpable mass; p = 0.004), rather than age, family history of breast cancer, T category, or surgeon.

CONCLUSION

Physical examination findings and tumor size were statistically significant determinants influencing patients to choose mastectomy. Because geographic and practice style explanations fail to explain these variations, surgeons can identify, anticipate, and consider these factors when counseling patients about mastectomy and BCT therapeutic equivalency.

Surgical treatment choices for breast cancer in Newfoundland and Labrador: a retrospective cohort study

BACKGROUND

Mastectomy is often chosen by women for treatment of breast cancer, even when breast-conserving surgery (BCS) is an option. Newfoundland and Labrador has a high mastectomy rate. We documented the number of breast cancers over a given period in the province and their related surgical treatments, and explored the impact of several variables on surgical choice.

METHODS

A retrospective cohort design linked diagnosis data from the Newfoundland and Labrador tumour registry to surgery data from the Canadian Institute for Health Information Discharge Abstract Database. Data were extracted for all women aged 19 years or more in whom breast cancer was diagnosed in 2009-2014.

RESULTS

A total of 2346 cases of breast cancer with a linked surgical procedure were included. Most operations (1605 [68.4%]) were mastectomy procedures, with the remainder being BCS. Logistic regression analysis revealed that women were 1.82 times (95% confidence interval [CI] 1.64-2.02) more likely to have mastectomy for each unit of stage increase from 0 to IV and 1.15 times (95% CI 1.11-1.21) more likely for each unit of driving time increase.

CONCLUSION

Tumour stage and driving time to a radiation facility significantly predicted Newfoundland and Labrador women's surgical treatment choices for breast cancer. Notably, mastectomy was the favoured choice across all age groups, tumour stages and geographical regions of the province. We hope that these results will galvanize efforts to better understand local surgical practices and assist in improving the quality of surgical care of women with breast cancer.

Factors influencing surgical treatment decisions for breast cancer: a qualitative exploration of surgeon and patient perspectives

Background

The rate of mastectomy is much higher in Newfoundland and Labrador than in any other province in Canada, even for women diagnosed at an early stage. In this paper, we present qualitative data from women who have made a decision for surgical treatment and from breast surgeons in an effort to better explicate factors influencing breast cancer (bca) surgical decision-making.

Methods

The study's descriptive, qualitative design involved holding interviews with breast surgeons and holding focus groups and interviews with women who were offered the choice of breast-conserving surgery (bcs) or mastectomy (mt).

Results

Participants included 35 women and 13 surgeons. High interest in mt and increasing requests for prophylactic contralateral mt were evident. A host of factors-clinical, demographic, psychosocial, education-related, and cultural-influenced the decisions. A key factor for women was fear of recurrence and a need to "just get rid of it," but the experiences of others also influenced the decisions. Life stage and family considerations also factored prominently into women's decisions.

Conclusions

Women with early-stage bca more often chose mt and often demanded prophylactic removal of the healthy breast. Findings highlight the importance of ensuring that women at average risk are appropriately counselled about the low likelihood of a subsequent contralateral bca and the lack of survival benefit associated with prophylactic contralateral mt. Findings also revealed other areas of presurgical discussion that might help women think through their personal circumstances and values so as to encourage informed surgical decisions.

Effect of 21-gene recurrence score in decision-making for surgery in early stage breast cancer

Aim

We aimed to assess the role of 21-gene recurrence score (RS) in the decision-making for surgical treatment in early stage breast cancer and compared the outcomes between breast-conserving surgery (BCS) and mastectomy (MAST) among various 21-gene RS groups.

Methods

We included patients with stage T1-2M0M0 and estrogen receptor-positive breast invasive ductal carcinoma who underwent BCS + radiotherapy or MAST between 2004 and 2012 as part of the Surveillance, Epidemiology, and End Results program. Data were analyzed using binomial logistic regression, multivariate Cox proportional hazards models, and propensity score matching (PSM).

Results

We enrolled 34,447 patients including 22,681 (65.8%) and 11,766 (34.2%) who underwent BCS and MAST, respectively. Patients with high-risk RS were more likely to receive MAST. Multivariate analysis indicated that patients with intermediate-risk (P<0.001) and high-risk (P<0.001) RS had poor breast cancer-specific survival (BCSS), as compared to those with low-risk RS. Moreover, patients who underwent MAST also exhibited poor BCSS (P<0.001), as compared to those who underwent BCS. In low-risk (P<0.001) and intermediate-risk (P=0.020) RS groups, patients who underwent MAST had poor BCSS, as compared to those treated with BCS. However, BCSS was comparable between patients who underwent MAST and BCS (P=0.952); similar trends were also observed after PSM.

Conclusion

The 21-gene RS may impact the decision-making for surgery in early stage breast cancer. Our study provides additional support for a shared decision-making process for BCS when both local management options are appropriate choices regardless of the 21-gene RS.

Socioeconomic Factors Associated with the Receipt of Contralateral Prophylactic Mastectomy in Women with Breast Cancer

Background: Contralateral prophylactic mastectomy (CPM) treatments have been on the rise among white women with early stage unilateral breast cancer who have a higher socioeconomic status (SES) and private insurance. Low income and uninsured women are not choosing CPM at the same rate. The purpose of this study was to evaluate the socioeconomic factors related to the choice of surgical treatment in women diagnosed with unilateral breast cancer in the state of New Jersey. Materials and Methods: This retrospective study of 10 years of breast cancer data abstracted from the New Jersey State Cancer Registry utilized bivariate analyses and two multivariate logistic regression models to analyze the effect of socioeconomics on choice of surgical treatment. Results: In New Jersey, 52,529 women were treated for breast cancer from 2004 to 2014. CPM rates increased gradually over time from 3.72% in 2004 to 10.82% in 2014 with women more likely to choose CPM if they were younger, white, and had private insurance (p < 0.001). The single factor that was most predictive of choosing CPM was access to immediate reconstruction (odds ratio 2.36, confidence interval 2.160-2.551). Women with low SES were much less likely to choose CPM. Conclusions: Results of this study may provide incentive for researchers to assess the impact of culture, race/ethnicity, and socioeconomics on a woman's interactions with health care providers so as to allow all women regardless of SES to express their needs, concerns, and wishes when confronted with a breast cancer diagnosis.

Patients' participation during treatment and care of breast cancer - a possibility and an imperative

PURPOSE

To explore how patients experience participation during treatment and care for breast cancer related to their understanding.

METHOD

Semi-structured individual interviews with 16 women diagnosed with breast cancer. Interpretative qualitative content analysis was performed.

RESULTS

Three main themes describe patient participation. Theme 1 Respectful and personal encounters illustrates how the treatment from health care staff contributed to feelings of being "seen" as a human, a basis for participation. Theme 2 Part-owner in decision making describes the women's varied wishes of participating in treatment decisions. Theme 3 Striving to manage treatment, care and self-care concerns the need to manage self-care for well-being.

CONCLUSIONS

Patient participation is both a possibility and an imperative. Patients must be recognized as unique human beings with varying needs of participation. Shared learning and understanding in dialogue with health care staff is a prerequisite. A novel approach where patients and health care staff are both partners and participants is presented.

PRACTICAL IMPLICATION

The results call for an initiation of training programs supporting pedagogical competence in staff and patients' learning in breast cancer care. Access to health care in the outpatient and the hospital settings is needed long term after treatment to support patient participation.

Defining the Need for Imaging and Biopsy After Mastectomy

BACKGROUND

The proportion of patients eligible for breast-conservation therapy (BCT) yet opting for mastectomy is increasing. This decision is often driven by the desire to eliminate future screening and/or biopsy of the remaining breast or breasts. This study investigated the incidence of post-mastectomy imaging and biopsy.

METHODS

A retrospective review of all unilateral mastectomy (UM) and bilateral mastectomy (BM) cases managed at a single institution was undertaken. Post-mastectomy imaging and biopsy rates were determined.

RESULTS

Between 2009 and 2015, 185 UM and 200 BM cases managed for breast cancer were identified. The mean follow-up period was 30 months (range 3-75 months). For the patients with UM, imaging studies and biopsies done on the contralateral side were excluded given the standard of care for continued surveillance of the contralateral breast. Of the 185 UM patients, 19 (10%) underwent ipsilateral imaging (all ultrasounds) for physical examination findings, 11 (6%) underwent biopsy, and 2 (1%) had malignant findings. Of the 200 BM patients, 31 (15.5%) required imaging (29 ultrasounds and 2 MRIs), with 76% of the ultrasounds performed on the side with previous cancer. Subsequently, 16 (8%) of the BM patients had biopsy, with 11 (69%) of the 16 biopsies performed on the ipsilateral side. Three (1.5%) of the biopsies done on ipsilateral side demonstrated malignancy, whereas all the contralateral biopsies were benign.

CONCLUSIONS

For 10-15.5% of patients who undergo mastectomy, either UM or BM, subsequent imaging is required, whereas 6-8% undergo biopsy. The yield of malignancy is low, approximately 1%. Thus, after mastectomy, the need for imaging and biopsy is not eliminated. This information is critical for patient understanding and expectation related to surgical decision making.

Patients electing to have PET rather than surgery for operable breast cancer are a high risk of treatment failure

BACKGROUND

Primary endocrine therapy (PET) is a treatment option for elderly patients with ER-positive breast cancer enabling frail patients to avoid surgery. As a long-term treatment option, it has been shown to be inferior to surgery in controlling local disease. Decision-making in these patients is crucial in avoiding treatment failure. We examined the influence of decision-making on outcomes of PET failure as a secondary analysis as part of a large observational study.

METHODS

Consecutive patients treated with PET between 2005 and 2015 for operable breast cancers were included in a retrospective observational study in 3 breast centres in the North-East. Treatment decision processes were examined by case note review and outcomes of treatment success or failure recorded.

RESULTS

488 patients were included with mean follow-up of 31 months. Overall 63 (12%) experienced treatment failure. 227 (46.6%) were given a choice between surgery and PET at diagnosis. Logistic regression identified older age [OR 0.94 (0.91-0.96) p < 0.001] and reduced mobility [OR 0.6 (0.37-0.97) p 0.036] to be less likely offered surgery. Those offered surgery were more likely to experience treatment failure with PET [SHR 1.78 (1.05-3.02) p 0.033].

CONCLUSIONS

Despite a low failure rate in our series (literature failure rates vary between 12 and 85%), these results suggest that those actively offered a choice between surgery and PET are at greater risk of failure when choosing PET.

Comparison of Treatment Outcomes With Breast-conserving Surgery Plus Radiotherapy Versus Mastectomy for Patients With Stage I Breast Cancer: A Propensity Score-matched Analysis

BACKGROUND

To investigate the superiority of breast-conserving surgery (BCS) plus radiotherapy (RT) compared with mastectomy alone for patients with stage I breast cancer in a real-world setting.

PATIENTS AND METHODS

The data from patients with histologically confirmed stage I breast cancer treated from 1999 to 2014 were retrospectively reviewed. The association of outcomes with the choice of treatment (BCS plus RT vs. mastectomy) was evaluated using multivariable proportional hazards regression and further confirmed using propensity score matching methods.

RESULTS

Of 6137 eligible patients in the present study, 1296 underwent BCS plus RT and 4841 underwent mastectomy plus axillary lymph node dissection without RT (mastectomy group). Multivariate analysis revealed that BCS plus RT was related to similar locoregional recurrence-free survival but greater distant metastasis-free survival (P = .003) and overall survival (P = .036) compared with mastectomy. For the 1252 pairs of patients matched using propensity score matching, the BCS plus RT groups enjoyed significantly greater 5-year overall survival (99.1% vs. 96.1%; P = .001), distant metastasis-free survival (97.0% vs. 92.2%; P < .001), and disease-free survival (95.3% vs. 90.2%; P = .001) compared with the mastectomy group.

CONCLUSION

BCS plus RT provided better outcomes than mastectomy for eligible patients with stage I breast cancer and should be offered as a preferred treatment option.

Quantitative analysis of shoulder function and strength after breast reconstruction: A retrospective cohort study

Immediate breast reconstruction (IBR) after mastectomy has been proven to affect patient quality of life, psychological well-being, and functional capacities. In the present study, we aimed to investigate the effect of breast reconstruction on postoperative shoulder function and muscle performance by evaluating isokinetic muscle performance tests.A retrospective chart review to collect data on shoulder function analysis with isokinetic muscle performance testing was performed among patients who received mastectomy with IBR from July 2013 to March 2015. Patients were categorized into 4 groups: a control group that underwent mastectomy without reconstruction, a tissue expander/implant insertion group, a pedicled latissimus dorsi (LD) flap group, and a free transverse rectus abdominis muscle (TRAM) flap group.Analysis of the groups at 1 to 3, 4 to 6, 7 to 9, 10 to 12, and 13 to 15 months postoperatively showed significant shoulder function improvement in the tissue expander/implant and TRAM groups as measured by linear regression analysis. Compared with the control group, patients who received immediate reconstruction with tissue expander/implant insertion or a TRAM flap showed statistically significant improvement in shoulder function after mastectomy.IBR with a TRAM flap or tissue expander/implant insertion were more beneficial for shoulder rehabilitation and for regaining function compared to mastectomy alone and breast reconstruction with a LD flap.

Breast cancer surgical treatment choices in Newfoundland and Labrador, Canada: Patient and surgeon perspectives

Background

Breast cancer remains the second-leading cause of cancer death among Canadian women. Treatment for breast cancer often includes surgery. Many women have a choice between mastectomy (MT; removal of the entire breast) or breast conserving surgery (BCS; removal of the tumour and some noncancerous breast tissue) followed by radiation. However, Newfoundland and Labrador consistently has a higher rate of mastectomies than the rest of Canada. In this project, we aim to better understand that trend.

Design and methods.

A multi-method design was chosen. Surgical treatment data kept by the province will be examined to describe the number and types of breast cancer surgeries over time. Second, we will hold focus groups with women around the province who have made surgical treatment choices to explore influences on their decisions. Finally, semi-structured interviews with breast cancer surgeons and surgical residents will explore their opinions on surgical treatment choices.

Expected impact for public health.

Cancer treatment choices are complex decisions, affected by clinical, demographic and social variables. Understanding why women from Newfoundland and Labrador have the highest rate of mastectomy in Canada is critical to ensure they are receiving appropriate screening and care. Greater understanding of the influences on women’s surgical choices may encourage informed decisions amongst women and physicians and promote active communication about treatment, benefits relevant to all jurisdictions and health authorities. Further, if factors such as geographic proximity to treatment facilities are associated with treatment decisions, this information is important for public health screening and service planners.

Changes in shoulder muscle activity pattern on surface electromyography after breast cancer surgery

BACKGROUND AND OBJECTIVES

Alterations in muscle activation and restricted shoulder mobility, which are common in breast cancer patients, have been found to affect upper limb function. The purpose of this study was to determine muscle activity patterns, and to compare the prevalence of abnormal patterns among the type of breast surgery.

METHODS

In total, 274 breast cancer patients were recruited after surgery. Type of breast surgery was divided into mastectomy without reconstruction (Mastectomy), reconstruction with tissue expander/implant (TEI), latissimus dorsi (LD) flap, or transverse rectus abdominis flap (TRAM). Activities of shoulder muscles were measured using surface electromyography. Experimental analysis was conducted using a Gaussian filter smoothing method with regression.

RESULTS

Patients demonstrated different patterns of muscle activation, such as normal, lower muscle electrical activity, and tightness. After adjusting for BMI and breast surgery, the odds of lower muscle electrical activity and tightness in the TRAM are 40.2% and 38.4% less than in the Mastectomy only group. The prevalence of abnormal patterns was significantly greater in the ALND than SLNB in all except TRAM.

CONCLUSIONS

Alterations in muscle activity patterns differed by breast surgery and reconstruction type. For breast cancer patients with ALND, TRAM may be the best choice for maintaining upper limb function.

Improved immediate breast reconstruction as a result of oncoplastic multidisciplinary meeting

Introduction

The National Institute for Health and Clinical Excellence guidelines recommend that breast reconstruction should be available to all women undergoing mastectomy and discussed at the initial surgical consultation (2002, and updated 2009). The National Mastectomy and Breast Reconstruction Audit (2009) showed that 21% of mastectomy patients underwent immediate breast reconstruction (IBR) and 11% had delayed breast reconstruction (DBR). Breast reconstruction has been shown to have a positive effect on quality of life postmastectomy. This retrospective study investigated the impact of the introduction of a dedicated oncoplastic multidisciplinary meeting (OP MDM) on our unit’s breast reconstruction rate.

Patients and methods

A retrospective analysis of 229 women who underwent mastectomy, of whom 81 (35%) underwent breast reconstruction between April 2014 and March 2016. Data were analyzed before and after introduction of OP MDM in April 2015. Data on patient age, type of surgery (mastectomy only, mastectomy and reconstruction), timing of reconstruction (IBR, DBR), and type of reconstruction (implant, autologous) were collected.

Results

Between April 2015 and March 2016, following establishment of OP multidisciplinary team in April 2015, of the 120 patients who had mastectomy, 50 (42%) underwent breast reconstruction with 78% (39/50) choosing IBR (56% implant reconstruction and 22% autologous). Compared to the period between April 2014 and March 2015 preceding the OP MDM, of 109 patients who underwent mastectomy, only 31 (28%) had breast reconstruction with 64% (20/31) choosing IBR (45% implant reconstruction and 19% autologous). The rate of DBR was lower, 22% (11/50), following OP MDM compared to 35% (11/31) before OP MDM.

Conclusion

There has been an increased uptake of breast reconstruction surgery from 28% to 42%. The biggest impact was on those opting for the immediate type reconstruction option (78%). The OP MDM has significantly contributed to this increased rate of reconstruction.

Squamous cell carcinoma of the breast in the United States: incidence, demographics, tumor characteristics, and survival

PURPOSE

Squamous cell carcinoma of breast accounts for less than 0.1% of all breast cancers. The purpose of this study is to describe the epidemiology and survival of this rare malignancy.

METHODS

Data were extracted from the National Cancer Institute's Surveillance, Epidemiology and End Results Registry to identify women diagnosed with squamous cell carcinoma of breast between 1998 and 2013. SEER*Stat 8.3.1 was used to calculate age-adjusted incidence, age-wise distribution, and annual percentage change in incidence. Kaplan-Meier curves were plotted for survival analysis. Univariate and multivariate Cox proportional hazard regression model was used to determine predictors of survival.

RESULTS

A total of 445 cases of squamous cell carcinoma of breast were diagnosed during the study period. The median age of diagnosis was 67 years. The overall age-adjusted incidence between 1998 and 2013 was 0.62 per 1,000,000 per year, and the incidence has been on a decline. Approximately half of the tumors were poorly differentiated. Stage II was the most common stage at presentation. Majority of the cases were negative for expression of estrogen and progesterone receptor. One-third of the cases underwent breast conservation surgery while more than half of the cases underwent mastectomy (unilateral or bilateral). Approximately one-third of cases received radiation treatment. The 1-year and 5-year cause-specific survival was 81.6 and 63.5%, respectively. Excluding patient with metastasis or unknown stage at presentation, in multivariate Cox proportional hazard model, older age at diagnosis and higher tumor stage (T3 or T4) or nodal stage at presentation were significant predictors of poor survival.

CONCLUSIONS

Our study describes the unique characteristics of squamous cell carcinoma of breast and demonstrates that it is an aggressive tumor with a poor survival. Older age and higher tumor or nodal stages at presentation were independent predictors of poor survival for loco-regional stages.

Disparities in contralateral prophylactic mastectomy use among women with early-stage breast cancer

Contralateral prophylactic mastectomy use has increased over the past decades among women with early-stage breast cancer. Racial differences in contralateral prophylactic mastectomy use are well described, but with unclear causes. This study examined contralateral prophylactic mastectomy use among black and white women and the contribution of differences in perceived risk to differences in use. We surveyed women diagnosed with early-stage unilateral breast cancer between ages 41-64 in Pennsylvania and Florida between 2007-2009 to collect data on breast cancer treatment, family history, education, income, insurance, and perceived risk. Clinical factors-age,stage at diagnosis, receptor status-were obtained from cancer registries. The relationships between patient factors and contralateral prophylactic mastectomy were assessed using logistic regression. The interaction between race and contralateral prophylactic mastectomy on the perceived risk of second breast cancers was tested using linear regression. Of 2182 study participants, 18% of whites underwent contralateral prophylactic mastectomy compared with 10% of blacks (p < 0.001). The racial difference remained after adjustment for clinical factors and family history (odds ratio = 2.32, 95% confidence interval 1.76-3.06, p < 0.001). The association between contralateral prophylactic mastectomy and a reduction in the perceived risk of second breast cancers was significantly smaller for blacks than whites. Blacks were less likely than whites to undergo contralateral prophylactic mastectomy even after adjustment for clinical factors. This racial difference in use may relate to the smaller impact of contralateral prophylactic mastectomy on the perceived risk of second breast cancers among blacks than among whites. Future research is needed to understand the overall impact of perceived risk on decisions about contralateral prophylactic mastectomy and how that may explain racial differences in use.

Sexual dysfunction in medical practice

PURPOSE OF REVIEW

Sexual dysfunction is associated with many medical disorders. Lack of recognition of sexual dysfunction commonly occurs in medical practice. The impact of unrecognized sexual dysfunction affects quality of life, which in turn affects the recovery from medical illness. This article reviews the recent literature regarding sexual dysfunction in medical practice published in PubMed, Clinical key, Scopus, Google scholar from November 2014 to May 2016.

RECENT FINDINGS

New findings suggest that sexual dysfunction is associated with most of the disorders affecting various systems. Sexual dysfunction associated with medical disorders, apart from having effects on patients, also has impact on spouses. Sexual dysfunction may also be a predictor of future major adverse event. Prevelance of sexual dysfunction in various major illness is in the range of 20-75%. Phosphodiesterase-5 inhibitors which are first line drugs to treat erectile dysfunction cause no increase in myocardial infarction or death.

SUMMARY

Sexual functioning is impaired in neurological, endocrinal, cardiovascular, pelvic, dermatological, and other disorders. Stroke, epilepsy, traumatic brain injury, and other neurological disorders cause significant impairment in sexual functioning. Though exact correlation between androgen and sexual functioning cannot be made, androgen plays important role various phases of sexual cycle in both men and women. Diabetes has impact on all the phases of sexual cycle. Hypertension, as well as certain drugs used to treat hypertension also causes sexual dysfunction, judicious use of hypotensive drugs is recommended.

Outcomes of contralateral prophylactic mastectomy in relation to familial history: a decision analysis (BRCR-D-16-00033)

Background

Family history of breast cancer is associated with an increased risk of contralateral breast cancer (CBC) even in the absence of mutations in the breast cancer susceptibility genes BRCA1/2. We compared quality-adjusted survival after contralateral prophylactic mastectomy (CPM) with surveillance only (no CPM) among women with breast cancer incorporating the degree of family history.

Methods

We created a microsimulation model for women with first-degree, second-degree, and no family history treated for a stage I, II, or III estrogen receptor (ER)-positive or ER-negative breast cancer at the ages of 40, 50, 60, and 70. The model incorporated a 10-year posttreatment period for risk of developing CBC and/or dying of the primary cancer or CBC. For each patient profile, we used 100,000 microsimulation trials to estimate quality-adjusted life expectancy for the clinical strategies CPM and no CPM.

Results

CPM showed minimal improvement on quality-adjusted life expectancy among women age 50–60 with no or a unilateral first-degree or second-degree family history (decreasing from 0.31 to –0.06 quality-adjusted life-years (QALYs)) and was unfavorable for most subgroups of women age 70 with stage III breast cancer regardless of degree of family history (range –0.08 to –0.02 QALYs). Sensitivity analysis showed that the highest predicted benefit of CPM assuming 95 % risk reduction in CBC was 0.57 QALYs for a 40-year-old woman with stage I breast cancer who had a first-degree relative with bilateral breast cancer.

Conclusions

Women age 40 with stage I breast cancer and a first-degree relative with bilateral breast cancer have a QALY benefit from CPM similar to that reported for BRCA1/2 mutation carriers. For most subgroups of women, CPM has a minimal to no effect on quality-adjusted life expectancy, irrespective of family history of breast cancer.

Geographical Inequalities in Surgical Treatment for Localized Female Breast Cancer, Queensland, Australia 1997-2011: Improvements over Time but Inequalities Remain

The uptake of breast conserving surgery (BCS) for early stage breast cancer varies by where women live. We investigate whether these geographical patterns have changed over time using population-based data linkage between cancer registry records and hospital inpatient episodes. The study cohort consisted of 11,631 women aged 20 years and over diagnosed with a single primary invasive localised breast cancer between 1997 and 2011 in Queensland, Australia who underwent either BCS (n = 9223, 79%) or mastectomy (n = 2408, 21%). After adjustment for socio-demographic and clinical factors, compared to women living in very high accessibility areas, women in high (Odds Ratio (OR) 0.58 (95% confidence intervals (CI) 0.49, 0.69)), low (OR 0.47 (0.41, 0.54)) and very low (OR 0.44 (0.34, 0.56)) accessibility areas had lower odds of having BCS, while  the odds for women from middle (OR 0.81 (0.69, 0.94)) and most disadvantaged (OR 0.87 (0.71, 0.98)) areas was significantly lower than women living in affluent areas. The association between accessibility and the type of surgery reduced over time (interaction p = 0.028) but not for area disadvantage (interaction p = 0.209). In making informed decisions about surgical treatment, it is crucial that any geographical-related barriers to implementing their preferred treatment are minimised.