Post Treatment Mastalgia is a Common Complaint but not an Indication of Recurrence or Second Primary Breast Cancer

BACKGROUND

Post-treatment mastalgia is a common complaint in up to 68% of patients after treatment. This symptom is worrisome to patients as many believe it is a sign of recurrence. The current study was performed to evaluate if post-treatment mastalgia is associated with a second breast cancer diagnosis.

MATERIALS AND METHODS

Patients included were seen from January 1, 2000 to December 31, 2020. All patients who were treated for breast cancer and then presented with breast pain during follow up were considered to have post-treatment mastalgia. All patients who were diagnosed with a second breast cancer but did not experience post-treatment mastalagia were also evaluated.

RESULTS

1799 patients had a mean age 52.9 years. 36% of patients experienced post-treatment mastalgia. Of patients who complained of post-treatment mastalgia, 19 were diagnosed with a chest wall recurrence (CW), ipsilateral breast tumor recurrence (IBTR), or contralateral breast cancer (CBC). 17 of the 19 patients had breast pain after the second diagnosis and treatment were completed. The average duration between their second diagnosis and initial complaint of breast pain was 6.2 years. The two patients who complained of breast pain prior to their second diagnosis did not have mastalgia at the time of their second diagnosis. Local recurrence or contralateral breast cancer were more common in patients without post treatment mastalgia (10.1% vs 0.3%, p < 0.0001) during follow up.

CONCLUSION

Post treatment mastalgia is not associated with recurrence. Interval or repeat imaging does not appear necessary and instead patient education and reassurance are important in its management.

Mastalgia is Not An Indication for Mammogram

BACKGROUND

Mastalgia is a common breast complaint that is worrisome to patients. This study was performed to determine if mastalgia is a sign of breast cancer and to evaluate the benefit of its work up. METHODS: Retrospective review of prospectively collected data on 8960 consecutive patients at a safety net institution from June 1, 2006 to December 31, 2020. Data on patient reported mastalgia and diagnosis of breast cancer were collected. RESULTS: 8960 patients had a mean age of 45 years. The population was predominantly underinsured, 70% Hispanic, and 16% had adequate health literacy. Approximately 31% (2820 of 8960) of patients presented with a complaint of breast pain. Of 2820 patients with breast pain, 20 (0.7%) were found to have breast cancer. The average age of patients with breast cancer was 49 years. Physical examination identified a mass in 6 patients and only 3 patients had pain limited to the side of the cancer (10 bilateral, 7 contralateral). Of 1280 patients who were under age 40 years, 88% underwent breast imaging. The Cancer Detection Rate (CDR) was 0.9 per 1000 examinations. For 950 patients age 40 to 49 years and 590 patients age 50 years and older, 98% and 99% underwent breast imaging, respectively. The CDR was 10 per 1000 examinations for age 40 to 49 and 14 per 1000 examinations for age 50 years and older. CONCLUSIONS: Mastalgia is rarely associated with breast cancer. In the absence of other findings, imaging of patients less than age 40 is not recommended. Any workup beyond routine screening mammography in age-appropriate patients, to identify the "cause" of breast pain, does not seem warranted.

Re-evaluating if observation continues to be the best management of idiopathic granulomatous mastitis

BACKGROUND

The presentation of idiopathic granulomatous mastitis can mimic breast cancer. Therefore, awareness of the condition is important for surgeons. The current series is the largest in a US population.

METHODS

Retrospective chart review of patients treated at a county, safety-net hospital in Arizona. Cases were identified from January 2006 to January 2019. Sociodemographic information, clinical history, management, and outcomes were collected.

RESULTS

There were 145 occurrences of idiopathic granulomatous mastitis among 120 women. Most of the patients (92%) were of Hispanic ethnicity and born outside (87%) of the United States. The average age was 35 years. Nearly all patients (95%) were parous, with an average of 3 pregnancies. Most (88%) presented with a palpable mass, and more than half (54%) of these masses were painful. Six patients had prolactinomas or hyperprolactinemia, 11 patients were pregnant, and 5 were postpartum. Early in the time period studied, 6 patients underwent excision of the masses. The remaining 114 underwent planned observation after biopsy confirmation of the diagnosis. Two patients were lost to follow-up, and the other 112 patients with idiopathic granulomatous mastitis resolved spontaneously. Nineteen had more than 1 episode. Average time to resolution was 5 months (range 0-20). Adjusted log-normal regression analysis found that later age of first live birth was associated with greater time to resolution (P < .01).

CONCLUSION

Idiopathic granulomatous mastitis is a self-limited, benign condition that waxes and wanes and eventually resolves without resection. After diagnosis, medications are unnecessary, and operations can be limited to drainage procedures for fluid collections.

Awareness of residents' technical ability can affect margin status in breast conserving operations

PURPOSE

The current study was performed to determine if awareness of the potential affect of residents could affect margin status.

METHODS

Retrospective review of all patients who underwent lumpectomy from July 2006 to May 2017 was evaluated. The effect of surgical residents' participation and their technical ability was evaluated to determine the effect on margin status. Logistic regression analysis was performed to determined factors which affect margin status.

RESULTS

Of 444 patients, 14% of patients had positive margins. The positive margin rate was lower during the second time period after the effect of technical ability of the residents was known 12% versus 19% (p = 0.10). Greater participation by the attending surgeon (32% vs. 21%) occurred in the second time period. In multivariate logistic regression analysis, operations done by residents with satisfactory technical skills or attending surgeon were less likely to have positive margins than those done by residents with unsatisfactory technical skills (OR 0.19, 95% CI 0.10-0.38; p = 0.0001). With mean follow-up of 48 months, 1.4% had local recurrences as a first event.

CONCLUSIONS

Technically ability of residents appears to affect margin status after lumpectomy. Increased intervention by the attending surgeon can improve this outcome.

Germline mutation profile among Hispanic women with epithelial ovarian cancer (EOC)

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Background: Hospital-based studies have reported a 15% prevalence of BRCA1/ BRCA2( BRCA) mutations, with a slightly higher yield of other predisposition genes on multigene panel testing (MGPT) among women with EOC, and National Comprehensive Cancer Network guidelines recommend genetic cancer risk assessment for women with EOC. However, there is limited data about the genetic epidemiology of EOC among underrepresented populations, such as Hispanics. Consequently, we determined the germline mutation profile of Hispanics with EOC, and compared them with non-Hispanics. Methods: We included all women with a personal history of EOC from the U.S. and Latin America (LatAm; Mexico, Colombia, and Peru), enrolled in the Clinical Cancer Genomics Community Research Network registry. We assessed the prevalence of pathogenic variants (PV) in BRCA1/ BRCA2( BRCA) and other genes, contrasting the germline mutation profile between Hispanics living in LatAm, U.S. Hispanics, women of Ashkenazi Jewish (AJ) ancestry in the US, and other U.S. non-Hispanics. Results: Among 1186 women with EOC (209 from LatAm, 254 U.S. Hispanics l, 78 AJ, and 645 other non-Hispanic), 262 (22%) had a PV in BRCAgenes. Hispanics from LatAm and the U.S. had a similar frequency of BRCAmutations to AJ (30.6%, 29.9%, and 38.4%, respectively; p = 0.14); while non-Hispanics showed a significantly lower frequency of BRCAmutations (14.2%, p = 0.03). The most frequently mutated gene was BRCA1(n = 197, 74.6%), followed by BRCA2(n = 67, 25.3%). Among BRCA-negative cases (n = 924), 59% (n = 545) were evaluated by MGPT and PVs were identified in 2.9% [6 Hispanics (1.2%), 3 AJ (3.8%) and 26 Non-Hispanics (4%)]), of which 66% (n = 23) were in mismatch repair genes ( MSH2, MLH1, MSH6, PMS2), and 34% (n = 12) in other EOC-associated genes ( BRIP1, NBN, PALB2, RAD51C, and RAD51D). Clinically actionable PVs in ATM (n = 4; 0.3% ) and CHEK2 (n = 6; 0.5% ) were also observed. Conclusions: Hispanics with EOC have an elevated frequency of PV, similar to that of classic founder populations such as AJ, and significantly higher than other non-Hispanics. This is partially explained by a high prevalence of recurrent LatAm-specific PV, highlighting the importance of conducting genetic studies in underrepresented populations. There was modest incremental benefit of MGPT.

Abstract P5-13-08: Association of tumor infiltrating lymphocytes and chemotherapy regimen in response to preoperative chemotherapy in underserved patients

Introduction

Preoperative chemotherapy can demonstrate an individual's response to the chemotherapeutic regimen by comparing the amount of cancer at presentation to the amount remaining after treatment. Multiple previous studies have demonstrated that the amount of residual cancer, or final pathologic stage, is a better indicator of prognosis than the initial stage at presentation.

Tumor infiltrating lymphocytes have been recognized in breast cancer, and when found concentrated in breast cancer specimens, have been associated with a good prognosis. Breast cancer is not only a heterogeneous disease, but also displays varied presentation and behavior in patients of different race/ethnicities.

This study was performed to evaluate factors which predict response to chemotherapy. The effectiveness of different chemotherapeutic regimens, the effect of breast cancer subtype, and tumor infiltrating lymphocytes (TILs) were evaluated in our racial/ethnic minority population.

Methods

All patients at the safety net institution in Phoenix, AZ who underwent preoperative chemotherapy from 2002 to 2017 and had tissue available for evaluation were included in the study. Response to chemotherapy regimen was recorded. Pathologic complete response (pCR) was defined as no invasive cancer in the breast and lymph nodes in the final pathologic specimen. Breast cancer subtypes were divided based on IHC and FISH testing. Luminal subtypes were classified based on Ki67 (&gt;15%) and/or PR (&lt;20%) for Luminal B. Her2 subtype was defined as Her2 IHC 3+ or Her2 FISH amplified. Triple negative breast cancer (TNBC) was defined as ER and PR (&lt;5%) and Her2 negative. TILs concentration was determined from fixed formalin paraffin embedded (FFPE) core needle biopsy specimens.

Results

A total of 259 patients were included in the study. The mean age was 45 years. 80% of the population were racial/ethnic minorities. The vast majority (94%) were underinsured or uninsured, with 75% uninsured. The mean clinical tumor size at presentation was 6cm. 52% presented at clinical stage 2 while 48% presented at clinical stage 3. The overall pCR rate was 32%. pCR rate was impacted by breast cancer subtype with TNBC 52% and Her2 38% showing a better response to chemotherapy, while Luminal B was 16% and Luminal A 2% (p &lt; 0.05). In TNBC, chemotherapy regimens with anthracycline and docetaxel may have improved efficacy with pCR of 56% (p = 0.05). In the subgroup available for TIL evaluation, breast cancer subtype appeared to show similar importance with pathologic complete response rates of TNBC 50%, Her2 44%, Luminal B 12%, and Luminal A 0%. TIL appeared to affect the likelihood of pCR. When TIL were less than 5% the pCR rate was 16% compared to when there were TIL of at least 5% or more the pCR rate was 41% (p &lt; 0.05).

Conclusions

In our racial/ethnic minority population, breast cancer subtype and chemotherapy regimen did affect likelihood of pathologic complete response. Tumor infiltrating lymphocyte concentration as low as 5% may indicate a higher likelihood of pathologic complete response and could be used as an additional factor in the evaluation of patients for preoperative therapy.

Citation Format: Komenaka IK, Cocco D, Huliyar R, Hsu C-H, Martinez ME, Gago M, Nodora J, Mehta D, Caruso DM. Association of tumor infiltrating lymphocytes and chemotherapy regimen in response to preoperative chemotherapy in underserved patients [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-13-08.

Feasibility of a patient-reported outcomes quality-of-life instrument to improve care in underserved, ethnic minority patients with cancer

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Background: We need better methods to understand the social determinants of health and integrate psychosocial and economic sequelae of cancer and its treatment into healthcare delivery for ethnoculturally diverse population. A Patient-Reported Outcomes Quality of Life (PROQOL) instrument has been developed to capture less commonly discussed patient concerns (Personal Relationships, Emotional health, Physical health, Cancer diagnosis and treatment, Money and Care planning) and improve patient-provider communication. We sought to adapt this instrument and pilot it in underserved, ethnically diverse solid tumor and hematological malignancies patients at Maricopa Integrated Health System (MIHS) in Phoenix, AZ. Methods: Two focus groups (FG) were conducted to understand patient perspectives of an adapted Spanish version of PROQOL. This version was then piloted among patients on active cancer treatment. Patients also completed a Linear Analog Scale Assessment (from 1-10) for quality of life (QOL) and its domains (higher scores indicate better QOL). Results: All participants in both FG (11/12 female) were Hispanics, with a median age of 53 years. Participants agreed that the domains covered in the PROQOL represented the most important psychosocial needs in their cancer continuum. No difficulty in understanding the individual domains or questions for delving deeper into each domain was noted. Median age of 34 pilot study participants (74% female) was 48 years, 79% were Hispanic, 10% were African Americans and median household income was $ 43,924 (range 23,002-98,382). 28/34 completed the Spanish version. Most common concerns were ‘Money’ (32%): difficulty paying medical bills and non-medical expenses and ‘Cancer Diagnosis, Treatment and Survivorship’ (32%): type of cancer and treatment concerns. Median overall QOL was 8 (range 3-10). Conclusions: PROQOL is feasible for systematic capture of patient concerns in underserved, ethnic minority cancer patients. A better understanding of these challenges can help design interventions to improve psychosocial and financial outcomes for the vulnerable groups and decrease disparities in care delivery.

Breast Cancer Mortality in Older and Younger Patients in California

BACKGROUND

Breast cancer in younger patients is reported to be more aggressive and associated with lower survival; however, factors associated with age-specific mortality differences have not been adequately assessed.

METHODS

We used data from the population-based California Cancer Registry for 38,509 younger (18-49 years) and 121,573 older (50 years and older) women diagnosed with stage I to III breast cancer, 2005-2014. Multivariable Cox regression models were used to estimate breast cancer-specific mortality rate ratios (MRR) and 95% confidence intervals (CI), stratified by tumor subtype, guideline treatment, and care at an NCI-designated cancer center (NCICC).

RESULTS

Older breast cancer patients at diagnosis experienced 17% higher disease-specific mortality than younger patients, after multivariable adjustment (MRR = 1.17; 95% CI, 1.11-1.23). Higher MRRs (95% CI) were observed for older versus younger patients with hormone receptor (HR)⁺/HER2^- (1.24; 1.14-1.35) and HR⁺/HER2⁺ (1.38; 1.17-1.62), but not for HR^-/HER2⁺ (HR = 0.94; 0.79-1.12) nor triple-negative breast cancers (1.01; 0.92-1.11). The higher mortality in older versus younger patients was diminished among patients who received guideline-concordant treatment (MRR = 1.06; 95% CI, 0.99-1.14) and reversed among those seen at an NCICC (MRR = 0.86; 95% CI, 0.73-1.01).

CONCLUSIONS

Although younger women tend to be diagnosed with more aggressive breast cancers, adjusting for these aggressive features results in older patients having higher mortality than younger patients, with variations by age, tumor subtype, receipt of guideline treatment, and being cared for at an NCICC.

IMPACT

Higher breast cancer mortality in older compared with younger women could partly be addressed by ensuring optimal treatment and comprehensive patient-centered care.

Genetic, clinical and pathological characteristics of BRCA-associated breast cancer (BC) in Hispanic patients in the United States (US) and Latin America (LatAm)

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Background: Hispanic women with BC present at a younger age, have a higher frequency of BRCA mutations and show a worse incidence-to-mortality ratio than non-Hispanic women. Information regarding the characteristics of BRCA-associated BC in Hispanics is limited. Here, we assess differences in BRCA-associated BC between Hispanic patients in the US and in LatAm. Methods: Hispanic patients from the US and LatAm (Mexico, Colombia, Peru, and Puerto Rico) with a history of BRCA-associated BC enrolled in the Clinical Cancer Genomics Community Research Network registry were included. We compared the genetic, demographic, clinical and pathologic characteristics between Hispanics from the US and LatAm using Fisher’s exact test and x2statistics. Results: Between 1997 and 2016, 3670 Hispanic patients with a history of BC from LatAm (n = 1341) and the US (n = 2329) were identified, of which 490 (13.3%) had a deleterious BRCA mutation. The frequency of BRCA mutations was similar in Hispanics from LatAm (13.8%, n = 185) and the US (13.1%, n = 305). No significant differences were found in the frequency of BRCA1 vs BRCA2 mutations between patients from LatAm (BRCA1 68%, BRCA2 31.8%) and the US (BRCA1 61.3%, BRCA2 39%) (p = .12). The most frequent mutations found in BRCA1 were: ex 9-12del (LatAm n = 24, US n = 15), 185delAG (LatAm n = 13, US n = 18) and 943ins10 (LatAm n = 3, US n = 8), and in BRCA2 3492insT (LatAm n = 3, US n = 28). Mean age at BC diagnosis was 39.1 (SD 9.5) in LatAm and 41.7 (SD 10.6) in the US (p = 0.01). US patients were significantly more likely to present with Stage 0-II BC than those from LatAm (77.1% vs. 47.6%, p < .001). We found no differences in the proportion of hormone receptor positive tumors between patients from LatAm (45%) and the US (47%) (p = .78). Conclusions: The frequency of BRCA-associated BC was similar between Hispanics in LatAm and the US. Women from LatAm with BRCA mutations present at a younger age, as seen for sporadic BC; the causes for this finding warrant further research. Women with BRCA-associated BC in LatAm are more likely to have advanced BC at presentation, which may be a reflection of disparities and barriers in access to care.

The Feasibility and Time Required for Routine Health Literacy Assessment in Surgical Practice and Effect on Patient Satisfaction

Patients with limited health literacy (HL) have higher likelihood of problems with communication and may decrease patient satisfaction. This study was performed to determine the time required for routine HL assessment and its effect on patient satisfaction. Retrospective review over four years of consecutive patients who attended a breast clinic who underwent HL assessment as part of routine care. A total of 3126 consecutive patients from 2010 to 2014. Of the 3126 patients (96.9%), 3030 of were capable of undergoing HL assessment. No patients refused assessment, but one patient was inadvertently missed [3029 of 3030 patients (99.9%)]. The average age was 45 years and 10.5 years of education. The average time required was 1:57 minutes. Only 19 per cent of patients had adequate HL. Per each 1000 patients the time decreased (2:07, 1:58, 1:47; P < 0.001). Newest Vital Sign score did not change with time (1.6, 1.8, 1.7; P = NS). Patient satisfaction ratings increased during each subsequent year of HL assessments (P = 0.002). Routine HL assessment is feasible in surgical practice. HL assessment allows for identification of patients at risk for miscommunication. Implementation of communication strategies as described on the AMA website can improve patient-clinician communication and improve patient satisfaction.

The Feasibility and Time Required for Routine Health Literacy Assessment in Surgical Practice and Effect on Patient Satisfaction

Patients with limited health literacy (HL) have higher likelihood of problems with communication and may decrease patient satisfaction. This study was performed to determine the time required for routine HL assessment and its effect on patient satisfaction. Retrospective review over four years of consecutive patients who attended a breast clinic who underwent HL assessment as part of routine care. A total of 3126 consecutive patients from 2010 to 2014. Of the 3126 patients (96.9%), 3030 of were capable of undergoing HL assessment. No patients refused assessment, but one patient was inadvertently missed [3029 of 3030 patients (99.9%)]. The average age was 45 years and 10.5 years of education. The average time required was 1:57 minutes. Only 19 per cent of patients had adequate HL. Per each 1000 patients the time decreased (2:07, 1:58, 1:47; P < 0.001). Newest Vital Sign score did not change with time (1.6, 1.8, 1.7; P = NS). Patient satisfaction ratings increased during each subsequent year of HL assessments (P = 0.002). Routine HL assessment is feasible in surgical practice. HL assessment allows for identification of patients at risk for mis-communication. Implementation of communication strategies as described on the AMA website can improve patient-clinician communication and improve patient satisfaction.

Abstract P3-13-18: Technical skill of surgical residents may affect margin status of breast conserving operations

Background: Quality of patient care and surgical outcomes have come under increased scrutiny. Numerous other studies have examined outcomes at teaching hospitals compared to non-teaching hospitals. The most important factor to determine early success of breast conservation is the attainment of pathologically negative margins. Few studies, however, have examined the effect of teaching residents on margin status. The current study was performed to evaluate the effect teaching residents on margin status after lumpectomy.

Methods: Retrospective review of all patients from July 2006-June 2015 was evaluated. A resident was usually considered the primary surgeon. If the resident was unavailable or unprepared to operate, the attending surgeon was the primary surgeon. As part of the routine evaluation of surgical residents, technical ability was classified as satisfactory or unsatisfactory for level of training. All evaluations of the technical ability of the residents were completed prior to the collection of the current data. The effect of surgical residents' participation and their technical ability to perform lumpectomy was evaluated to determine if there was an effect on margin status. Logistic regression analysis was performed to adjust for clinical variables known to affect margin status.

Results: Of 292 patients, 15% of patients had positive margins. The attending surgeon has positive margin rate of 10.7% vs 16% for Residents (p = 0.32).When technical skill evaluation was included, Residents with unsatisfactory technical skills had positive margin rate of 27% compared to 10.2% for residents with satisfactory skills (p = 0.002). In multivariate logistic regression analysis, operating surgeon remained significantly associated with positive margins. Operations done by residents with satisfactory technical skills or attending surgeon were less likely to have positive margins than those done by residents with unsatisfactory technical skills (OR 0.39, 95% CI 0.22-0.86; p = 0.03). Patients who underwent preoperative chemotherapy were also less like to have positive margins (OR 0.40, 95% CI 0.18-0.91); p = 0.04). In patients with at least 2 years of followup (mean follow up of 48 months) breast cancer specific survival was 94% and 2% had local recurrences as a first event.

Conclusions: Technically ability of residents may affect margin status after lumpectomy. With the increased use of surgical outcomes to measure quality of care in medicine, the importance of teaching surgical residents needs to be considered in future quality of care evaluation.

Citation Format: Komenaka IK, Djenic B, Hsu C-H, Nodora J, Winton L, Bouton M, Martinez ME. Technical skill of surgical residents may affect margin status of breast conserving operations [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-13-18.

Abstract P5-13-02: Weight gain after breast cancer diagnosis and patients' opinion on weight loss strategies

Background: The rate of obesity is increasing in many countries worldwide. Most populations are not aware of steady weight gain with age. In addition, obesity is increasingly being recognized as a risk factor for breast cancer. Some studies have also demonstrated that weight gain after diagnosis is associated with increased risk for recurrence. The current study was performed to evaluate weight gain in a population of patients seen at a safety net institution. Additionally, patients also gave their opinion on weight loss strategies.

Methods: A retrospective review of all breast cancer patients seen at the county, safety net institution from July 2001 to June 2014 who had at least 2 years of follow up were evaluated for change in weight. For the question on weight loss strategies, all patients from May 2014 to May 2015 were included. Sociodemographic, clinical, and treatment variables were evaluated.

Results: From July 2001 to June 2014, 225 breast cancer patients had follow up prior to January 2013. Of these patients 59% gained weight after their diagnosis of breast cancer. Overall these patients gained an average of 2 kg after their diagnosis.

Starting in January 2013, patients were given a simple message, “avoiding gaining weight” after their diagnosis. For 115 patients with follow up after January 2013, only 35% gained weight and on average, this group of patient lost 4 kg from diagnosis. Patients who initially gained weight were provided with basic weight loss strategies.

From May 2014 to May 2015, 1198 consecutive patients were seen. The average age was 45 years. 12% were non-Hispanic White. Only 30% of patients stated that their primary care provider discussed weight maintenance or weight loss as part of their routine health care. 40% of patients did feel that a permanent change was necessary to facilitate weight loss. However, fewer than half (44%) the patients felt that exercise was necessary. Dietary beliefs were varied, with the most commonly held belief was that vegetarian/vegan diet was necessary (28%). Patients rarely cited commonly recommended weight loss strategies: lower caloric intake (9%), eat frequently (0.3%), adequate fiber (0.1%), adequate protein (0.6%), enough sleep (0.1%), don't eat late (0.1%), no fast food (2%), avoid soda (1%), drink more water (1%). 6% of patients felt a low/no carbohydrate diet was important. By contrast, older strategies or popular ideas: low fat (8%), no flour/wheat/gluten (4%) were also felt to be important. 7.3% stated they did not know any strategy. 5% patients recommended stopping eating altogether to lose weight.

Conclusions: Similar to population wide data, breast cancer patients treated at a safety net institution tend to gain weight with follow up. Also similar to most populations, the population was not aware of recommended weight loss strategies and most do not feel that exercise is an important component of weight maintenance. As with the rest of the US population significant effort will be necessary to help patients avoid weight gain after diagnosis. Making patients aware of their weight may help patients avoid gaining weight.

Citation Format: Komenaka IK, VanderVelde J, Hsu C-H, Nodora J, Winton L, Bouton M, Martinez ME. Weight gain after breast cancer diagnosis and patients' opinion on weight loss strategies [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-13-02.

Does Self-Assessment Improve the Effectiveness of Grand Rounds Lectures in a Community-Based Teaching Hospital?

OBJECTIVE

To determine whether use of self-assessment (SA) questions affects the effectiveness of weekly didactic grand rounds presentations.

DESIGN

From 26 consecutive grand rounds presentations from August 2013 to April 2014, a 52-question multiple-choice test was administered based on 2 questions from each presentation.

SETTING

Community teaching institution.

PARTICIPANTS

General surgery residents, students, and attending physicians.

RESULTS

The test was administered to 66 participants. The mean score was 41.8%. There was no difference in test score based on experience with similar scores for junior residents, senior residents, and attending surgeons (43%, 46%, and 44%; p = 0.13). Most participants felt they would be most interested in presentations directly related to their surgical specialty. Participants, however, did not score differently on topics which were the focus of the program (40% vs. 42%; p = 0.85). Journal club presentations (39% vs. others 42%; p = 0.33) also did not affect the score. The Pearson correlation coefficient for attendance was 0.49 (p < 0.0001) demonstrated that attendance was very important. Participation in the weekly SA was significantly associated with improved score as those who participated in SA scored over 20% higher than those who did not (59% vs. 38%; p < 0.0001). Based on multiple linear regression for mean score, SA explained the variation in score more than attendance.

CONCLUSIONS

The current study found that without preparation approximately 40% of material presented is retained after 10 months. Participation in weekly SA significantly improved retention of information from grand rounds presentations.

Factors associated with cervical cancer screening in a safety net population

AIM

To identify factors associated with Papanicolaou-smear (Pap-smear) cervical cancer screening rates in a safety net population.

METHODS

From January 2012 to May 2013, the use of Pap-smear was determined for all patients seen at the breast clinic in a safety net hospital. Health literacy assessment was performed using the validated Newest Vital Sign. The records of patients were reviewed to determine if they had undergone Pap-smears for cervical cancer screening. Sociodemographic information was collected included age, education, monthly income, race/ethnicity, employment, insurance status, and primary care provider of the patient. Logistic regression analysis was then performed to determine factors associated with utilization of Pap-smears. Crude and adjusted odds ratios derived from multivariate logistic regression models were calculated as well as the associated 95%CIs and P-values.

RESULTS

Overall, 39% had Pap-smears in the prior 15 mo, 1377 consecutive women were seen during the study period and their records were reviewed. Significantly more patients with adequate health literacy underwent Pap-smears as compared to those with limited health literacy (59% vs 34%, P < 0.0001). In multivariate analysis, patients with adequate health literacy, younger patients, and those with later age of first live birth were more likely to undergo Pap-smears. Patients whose primary care providers were gynecologists were also significantly more likely to have Pap-smears compared to other specialties (P < 0.0001). Patients younger than 21 years or older than 65 years underwent screening less frequently (11% and 11%, respectively) than those 21-64 years (41%, P < 0.0001). Race, ethnicity, language, and insurance status were not associated with Pap-smear screening rates.

CONCLUSION

Patient health literacy and primary care physician were associated with Pap-smear utilization. Development of interventions to target low health literacy populations could improve cervical cancer screening.

Biospecimen Sharing Among Hispanic Women in a Safety-Net Clinic: Implications for the Precision Medicine Initiative

Biospecimen donation is key to the Precision Medicine Initiative, which pioneers a model for accelerating biomedical research through individualized care. Personalized medicine should be made available to medically underserved populations, including the large and growing US Hispanic population. We present results of a study of 140 Hispanic women who underwent a breast biopsy at a safety-net hospital and were randomly assigned to receive information and request for consent for biospecimen and data sharing by the patient’s physician or a research assistant. Consent rates were high (97.1% and 92.9% in the physician and research assistant arms, respectively) and not different between groups (relative risk [RR] = 1.05, 95% confidence interval [CI] = 0.96 to 1.10). Consistent with a small but growing literature, we show that perceptions of Hispanics’ unwillingness to participate in biospecimen sharing for research are not supported by data. Safety-net clinics and hospitals offer untapped possibilities for enhancing participation of underserved populations in the exciting Precision Medicine Initiative.

Subclavian Steal Syndrome in Acute Myocardial Infarction Masquerading as Acute Embolism to Left Upper Extremity

Subclavian steal syndrome is an uncommon entity diagnosed with angiography after neurologic symptoms occur during activity with the upper extremity. Cardiac symptoms or silent ischemia have been described in patients who have undergone cardiac bypass using the ipsilateral internal mammary artery. Our patient presented with acute chest pain radiating to the left upper extremity and a diminished pulse. Angiography to rule out an acute embolus instead revealed subclavian artery occlusion. As atherosclerosis is the most common cause, the ipsilateral subclavian artery should be carefully evaluated, particularly in cardiac patients undergoing coronary angiography. Recognition of coexisting subclavian artery occlusion could prevent cardiac complications that may occur with use of the ipsilateral internal mammary artery during coronary artery bypass surgery.

Abstract P6-12-06: Preoperative chemotherapy regimens and breast cancer subtype in an underinsured Hispanic population

Background: Although the Hispanic population is among the fastest growing in the United States, however, less is known about them then other populations. Breast cancer in different racial/ethnic populations display different behaviors. The current study was performed to examine response to preoperative chemotherapy regimen and by breast cancer subtype in a Hispanic safety net population.

Methods: A retrospective review of Hispanic breast cancer patients who underwent preoperative chemotherapy from July 2001 to February May 2015 at a safety net hospital. Sociodemographic, clinical, and treatment variables were evaluated. Response to chemotherapy regimen was recorded. Breast cancer subtypes were divided based on IHC and FISH testing. Luminal B subtype was classified based on Ki67 (&gt;15%) and PR (&lt;20%).

Results: The average age of the 133 patients was 45 years. 93% of the patients were insured with Medicaid or uninsured (70%). The average size of the cancers at presentation was 5cm. Overall 86% of patients had a clinical response to preoperative chemotherapy and 35% had pathologic complete response (pCR). AC and TC regimens had the lowest rate of pCR at 16%. AC/T (every 3 week and weekly) had similar rates of pCR 23% and 29%, while dose dense regimens showed pCR 40%. Herceptin containing regimens had pCR 57%. 7 patients received TAC and 71% had pCR.

By subtype, Luminal A and B patients had low rates of pCR 9% and 14% respectively. Luminal B patients did benefit from preoperative chemotherapy as 86% of patients who were not candidates for breast conservation at presentation were able to undergo lumpectomy after preoperative chemotherapy. Her2 subtype patients who got Herceptin had pCR 57%. Triple negative patients had pCR 54%.

Conclusions: In this underinsured, Hispanic population who presented at advanced stages, differences in response to preoperative chemotherapy were seen based on breast cancer subtype. Differences were also seen based on chemotherapy regimen. TAC maybe a particularly effective regimen in triple negative Hispanic women.

Citation Format: Mehta D, Winton L, Walters J, Hsu C-H, Nodora J, Martinez ME, Bouton M, Komenaka IK. Preoperative chemotherapy regimens and breast cancer subtype in an underinsured Hispanic population. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-12-06.

Abstract P6-12-07: The benefit of preoperative chemotherapy in an underinsured Hispanic population with poor use of screening mammography

Background: Despite prospective clinical trials demonstrating the safety and effectiveness of preoperative chemotherapy for nearly 2 decades, it may still be underutilized in underserved, uninsured populations most likely to present with advanced cancers. The current study was performed to evaluate the effect of preoperative chemotherapy (PC) in a Hispanic safety net population.

Methods: A retrospective review of Hispanic breast cancer patients who presented at clinical stage 2 or higher and were treated from July 2001 to February May 2015 at a safety net hospital. Sociodemographic, clinical, and treatment variables were evaluated. Surgical outcomes were evaluated. Margin status was determined for those who underwent breast conservation.

Results: The average age of the 266 patients was 45 years. 93% of the patients were insured with Medicaid or uninsured (70%). Only 24% of patients underwent screening mammography. 133 underwent PC and 133 had primary operations. Patients who underwent PC presented with larger cancers (5cm vs 3.5cm, p &lt; 0.001). 96% of patients in PC group were not candidates for lumpectomy at presentation. However, lumpectomy was performed more often in those who underwent PC (75% vs. 57%, p = 0.01). Re-excision for margins were necessary less often in those who underwent PC (10.3% vs 27%, p = 0.01). Patients who underwent PC were also less likely to require an ALND (33% vs 47%, p = 0.04). Despite presentation at higher average clinical stage in patients who underwent PC, at average follow up of 52 months, risk of IBTR and risk of regional recurrence were similar in the PC and no-PC groups (IBTR: 4.4% vs 3%, p = 0.99 and Regional: 1.5% vs. 1.5%, p = 0.99). Breast cancer specific survival was 86.5% in the PC group compared to 84% in the no-PC group (p = 0.68). Patients in the no-PC group were less likely to comply with recommended chemotherapy.Conclusions: In this underinsured, Hispanic population who did not use screening mammography, preoperative chemotherapy allowed many women to undergo breast conservation, undergo fewer operations, and were less likely to require ALND. Risk of local and regional recurrence is low in these patients and comparable to those who underwent primary operation.

Citation Format: Komenaka IK, Djenic B, Walters J, Hsu C-H, Nodora JN, Martinez ME, Bouton M, Mehta D. The benefit of preoperative chemotherapy in an underinsured Hispanic population with poor use of screening mammography. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-12-07.

Participation of low-income women in genetic cancer risk assessment and BRCA 1/2 testing: the experience of a safety-net institution

Some communities and populations lack access to genetic cancer risk assessment (GCRA) and testing. This is particularly evident in safety-net institutions, which serve a large segment of low-income, uninsured individuals. We describe the experience of a safety-net clinic with limited resources in providing GCRA and BRCA1/2 testing. We compared the proportion and characteristics of high-risk women who were offered and underwent GCRA and genetic testing. We also provide a description of the mutation profile for affected women. All 125 patients who were offered GCRA accepted to undergo GCRA. Of these, 72 % had a breast cancer diagnosis, 70 % were Hispanic, 52.8 % were non-English speakers, and 66 % did not have health insurance. Eighty four (67 %) were offered genetic testing and 81 (96 %) agreed. Hispanic women, those with no medical insurance, and those with a family history of breast cancer were significantly more likely to undergo testing (p > 0.01). Twelve of 81 (15 %) patients were found to have deleterious mutations, seven BRCA1, and five BRCA2. Our experience shows that it is possible to offer GCRA and genetic testing even in the setting of limited resources for these services. This is important given that a large majority of the low-income women in our study agreed to undergo counseling and testing. Our experience could serve as a model for similar low-resource safety-net health settings.

The effect of an evidence-based medicine curriculum on breast cancer knowledge and satisfaction of surgical residents

OBJECTIVE

The current study was performed to determine if evidence-based medicine (EBM) curriculum would affect education of surgical residents.

DESIGN

A 5-year prospective study was designed to determine if EBM curriculum could improve residents' satisfaction and understanding of breast cancer management during a breast surgical oncology rotation. During the first 2 years, 45 journal articles were used. During the subsequent 3 years, journal articles were not used. The proportion of patients seen in clinic was collected as an objective measure of the "effort" made by the resident. The final assessment was a 120-question examination.

SETTING

Maricopa Medical Center, Phoenix, AZ. Safety net institution with General Surgery residency program.

PARTICIPANTS

Postgraduate year 2 general surgery residents.

RESULTS

Over 5 years, 30 postgraduate year 2 residents were involved. Univariate analysis showed that female sex (p = 0.04), residents with peer-reviewed publications (p = 0.03), younger age (p = 0.04), American Board of Surgery in-service training examination score (p = 0.01), and clinical effort (p < 0.01) were associated with higher scores. Although residents taught using the journal articles scored 7 points higher on the final examination, this was not significant (p = 0.10). Multivariate analysis showed that American Board of Surgery in-service training examination score and clinic efficiency remained statistically significant. Residents who were taught using the EBM curriculum had significantly higher satisfaction (4.4 vs 3.5, p = 0.001) compared with those who did not go through the EBM curriculum.

CONCLUSIONS

The current study demonstrates that an EBM curriculum significantly improved resident satisfaction with the rotation. The EBM curriculum may improve residents' breast cancer knowledge. The most important predictor of resident performance was the effort of resident.

Association of health literacy with adherence to screening mammography guidelines

OBJECTIVE

To investigate the relationship of health literacy and screening mammography.

METHODS

All patients seen at a breast clinic underwent prospective assessment of health literacy from January 2010 to April 2013. All women at least 40 years of age were included. Men and women diagnosed with breast cancer before age 40 years were excluded. Routine health literacy assessment was performed using the Newest Vital Sign. Demographic data were also collected. Medical records were reviewed to determine if patients had undergone screening mammography: women aged 40-49 years were considered to have undergone screening if they had another mammogram within 2 years. Women 50 years or older were considered to have undergone screening mammography if they had another mammogram within 1 year.

RESULTS

A total of 1,664 consecutive patients aged 40 years or older were seen. No patient declined the health literacy assessment. Only 516 (31%) patients had undergone screening mammography. Logistic regression analysis that included ethnicity, language, education, smoking status, insurance status, employment, income, and family history found that only three factors were associated with not obtaining a mammogram: low health literacy (odds ratio [OR] 0.27, 95% confidence interval [CI] 0.19-0.37; P<.001), smoking (OR 0.64, 95% CI 0.47-0.85; P=.002), and being uninsured (OR 0.66, 95% CI 0.51-0.85; P=.001).

CONCLUSION

Of all the sociodemographic variables examined, health literacy had the strongest relationship with use of screening mammography.

Abstract P1-11-04: Implementation of cancer risk assessment and genetic testing in underserved patients

PURPOSE:

There is great disparity in genetic testing for breast cancer. Hispanic/Latina women with breast cancer are more likely to have adverse clinical features and have a high prevalence of BRCA mutations. We propose that Academic-Community clinic partnerships offer great potential to provide access to genetic cancer risk assessment (GCRA) for underserved communities, including Hispanic/Latina women. The study also evaluated the willingness of these patients to participate in biospecimen collection.

METHODS:

This study assessed the implementation of a limited GRCA and testing service at a safety net institution from July 1, 2011 to December 31, 2013. In the 10 years prior, only two breast cancer patients had undergone genetic testing and both were insured.

The inability to perform GCRA was recognized as a critical area of need. Therefore, a breast surgical oncologist received training with City of Hope National Medical Center. The goal is to provide clinicians the appropriate skills to provide GCRA services in areas where these are not available.

Three generation pedigrees and sociodemographic information were collected including health literacy, education, self-reported income, employment status, and insurance status. We conducted a comparison of the patient characteristics along the continuum of GCRA, genetic testing, and mutation carriers, and for the latter group, we describe the BRCA mutation profile.

RESULTS:

125 patients were offered GCRA and all accepted, of which 70% of this patient population was Hispanic and 66% did not have health insurance. Of the 125 patients, 84 (67%) were recommended to undergo genetic testing and 81 (96%) agreed. Of the 81 patients who underwent genetic testing, 68 were also asked to participate in the City of Hope Cancer Screening and Prevention registry and all but one (94%) agreed.

Significant differences between patients who had genetic testing and those who did not were shown for race/ethnicity, insurance, and family history. A higher percentage of Hispanic patients and patients with no insurance underwent testing. Additional trends in differences between patients who were tested vs. those who were not were observed for education and health literacy but these were not statistically significant. Few differences were observed between women who had genetic testing and mutation carriers; however, the number of carriers was too small to merit statistical testing. Twelve of 81 (15%) patients were found to have deleterious mutations, seven BRCA 1 and five BRCA 2. Of the 12 mutation carriers, one patient had ovarian cancer and therefore had already undergone bilateral salpingo-oophorectomy and two others underwent RRSO. Six are either considering RRSO or getting financial assistance for the operation. The last three are still undergoing breast cancer treatment.

CONCLUSION:

Results of our experience at a safety net hospital with a largely minority and uninsured population show that limited GCRA and testing can be successfully implemented. The great majority of patients agree to undergo counseling, testing, and participate in biospecimen research registries. Current recommendations for genetic counseling are far from being met across the country and this model could be considered for similar safety net populations.

Citation Format: Ian K Komenaka, Lisa M Winton, Jesse N Nodora, Lisa Madlensky, Meredith A Heberer, Richard Schwab, Marcia E Bouton, Jeffrey N Weitzel, Maria Elena Martinez. Implementation of cancer risk assessment and genetic testing in underserved patients [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P1-11-04.

Abstract P1-11-05: Womens' opinion on when to start screening mammography and reasons for not undergoing screening

Background: In late 2009 significant controversy arose when some screening recommendations were changed to advocate screening mammography starting at age 50 rather than the long standing recommendation of starting at age 40 years. More recently some studies have called into question the benefit of screening mammography. The current study was performed to evaluate patients’ opinion on when women should start screening mammography and reasons for not undergoing screening.

Methods: Maricopa Medical Center is the safety net hospital in Phoenix, Arizona. 1,157 consecutive patients were seen at the Breast Clinic from May 2013 to May 2014. Sociodemographic variables were collected including health literacy assessment using the Newest Vital Sign (NVS) validated screening instrument. Patients were asked when they felt women should start screening mammography. In addition, in women at least 40 years of age, if they did not undergo screening mammography, they were asked for the primary reason for not undergoing screening. Differences in patient characteristics were evaluated based on a Fisher’s exact test for categorical variables and one-way ANOVA for continuous variables.

Results: Thirteen of the 1,157 consecutive patients were male and excluded. The average age of the 1,144 consecutive female patients was 45 years. Most patients were Hispanic, underinsured, and had limited health literacy. Overall use of screening mammography was poor at only 24%. 402 women (35%) felt that age 40 years was the most appropriate time to start screening. Only 30 women (3%) felt that age 50 years was the most appropriate age. More women, 470 (41%), chose an age younger than age 40 to start screening. More than half (55%) of these women who chose an age 50 years or younger, however, did not undergo screening because they felt they had "no problems" or "didn’t know" they should get a mammogram despite choosing an age to start that was below their current age. Only 187 women (32%) cited cost as the reason for not undergoing screening. Other reasons for not undergoing screening were: physician did not recommend and other medical problems/forgot/too busy. Few patients (4%) cited problems with mammograms for not undergoing screening and none cited concerns about false positives. Multivariate analysis showed that patients with adequate health literacy and insurance were more likely to use screening mammography than patients who were uninsured or had limited health literacy. Family history of breast cancer was not associated with use of screening mammography.

Conclusions: Use of screening mammography was poor in this underinsured population. Most women felt that screening mammography should start at age 40 years or younger. More than half of women who did not undergo screening did not do so because they had "no problems" or "didn't know" they should. Although many women feel that screening should start at age 40, most women in this population do not understand the concepts of screening and early detection. Interventions to increase use of screening mammography should focus of the concept of screening as well as the age.

Citation Format: Ian K Komenaka, Meredith Heberer, Jesse Nodora, Chiu-Hsieh Hsu, Lisa Winton, Marcia Bouton, Maria Elena Martinez. Womens' opinion on when to start screening mammography and reasons for not undergoing screening [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P1-11-05.

Differentially expressed microRNAs in postpartum breast cancer in Hispanic women

The risk of breast cancer transiently increases immediately following pregnancy; peaking between 3-7 years. The biology that underlies this risk window and the effect on the natural history of the disease is unknown. MicroRNAs (miRNAs) are small non-coding RNAs that have been shown to be dysregulated in breast cancer. We conducted miRNA profiling of 56 tumors from a case series of multiparous Hispanic women and assessed the pattern of expression by time since last full-term pregnancy. A data-driven splitting analysis on the pattern of 355 miRNAs separated the case series into two groups: a) an early group representing women diagnosed with breast cancer ≤ 5.2 years postpartum (n = 12), and b) a late group representing women diagnosed with breast cancer ≥ 5.3 years postpartum (n = 44). We identified 15 miRNAs with significant differential expression between the early and late postpartum groups; 60% of these miRNAs are encoded on the X chromosome. Ten miRNAs had a two-fold or higher difference in expression with miR-138, miR-660, miR-31, miR-135b, miR-17, miR-454, and miR-934 overexpressed in the early versus the late group; while miR-892a, miR-199a-5p, and miR-542-5p were underexpressed in the early versus the late postpartum group. The DNA methylation of three out of five tested miRNAs (miR-31, miR-135b, and miR-138) was lower in the early versus late postpartum group, and negatively correlated with miRNA expression. Here we show that miRNAs are differentially expressed and differentially methylated between tumors of the early versus late postpartum, suggesting that potential differences in epigenetic dysfunction may be operative in postpartum breast cancers.

Temporal resolution of idiopathic granulomatous mastitis with resumption of bromocriptine therapy for prolactinoma

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IGM is becoming recognized more frequently.

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Observation and patients with the natural history can be effective management.

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Prolactin may be involved in the pathophysiology of IGM.

Introduction

Idiopathic granulomatous mastitis (IGM) is becoming more commonly recognized and reported more often. Currently, many recommend corticosteroids in its management.

Presentation of case

A 34-year-old G3P2 Hispanic female, 28 weeks pregnant, presented with a 19 cm right breast mass. She had a known prolactinoma treated with bromocriptine which was discontinued during her pregnancy. Ultrasound guided core biopsy procedure revealed granulomatous mastitis. The patient was told that the mass would resolve with observation. The patient seen at another institution by an infectious disease specialist who started treatment with amphotericin for presumptive disseminated coccidioidomycosis. Repeated titers were negative for coccidioides antibody. Repeat cultures were negative as well. Due to the persistence of the infectious disease specialist, tissue cultures were performed on fresh tissue specimens, which did not grow bacterial, fungal, nor acid fast organisms. The amphotericin regimen resulted in no improvement of her breast mass after 10 weeks. Within two weeks of stopping the antifungal therapy, however, the mass diminished to 6 cm. The patient delivered at 39 weeks. Bromocriptine was restarted, and within 4 weeks, the lesion was no longer palpable. She had not shown signs of recurrence for 32 months.

Discussion

Treatment recommendations for IGM vary widely but antibiotics and antifungal medications are not recommended. Corticosteroid treatment is most commonly recommended, however, outcomes may not be different from management with observation. Prolactin may be involved in the pathophysiology of the process.

Conclusion

IGM is becoming recognized more frequently. Observation and patience with natural history can be an effective management.

Management of idiopathic granulomatous mastitis with observation

BACKGROUND

Idiopathic granulomatous mastitis (IGM) is becoming more commonly recognized and reported more often. Currently, many recommend corticosteroids in its management.

METHODS

A retrospective chart review was conducted from January 2002 to June 2013. Data were collected regarding sociodemographic information, clinical history, treatment, and outcomes.

RESULTS

Thirty-seven patients were found with IGM. Thirty-five patients were Hispanic born outside the United States. Early in the time period reviewed, 5 patients had masses excised and 5 patients were lost to follow-up. Twenty-seven cases of IGM resolved with observation. Corticosteroids were not used in the management. The average time to resolution was 7.4 months. Three patients (11%) had recurrent episodes after resolution.

CONCLUSIONS

IGM is a self-limited benign condition that will resolve spontaneously without treatment. Patience with the natural history of IGM is important, as the process often includes periods of exacerbation before resolution.

Family history of breast and ovarian cancer and triple negative subtype in hispanic/latina women

Familial breast and ovarian cancer prevalence was assessed among 1150 women of Mexican descent enrolled in a case-only, binational breast cancer study. Logistic regression was conducted to compare odds of triple negative breast cancer (TNBC) to non-TNBC according to family history of breast and breast or ovarian cancer among 914 of these women. Prevalence of breast cancer family history in a first- and first- or second-degree relative was 13.1% and 24.1%, respectively; that for breast or ovarian cancer in a first-degree relative was 14.9%. After adjustment for age and country of residence, women with a first-degree relative with breast cancer were more likely to be diagnosed with TNBC than non-TNBC (OR=1.98; 95% CI, 1.26-3.11). The odds of TNBC compared to non-TNBC were 1.93 (95% CI, 1.26-2.97) for women with a first-degree relative with breast or ovarian cancer. There were non-significant stronger associations between family history and TNBC among women diagnosed at age <50 compared to ≥50 years for breast cancer in a first-degree relative (P-interaction = 0.14) and a first- or second-degree relative (P-interaction = 0.07). Findings suggest that familial breast cancers are associated with triple negative subtype, possibly related to BRCA mutations in Hispanic/Latina women, which are strongly associated with TNBC. Family history is an important tool to identify Hispanic/Latina women who may be at increased risk of TNBC, and could benefit from prevention and early detection strategies.

Women's Impression of the Expected Breast Appearance and its Association with Breast Cancer Operations

BACKGROUND

Significant concern exists from clinicians in all fields that rates of bilateral mastectomy and prophylactic mastectomy are increasing. This study was performed to evaluate women's perception of breast appearance and its association with breast cancer operations.

METHODS

From April 2012 to May 2013, all women attending a breast clinic were shown two breast pictures, "natural" and "augmented," and asked which photograph represented the current expected appearance of breasts. Among breast cancer patients, the choice of breast cancer operation was correlated with picture selection.

RESULTS

Of 1,177 consecutive women, mean age was 45 years. Overall, 70 % of patients felt that the augmented appearance is expected. This impression was seen in all racial/ethnic groups: non-Hispanic White 65 %, African American 67 %, Hispanic 71 %, and other groups 70 %. Younger age was strongly associated with the augmented appearance (p < 0.0001). Patients older than age 60 years selected the augmented appearance only 51 % of the time. This percentage increased with each younger decade with patients younger than 40 years selecting the augmented appearance in 85 %. Among breast cancer patients, augmented appearance selection was more likely for patients who underwent reconstruction (92 %; p < 0.001), as well as for those undergoing bilateral mastectomy (74 %; p = 0.057) compared with mastectomy alone (49 %).

CONCLUSIONS

Most women felt that the augmented appearance of breasts is currently expected, and this impression was more common in young women. This impression may be another factor contributing to the current trend of more extensive breast cancer operations and implant-based reconstructions.

Factors which affect use of breast conservation and mastectomy in an underinsured Hispanic population

BACKGROUND

Despite no difference in overall survival between breast conservation and mastectomy, significant variation exists between institutions and within populations. Less data exists about racial and ethnic minority populations. The current study was performed to evaluate variables that affect use of breast conservation and mastectomy in an underinsured Hispanic population.

METHODS

A retrospective review was performed of all patients who self-identified as of Hispanic ethnicity and underwent breast cancer operations from July 2001 to February 2011 at a safety net hospital. Sociodemographic, clinical, and treatment variables were evaluated. All patients with documented contraindications to breast conservation were excluded. Univariate analysis and multivariate analysis were performed to identify variables which were associated with type of operation.

RESULTS

The average age of the 219 patients included was 50 years. Most of the patients (93%) were insured with Medicaid or uninsured and 59% presented with clinical stage 2A/B cancers. Mastectomy was performed in 33% of patients and 67% had breast conservation. In adjusted multivariate analysis higher pathologic stage (p=0.01) and English speakers (p=0.03) were associated with mastectomy. By contrast, higher BMI (p=0.03) and use of preoperative chemotherapy (p=0.01) were associated with breast conservation.

CONCLUSIONS

In this underinsured Hispanic population, patients with higher pathologic stage and English speaking patients were more likely to undergo mastectomy. Patients who underwent preoperative chemotherapy and who had higher BMI were more likely to undergo breast conservation.

Family history and breast cancer subtype among women of Mexican descent

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Background: A family history of breast cancer in a first-degree relative is associated with a 2-fold increase in breast cancer risk; however, breast cancer is a heterogeneous disease and there may be differences in risk profiles driven by tumor subtype or by racial/ethnic group. Methods: We assessed prevalence of familial breast cancer and its association with tumor subtype among 914 women with breast cancer of Mexican descent enrolled in the Ella Study, a case-only, binational (U.S.-Mexico) breast cancer study. Logistic regression was conducted to compare odds of triple negative breast cancers to non triple-negative breast cancers according to family history. Results: The prevalence of family history of breast cancer in a first- or second-degree relative was 24.1%, with 13.1% having an affected first-degree relative. Among participants who were diagnosed at age < 50, prevalence of family history of breast cancer in a first- or second-degree relative was 27.4%. After adjustment for age and country of residence, women with a first-degree relative with breast cancer were significantly more likely to be diagnosed with triple-negative breast cancers compared to non triple-negative breast cancers (OR = 1.98; 95% CI, 1.26-3.11). Similar results were seen for odds of triple-negative breast cancers compared to non-triple negative breast cancers for women with affected first- or second-degree relatives (OR=2.04; 95% CI, 1.40–2.98). The odds of triple-negative breast cancer compared to non-triple negative breast cancer was 1.93 (95% CI, 1.26–2.97) for women with first-degree relatives affected with breast or ovarian cancer. Conclusions: Findings suggest that familial cancers are most likely to be associated with triple negative subtype, supporting etiologic heterogeneity by tumor subtype in this population of Hispanic women. This association may be related to the prevalence of BRCA1 founder mutations in this population, which are strongly associated with triple-negative breast cancers. Identification of such differences in risk factors can help personalize screening and prevention approaches.

Reproductive and hormonal risk profile according to language acculturation and country of residence in the Ella Binational Breast Cancer Study

BACKGROUND

We compared the distribution of breast cancer reproductive and hormonal risk factors by level of acculturation and country of residence in women of Mexican descent.

METHODS

To compare the distribution of breast cancer reproductive and hormonal risk factors by level of acculturation and country of residence in women of Mexican descent, taking into account level of education, we analyzed data on 581 Mexican and 620 Mexican American (MA) women with a history of invasive breast cancer from the Ella Binational Breast Cancer Study. An eight-item language-based acculturation measure was used to classify MA women. Multivariate logistic regression was used to test associations between language acculturation, country of residence, and reproductive and hormonal risk factors.

RESULTS

After adjustment for age and education, compared to women residing in Mexico, English-dominant MAs were significantly more likely to have an earlier age at menarche (<12 years; odds ratio [OR]=2.08; 95% confidence interval [CI], 1.30-3.34), less likely to have a late age at first birth (≥30 years; OR=0.49; 95% CI, 0.25-0.97), and less likely to ever breastfeed (OR=0.13; 95% CI, 0.08-0.21).

CONCLUSIONS

Differences in reproductive and hormonal risk profile according to language acculturation and country of residence are evident; some of these were explained by education. Results support continued efforts to educate Mexican and MA women on screening and early detection of breast cancer along with promotion of modifiable factors, such as breastfeeding.

Association between parity and obesity in Mexican and Mexican-American women: findings from the Ella binational breast cancer study

Obesity at diagnosis of breast cancer is associated with higher all-cause mortality and treatment-associated toxicities. We evaluated the association between parity and obesity in the Ella study, a population of Mexican and Mexican-American breast cancer patients with high parity. Obesity outcomes included body mass index (BMI) ≥30 kg/m(2), waist circumference (WC) ≥35 in (88 cm), and waist-to-hip-ratio (WHR) ≥0.85. Prevalence of obesity ([BMI] ≥ 30 kg/m(2)) was 38.9 %. For WC, the multivariate odds ratio (OR) (95 % confidence interval [CI]) for having WC ≥ 35 inches in women with ≥4 pregnancies relative to those with 1-2 pregnancies was 1.59 (1.01-2.47). Higher parity (≥4 pregnancies) was non-significantly associated with high BMI (OR = 1.10; 95 % CI 0.73-1.67). No positive association was observed for WHR. Our results suggest WC is independently associated with high parity in Hispanic women and may be an optimal target for post-partum weight loss interventions.

Abstract P2-18-16: Patients’ impression of the expected appearance of breasts in 2013

Background: Concern exists about the increasing rate of bilateral mastectomy for patients with unilateral breast cancer. Patient concern for second primary, use of breast MRI, and increased genetic cancer risk assessment all may influence choice of operation. In recent years, cosmetic breast augmentation has also become more common. This study was performed to evaluate women's perception of the current expected appearance of breasts.

Methods: From April 2012 to May 2013, all patients seen at a Breast Clinic were shown two pictures (A “natural” and B “augmented”) and asked “What is the expected appearance of breasts in 2012(2013)?” Sociodemographic, clinical, and treatment variables were collected. Univariate analysis was performed to identify variables which were associated with picture choice. All of the variables with a p-value &lt;0.10 were included in the multivariate analysis.

Results: 1,177 consecutive patients were seen with mean age 45 years. 93% of the patients were insured with Medicaid or uninsured and 19% were non-Hispanic White (NHW). The mean monthly income was only $1104. Overall 70% of patients felt that the augmented appearance is “expected in 2013.” Age was strongly associated with augmented appearance as younger patients were significantly more likely to choose picture B: age less than 40 years (85%), age 40-49 years (67%), age 50-59 years (65%), and age 60+ years (51%). Patients of all race/ethnic groups felt that the augmented appearance was expected. NHW 65%, AA 67%, and Hispanic 71%. Multivariate analysis found that more years of education (p = 0.001), younger age and lower BMI were strongly associated (p &lt; 0.0001) with choosing the augmented appearance as “expected in 2013.”

Of the 1177 patients, 337 breast cancer patients were seen. Overall 62% felt that the augmented appearance was expected. Of those who underwent an operation, 178 (58%) patients underwent breast conservation and 62% felt the augmented appearance was expected. Of 128 patients who underwent mastectomy, 36 (28%) underwent reconstruction. 23 patients underwent bilateral mastectomy. Of those who underwent mastectomy alone (41/83 = 49%) only about half felt the augmented appearance was expected. By contrast those who underwent reconstruction (33/36 = 92%; p &lt; 0.001) or bilateral mastectomy (17/23 = 74%; p = 0.057), were significantly more likely than those who underwent mastectomy alone to feel the augmented appearance was expected.

Conclusions: The current study suggests women's perception of the expected appearance of breasts is changing. Younger age was strongly associated with the perception that the “augmented” appearance is expected. This change may affect patients’ choice in surgical operations with more mastectomies and reconstructions in the future. In October 2012 from a common women's periodical, when asked about her choice of operation for a small area of unilateral DCIS, one woman responded, “Just take them off and give me implants. Everybody has implants; it's no big deal.”

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-18-16.

Abstract P1-09-15: Perception of breast cancer risk in an underinsured safety net population

Background: Patient perception of breast cancer risk can affect compliance with screening mammography. In an underinsured population, we have previously found that being insured and adequate health literacy were strong predictors of use of screening mammography. Previous studies in other populations have found that patients with heighted perceived risk also have increased use of screening. Previous studies have found an average perceived risk of 30%. “Risk” and risk assessment are difficult concepts for many people and this may be problematic in undereducated populations. The current study was performed to evaluate women's perception of their lifetime risk of breast cancer in a safety net population.

Methods: From May 2012 to May 2013, all patients seen at a safety net Breast Clinic were asked to estimate their lifetime risk of breast cancer. “If 0 = no chance and 100% = for sure, what are your chances of getting breast cancer in your life?” Sociodemographic, clinical, and treatment variables were collected. Univariate analysis was performed to identify variables which were associated with picture choice. All of the variables with a p-value &lt;0.10 were included in the multivariate analysis.

Results: 1,089 consecutive patients were seen. After exclusion of men and patients known to have breast cancer, 838 patients were included. The mean age was 43 years. 93% of the patients were uninsured or insured with Medicaid. Average education 10 years and 17% were non-Hispanic White (NHW). Overall the average perceived lifetime risk for the population was 29.7%. For all patients age 35 years+, the average Gail model Risk Assessment scores were 1.1% (5 year) and 9% (LT). Only 17% of patients would be considered at increased risk according to Gail model 5 year risk (&gt; 1.6%).

In univariate analysis, continuous variables associated with higher perceived risk were higher BMI (p = 0.003), more years of education (p = 0.0009), and higher 5 year Gail model score (p = 0.0005). Categorical variables associated with higher perceived lifetime risk were being insured (34% vs 27%; p = 0.004) and NonHispanic patients (34% vs 27%; p = 0.003). Adequate health literacy (38% vs 27%; p = 0.0001) and family history of breast cancer in a first degree relative (FDR; 43% vs 27%; p = 0.0001) were the variables with the strongest association with perceived risk. In multivariate analysis after adjustment for the above factors, only family history in FDR remained significant (p = 0.003).

Over a similar time period, being insured (OR 1.52; 95% CI 1.18 – 1.95; p = 0.001) and adequate health literacy (OR 3.75; 95% CI 2.71 – 5.19; p &lt; 0.0001) were the only variables significantly associated with the use of screening mammography.

Conclusions: Underinsured, minority women overestimate their lifetime risk of breast cancer (30%) at a magnitude similar to other populations. Family history has a strong influence on an underinsured populations’ perception of breast cancer risk. Patients who were insured or had adequate health literacy perceived a higher lifetime risk of breast cancer and were significantly more likely to use screening mammography.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-09-15.

Health literacy assessment and patient satisfaction in surgical practice

BACKGROUND

Individuals with limited health literacy have barriers to patient-physician communication. Problems in communication are known to contribute to malpractice litigation. Concern exists, however, about the feasibility and patient acceptance of a health literacy assessment. This study was performed to determine the feasibility of health literacy assessment in surgical practice and its effect on patient satisfaction.

STUDY DESIGN

Every patient seen in a Breast Surgery Clinic during a 2-year period was asked to undergo a health literacy assessment with the Newest Vital Sign (NVS) as part of the routine history and physical examination. During the year before routine NVS assessments and during the 2-year study period, all patients were asked to rate their "overall satisfaction with clinic visit" on a 5-point scale.

RESULTS

A total of 2,026 of 2,097 patients (96.6%) seen during the study were eligible for the health literacy assessment. Of those, no patients refused assessment, and only one patient was missed. Therefore, 2,025 of 2,026 eligible patients (99.9%) underwent the assessment. The average time for NVS assessment was 2:02 minutes. Only 19% of patients had adequate health literacy. Patient satisfaction ratings were slightly greater during the first year of the health literacy assessment (3.8 vs 3.7, P = .049) compared with the year prior to health literacy assessment and greater during the second year of health literacy assessment (4.1 vs 3.7, P < .0001).

CONCLUSION

Routine health literacy assessment is feasible in surgical practice and results in no decrease in patient satisfaction. In fact, satisfaction was greater during the years when health literacy assessments were performed.

Abstract B119: Presence of etiologic heterogeneity by breast tumor subtypes in Hispanic women with unique reproductive risk factor patterns

Background: Published data support the presence of etiologic heterogeneity by breast tumor subtype, but few studies have assessed this in Hispanic populations. Methods: We assessed tumor subtype prevalence and associations between reproductive factors and tumor subtypes in 1041 women of Mexican descent (559 U.S. and 482 Mexico) who participated in the Ella Binational Breast Cancer Study. Multinomial logistic regression comparing human epidermal growth factor receptor 2 positive tumors (HER2+, regardless of ER or PR status) and triple negative breast cancer (TNBC) to hormone receptor positive (HR+) tumors was conducted. Results: A higher proportion of ER- tumors was shown for women in Mexico (40.5%) vs. those in the U.S. (27.2%) and slightly higher proportions of HR+ (61.2% vs. 57.9%) and HER2+ (23.8% vs. 20.3%) tumors were observed in the U.S. compared to Mexico. Prevalence of TNBC was 16.7% overall; the percentage was higher for Mexican vs. U.S. women (19.5% vs. 14.5%). After adjustment for age and country of residence, compared to women with HR+ tumors, those with a later age at first pregnancy were significantly less likely to have TNBC (odds ratio [OR]=0.61; 95% confidence interval [CI]=0.39-0.95), whereas those with ≥ 3 full-term pregnancies were significantly more likely to have TNBC (OR=1.68; 95% CI=1.10-2.55). Patients who reported breastfeeding for &gt;12 months were over twice as likely to have TNBC than HR+ tumors (OR=2.14; 95% CI=1.24–3.68). A lower odds of TNBC was shown for longer menstruation duration, whether prior to first pregnancy (OR=0.78; 95% CI= 0.65–0.93 per 10 years) or prior to menopause (OR=0.79; 95% CI, 0.69–0.91 per 10 years). Associations comparing HER2+ to HR+ tumors were weak or non-existent except for the interval between last full-term pregnancy and breast cancer diagnosis. Conclusions: Findings show etiologic heterogeneity by tumor subtype in a population of Hispanic women with a unique reproductive profile. Given that Hispanic women have higher risk of breast cancer-specific mortality than non-Hispanic whites, our findings add to growing evidence of opposing effects of reproductive factors on breast tumor subtypes, which may partly explain disparities in outcomes.

Citation Format: Maria Elena Martinez, Betsy Wertheim, Loki Natarajan, Richard Schwab, Melissa Bondy, Adrian Daneri-Navarro, Maria Mercedes Meza-Montenegro, Luis Enrique Gutierrez-Millan, Abenaa Brewster, Ian K. Komenaka, Patricia A. Thompson. Presence of etiologic heterogeneity by breast tumor subtypes in Hispanic women with unique reproductive risk factor patterns. [abstract]. In: Proceedings of the AACR Special Conference on Advances in Breast Cancer Research: Genetics, Biology, and Clinical Applications; Oct 3-6, 2013; San Diego, CA. Philadelphia (PA): AACR; Mol Cancer Res 2013;11(10 Suppl):Abstract nr B119.

Reproductive factors, heterogeneity, and breast tumor subtypes in women of mexican descent

BACKGROUND

Published data support the presence of etiologic heterogeneity by breast tumor subtype, but few studies have assessed this in Hispanic populations.

METHODS

We assessed tumor subtype prevalence and associations between reproductive factors and tumor subtypes in 1,041 women of Mexican descent enrolled in a case-only, binational breast cancer study. Multinomial logistic regression comparing HER2(+) tumors and triple-negative breast cancer (TNBC) to luminal A tumors was conducted.

RESULTS

Compared with women with luminal A tumors, those with a later age at first pregnancy were less likely to have TNBC [OR, 0.61; 95% confidence interval (CI), 0.39-0.95], whereas those with three or more full-term pregnancies were more likely to have TNBC (OR, 1.68; 95% CI, 1.10-2.55). A lower odds of TNBC was shown for longer menstruation duration, whether before first pregnancy (OR, 0.78; 95% CI, 0.65-0.93 per 10 years) or menopause (OR, 0.79; 95% CI, 0.69-0.91 per 10 years). Patients who reported breastfeeding for more than 12 months were over twice as likely to have TNBC than luminal A tumors (OR, 2.14; 95% CI, 1.24-3.68). Associations comparing HER2(+) with luminal A tumors were weak or nonexistent except for the interval between last full-term pregnancy and breast cancer diagnosis.

CONCLUSIONS

Findings show etiologic heterogeneity by tumor subtype in a population of Hispanic women with unique reproductive profiles.

IMPACT

Identification of etiologically distinct breast tumor subtypes can further improve our understanding of the disease and help provide personalized prevention and treatment regimens.

Hypothesized role of pregnancy hormones on HER2+ breast tumor development

Breast cancer incidence rates have declined among older but not younger women; the latter are more likely to be diagnosed with breast cancers carrying a poor prognosis. Epidemiological evidence supports an increase in breast cancer incidence following pregnancy with risk elevated as much as 10 years post-partum. We investigated the association between years since last full-term pregnancy at the time of diagnosis (≤10 or >10 years) and breast tumor subtype in a case series of premenopausal Hispanic women (n = 627). Participants were recruited in the United States, Mexico, and Spain. Cases with known estrogen receptor (ER), progesterone receptor (PR), and HER2 status, with one or more full-term pregnancies ≥1 year prior to diagnosis were eligible for this analysis. Cases were classified into three tumor subtypes according to hormone receptor (HR+ = ER+ and/or PR+; HR- = ER- and PR-) expression and HER2 status: HR+/HER2-, HER2+ (regardless of HR), and triple negative breast cancer. Case-only odds ratios (ORs) and 95 % confidence intervals (CIs) were calculated for HER2+ tumors in reference to HR+/HER2- tumors. Participants were pooled in a mixed-effects logistic regression model with years since pregnancy as a fixed effect and study site as a random effect. When compared to HR+/HER2- cases, women with HER2+ tumors were more likely be diagnosed in the post-partum period of ≤10 years (OR = 1.68; 95 % CI, 1.12-2.52). The effect was present across all source populations and independent of the HR status of the HER2+ tumor. Adjusting for age at diagnosis (≤45 or >45 years) did not materially alter our results (OR = 1.78; 95 % CI, 1.08-2.93). These findings support the novel hypothesis that factors associated with the post-partum breast, possibly hormonal, are involved in the development of HER2+ tumors.

Abstract PD08-04: Factors which affect surgical management in an underinsured, county hospital population

Background: Significant variation exists between institutions in the use of lumpectomy, mastectomy, and reconstruction. Much less is known about minorities and populations outside the large academic institutions. The current study was performed to evaluate variables that affect patient choice in surgical management in a county hospital population.

Methods: A retrospective review of all patients seen at the county, safety net institution with breast cancer from January 2010 to May 2012. Sociodemographic, clinical, and treatment variables were evaluated. Univariate analysis was performed to identify variables which were associated with type of operation. All of the variables with a p-value &lt;0.10 were included in the multivariate analysis.

Results: 403 patients were seen with mean age 53 years. 92% of the patients were insured with Medicaid or uninsured and 29% were non-Hispanic White. Only 20% of patients underwent screening mammography and therefore presentation with palpable, Stage 2A/B cancer was most common (46%). 54 patients presented with T4 tumors and 13 (24%) were found to have metastases. Only 2 of 340 (0.6%) patients who presented at Stage 3A or earlier presented with metastatic disease. Patients with operable cancer underwent lumpectomy in 65%, mastectomy in 26%, and 9% mastectomy with reconstruction. With respect to breast conservation vs mastectomy, in adjusted analysis, married patients (OR 2.59, p = 0.003) and patients with larger tumors (p = 0.003) were more likely to undergo mastectomy, while patients who were Hispanic (OR 0.38, p = 0.004), underwent preoperative chemotherapy (OR 0.25, p = 0.002), or had their operation by breast surgical oncologist (OR 0.30, p = 0.005) were more likely to undergo breast conservation. When patients who underwent mastectomy alone were compared to those who underwent reconstruction, unadjusted analysis suggested that reconstruction patients were more likely to speak English, have adequate health literacy (HL), lower clinical stage, and be seen by a breast surgical oncologist. Adjusted analysis demonstrated that having been seen by a breast surgical oncologist (OR 18.4, p = 0.007), younger age (p = 0.05) and adequate HL (OR 3.13, p = 0.06) were associated with likelihood of reconstruction compared to mastectomy alone.

Conclusions: Breast conservation and mastectomy with reconstruction can be achieved in a significant proportion (74%) of underscreened and underinsured patients. Patients who underwent preoperative chemotherapy were more likely to undergo breast conservation. Younger patients and patients with adequate HL were more likely to choose reconstruction after mastectomy. Patients treated by breast surgical oncologists were more likely to have breast conservation or mastectomy with reconstruction. Even in an underscreened population, presentation with metastatic disease is uncommon in patients with operable breast cancer.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PD08-04.

Factors that influence mammography use and breast cancer detection among Mexican-American and African-American women

OBJECTIVE

This study examined factors that influence mammography use and breast cancer detection, including education, health insurance, and acculturation, among Mexican-American (MA) and African-American (AA) women.

METHODS

The study included 670 breast cancer cases (388 MAs and 282 AAs), aged 40-86 years at diagnosis. Data on mammography use, detection, and delay in seeking care were collected via questionnaires and medical records. Using a language-based bidimensional acculturation measure, MAs were classified as English-dominant (n = 67), bilingual (n = 173), and Spanish-dominant (n = 148). Mammography prior to diagnosis was assessed by racial/ethnic acculturation subgroup using logistic regression.

RESULTS

In age-adjusted models, mammography use was non-significantly lower among English-dominant (OR = 0.84; 95% CI: 0.45-1.59) and bilingual (OR = 0.86; 95% CI: 0.55-1.35) MAs and significantly lower among Spanish-dominant MAs (OR = 0.53; 95% CI: 0.34-0.83) than among AA women. After adjustment for education or insurance, there was no difference in mammography use by race/ethnicity and acculturation subgroup. Despite high self-reported mammography use (75%), a large proportion of cases reported self-detection (59%) and delay in seeking care >90 days (17%).

CONCLUSIONS

These findings favor promoting culturally appropriate messaging about the benefits and limitations of mammography, education about breast awareness, and prompt reporting of findings to a health professional.

Intraoperative ultrasound can decrease the re-excision lumpectomy rate in patients with palpable breast cancers

Positive margins occur in 15 to 69 per cent of patients undergoing lumpectomy. The current study was performed to evaluate intraoperative ultrasound in patients undergoing lumpectomy for palpable breast cancer. A retrospective chart review was performed of patients with palpable cancer who underwent lumpectomy with intraoperative ultrasound from 2004 to 2009. Each patient was matched with two patients who underwent lumpectomy alone over the same time period. Matching criteria included tumor size, clinical stage, body mass index, age at diagnosis, and lymphovascular invasion or extensive intraductal component. Twenty-two consecutive patients who underwent lumpectomy with intraoperative ultrasound were matched with 44 patients who underwent lumpectomy without intraoperative ultrasound. In addition to matching criteria, the patients were similar with respect to ethnicity, insurance status, weight, predominant histology, estrogen receptor, progesterone receptor, and Her2 status. Patients who underwent lumpectomy with intraoperative ultrasound were significantly less likely to have an involved margin (41 vs 9%, P = 0.01) and less likely to require a re-excision (34 vs 9%, P = 0.04). The lumpectomy volumes in the intraoperative ultrasound group were smaller than the volumes in the lumpectomy alone group. Intraoperative ultrasound can decrease the rate of positive margins and re-excision lumpectomy in patients with palpable breast cancers.

An alternative technique for immediate breast reconstruction

Immediate reconstruction has demonstrated superior cosmesis compared with delayed reconstruction, however, unexpected final pathology may necessitate post mastectomy radiation. We describe an alternative technique for immediate breast reconstruction. Twelve patients underwent 14 skin-sparing mastectomies from July 2006 to December 2009. The skin-sparing mastectomies and sentinel node biopsies were performed through a periareolar incision. At the completion of the operation the incision was closed in a transverse fashion. No simultaneous reconstruction was performed. No drains were placed. After 3 days seroma developed, which maintained the integrity of the skin envelope and appearance of a breast. Nine patients (75%) had a contraindication to breast conservation. All patients were clinically node negative and 67 per cent were clinical stage 0. The majority (75%) experienced an adverse change from clinical stage to final pathologic stage. Four patients (33%) required postmastectomy radiation. The mean time from oncologic procedure to initial reconstruction procedure was 14 days. Two patients (17%) developed postoperative infections. This technique allows immediate reconstruction and avoids the fear of adverse final pathology indicating radiation to the reconstructed breast. In addition, it provides flexibility in scheduling for the surgeons and allows the patient to maintain the appearance of the breast.

An Alternative Technique for Immediate Breast Reconstruction

Immediate reconstruction has demonstrated superior cosmesis compared with delayed reconstruction, however, unexpected final pathology may necessitate post mastectomy radiation. We describe an alternative technique for immediate breast reconstruction. Twelve patients underwent 14 skin-sparing mastectomies from July 2006 to December 2009. The skin-sparing mastectomies and sentinel node biopsies were performed through a periareolar incision. At the completion of the operation the incision was closed in a transverse fashion. No simultaneous reconstruction was performed. No drains were placed. After 3 days seroma developed, which maintained the integrity of the skin envelope and appearance of a breast. Nine patients (75%) had a contraindication to breast conservation. All patients were clinically node negative and 67 per cent were clinical stage 0. The majority (75%) experienced an adverse change from clinical stage to final pathologic stage. Four patients (33%) required postmastectomy radiation. The mean time from oncologic procedure to initial reconstruction procedure was 14 days. Two patients (17%) developed postoperative infections. This technique allows immediate reconstruction and avoids the fear of adverse final pathology indicating radiation to the reconstructed breast. In addition, it provides flexibility in scheduling for the surgeons and allows the patient to maintain the appearance of the breast.

Intraoperative Ultrasound Can Decrease the Re-excision Lumpectomy Rate in Patients with Palpable Breast Cancers

Positive margins occur in 15 to 69 per cent of patients undergoing lumpectomy. The current study was performed to evaluate intraoperative ultrasound in patients undergoing lumpectomy for palpable breast cancer. A retrospective chart review was performed of patients with palpable cancer who underwent lumpectomy with intraoperative ultrasound from 2004 to 2009. Each patient was matched with two patients who underwent lumpectomy alone over the same time period. Matching criteria included tumor size, clinical stage, body mass index, age at diagnosis, and lymphovascular invasion or extensive intraductal component. Twenty-two consecutive patients who underwent lumpectomy with intraoperative ultrasound were matched with 44 patients who underwent lumpectomy without intraoperative ultrasound. In addition to matching criteria, the patients were similar with respect to ethnicity, insurance status, weight, predominant histology, estrogen receptor, progesterone receptor, and Her2 status. Patients who underwent lumpectomy with intraoperative ultrasound were significantly less likely to have an involved margin (41 vs 9%, P = 0.01) and less likely to require a re-excision (34 vs 9%, P = 0.04). The lumpectomy volumes in the intraoperative ultrasound group were smaller than the volumes in the lumpectomy alone group. Intraoperative ultrasound can decrease the rate of positive margins and re-excision lumpectomy in patients with palpable breast cancers.

Preoperative chemotherapy for operable breast cancer is associated with better compliance with adjuvant therapy in matched stage II and IIIA patients

INTRODUCTION

Preoperative chemotherapy (PC) for operable breast cancer has shown significant benefits in prospective trials. Many patients are treated in the community setting and some may question the applicability of PC outside the university setting.

METHODS

Retrospective review was performed of stage II and IIIA breast cancer patients treated from January 2002 to July 2009. Fifty-three of 57 patients who underwent PC were matched based on age, tumor size, and hormone receptor status with 53 patients who did not undergo PC. Differences in patient compliance with physician recommendations for all types of adjuvant therapy were evaluated. Crude odds ratios and adjusted odds ratios derived from conditional logistic regression models were calculated.

RESULTS

There were 106 patients included. Patient compliance with chemotherapy was better in the PC group than in the adjuvant chemotherapy (AC) group (100% versus 70%; p = .0001). Similarly, more patients in the PC group completed radiation therapy (96% versus 65%; p = .0003) and initiated hormonal therapy (100% versus 62%; p = .0001). Conditional logistic regression revealed that higher pathologic stage and current cigarette smoking were associated with poorer compliance with chemotherapy. For radiation therapy, the univariate model revealed that compliance with chemotherapy and being employed were associated with completion of radiation, whereas current cigarette smoking and larger pathologic size were associated with poorer compliance with radiation. For hormonal therapy, current cigarette smokers were more likely to be noncompliant with initiation of hormonal therapy.

CONCLUSIONS

PC for operable breast cancer can improve patient compliance with chemotherapy. Current cigarette smokers were more likely to be noncompliant with all types of adjuvant therapy.

Preoperative chemotherapy for operable breast cancer improves surgical outcomes in the community hospital setting

BACKGROUND

Preoperative chemotherapy (PC) for operable breast cancer has demonstrated significant benefits in clinical trials. Many patients are treated in the community setting and some may question the applicability of PC outside the university setting. The potential benefits of PC in terms of surgical outcomes in a community practice were examined.

METHODS

A retrospective review was performed of stage II and stage IIIA breast cancer patients from January 1, 2002 to July 31, 2009. Surgical outcomes of margin status, volume of lumpectomy, rate of lumpectomy, and re-excision lumpectomy were evaluated.

RESULTS

There were 212 patients included. Seventy-nine percent of patients who underwent PC had a clinical response and 25% had a pathologic complete response. For clinical stage T2 and stage T3 tumors, the PC group underwent lumpectomy more often than patients in the adjuvant chemotherapy (AC) group (78% versus 50%; p = .016 and 60% versus 29%; p = .015, respectively). The rate of close or positive margins in the PC group was half the rate in the AC group (23% versus 46%; p = .04) and this resulted in fewer re-excisions (p = .01). The volume of tissue removed was also smaller in the PC group (143.6 cm³ versus 273.9 cm³; p = .003). Conclusions. PC for operable breast cancer can significantly improve surgical outcomes in community-based practice.