Differential response to neoadjuvant endocrine therapy for Black/African American and White women in NCDB

PURPOSE

Compared to White women, there are higher mortality rates in Black/African American (BAA) women with hormone receptor-positive breast cancer (HR + BC) which may be partially due to differences in treatment resistance. We assessed factors associated with response to neoadjuvant endocrine therapy (NET).

METHODS

The National Cancer Database (NCDB) was queried for women with clinical stage I-III HR + BC diagnosed 2006-2017 and treated with NET. Univariate and multivariate analyses described associations between the sample, duration of NET, and subsequent treatment response, defined by changes between clinical and pathological staging.

RESULTS

The analytic sample included 9864 White and 1090 BAA women. Compared to White women, BAA women were younger, had more co-morbidities, were higher stage at presentation, and more likely to have > 24 weeks of NET. After excluding those with unknown pT/N/M, 3521 White and 365 BAA women were evaluated for NET response. On multivariate analyses, controlling for age, stage, histology, HR positivity, and duration of NET, BAA women were more likely to downstage to pT0/Tis (OR 3.0, CI 1.2-7.1) and upstage to Stage IV (OR 2.4, CI 1.002-5.6). None of the women downstaged to pT0/Tis presented with clinical stage III disease; only 2 of the women upstaged to Stage IV disease presented with clinical Stage I disease.

CONCLUSION

Independent of NET duration and clinical stage at presentation, BAA women were more likely to experience both complete tumor response and progression to metastatic disease. These results suggest significant heterogeneity in tumor biology and warrant a more nuanced therapeutic approach to HR + BC.

Effect of rurality and travel distance on contralateral prophylactic mastectomy for unilateral breast cancer

PURPOSE

Despite lack of survival benefit, demand for contralateral prophylactic mastectomy (CPM) to treat unilateral breast cancer remains high. High uptake of CPM has been demonstrated in Midwestern rural women. Greater travel distance for surgical treatment is associated with CPM. Our objective was to examine the relationship between rurality and travel distance to surgery with CPM.

METHODS

Women diagnosed with stages I-III unilateral breast cancer between 2007 and 2017 were identified using the National Cancer Database. Logistic regression was used to model likelihood of CPM based on rurality, proximity to metropolitan centers, and travel distance. A multinomial logistic regression model compared factors associated with CPM with reconstruction versus other surgical options.

RESULTS

Both rurality (OR 1.10, 95% CI 1.06-1.15 for non-metro/rural vs. metro) and travel distance (OR 1.37, 95% CI 1.33-1.41 for those who traveled 50 + miles vs. < 30 miles) were independently associated with CPM. For women who traveled 30 + miles, odds of receiving CPM were highest for non-metro/rural women (OR 1.33 for 30-49 miles, OR 1.57 for 50 + miles; reference: metro women traveling < 30 miles). Non-metro/rural women who received reconstruction were more likely to undergo CPM regardless of travel distance (ORs 1.11-1.21). Both metro and metro-adjacent women who received reconstruction were more likely to undergo CPM only if they traveled 30 + miles (ORs 1.24-1.30).

CONCLUSION

The impact of travel distance on likelihood of CPM varies by patient rurality and receipt of reconstruction. Further research is needed to understand how patient residence, travel burden, and geographic access to comprehensive cancer care services, including reconstruction, influence patient decisions regarding surgery.

Patterns of Evidence-Based Care for the Diagnosis, Staging, and First-line Treatment of Breast Cancer by Race-Ethnicity: A SEER-Medicare Study

BACKGROUND

Racial and ethnic disparities in guideline-recommended breast cancer treatment are well documented, however studies including diagnostic and staging procedures necessary to determine treatment indications are lacking. The purpose of this study was to characterize patterns in delivery of evidence-based services for the diagnosis, clinical workup, and first-line treatment of breast cancer by race-ethnicity.

METHODS

SEER-Medicare data were used to identify women diagnosed with invasive breast cancer between 2000 and 2017 at age 66 or older (n = 2,15,605). Evidence-based services included diagnostic procedures (diagnostic mammography and breast biopsy), clinical workup (stage and grade determination, lymph node biopsy, and HR and HER2 status determination), and treatment initiation (surgery, radiation, chemotherapy, hormone therapy, and HER2-targeted therapy). Poisson regression was used to estimate rate ratios (RR) and 95% confidence intervals (CI) for each service.

RESULTS

Black and American Indian/Alaska Native (AIAN) women had significantly lower rates of evidence-based care across the continuum from diagnostics through first-line treatment compared to non-Hispanic White (NHW) women. AIAN women had the lowest rates of HER2-targeted therapy and hormone therapy initiation. While Black women also had lower initiation of HER2-targeted therapy than NHW, differences in hormone therapy were not observed.

CONCLUSIONS

Our findings suggest patterns along the continuum of care from diagnostic procedures to treatment initiation may differ across race-ethnicity groups.

IMPACT

Efforts to improve delivery of guideline-concordant treatment and mitigate racial-ethnic disparities in healthcare and survival should include procedures performed as part of the diagnosis, clinical workup, and staging processes.

A Randomized Single-Blinded Study Comparing Preoperative with Post-Mastectomy PECS Block for Post-operative Pain Management in Bilateral Mastectomy with Immediate Reconstruction

BACKGROUND

Ultrasound-guided pectoralis muscle blocks (PECS I/II) are well established for postoperative pain control after mastectomy with reconstruction. However, optimal timing is unclear. We conducted a randomized controlled single-blinded single-institution trial comparing outcomes of block performed pre-incision versus post-mastectomy.

METHOD

Patients with breast cancer undergoing bilateral mastectomy with immediate expander/implant reconstruction were randomized to receive ultrasound-guided PECS I/II either pre-incision (PreM, n = 17) or post-mastectomy and before reconstruction (PostM, n = 17). The primary outcome was the average pain score using the Numerical Rating Score during post-anesthesia care unit (PACU) and inpatient stay, with the study powered to detect a difference in mean pain score of 2. Secondary outcomes included mean pain scores on postoperative day (POD) 2, 3, 7, 14, 90, and 180; pain catastrophizing scores; narcotic requirements; PACU/inpatient length of stay; block procedure time; and complications.

RESULT

No significant differences between the two groups were noted in average pain score during PACU (p = 0.57) and 24-h inpatient stay (p = 0.33), in the 2 weeks after surgery at rest (p = 0.90) or during movement (p = 0.30), or at POD 90 and 180 at rest (p = 0.42) or during movement (p = 0.31). Median duration of block procedure (PreM 7 min versus PostM 6 min, p = 0.21) did not differ. Median PACU and inpatient length of stay were the same in each group. Inpatient narcotic requirements were similar, as were length of stay and post-surgical complication rates.

CONCLUSION

Intraoperative ultrasound-guided PECS I/II block administered by surgeons following mastectomy had similar outcomes to preoperative blocks.

TRIAL REGISTRATION

This trial is registered with Clinical Research Information Service (NCT03653988).

Improving cancer care locally: Study of a hospital affiliate network model

PURPOSE

The University of Kentucky Markey Cancer Center Affiliate Network (MCCAN) increased access to high-quality cancer care for patients treated in community hospitals across the state by leveraging the American College of Surgeons Commission on Cancer (CoC) standards to improve quality among its member sites. This study describes the network activities and services identified as most helpful or effective to its members, as well as the perceived value of joining MCCAN or pursing accreditation.

METHODS

An independent research team conducted in-depth, semistructured interviews with 18 administrators and clinicians from 10 MCCAN hospitals in 2019. Interviews were transcribed and a thematic analysis was conducted.

FINDINGS

Network affiliation and CoC accreditation were perceived as helpful to improving quality of care. Having both clinician and administrative champions were key facilitators to achieving CoC standards and made mentoring of member sites a critical activity of the Network. Other components identified as valuable and/or key to the Network's success included providing access to specific CoC-required clinical services (eg, genetic counseling); offering regular performance monitoring and individualized feedback; establishing a culture of quality improvement; and fostering trust within the Network with patient referrals (ie, sending patients back to their local hospital for ongoing care).

CONCLUSIONS

Quality improvement in community cancer programs is challenging but several strategies were identified by members as valuable and effective. Efforts to disseminate the MCCAN model should focus on identifying the needs of community hospitals, implementing a quality monitoring system, and fostering site-level champions who can be influential drivers of change.

Analysis of the Understanding and Worry about Lymphedema of Patients with Breast Cancer

BACKGROUND

Lymphedema is a potential lifelong sequela of breast cancer treatment. We sought to: (1) evaluate the worry and knowledge of patients about lymphedema, (2) quantify patients reporting lymphedema education and screening, and (3) determine willingness to participate in lymphedema screening and prevention programs.

PATIENTS AND METHODS

A survey evaluating lymphedema-related knowledge and worry was sent to patients treated for stage 0-III breast cancer. Exclusion criteria included > 10 years since diagnosis, missing clinical staging, and those without axillary surgery. Responses were linked with clinicopathologic information.

RESULTS

Of 141 patients meeting inclusion criteria, 89% of those without lymphedema were not at all or slightly worried about lymphedema. Higher levels of worry were associated with clinical stage II-III disease [odds ratio (OR) 2.63, p = 0.03], a history of axillary lymph node dissection (ALND) (OR 4.58, p < 0.01), and employment (OR 2.21, p = 0.05). A total of 102 (72%) patients recalled receiving lymphedema education. Lymphedema knowledge was limited, with < 25% of respondents answering > 50% of the risk factor questions correctly. Worry and knowledge were not significantly associated. Of patients without lymphedema, 36% were interested in learning more about lymphedema and 64% were willing to participate in or learn more about a screening program. Most (66%) felt that lymphedema information should be provided before and after cancer treatment.

DISCUSSION

A majority of our breast cancer survivors had limited knowledge about lymphedema risk factors. While most patients were not worried about developing lymphedema, higher worry was seen in patients with a higher clinical stage at diagnosis, ALND, and employment. Our findings suggest potential targets and timing for patient-centered educational interventions.

Identifying Core Functions of an Evidence-Based Intervention to Improve Cancer Care Quality in Rural Hospitals

Background:

Rural patients experience worse cancer survival outcomes than urban patients despite similar incidence rates, due in part to significant barriers to accessing quality cancer care. Community hospitals in non-metropolitan/rural areas play a crucial role in providing care to patients who desire and are able to receive care locally. However, rural community hospitals typically face challenges to providing comprehensive care due to lack of resources. The University of Kentucky’s Markey Cancer Center Affiliate Network (MCCAN) is an effective complex, multi-level intervention, improving cancer care in rural/under-resourced hospitals by supporting them in achieving American College of Surgeons Commission on Cancer (CoC) standards. With the long-term goal of adapting MCCAN for other rural contexts, we aimed to identify MCCAN’s core functions (i.e., the components key to the intervention’s effectiveness/implementation) using theory-driven qualitative data research methods.

Methods:

We conducted eight semi-structured virtual interviews with administrators, coordinators, clinicians, and certified tumor registrars from five MCCAN affiliate hospitals that were not CoC-accredited prior to joining MCCAN. Study team members coded interview transcripts and identified themes related to how MCCAN engaged affiliate sites in improving care quality (intervention functions) and implementing CoC standards (implementation functions) and analyzed themes to identify core functions. We then mapped core functions onto existing theories of change and presented the functions to MCCAN leadership to confirm validity and completeness of the functions.

Results:

Intervention core functions included: providing expertise and templates for achieving accreditation, establishing a culture of quality-improvement among affiliates, and fostering a shared goal of quality care. Implementation core functions included: fostering a sense of community and partnership, building trust between affiliates and Markey, providing information and resources to increase feasibility and acceptability of meeting CoC standards, and mentoring and empowering administrators and clinicians to champion implementation.

Conclusion:

The MCCAN intervention presents a more equitable strategy of extending the resources and expertise of large cancer centers to assist smaller community hospitals in achieving evidence-based standards for cancer care. Using rigorous qualitative methods, we distilled this intervention into its core functions, positioning us (and others) to adapt the MCCAN intervention to address cancer disparities in other rural contexts.

Rural-urban differences in secular trends of locoregional treatment for ductal carcinoma in situ: A patterns of care analysis

Precis

Omission of PORT following BCS remains high among rural patients despite evidence that PORT leads to a significant reduction in the risk of local recurrence. Further research is needed to examine the impact of rural residence on treatment choices and develop methods to ensure equitable care among all breast cancer patients.

Background

Despite national guidelines, debate exists among clinicians regarding the optimal approach to treatment for patients diagnosed with ductal carcinoma in situ (DCIS). While regional variation in practice patterns has been well documented, population‐based information on rural–urban treatment differences is lacking.

Methods

Data from the SEER Patterns of Care studies were used to identify women diagnosed with histologically confirmed DCIS who underwent cancer‐directed surgery in the years 1991, 1995, 2000, 2005, 2010, and 2015. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were estimated using weighted multivariable logistic regression to evaluate cancer‐directed surgery and use of post‐operative radiation therapy (PORT).

Results

Of the 3337 patients who met inclusion criteria, 27% underwent mastectomy, 26% underwent breast‐conserving surgery (BCS) without PORT, and 47% underwent BCS with PORT. After adjustment for other covariates, there was no difference in the likelihood of receiving mastectomy between rural and urban patients (aOR = 0.65; 95% CI 0.37–1.14). However, rural residents were more likely than urban residents to have mastectomy during 1991/1995 (aOR = 1.78; 95% CI 1.09–2.91; p_interaction = 0.022). Across all diagnosis years, patients residing in rural areas were less likely to receive PORT following BCS compared to urban patients (aOR = 0.35; 95% CI 0.18–0.67).

Conclusions

Omission of PORT following BCS remains high among rural patients despite evidence that PORT leads to a significant reduction in the risk of local recurrence. Further research is needed to examine the impact of rural residence on treatment choices and develop methods to ensure equitable care among all breast cancer patients.

A Pilot Study of Preoperative Vandetanib on Markers of Proliferation and Apoptosis in Breast Cancer

INTRODUCTION

Preclinical data supports antitumor activity of tyrosine kinase inhibitor vandetanib with Ret as the therapeutic target in breast cancer. We investigated the effect of preoperative vandetanib on markers of proliferation and apoptosis in breast cancer.

METHODS

Patients with invasive breast cancer were randomly assigned vandetanib 300 mg or placebo PO daily for 2 weeks before operative resection from January 2014 to June 2017. Pretreatment and posttreatment specimens were analyzed by immunohistochemistry for Ki-67, TUNEL, and p-ERK with stratification by Ret expression by immunohistochemistry.

RESULTS

Ten patients were enrolled. There was no statistically significant difference in ERK activation compared with placebo (P=0.45); however, ERK activation was reduced 74% compared with pretreatment biopsy with vandetinib treatment (P=0.005) without a significant reduction in the placebo group (-29%, P=0.55). Mean change in Ki-67 after vandetanib treatment was +0.3% compared with +2.0% in placebo treated patients, P=0.72. Mean change in TUNEL was +0.48 apoptotic nuclei per HPF in the vandetanib arm compared with +1.02 in the placebo arm, P=0.32. In vandetanib treated patients, Ki-67 was reduced 0.3% in RET-positive tumors compared with increased 1.0% in RET-negative tumors, P=0.43 and TUNEL was increased 0.77 in RET-positive tumors and 0.2 in RET-negative tumors, P=0.21.

CONCLUSIONS

In this pilot study, no statistically significant differences on prespecified markers were seen with vandetanib compared with placebo. In accordance with the investigational hypothesis, there was a nonsignificant trend with vandetanib treatment of reduction in p-ERK and increased effects in Ret expressing tumors.

Surgical Decision-Making Surrounding Contralateral Prophylactic Mastectomy: Comparison of Treatment Goals, Preferences, and Psychosocial Outcomes from a Multicenter Survey of Breast Cancer Patients

BACKGROUND

Differences in patient characteristics and decision-making preferences have been described between those who elect breast-conserving surgery (BCS), unilateral mastectomy (UM), or contralateral prophylactic mastectomy (CPM) for breast cancer. However, it is not known whether preferred and actual decision-making roles differ across these surgery types, or whether surgery choice reflects a woman's goals or achieves desired outcomes.

METHODS

Women diagnosed with stage 0-III unilateral breast cancer across eight large medical centers responded to a mailed questionnaire regarding treatment decision-making goals, roles, and outcomes. These data were linked to electronic medical records. Differences were assessed using descriptive analyses and logistic regression.

RESULTS

There were 750 study participants: 60.1% BCS, 17.9% UM, and 22.0% CPM. On multivariate analysis, reducing worry about recurrence was a more important goal for surgery in the CPM group than the others. Although women's preferred role in the treatment decision did not differ by surgery, the CPM group was more likely to report taking a more-active-than-preferred role than the BCS group. On multivariate analysis that included receipt of additional surgery, posttreatment worry about both ipsilateral and contralateral recurrence was higher in the BCS group than the CPM group (both p < 0.001). The UM group was more worried than the CPM group about contralateral recurrence only (p < 0.001).

CONCLUSIONS

Women with CPM were more likely to report being able to reduce worry about recurrence as a very important goal for surgery. They were also the least worried about ipsilateral breast recurrence and contralateral breast cancer almost two years postdiagnosis.

Impact of age, rurality and distance in predicting contralateral prophylactic mastectomy for breast cancer in a Midwestern state: a population-based study

PURPOSE

Iowa is among several rural Midwestern states with the highest proportions of contralateral prophylactic mastectomy (CPM) in women < 45 years of age. We evaluated the role of rurality and travel distance in these surgical patterns.

METHODS

Women with unilateral breast cancer (2007-2017) were identified using Iowa Cancer Registry records. Patients and treating hospitals were classified as metro, nonmetro, and rural based on Rural-Urban Continuum Codes. Differences in patient, tumor, and treatment characteristics and median travel distance (MTD) were compared. Characteristics associated with CPM were evaluated with multivariate logistic regression.

RESULTS

22,158 women were identified: 57% metro, 26% nonmetro and 18% rural. Young rural women had the highest proportion of CPM (52%, 39% and 40% for rural, metro, nonmetro women < 40 years). Half of all rural women had surgery at metro hospitals; these women had the longest MTD (62 miles). Among all women treated at metro hospitals, rural women had the highest proportion of CPM (17% rural vs 14% metro/nonmetro, p = 0.007). On multivariate analysis, traveling ≥ 50 miles (ORs 1.43-2.34) and rural residence (OR = 1.29) were independently predictive of CPM. Other risk factors were young age (< 40 years: OR = 7.28, 95% CI 5.97-8.88) and surgery at a metro hospital that offers reconstruction (OR = 2.30, 95% CI 1.65-3.21) and is not NCI-designated (OR = 2.34, 95% CI 1.92-2.86).

CONCLUSION

There is an unexpectedly high proportion of CPM in young rural women in Iowa, and travel distance and availability of reconstructive services likely influence decision-making. Improving access to multidisciplinary care in rural states may help optimize decision-making.

Rate of BRCA mutation in patients tested under NCCN genetic testing criteria

BACKGROUND

BRCA genetic testing is recommended by the National Comprehensive Cancer Network (NCCN) in breast cancer patients who meet specific criteria. Limited data are available on the likelihood of detecting a mutation when these guidelines are followed.

METHODS

A retrospective chart review examined patients with breast cancer who underwent BRCA testing based on NCCN guidelines.

RESULTS

Twelve (6.0%) of the 199 patients had a deleterious BRCA mutation. Family history of BRCA mutations (50%, p = 0.019), age ≤45 at diagnosis (9.7%, p = 0.034) and meeting ≥3 NCCN criteria (13.3%, p = 0.03) yielded the highest rates of BRCA mutation. Having a family history of BRCA mutation and age ≤45 were associated with increased rate of BRCA mutation on multivariate analysis (OR 14.3, CI 1.2-166.3; OR 11.6, CI 1.2-108.6).

CONCLUSION

Select NCCN criteria are associated with higher rates of BRCA mutations. Waiting for genetic testing results to guide surgical management may be warranted in this subset of patients.

Upper extremity disability and quality of life after breast cancer treatment in the Greater Plains Collaborative clinical research network

PURPOSE

Chronic upper extremity disability (UED) is common after breast cancer treatment but under-identified and under-treated. Although UED has been linked to quality of life (QoL), the role of UED as mediator between contemporary treatment practices and QoL has not been quantified. This investigation describes UED in a contemporary sample of breast cancer patients and examines its relationship with personal and treatment factors and QoL.

METHODS

Eight hundred and thirty-three women diagnosed at eight medical institutions during 2013-2014 with microscopically confirmed ductal carcinoma in situ or invasive stage I-III breast cancer were surveyed an average of 22 months after diagnosis. UED was measured with a modified QuickDASH and QoL with the FACT-B. The questionnaire also collected treatments, sociodemographic information, comorbidity, body mass index, and a 3-item health literacy screener.

RESULTS

Women who received post-mastectomy radiation and chemotherapy experienced significantly worse UED and QoL. Women who had lower income, lower health literacy and prior diabetes, arthritis or shoulder diagnoses had worse UED. Patients with worse UED reported significantly worse QoL. Income and health literacy were independently associated with QoL after adjustment for UED but treatment and prior conditions were not, indicating mediation by UED. UED mediated 52-79% of the effect of mastectomy-based treatments on QoL as compared with unilateral mastectomy without radiation. UED and QoL did not differ by type of axillary surgery or post-mastectomy reconstruction.

CONCLUSIONS

A large portion of treatment effect on QoL is mediated by UED. Rehabilitation practices that prevent and alleviate UED are likely to improve QoL for breast cancer survivors.

Intraoperative Radiotherapy for Breast Cancer Treatment in a Rural Community

BACKGROUND

Access to health care poses particular challenges for patients living in rural communities. Intraoperative radiotherapy (IORT) offers a treatment alternative to traditional whole-breast radiation therapy (WBRT) for select patients. This study aimed to analyze the use of IORT for patients undergoing breast-conserving surgery at an academic institution located in a rural state.

METHODS

A retrospective review analyzed all patients at a single institution with a diagnosis of ductal carcinoma in situ (DCIS) or invasive breast cancer from April 2012 to January 2017 who were undergoing breast-conserving surgery with either IORT or WBRT. Student's t test or Fisher's exact test was used to make statistical comparisons.

RESULTS

Patients undergoing IORT (n = 117) were significantly older than patients treated with WBRT (n = 191) (65.6 vs 58.6 years; p < 0.001) and had smaller tumors on both preoperative imaging (1.04 vs 1.66 cm; p < 0.05) and final pathology (0.99 vs 1.48 cm; p < 0.05). Patients receiving IORT lived farther from the treating facility than patients treated with WBRT (67.2 vs 30.8 miles; p < 0.05). To account for biases created in the IORT selection criteria, subgroup analysis was performed for women receiving WBRT who fulfilled IORT selection criteria, and distance traveled remained significant (67.2 vs 31.4 miles; p < 0.05). Neither recurrence nor survival differed between the IORT and WBRT groups. Medicare reimbursement for IORT was approximately 50% more than for WBRT.

CONCLUSIONS

For women from rural communities, IORT appears to be an attractive option because these women tend to be older and to live farther from the treatment facility.

Nipple-Sparing Mastectomy is Not Associated with a Delay of Adjuvant Treatment

BACKGROUND

High-volume single-institution studies support the oncologic safety of nipple sparing mastectomy (NSM). Concerns remain regarding the increased potential for complications, recurrence, and delays to subsequent adjuvant therapy. A national database was used to examine treatment and outcomes for NSM patients.

METHODS

Women undergoing unilateral NSM or skin sparing mastectomy (SSM) for stage 0-4 breast cancer from 2004 to 2013 were identified from the National Cancer Database. Demographic and oncologic characteristics, short-term outcomes and time to local and systemic treatment were compared.

RESULTS

NSM was performed on 8173 patients: 8.7% were node positive, and for stage 1-4 disease, 10.6% were triple negative (TN) and 15.3% were HER2-positive. NSM patients were less likely than SSM patients to receive chemotherapy [CT] (37.4 vs. 43.4%) or radiation [PMRT] (15.6 vs. 16.9%), and were also more likely to present with clinically early-stage disease. NSM patients with high-risk features were more likely to receive CT in the neoadjuvant [NCT] than adjuvant setting [AC] (OR 3.76, 1.81, and 1.99 for clinical N2/3, TN, and HER2-positive disease, all p < 0.001). On multivariate analysis, NSM patients had a higher rate of pathologic complete response [pCR] (OR 1.41, p < 0.001). Readmission rate, positive margin rate and time to CT, PMRT or hormonal therapy were not increased for NSM compared to SSM patients.

CONCLUSIONS

Over one third of NSM patients received chemotherapy and/or radiation. NSM patients with high-risk features were more likely to receive NAC and obtain a pCR. NSM patients did not experience worse outcomes or delayed adjuvant therapy compared to SSM.

Abstract P1-11-04: Long-term patient satisfaction with cosmetic outcome and psychosocial wellbeing after breast conserving therapy is affected only by lumpectomy volume

Introduction: Breast conserving therapy (BCT) is considered the treatment of choice for early stage breast cancer by National Cancer Institute guidelines. Little data exists on patient-reported satisfaction and quality of life outcomes after lumpectomy with radiation. This study aims to identify factors influencing satisfaction with cosmetic outcome and quality of life in patients receiving BCT using a validated instrument.

Methods: All patients treated with lumpectomy and radiation for breast cancer at our institution from 1997-2012 received a mailed questionnaire containing the BREAST-Q breast conservation module (graciously provided by Dr A. Pusic, Memorial Sloan Kettering Cancer Center), a validated quality of life survey instrument. A retrospective chart review was performed for survey responders for demographic, treatment, and staging information. Scores were calculated for satisfaction with appearance of the breast, adverse effects of radiation, sexual wellbeing, psychosocial wellbeing and physical wellbeing: upper body and arm. Pearson correlation coefficients were obtained. Wilcoxon rank-sum and one-way ANOVA were used to identify associations between patient variables and satisfaction scores. Multivariate regression was used to assess confounding variables.

Results: A total of 110 questionnaires (response rate of 29.5%) fit criteria for analysis. The mean age of respondents was 65.9±11.2 yrs, and mean time since diagnosis was 91.8±53.1 mos. We observed the strongest correlations between satisfaction with breast appearance and sexual wellbeing (r=0.66, p&lt;0.01), breast appearance and psychosocial wellbeing (r=0.62, p&lt;0.01), and fewer effects of radiation and physical wellbeing (r=0.65, p&lt;0.01). Lumpectomy volume was associated with decreased satisfaction with breast appearance (r=-0.32, p &lt;0.01) and psychosocial wellbeing (r=-0.19, p&lt;0.05). There was no correlation between satisfaction with breast appearance and patient age, time since surgery, history of re-excision, stage or localization technique. Patients with older age at diagnosis reported significantly fewer effects of radiation and better psychosocial, physical, and sexual wellbeing (all p&lt;0.05) (Table 1). The incidence of recurrence was 2.7% and did not impact satisfaction scores.

Distribution of Satisfaction/Quality of Life Outcomes by Age at Diagnosis  Satisfaction/Quality of Life*AgeNBreastAdverse Effects of RadiationPsychosocialSexualPhysical&lt;451458±2282±1973±1945±2074±1645-553264±2683±1980±2054±2579±1756-602667±1794±983±2370±1885±1361-651267±2989±2383±2053±2983±17&gt;652670±2391±1288±1663±2588±25All11065±2388±1682±2058±2482±19P 0.1590.0190.0140.0300.002*Rasch scores range from 0-100 where 100 indicates highest satisfaction

Conclusions: In women undergoing BCT, patient satisfaction with appearance of the breast and psychosocial wellbeing at 7.6 years of follow-up correlated with the volume of tissue removed but no other patient or tumor characteristics. Increasing age at diagnosis was associated with greater satisfaction in multiple domains. These results emphasize the importance of precise surgical technique and patient selection in order to achieve long-term patient satisfaction with BCT.

Citation Format: Welsh JL, Fu S, Liao J, Sugg SL, Scott-Conner CE, Weigel RJ, Erdahl LM, Lizarraga IM. Long-term patient satisfaction with cosmetic outcome and psychosocial wellbeing after breast conserving therapy is affected only by lumpectomy volume. [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 P1-11-04.

Review of risk factors for the development of contralateral breast cancer

BACKGROUND

Women treated for breast cancer have an increased risk for developing metachronous contralateral breast cancer (CBC). Patient perception of this risk is often overestimated and has been found to contribute to the decision to undergo contralateral prophylactic mastectomy. An individual's risk is dependent on both patient and tumor characteristics. This review examines and summarizes the current literature on the factors that affect CBC risk.

DATA SOURCES

English-language publications with the keyword "contralateral breast cancer" were identified through a MEDLINE literature search.

CONCLUSIONS

The global incidence of CBC is decreasing, a trend that is attributed to more effective adjuvant therapies. Patients with BRCA germ-line mutations demonstrate the highest risk for CBC. In the absence of known genetic mutations, patients with strong family histories who are diagnosed at young ages (<35 years) with estrogen receptor-negative index tumors appear to have a higher incidence of CBC.