Breast-conserving surgery versus mastectomy in young women with breast cancer in Asian settings

Background

Mastectomy rates among women with early breast cancer in Asia have traditionally been high. This study assessed trends in the surgical management of young women with early‐stage breast cancer in Asian settings. Survival in women treated with breast‐conserving surgery (BCS; lumpectomy with adjuvant radiotherapy) and those undergoing mastectomy was compared.

Methods

Young women (aged less than 50 years) newly diagnosed with stage I or II (T1–2 N0–1 M0) breast cancer in four hospitals in Malaysia, Singapore and Hong Kong in 1990–2012 were included. Overall survival (OS) was compared for patients treated by BCS and those who had a mastectomy. Propensity score analysis was used to account for differences in demographic, tumour and treatment characteristics between the groups.

Results

Some 63·5 per cent of 3536 women underwent mastectomy. Over a 15‐year period, only a modest increase in rates of BCS was observed. Although BCS was significantly associated with favourable prognostic features, OS was not significantly different for BCS and mastectomy; the 5‐year OS rate was 94·9 (95 per cent c.i. 93·5 to 96·3) and 92·9 (91·7 to 94·1) per cent respectively. Inferences remained unchanged following propensity score analysis (hazard ratio for BCS versus mastectomy: 0·81, 95 per cent c.i. 0·64 to 1·03).

Conclusion

The prevalence of young women with breast cancer treated by mastectomy remains high in Asian countries. Patients treated with BCS appear to survive as well as those undergoing mastectomy.

Low Lifetime Risk of Contralateral Breast Cancer in a Middle-Income Asian Country: Evidence to Guide Post-treatment Surveillance

BACKGROUND

The rate of contralateral risk-reducing mastectomy (CRRM) is increasing in the West with controversial evidence of improved survival in early breast cancer patients. Although uptake of CRRM in Asia appears low, the trends may rise, and there is currently an urgent need to provide evidence for informed decision-making in clinical practice. This study aims to determine the risk of contralateral breast cancer (CBC) and its associated factors in an Asian setting.

METHOD

A total of 2937 newly diagnosed patients with stage I and stage II breast cancer in University Malaya Medical Centre between Jan 1993 to Dec 2012 were included in the study. Multinomial logistic regression analysis allowing death to compete with CBC as a study outcome was used; patients with unilateral breast cancer who were alive were taken as reference. A stepwise backward regression analysis including age at diagnosis, ethnicity, family history of breast cancer, TNM stage, hormonal receptor status, HER2 status, chemotherapy, radiotherapy, and hormone therapy was conducted.

RESULTS

Fifty women developed CBC, over a median follow-up of 6 years. The 5- and 10-year cumulative risk of contralateral breast cancer was 1.0% (95% CI 0.6-1.4%) and 2.8% (95% CI 2.0-3.6%), respectively. Young age at diagnosis of first cancer, positive family history, and stage I disease were independent predictors of CBC.

DISCUSSION

The current study suggests that the risk of CBC is very low in a Southeast Asian setting. Any recommendations or practice of CRRM should be reviewed with caution and patients must be counseled appropriately.

Breast Cancer Outcomes as Defined by the Estrogen Receptor, Progesterone Receptor, and Human Growth Factor Receptor-2 in a Multi-ethnic Asian Country

INTRODUCTION

Breast cancer can be divided into four subtypes based on the expressions of estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor-2 (HER2). Each subtype has different clinicopathological features and outcomes.

OBJECTIVE

To compare the clinicopathological features and survival of ER and/or PR positive HER2 negative (ER+PR+HER2-, ER+PR-HER2- or ER-PR+HER2-), ER and/or PR positive HER2 positive (ER+PR+HER2+, ER+PR-HER2+ or ER-PR+HER2+), ER negative PR negative HER2 positive (ER-PR-HER2+), and ER negative PR negative HER2 negative (ER-PR-HER2-) subtypes.

METHODS

1957 patients with Stage 1-3 breast carcinoma diagnosed between Jan 2005 and Dec 2011 were categorized into the four subtypes. The clinicopathological features between the subtypes were compared using χ (2) test. Kaplan-Meier analysis was performed to estimate 5-year overall survival. Multivariate Cox regression was used to determine the association between subtypes and mortality adjusted for age, ethnicity, stage, pathological features, and treatment.

RESULTS

ER-PR-HER2+ and ER-PR-HER2- subtypes were associated with younger age, larger tumors, and higher grade. There was no difference in the 5-year survival of the ER-PR-HER2+ and ER-PR-HER2- subtypes (75.1 and 74.4 %, respectively) and survival was poorer than in the ER and/or PR positive HER2 negative and ER and/or PR positive HER2 positive subtypes (87.1 and 83.1 %, respectively). Only 9.5 % of women with HER2 positive breast cancer had access to trastuzumab.

CONCLUSION

In a low resource setting with limited access to trastuzumab, there is no difference in survival between the ER-PR-HER2+ and ER-PR-HER2- subtypes of breast cancer.

Abstract P5-08-39: Low risk of contralateral breast cancer rates in Asian women- A case for not recommending contralateral prophylactic mastectomy

Introduction

The rates of contralateral prophylactic mastectomy (CPM)appears to be higher in the west as compared to the east.1,2There is a suggestion of an improved survival benefit of CPM. 1The trends are increasing in the west and little is known in Asia. In western data a rate of 0.5 to 1% per year is often quoted. However, There is scarcity of epidemiological data on rates of contralateral breast cancer (CBC) in Asia.

Known predictors of CBC in the west include high stage at diagnosis, early age at diagnosis, presence of family history, genetic predisposition, time from first diagnosis and hormone receptor status. Little is known in Asia. Population based registries are not available in Malaysia as in many Southeast Asian countries. This study aims to provide CBC rates to provide evidence for informed decision making of CPM in Asians.

Method

A prospective database of newly diagnosed Stage I and II breastcancer patients diagnosed in University Malaya Medical Centre between 1993 to 2012 were analysed. Data on CBC were obtained from institutional database and medical records. Multivariate analysis used Cox regression was applied to observe for any associations with multiple variables such as age at diagnosis, time from diagnosis, presence of family history, menopausal status, ethnic groups, parity and hormone status.

Results

A total of 3060 Stage I and II patients were prospectively followed up. 127 (4.2%) women developed contralateral breast cancer.At 5 years, 57 (1.9%) and at 10 years, 100(3.4%) developed CBC. Using a multivariate model, the only independent predictor of developing contralateral breast cancer at 5 years was a positive family history OR 1.97(CI 1.02-3.80).

However, at 10 years we found the effect of positive family history diminished OR1.57 (CI 0.94-2.64) and younger women were more likely to develop cancer, those aged 51 to 64 years OR 0.29 (CI 0.11-0.73) , >65 years OR 0.20 (CI 0.07-0.60)compared to those less than 35 years. The other factors in the model were not significant.

Discussion

There is an increasing rate of CPM at 22% from 9% in the west1. A study in Singapore showed a low CPM rate of 1.25%2 . Although uptake of CPM in Asia has not been reported extensively and appears low, the trends may rise and that evidence is needed to counsel patients on the benefits and harms of CPM if patients request for CPM. Given the lower incidence of breast cancer in Malaysia ie 5% average risk compared to 10% in the west, an urgent need to document the risk of contralateral breast cancer, and this data from a single institution is the first to report this rates in Southeast Asia.

Conclusion

The data shows that risk of contralateral breast cancer is low in this Southeast Asian country. Any recommendations or practice of CPM should be dealt with extreme caution.

References

1. Kauffmann R, Nelson R, Smith D, et al: Improved survival with contralateral prophylactic mastectomy. Abstract in 2014 Society of Surgical Oncology Cancer Symposium.

2. Sim Y, Tan VK, Ho GH, Wong CY, Madhukumar P, Tan BK, Yong WS, Ng YY, OngKW.Contralateral prophylactic mastectomy in an Asian population: a single institution review. Breast. 2014 Feb;23(1):56-62. doi: 10.1016/j.breast.2013.10.008. Epub 2013 Nov 23.

Citation Format: Taib NA, See MH, Bhoo Pathy N, Yahya A, Tan GH, Jamaris S, Yip CH. Low risk of contralateral breast cancer rates in Asian women- A case for not recommending contralateral prophylactic mastectomy. [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 P5-08-39.

Prediction of lymph node involvement in patients with breast tumors measuring 3-5 cm in a middle-income setting: the role of CancerMath

BACKGROUND

In settings with limited resources, sentinel lymph node biopsy (SNB) is only offered to breast cancer patients with small tumors and a low a priori risk of axillary metastases.

OBJECTIVE

We investigated whether CancerMath, a free online prediction tool for axillary lymph node involvement, is able to identify women at low risk of axillary lymph node metastases in Malaysian women with 3-5 cm tumors, with the aim to offer SNB in a targeted, cost-effective way.

METHODS

Women with non-metastatic breast cancers, measuring 3-5 cm were identified within the University Malaya Medical Centre (UMMC) breast cancer registry. We compared CancerMath-predicted probabilities of lymph node involvement between women with versus without lymph node metastases. The discriminative performance of CancerMath was tested using receiver operating characteristic (ROC) analysis.

RESULTS

Out of 1,017 patients, 520 (51 %) had axillary involvement. Tumors of women with axillary involvement were more often estrogen-receptor positive, progesterone-receptor positive, and human epidermal growth factor receptor (HER)-2 positive. The mean CancerMath score was higher in women with axillary involvement than in those without (53.5 vs. 51.3, p = 0.001). In terms of discrimination, CancerMath performed poorly, with an area under the ROC curve of 0.553 (95 % confidence interval CI 0.518-0.588). Attempts to optimize the CancerMath model by adding ethnicity and HER2 to the model did not improve discriminatory performance.

CONCLUSION

For Malaysian women with tumors measuring 3-5 cm, CancerMath is unable to accurately predict lymph node involvement and is therefore not helpful in the identification of women at low risk of node-positive disease who could benefit from SNB.

Abstract P6-06-11: The Will Rogers phenomenon in breast cancer - How does the change from AJCC 5th edition to AJCC 6th edition affect cancer survival?

Introduction: Staging of cancers are important to select appropriate treatment and to estimate prognosis. The most extensive and significant revisions that have ever been made in the breast cancer staging system occurred when the 5th Edition (AJCC5) was updated to the 6th Edition (AJCC6) in Jan 2003. The principal changes were related to the size, number, and location of metastases to the lymph nodes. AJCC6 takes into account the number of lymph nodes involved, and if 4 or more lymph nodes are involved, a Stage 2 breast cancer under AJCC5 is upstaged to Stage 3 under AJCC6. The presence of a supraclavicular lymph node in the absence of other metastases was considered a Stage 4 under AJCC5, but under AJCC6, patients with a supraclavicular lymph node is downstaged to Stage 3. The Will Rogers phenomenon to describe the effect of the “stage migration” has been described as one of the most important biases limiting the use of historical cohorts when comparing survival or treatment. In breast cancer, when we move the “poor prognosis” Stage 2’s, with 4 or more nodes involved, to Stage 3, the Stage 2's remaining will be a “better prognosis” Stage 2, and hence survival should improve. These “poor prognosis” Stage 2's will then be the “better prognosis” Stage 3's and hence the survival of Stage 3 should improve. The aim of this study is to investigate how the change from AJCC5 to AJCC6 affected stage-specific survival in a group of Asian breast cancer patients.

Patients and Methods: 3127 new cases of breast cancer cases presenting to the University Malaya Medical Centre between Jan 1993 and Dec 2007 were prospectively registered into the UMMC Breast Cancer Database. Non-epithelial cancers and ductal carcinoma in situ were excluded. All patients were restaged into AJCC5 and AJCC6

Results:

Comparison of Staging by AJCC5 and AJCC6StageAJCC5AJCC61706 (22.6%)706 (22.6%)21553 (49.7%)1230 (39.3%)3511 (16.3%)854 (27.3%)4357 (11.4%)337 (10.8%)Total31273127

Discussion: It is important to compare stage-specific survival in different time periods to determine whether survival has improved, usually due to timely and optimal treatment. Out of 1553 women classified into Stage 2 breast cancer, 323 or 20.8%, were moved to Stage 3 under AJCC6. The shift from Stage 4 to 3 is less significant because only 20 out of 357 women (5.6%) had supraclavicular lymph node metastases only. The survival of AJCC 5 Stage 2 breast cancer had a 5 year survival rate of 82.9% compared to a 86.1% with AJCC6 Stage 2. Similarly, the 5 year survival of AJCC5 Stage 3 was 50.6% compared to 59% with AJCC6 Stage 3.

Conclusion: Similar to other studies, the stage specific survival in women with Stage 2 and 3 breast cancer improves significantly when AJCC6 is used for staging in the same cohort of patients, again underlying the importance of standardizing the stage when comparing survival from two time periods.

Comparison of 5-year relative survival by AJCC5 and AJCC6StageAJCC5AJCC6196.996.9282.986.1350.659414.412.6

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-06-11.

Laser arytenoidectomy for bilateral vocal fold palsy in Parkinson's disease

We report a case of laser arytenoidectomy for bilateral abductor palsy of the vocal fold in a patient with Parkinson's disease. Parkinson's disease is known to be a rare cause for bilateral vocal fold palsy and this is the second case reported in the English literature. Majority of the reports to date are in the non-English literature. Tracheostomy has been the classic treatment option offered to these patients. To date no report has been found in the literature about a laser arytenoidectomy being performed in a patient suffering from bilateral vocal fold palsy in Parkinson's disease. We have suggested this option as it improves the quality of life of the individual and avoids the difficulty faced by a Parkinson's patient in managing tracheostomy care due to bradykinesia, rigidity and tremor.

Audit of birth defects in 34,109 deliveries in a tertiary referral center

The objective of the study is to determine the proportion and different types of birth defects among the children born in Hospital Kuala Lumpur. A cross-sectional study was conducted for a period of 18 months where all consecutively born infants, dead or alive were included. There were total of 34,109 births recorded during this period. The proportion of birth defects in Hospital Kuala Lumpur was 3.1% (n = 1056). The commonest involved were the hematology system, (157.7 per 10,000 births), the central nervous system, genitourinary system and chromosomal anomalies. The proportion was significantly higher in males and in the Chinese (p < 0.001). The commonest abnormalities are Glucose 6 Phosphate Deficiency (157.7/10000), Down's syndrome (12.6/10000), thalassaemia (8.8/10000), cleft lip and/or palate (7.6/10000) and anencephaly (7.3/10000). Neural tube defect is common and ranked second after G6PD deficiency. There is a need for a birth defect registry to assess the extent of the problem in Malaysia.

The value of bone scintigraphy in the evaluation of osteoporotic patients with back pain

We evaluated the role of bone scintigraphy in 60 osteoporotic patients with back pain. Thirty-four had scintigraphic evidence of vertebral fracture and were found to have a significantly lower bone density compared to those without fractures (p = 0.01). In only 14 patients was vertebral fracture considered to be the sole cause of pain with 38 having alternative abnormalities, the most common of which was facet joint disease (n = 30). Results of bone scintigraphy influenced a direct change in management in 18 patients and were able to exclude vertebral fracture as a cause of symptoms in 30. In symptomatic osteoporotic patients the bone scan may be helpful in elucidating the etiology of back pain and can impact on patient management.

Availability of cigarettes to minors

Legislation banning the sale of cigarettes to minors is potentially a cost-effective means of reducing smoking rates among adolescents. Such legislation has been in existence in Australia for over 80 years. Two studies examined the retail industry's adherence to the sales ban in two regions of New South Wales in 1990. The first study was a survey of 1,849 12- to 15-year-old adolescents from 12 high schools in New South Wales, providing data on self-reported purchasing of cigarettes from retail outlets by minors. In all, 38 per cent reported having purchased cigarettes illegally. A second study was undertaken to determine the proportion of retail shops which sell cigarettes to apparently underage youth. Two 16-year-olds who looked young for their age attempted to purchase cigarettes from 101 different retail outlets in one region of New South Wales. No challenge about age was made for 70 per cent of purchases, and proof of age was requested on only 15 per cent of occasions. The results suggest that legislation banning sales of cigarettes to minors requires strong enforcement procedures to be effective.