Efficient management of new patient referrals to a breast service: the safe introduction of an advanced nurse practitioner-led telephone breast pain service

INTRODUCTION

There has been an almost 100% increase in referrals to breast cancer diagnostic clinics in the past decade. Breaching of the two-week cancer referral target is now commonplace, potentially delaying diagnoses of breast malignancy in many women. Almost one in five of these referrals are women with mastalgia, not a symptom linked to breast cancer. The objective of the study was the safe introduction of an advanced nurse practitioner-led telephone service for women with mastalgia to improve the service for women and create capacity for those with "red flag" breast symptoms.

METHODS

Referrals to clinic were triaged, women with mastalgia only were directed to a telephone-based assessment clinic and symptoms evaluated using a multidisciplinary created proforma.

RESULTS

Within 23 months, 1,427 women were assessed in the breast pain telephone assessment clinic: 863 (61%) were aged over 40 and 564 (39%) aged under 40. A total of 1,238 underwent telephone assessment. Reassurance and discharge only was needed for 365 (26%). The aetiology of pain was identified as musculoskeletal in 1,104/1,238 (89%) of patients, with only 39/1,238 (3.2%) identified as having true breast pain. Additional symptoms were mentioned by 264 women (18%) during the consultation; all immediately redirected back to a diagnostic clinic. Mammography was undertaken in 609 women (43%). Seven women (0.6%) were diagnosed with a breast malignancy. Patient survey indicated that 93% of patients were satisfied with the care received and 97% said they would recommend the service to a family member or friend.

CONCLUSIONS

Although face-to-face assessments for breast pain remain the standard practice in many breast units, data indicating the safety of a telephone assessment clinic, along with high levels of patient satisfaction, question whether services can be delivered differently.

Serial MRI scans help in assessing early response to neoadjuvant chemotherapy and tailoring breast cancer treatment

BACKGROUND

Tailoring neoadjuvant chemotherapy (NAC) during breast cancer treatment is performed to improve overall tumour response, with increasing evidence to support its role. This study evaluates our breast unit's experience in MRI assessment of tumour response as an aid in tailoring NAC.

MATERIALS AND METHODS

This is a retrospective study of patients treated with NAC for breast cancer between 2005 and 2009 who underwent MRI to assess tumour response. Response to NAC was monitored before NAC and after 2 and/or 4 cycles of anthracycline and cyclophosphamide (AC) chemotherapy. Taxane was substituted for AC if MRI response was deemed inadequate. Tumour response on last MRI was correlated with final pathology against different tumour subtypes and in inflammatory tumours. Strength of agreement was measured using Kappa analysis. Potential predictive factors for MRI response were assessed for significance.

RESULTS

166 tumours were assessed with serial MRI scans. MRI showed high sensitivity rate (93.1%) in predicting response to NAC particularly for tumours showing partial (PR) or complete (CR) response on pathology (p < 0.001) with fair agreement on Kappa analysis (K = 0.31). MRI seems more accurate in triple negative, HR+/HER2+ and high-grade tumours. Early identification of non-responders on MRI resulted in early tailoring of NAC, with improved rates of tumour response seen in 74.2% following switching NAC. Logistic regression showed that PR or CR observed on MRI after 2 NAC cycles significantly predicted pCR (p < 0.001).

CONCLUSION

Serial MRI can be used to assess patterns of tumour response to NAC. This study shows that tailoring NAC according to pattern of response can improve overall tumour response rates.

Abstract P3-14-09: Should testing for estrogen receptor, progesterone receptor and HER2 be repeated following neoadjuvant chemotherapy?

Introduction

Neoadjuvant chemotherapy (NACT) is increasingly being used for the management of breast carcinomas including inflammatory breast carcinoma and locally advanced cancer. Testing for molecular markers (ER/PR/HER2) is generally performed on the pre-treatment biopsy sample. It is not known whether the histological type, grade and/or molecular profile of those tumour change as a result of chemotherapy. Potential changes particularly from negative to positive status may provide further treatment options for those patients.

Materials & Method

Patients who underwent NACT for primary and operable invasive carcinoma in the period between 2005 to 2009 were identified from the database of a single large UK tertiary referral breast unit. Comprehensive data on chemotherapy regimen, surgical treatment, pathological response and survival were collected. For residual invasive disease (partial pathological response), slides were reviewed and a representative block was selected and marked for tissue microarray (TMA) construction. TMA and pre treatment core biopsy sections, where available, were stained for ER/PR and HER2. Histological type and grade of invasive carcinoma were recorded for pre and post treatment samples for each patient.

Results

A total of 124 patients including 19 presenting as inflammatory carcinoma were included. Median age was 46yrs, IQ range = 41-53. Patients predominantly received anthracyclin-based therapy. Complete pathological response was achieved in 21.8% of patients.

The commonest histological type on core biopsy was ductal carcinoma of no special type (n = 108, 63.9%) followed by lobular (7), mixed (5), metaplastic (2) and mucinous (2). There was a change in histological type in 14.9% of cases. Of the partial responders, grade was available on excision of 111 patients (additional 6 were not gradable). The histological grade was different between the core biopsy and final excision in 29 tumours (26%) including 10 upgrades and 19 downgrades (p&lt;0.001). The downgrade was due to increase in tubule formation and decrease in mitotic count on the final excision sample.

Out of 83 ER stained paired pre and post tumour samples, 7 tumours (8.4%) changed profile from ER negative (Allred score 0/8) to positive (score 2 or above) including a strongly positive tumour (score 7/8) and 2 from positive to negative. Three out of 80 cases changed from PR negative to positive including a moderately positive case (6/8) whereas 2 changed from positive to negative. HER2 status changed from negative to positive in one patient and positive to negative in 2 /72 cases.

Conclusion

Significant changes in histological grade, type and molecular marker status occur following neoadjuvant chemotherapy. Tumours were more likely to be downgraded than upgraded following NACT. Changes in the ER, PR and HER2 status following chemotherapy occurred in 12%, 6.3% and 4.2% of cases respectively. This may have important implications in tailoring treatment options for patients that would otherwise be denied hormonal and/or Herceptin therapy if testing was solely done on the pre-treatment biopsy. Based on this data, we recommend repeat testing on residual carcinoma and prospective collection of data on management and outcome of those patients.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-14-09.

Abstract P4-01-14: Can MRI predict the response to neoadjuvant chemotherapy in breast cancer accurately?

Introduction: Magnetic resonance imaging (MRI) has been increasingly used to assess response to neoadjuvant chemotherapy (NAC). The aim of this retrospective study was to investigate the accuracy of MRI in predicting pathological complete response (pCR) and residual disease in patients treated with NAC.

Methods: 152 patients with invasive breast cancer were treated with NAC (2005–2009). In our institute the response to neoadjuvant anthracycline (AC) based chemotherapy is monitored with MRI scanning before NAC and after 2 and 4 cycles. Taxane based chemotherapy was substituted for AC chemotherapy if MRI response was deemed inadequate.

Response to NAC was measured using the modified response evaluation criteria in solid tumours (RECIST). Tumour extent and response on final MRI were correlated with the pathological findings on post-surgical specimens. pCR was defined as absence of invasive cancer. Sensitivity and specificity of MRI reporting was determined against response on histopathology. Potential predictive factors for response on MRI were assessed for significance.

Results: In total, patients had 2(14.5%), 3(60.5%) or 4(25%) MRI scans. pCR was seen in 37(24.3%) patients. After 2 cycles of NAC, positive response (partial or complete) was seen on MRI in 76(50%) patients. Response was more likely in focal tumours versus multifocal tumours (chi square (χ2) 3.83, p = 0.05). In the non-responding group (n = 76), 74 had their treatment switched and a later response was detected in 50(67.6%) cases on MRI.

In the 133 patients with 3 or more MRI scans, final MRI size was compared to tumour size on pathology. Median tumour extent on final MRI was 25.5mm (range 0–120) and median whole tumour size on pathology was 22.5mm (range 0–120). MRI response was apparent in 115 (75.7%) cases (sensitivity = 92.3%, specificity = 56.3% and PPV = 93.9%). In a 2-tailed analysis MRI response showed strong correlation with actual pathological response (spearman's = 0.501, p &lt; 0.0001). MRI correctly diagnosed pCR in 15 of 37(40.5%) patients with pCR. Linear regression shows that overall tumour extent on MRI was highly predictive of whole tumour size on pathology (coefficient = 0.459, p &lt; 0.0001). However, MRI overestimated residual disease in 24(18%) cases (median size difference of 39mm, range 12–120mm) and underestimated minimal residual disease in 12(9%) cases.

In univariate analysis, time of response to NAC was a predictor of pCR (p = 0.013), with greater number of early responders having pCR than late responders. Complete response on MRI was a significant predictor of pCR (p &lt; 0.0001), with a greater proportion of patients having pCR compared to those not showing complete response on MRI. Both complete response on final MRI (p = 0.276) and pCR (p = 0.069) show favourable disease-free survival (DFS), however neither reaches statistical significance on Kaplan-Meier curve (Median follow up of 43 months, range 13–78).

Conclusions: Early responders and tumours achieving complete response on MRI are significant predictors of histopathological response. Serial MRI is predictive of response to NAC and possibly also a predictor of DFS. In this series MRI overestimated residual disease in nearly 1 in 5 patients.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-01-14.