Breast cancer research and treatment 2013 Dec
Authors: Yao K,
The use of contralateral prophylactic mastectomy (CPM) has been increasing despite questionable survival benefit. We examined the effect of CPM on survival using the National Cancer Data Base. We examined overall survival on 219,983 mastectomy patients diagnosed with unilateral AJCC Stage 1-III invasive breast cancer between 1998 and 2002 of which 14,994 (7 %) underwent CPM at the time of their index mastectomy. Median follow up time was 5 years. Neoadjuvant and locally advanced breast cancers were excluded. Approximately 4 % underwent CPM in 1998 compared to 9.4 % in 2002, an ~125 % increase. CPM patients were significantly younger than non-CPM patients, on managed care plans, and were treated at high volume centers. The unadjusted hazard ratio (HR) of death was 0.55 (95 % CI 0.52-0.57) for CPM compared to unilateral mastectomy. In a multivariable Cox model adjusting for age, race, stage, grade, histology, insurance, facility characteristics, use of adjuvant hormonal, chemotherapy, and radiotherapy, and year of diagnosis, the adjusted HR was 0.88 (95 % CI 0.83-0.93; p < 0.001) which translated into an absolute 5-year benefit of 2 %. There was a differential effect of CPM by stage and age: HR = 0.88 (95 % CI 0.82-0.94; p < 0.001) in women younger than 70 with stage I/II, and HR = 0.95 (95 % CI 0.88-1.04; p = 0.28) in women with stage III or older than age 69 which translated into an absolute 5-year benefit of 1.3 %. Utilization of hormonal therapy or chemotherapy had no effect on the HR. After adjusting for confounding, the overall survival benefit for CPM is minimal at best.
PMID: 24218052 [PubMed - as supplied by publisher]
Annals of surgical oncology 2013 Dec
Authors: Gnerlich JL,
Adipokines in the tumor microenvironment may contribute to cancer growth. We hypothesized that peritumoral fat can be a source of lipid-derived energy for tumors by increasing adipose triglyceride lipase (ATGL)-mediated lipolysis and down-regulating a negative regulator of adipogenesis, pigment epithelium-derived factor (PEDF).
In a pilot study, tissue from mastectomies (n = 19) was collected from sites both adjacent (peritumoral) and distant to the tumor for comparison of ATGL, PEDF, and leptin expression levels using immunohistochemistry. Statistical analysis was performed by Student's t test to determine significance.
Mean tumor size was 2.4 cm, and 10 (59 %) patients had tumor-positive nodes. Mean body mass index (BMI) was 28.1 kg/m(2). ATGL expression was significantly increased in obese patients (BMI ≥30 kg/m(2)) compared with the nonobese group (P < 0.04). Leptin expression was increased in the peritumoral stroma of obese patients compared with distant sites (P = 0.03). Peritumoral PEDF and the leptin/PEDF ratio were significantly affected by tumor size and node status. Tumors ≥2 cm had lower peritumoral stromal expression of PEDF than tumors <2 cm (P = 0.01). In node-positive cases, expression of PEDF was significantly decreased in the peritumoral stroma compared with node-negative cases (1.22 vs. 1.80, P < 0.04). The leptin/PEDF ratio was markedly elevated in the peritumoral region of node-positive cases versus node-negative cases (2.17 vs. 1.18, P < 0.001).
Peritumoral expression of adipokines was altered in both obesity and more advanced breast tumors, suggesting a role for adipokines in enhancing tumor growth. Future studies should focus on the use of adipokines as biomarkers.
PMID: 24052317 [PubMed - as supplied by publisher]
Annals of surgical oncology 2013 Oct
Authors: Czechura T,
Previous studies have demonstrated an increase in the utilization of accelerated partial-breast irradiation via brachytherapy (APBI-b), but larger, more contemporary studies examining overall APBI use are lacking.
A total of 575,438 nonneoadjuvant American Joint Committee on Cancer stage 0 to II breast conservation patients were selected from the National Cancer Data Base from 2003 to 2010 who underwent either whole-breast irradiation or APBI.
Overall, 59,396 patients (10.3 %) underwent APBI. The use of APBI for the entire cohort increased from 3.4 % in 2003 to 12.8 % (p < 0.001) in 2008 and then decreased to 12.4 % in 2010. Three-dimensional conformal radiation increased from 0.8 to 2.2 %, intensity-modulated radiotherapy increased from 0.7 to 1.3 %, and brachytherapy (APBI-b) increased from 2.0 to 8.9 %. The most significant factors associated with APBI use were patient age and facility location. Patients 80-89 years old were 3.8 times more likely to undergo APBI compared to patients 30-39 years old (odds ratio [OR] 3.77, 95 % confidence interval [CI] 3.45-4.10, p < 0.001). Patients living in the West census region were 2.0 times more likely to undergo APBI compared to patients living in the Northeast (OR 2.0, 95 % CI 1.93-2.15, p < 0.001). Using the American Society of Radiation Oncology (ASTRO) guidelines, among patients with noninvasive cancer who received APBI, 95.6 % were categorized as "cautionary" and 4.4 % as "unsuitable." Of the invasive patients, 43.8 % were categorized as "suitable," 47.0 % as "cautionary," and 9.2 % as "unsuitable."
The utilization of APBI has stabilized at approximately 12 % starting in 2008. The majority of APBI is delivered using APBI-b, with patient age being the most significant factor associated with APBI use.
PMID: 23975298 [PubMed - as supplied by publisher]
Annals of surgical oncology 2013 Oct
Authors: Pesce C,
Randomized trials have not demonstrated a survival benefit for axillary dissection in the elderly, but the use of axillary staging for women 70 years of age and older remains controversial.
We utilized the National Cancer Data Base to study the use of axillary staging from 2004 to 2010 on 102,026 clinically node-negative and estrogen receptor-positive cases of pT1N0 tumors. Chi-square and logistic regression models were used to determine the trends and factors related to axillary staging.
Axillary nodes were examined in 88.9 % of the total cohort, and the trend significantly increased from 87.7 % in 2004 to 89.2 % in 2010. A total of 77.2 % of patients underwent lumpectomy and 22.8 % mastectomy, with 87.0 % of lumpectomy patients undergoing axillary staging compared to 95.5 % of mastectomy patients. Predictors of axillary staging examined were age, comorbidity, income, histology, grade, facility type, facility location, and population density. The strongest independent predictor of axillary staging was age: 96.0 % of women aged 70-75 years underwent axillary staging, versus 92.3 % of women 75-80 years old, 83.2 % of women 80-85 years old, 66.5 % of women 86-90 years old, and 45.6 % of women >90 years old. Patients treated at academic/research facilities were 18.5 % less likely (odds ratio 0.81, 95 % confidence interval 0.76-0.87) than community cancer programs to undergo axillary staging. There was significant regional variation among U.S. Census regions: patients treated in the Midwest were 3.8 times more likely to undergo axillary staging than those treated in the Northeast.
Despite data indicating decreased utility, axillary staging remains overutilized in women with advancing age.
PMID: 23975297 [PubMed - as supplied by publisher]
Annals of surgical oncology 2013 Dec
Authors: Miller ME,
The purpose of this study was to determine if newly diagnosed breast cancer patients undergoing contralateral prophylactic mastectomy (CPM) experience more complications than patients undergoing unilateral mastectomy (UM).
A total of 600 patients underwent either UM or CPM between January 2009 and March 2012 for unilateral breast cancer. Operative complications were classified as minor (aspirations, infection requiring antibiotics, partial flap and nipple necrosis, minor bleeding, delayed wound healing) or major (hematoma or seroma requiring operation, infection requiring rehospitalization, blood product transfusion, total flap or nipple loss, implant removal), mixed (both minor and major complications), or multiple. Chi-square and multivariate logistic regressions were used for the analysis.
Of the 600 patients, 391 (65 %) underwent UM and 209 (35 %) underwent CPM. Across all complication groups, there were significantly more complications in the CPM group versus the UM group (41.6 vs. 28.6 %, p = 0.001). Major complications alone were significantly greater in the CPM versus the UM group (13.9 vs. 4.1 %, p < 0.001). When adjusting for age, body mass index, smoking and diabetes history, AJCC stage, reconstruction, previous radiation therapy, and adjuvant therapy, CPM patients were 1.5 times more likely to have any complication (odds ratio [OR] 1.53; 95 % CI 1.04-2.25, p = 0.029) and 2.7 times more likely to have a major complication compared with UM patients (OR 2.66; 95 % CI 1.37-5.19, p = 0.004).
CPM patients have an increased risk of complications, especially major complications requiring rehospitalization or reoperation. These complications may influence patient and physician decisions to choose CPM.
PMID: 23868655 [PubMed - as supplied by publisher]
Annals of surgical oncology 2012 Oct
Authors: Nguyen B,
To compare breast cancer subtyping with the three centrally assessed microarray-based assays BluePrint, MammaPrint, and TargetPrint with locally assessed clinical subtyping using immunohistochemistry (IHC) and fluorescence in situ hybridization (FISH).
BluePrint, MammaPrint, and TargetPrint were all performed on fresh tumor samples. Microarray analysis was performed at Agendia Laboratories, blinded for clinical and pathological data. IHC/FISH assessments were performed according to local practice at each institution; estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2) assessments were performed on 132 samples, and Ki-67 on 79 samples.
The concordance between BluePrint and IHC/FISH subtyping was 94 % for the Luminal-type, 95 % for the HER2-type, and 94 % for the Basal-type subgroups. The concordance of BluePrint with subtyping using mRNA single gene readout (TargetPrint) was 96 % for the Luminal-type, 97 % for the HER2-type, and 98 % for the Basal-type subgroups. The concordance for substratification into Luminal A and B using MammaPrint and Ki-67 was 68 %. The concordance between TargetPrint and IHC/FISH was 97 % for ER, 80 % for PR, and 95 % for HER2.
The implementation of multigene assays such as TargetPrint, BluePrint, and MammaPrint may improve the clinical management of breast cancer patients. High discordance between Luminal A and B substratification based on MammaPrint versus locally assessed Ki-67 or grade indicates that chemotherapy decisions should not be based on the basis of Ki-67 readout or tumor grade alone. TargetPrint serves as a second opinion for those local pathology settings where high-quality standardization is harder to maintain.
PMID: 22965266 [PubMed - as supplied by publisher]
Journal of the American College of Surgeons 2012 Nov
Authors: Sisco M,
Studies examining patterns of cancer care before 2000 have shown underuse of postmastectomy breast reconstruction as well as racial and socioeconomic disparities in its delivery. These findings prompted legislation designed to broaden use at the turn of the millennium. However, little is known about trends in these findings over the past decade.
Patients who underwent mastectomy for stage 0 to III breast cancer between 1998 and 2007 (n = 452,903) were studied using the National Cancer Data Base to evaluate trends in the receipt of immediate and early delayed breast reconstruction. Those who underwent mastectomy between 1998 and 2000 (n = 150,177) and between 2005 and 2007 (n = 123,518) were compared using logistic regression to identify factors influencing the use of breast reconstruction and how they changed over time.
The use of postmastectomy breast reconstruction increased from 13% to 26% from 1998 to 2007. This increase was statistically significant in almost all patient subsets. Independent factors associated with breast reconstruction included age less than 50 years old; higher census-derived household income; private or managed care insurance; non-African American race; and treatment in an academic hospital setting. Treatment in an academic hospital and higher income became stronger predictors of breast reconstruction over the study period, while age became less of a predictor.
Although the use of breast reconstruction has increased from 1998 to 2007, it is still underused among many patient populations. Furthermore, racial and socioeconomic disparities in its delivery have persisted or widened. Additional effort is necessary to broaden the use of breast reconstruction and to ensure equitable access to it.
PMID: 22921327 [PubMed - as supplied by publisher]
Advances in surgery 2012
Authors: Williams RT,
There have been dramatic changes in the approach to the axilla in women with breast cancer over the last 100 years, reflecting the evolution in our understanding of the underlying tumor biology, reduced disease burden because of early detection, and advances in all breast cancer treatment modalities. The approach to the axilla needs to be individualized, much like the extent of surgery for the primary tumor. Axillary dissection remains an important intervention for patients with more locally advanced disease. However, in patients with early-stage breast cancer, in whom regional recurrence is extremely low, the added benefit of an ALND has yet to be confirmed.
PMID: 22873029 [PubMed - as supplied by publisher]
Annals of surgical oncology 2011 Dec
Authors: Williams RT,
Needle biopsy to diagnose breast cancer may soon become a quality measure for which hospitals are held accountable. This study examines the utilization of needle versus excisional biopsy in a contemporary cohort of patients and identifies factors associated with biopsy type.
Women with nonmetastatic, clinical Tis-T3 breast cancers diagnosed between 2003 and 2008 were selected from the National Cancer Data Base, which captures information from ~79% of breast cancers in the United States. Patients whose cancer was diagnosed by needle biopsy (fine-needle aspiration or core) were compared with patients diagnosed via excision, analyzing patient, hospital, and tumor characteristics. Logistic regression was used to identify important predictors of biopsy type.
Of 373,837 patients, 303,677 (81.2%) underwent needle biopsy while 70,160 (18.8%) had excisional biopsy to diagnose their cancer. The needle biopsy rate increased from 73.8 to 86.7% whereas excisional biopsy declined from 26.2 to 13.3% over the study period (P < 0.001). In 2008, patients were statistically significantly more likely to undergo excisional biopsy if they had stage 0 disease; were treated at low-volume (<25 cases/year), community, or Atlantic census region hospitals; were <40 years old at diagnosis; were less educated; or were Asian/Pacific Islander (P < 0.001). The median rate of needle biopsy at high-volume hospitals (≥140 cases/year) was 89.6%.
The use of needle biopsy is increasing. Tumor stage, hospital volume, and hospital location were the most statistically significant predictors of biopsy type. Rates of needle biopsy at high-volume hospitals suggest that appropriate utilization of this preferred diagnostic method should approach 90%.
PMID: 21630122 [PubMed - as supplied by publisher]
Journal of the American College of Surgeons 2011 Jul
Authors: Spiguel L,
Complete node dissection for a tumor-positive sentinel node (SN) is becoming more controversial. We report our institution's 12-year experience with sentinel node biopsy (SNB) alone for a tumor-positive SN.
This was a retrospective review from 1998 to 2009. Of 3,806 patients who underwent SNB, 2,139 underwent SNB alone, of which 1,997 were tumor-negative and 123 were tumor-positive. SNs were staged node-positive (N1mic or N1) according to American Joint Committee on Cancer criteria.
One hundred and twenty-three node-positive patients underwent SNB alone with no completion axillary dissection for invasive breast cancer. Mean age was 57 years (range 32 to 92 years) and stage distribution was as follows: stage IIA: 76 (62%) patients; stage IIB: 40 (33%) patients; and stage III: 4 patients (3%). Mean size of the tumors was 1.9 cm (range 0.1 to 9 cm). Eighty-nine (72%) underwent lumpectomy and 34 (28%) underwent mastectomy. Ninety-three percent of patients underwent some form of adjuvant therapy. Forty-two patients (34%) did not undergo radiation and there were no axillary recurrences in this group. At median follow-up of 95 months, there has been 1 axillary recurrence (0.8%) and 13 deaths, 4 of which were attributed to metastatic breast cancer and the rest to non-breast-related causes.
Axillary recurrence is rare after SN biopsy alone. This might be related to favorable tumor and patient characteristics and frequent use of adjuvant therapy.
PMID: 21530326 [PubMed - as supplied by publisher]