Current Challenges and Perspectives in Breast Cancer in Elderly Women: The Senologic International Society (SIS) Survey

Objective

Mammographic screening and management of breast cancer (BC) in elderly women are controversial and continue to be an important health problem. To investigate, through members of the Senologic International Society (SIS), the current global practices in BC in elderly women, highlighting topics of debate and suggesting perspectives.

Materials and Methods

The questionnaire was sent to the SIS network and included 55 questions on definitions of an elderly woman, BC epidemiology, screening, clinical and pathological characteristics, therapeutic management in elderly women, onco-geriatric assessment and perspectives.

Results

Twenty-eight respondents from 21 countries and six continents, representing a population of 2.86 billion, completed and submitted the survey. Most respondents considered women 70 years and older to be elderly. In most countries, BC was often diagnosed at an advanced stage compared to younger women, and age-related mortality was high. For this reason, participants recommended that personalized screening be continued in elderly women with a long life expectancy.In addition, this survey highlighted that geriatric frailty assessment tools and comprehensive geriatric evaluations needed to be used more and should be developed to avoid undertreatment. Similarly, multidisciplinary meetings dedicated to elderly women with BC should be encouraged to avoid under- and over-treatment and to increase their participation in clinical trials.

Conclusion

Due to increased life expectancy, BC in elderly women will become a more important field in public health. Therefore, screening, personalized treatment, and comprehensive geriatric assessment should be the cornerstones of future practice to avoid the current excess of age-related mortality. This survey described, through members of the SIS, a global picture of current international practices in BC in elderly women.

Breast Cancer Management During the COVID-19 Pandemic: The Senologic International Society Survey

Objective

In early 2020, the spread of coronavirus disease-2019 (COVID-19) led the World Health Organization to declare this disease a pandemic. Initial epidemiological data showed that patients with cancer were at high risk of developing severe forms of COVID-19. National scientific societies published recommendations modifying the patients' breast cancer (BC) management to preserve, in theory, quality oncologic care, avoiding the increased risk of contamination. The Senology International Society (SIS) decided to take an inventory of the actions taken worldwide. This study investigates COVID-19-related changes concerning BC management and analyzes the will to maintain them after the pandemic, evaluating their oncological safety consequences.

Materials and Methods

SIS network members participated in an online survey using a questionnaire (Microsoft^® Forms) from June 15^th to July 31^st, 2020.

Results

Forty-five responses from 24 countries showed that screening programs had been suspended (68%); magnetic resonance imagines were postponed (73%); telemedicine was preferred when possible (71%). Surgeries were postponed: reconstructive (77%), for benign diseases (84%), and in patients with significant comorbidities (66%). Chemotherapy and radiotherapy protocols had been adapted in 28% of patients in both. Exception for telemedicine (34%), these changes in practice should not be continued.

Conclusion

The SIS survey showed significant changes in BC's diagnosis and treatment during the first wave of the COVID-19 pandemic, but most of these changes should not be maintained. Indeed, women have fewer severe forms of COVID-19 and are less likely to die than men. The risk of dying from COVID-19 is more related to the presence of comorbidities and age than to BC. Stopping screening and delaying treatment leads to more advanced stages of BC. Only women aged over 65 with BC under treatment and comorbidities require adaptation of their cancer management.

Development and use of health outcome descriptors: a guideline development case study

BACKGROUND

During healthcare guideline development, panel members often have implicit, different definitions of health outcomes that can lead to misunderstandings about how important these outcomes are and how to balance benefits and harms. McMaster GRADE Centre researchers developed 'health outcome descriptors' for standardizing descriptions of health outcomes and overcoming these problems to support the European Commission Initiative on Breast Cancer (ECIBC) Guideline Development Group (GDG). We aimed to determine which aspects of the development, content, and use of health outcome descriptors were valuable to guideline developers.

METHODS

We developed 24 health outcome descriptors related to breast cancer screening and diagnosis for the European Commission Breast Guideline Development Group (GDG). Eighteen GDG members provided feedback in written format or in interviews. We then evaluated the process and conducted two health utility rating surveys.

RESULTS

Feedback from GDG members revealed that health outcome descriptors are probably useful for developing recommendations and improving transparency of guideline methods. Time commitment, methodology training, and need for multidisciplinary expertise throughout development were considered important determinants of the process. Comparison of the two health utility surveys showed a decrease in standard deviation in the second survey across 21 (88%) of the outcomes.

CONCLUSIONS

Health outcome descriptors are feasible and should be developed prior to the outcome prioritization step in the guideline development process. Guideline developers should involve a subgroup of multidisciplinary experts in all stages of development and ensure all guideline panel members are trained in guideline methodology that includes understanding the importance of defining and understanding the outcomes of interest.

Breast Cancer Screening and Diagnosis: A Synopsis of the European Breast Guidelines

DESCRIPTION

The European Commission Initiative for Breast Cancer Screening and Diagnosis guidelines (European Breast Guidelines) are coordinated by the European Commission's Joint Research Centre. The target audience for the guidelines includes women, health professionals, and policymakers.

METHODS

An international guideline panel of 28 multidisciplinary members, including patients, developed questions and corresponding recommendations that were informed by systematic reviews of the evidence conducted between March 2016 and December 2018. GRADE (Grading of Recommendations Assessment, Development and Evaluation) Evidence to Decision frameworks were used to structure the process and minimize the influence of competing interests by enhancing transparency. Questions and recommendations, expressed as strong or conditional, focused on outcomes that matter to women and provided a rating of the certainty of evidence.

RECOMMENDATIONS

This synopsis of the European Breast Guidelines provides recommendations regarding organized screening programs for women aged 40 to 75 years who are at average risk. The recommendations address digital mammography screening and the addition of hand-held ultrasonography, automated breast ultrasonography, or magnetic resonance imaging compared with mammography alone. The recommendations also discuss the frequency of screening and inform decision making for women at average risk who are recalled for suspicious lesions or who have high breast density.

Methods for Development of the European Commission Initiative on Breast Cancer Guidelines: Recommendations in the Era of Guideline Transparency

Neither breast cancer prevention and early-detection programs, nor their outcomes, are uniform across Europe. This article describes the rationale, methods, and process for development of the European Commission (EC) Initiative on Breast Cancer Screening and Diagnosis Guidelines. To be consistent with standards set by the Institute of Medicine and others, the EC followed 6 general principles. First, the EC selected, via an open call, a panel with broad representation of areas of expertise. Second, it ensured that all recommendations were supported by systematic reviews. Third, the EC separately considered important subgroups of women, included patient advocates in the guidelines development group, and focused on good communication to inform women's decisions. Fourth, EC rules on conflicts of interest were followed and the GRADE (Grading of Recommendations Assessment, Development and Evaluation) Evidence to Decision frameworks were used to structure the process and minimize the influence of competing interests. Fifth, it focused its recommendations on outcomes that matter to women, and certainty of the evidence is rated for each. Sixth, the EC elicited stakeholder feedback to ensure that the recommendations remain up to date and relevant to practice. This article describes the approach and highlights ways of disseminating and adapting the recommendations both within and outside Europe, using innovative information technology tools.

Secondary involvement of breast with non-Hodgkin's lymphoma in a patient with HIV infection -- case report

Secondary lymphoma of the breast is a rare entity in patients with non-Hodgkin's lymphoma (NHL). HIV infection is associated with an increased risk for developing NHL, however lymphomatous involvement of the breast in AIDS patients has rarely been reported. We present the case of a 33-year-old HIV-infected female patient with diffuse NHL who presented with a unilateral breast mass. Histologic examination of the biopsy specimen revealed a highly-malignant diffuse large B-cell lymphoma.

Aesthetic reconstruction of the tuberous breast deformity

The tuberous breast deformity is a rare entity affecting young women bilaterally or unilaterally. The deformity is characterized by a constricting ring at the base of the breast, which leads to deficient horizontal and vertical development of the breast with or without herniation of the breast parenchyma toward the nipple-areola complex and areola enlargement. Several methods have been put forward to correct the deformity, but most of these fail to address the issue of the constricting ring and subsequently yield results that are not aesthetically satisfactory. A new approach to the treatment of the deformity is presented, which consists of a periareolar approach and rearrangement of the inferior part of the breast parenchyma by division of the constricting ring, thus creating two breast pillars. These pillars are allowed to redrape, and in cases of volume deficiency, a silicone breast implant is placed in a subglandular pocket. The procedure is completed by a donut-type excision to address the size of the nipple-areola complex. The technique has used on 11 patients (21 breasts) with excellent aesthetic results.

Liquid-based cytology in breast fine needle aspiration. Comparison with the conventional smear

OBJECTIVE

To compare the various cytologic features on AutoCyte Prep (ACP) (AutoCyte, Inc., Burlington, North Carolina, U.S.A.) and conventional preparation (CP) specimens from breast fine needle aspiration cytology material with a semi-quantitative scoring system.

STUDY DESIGN

A total of 100 randomized cases were studied. In each case, 2 passes were performed. One pass was used for CPs (Giemsa and Papanicolaou stain). The other pass produced material for the ACP technique and Papanicolaou stain. Both the conventional and liquid-based preparations were studied independently by two observers and compared for cellularity, obscuring and/or informing background, representative diagnostic material, preservation of cytomorphologic features, presence of monolayer cells and architectural arrangement.

RESULTS

Comparing the two preparations, the results were as follows: (1) ACP was superior to CP in 2 features, lack of obscuring background and presence of monolayer arrangement with preservation of cell architecture; (2) ACP was inferior to CP in 1 feature, lack of informing background; and (3) ACP was equal, with small deviations, to CP in the rest of the features evaluated: cellularity, representative diagnostic material, preservation of cell morphology and architectural arrangement.

CONCLUSION

The new technology of liquid-based cytology in breast FNA showed a good correlation with CP plus the advantages of: (1) easier and less time consuming evaluation of cell morphology (clear background, no overlapping, smaller area to screen); (2) reproducibility, a factor of great importance to quality control; and (3) possibility of adjunctive investigations (immunocytology, flow cytometry) on the same material.

Germ line BRCA1 & BRCA2 mutations in Greek breast/ovarian cancer families: 5382insC is the most frequent mutation observed

BRCA1 and BRCA2 genes were screened for loss-of-function mutations in a series of 85 patients having at least one first- or second-degree relative affected by breast and/or ovarian cancer. All BRCA1 exons and BRCA2 exons 10 and 11 were screened with a combination of methods including SSCP, PTT and direct sequencing. We have found disease-associated mutations in 14 families (16.5%), eleven in BRCA1 and three in BRCA2. The known founder mutation 5382insC of BRCA1 was identified in seven unrelated families. The other mutations identified include the non-sense R1751X, the splice junction variant 5586G>A of BRCA1 and three frameshifts, 2024del5, 3034del4, and 6631del5, of BRCA2. Nine out of these 14 families had a family history of three or more breast/ovarian cancer cases. A large number of polymorphic or unclassified variants is also reported. Combined with our previously published data 5382insC was found in nine out of 20 families (45%), suggesting that this mutation may represent a common founder mutation in the Greek population.

Interactive training for the management of breast cancer in general practice in Europe

BACKGROUND

General practitioners need to play a more active role in the management of patients with breast cancer, specifically in screening programs, counseling, follow-up, palliative care, and psychosocial support. Special training is needed to meet these demands.

METHODS

An interactive training program resident on CD-ROM was developed. It includes nine cases designed according to the case method and three cases created for group discussions. The program also contains a self-test and an encyclopedia with facts and figures about breast cancer. The program was tested by 20 trainers/trainees in each of four participating countries.

RESULTS

The formata, content, and usefulness of the program were ranked highly: generally between 4 and 5 on a scale from 1 (low) to 5 (high), based on 78 evaluation forms.

CONCLUSION

The program seems to be an adequate tool for GP training.

Pilot study on the treatment of cyclical mastodynia with Quinagolide

In a pilot clinical trial on 52 patients, 75 microg Quinagolide given once per day was administered for the treatment of cyclical mastodynia. Linear analogue charts were used for the assessment of response. Decrease in breast pain, heaviness, tenderness and serum prolactin level on the one hand, and increases in the serum estradiol and progesterone levels on the other hand were noted after 3 and 6 months administration, and were statistically significant. Statistical analysis was performed by Paired t-test or Wilcoxon test. One-Way Anova Repeated Measures and Wilcoxon test and analysis of Covariance model. The beneficial effect of Quinagolide also lasted after the cessation of treatment. Fourteen patients dropped out during treatment. Adverse effects like nausea, low blood pressure, dizziness and constipation were rarely reported.

PAPNET for cervical cytology screening. Experience in Greece

OBJECTIVE

To validate the efficacy of PAPNET for cervical cytology screening.

STUDY DESIGN

From a total of 50,000 gynecologic cases we selected 24 primarily negative smears from patients who, during follow-up, developed a precancerous lesion or cancer in a short time, ranging from a few months to two years. These negative smears were rescreened by the PAPNET automated system and reevaluated by two observers. A third observer blindly reevaluated the same cases manually.

RESULTS

Reevaluation after PAPNET screening showed one false negative smear, for a rate comparable to that of manual reevaluation, which also reclassified the same case. The time required to interpret a smear using the PAPNET system was approximately one minute, while the time required for conventional manual screening was approximately five.

CONCLUSION

PAPNET is an efficient and fast screener for the detection of precancerous cervical lesions and cancer.

Molecular aspects of breast and ovarian cancer

Extensive research has led to accumulation of common hereditary evidence concerning ovarian and breast cancer, suggesting that these two cancers can be considered as one type. Subsequently, women with breast cancer are susceptible to the risk of developing ovarian cancer. Highly expressed oncogenes such as bcl-2, HER2/neu and others or mutated suppressor genes such as p53 or BRCA1 have been characterised as hereditary susceptibility genes leading to syndromes such as breast/ovarian cancer syndrome, Li-Fraumeni and others. Furthermore, these genetic alterations can cause potent chemoresistance by inhibiting induction of apoptosis after DNA damage caused by chemotherapy and/or radiotherapy. Presently, molecular onco-biology has enabled us not only to detect susceptibility to ovarian and breast cancer but also ways to inhibit their further progression or even circumventing chemoresistance mechanisms after their development by gene therapy using delivery vectors such as liposomes or viruses, by which we can replace wild-type tumour suppressor genes or by using antigene, antisense oligonucleotides and antisense RNA leading to reduced oncogene expression, enabling induction of apoptosis after DNA damage into chemoresistant tumour cells. Furthermore efflux-genes such as MDR-1 or MRP can be circumvented, suicide-genes can be employed which can facilitate sensitivity by encoding enzymes capable of converting inactive forms of a drug into toxic antimetabolites and immunotherapy can be achieved, by transfection of tumour cells with adenoviral vectors encoding immunomodulators such as IL-2 or MHC molecules. Thus, molecular biology appears to be a very strong element for the screening, diagnosis, therapy and prognosis of ovarian and breast cancer. However, consistent future research is greatly needed because many points concerning ovarian and breast cancer genetics are still unknown. Finally, we strongly believe that gene therapy could be extremely useful when is combined with conventional therapy against ovarian and breast tumours.

Imprint cytology. A rapid, reliable method of diagnosing breast malignancy

OBJECTIVE

To compare imprint cytology with fine needle aspiration biopsy and histology for the intraoperative diagnosis of breast malignancy.

STUDY DESIGN

We evaluated imprint cytology, comparing it with other diagnostic techniques. Three hundred fifty-one cases (180 benign and 171 malignant) were studied by fine needle aspiration cytology, imprint cytology and histopathology.

RESULTS

Imprint cytology, as compared to histopathology, had 98.3% accuracy, with 97.1% sensitivity and 99.4% specificity. Aspiration cytology was less accurate than imprint cytology as compared to histopathology (accuracy 94.9%, sensitivity 93.9%, specificity 96.2%).

CONCLUSION

These data confirm the value of imprint cytology and suggest that it could be used intraoperatively as an alternative to frozen section if a pathology laboratory is not available.

Breast masses in young girls. Report of five cases

The pubertal breast may be the seat of lesions comparable to those of the adult female breast. Of the five girls referred to in this report, aged 11 to 15 years, three had fibrocystic disease, one had a huge intracystic papilloma and the last one had multiple papillomas. The two girls with fibrocystic disease and the one girl with multiple papillomas had a family history of breast cancer which had appeared in their grandmothers. The possible relationship between the breast diseases of the two generations is discussed.