Barriers,beliefs and practice patterns for breast cancer reconstruction: A provincial survey

BackgroundThe purpose of this study was to characterize beliefs and practice patterns for breast cancer reconstruction among physicians who treat patients with breast cancer, in order to delineate current clinical practice. This survey was administered prior to Cancer Care Ontario guideline publication.MethodSurvey questions addressed four domains: survival, delayed or obscured recurrence detection, delayed adjuvant therapy, and aesthetics. The survey was administered to 1160 Ontario plastic and general surgeons and radiation and medical oncologists. Data were compared to published guidelines.ResultsThe overall response rate was 48%, with 57% of respondents treating breast cancer. Of those treating breast cancer, 75% are affiliated with an academic center. Immediate breast reconstruction (IBR) is not available to 28%. Autologous reconstruction is thought to interfere with recurrence detection by 23% (oncologists 30%, surgeons 19%, p = 0.04). For patients not expected to require radiation therapy, IBR is not supported by 30%. Autologous IBR is believed to delay delivery of adjuvant chemotherapy by 45% (oncologists 55%, surgeons 41%, p = 0.02). Up to 42% of respondents believe delays in adjuvant therapy delivery following IBR are due to insufficient health care resources (ie. coordinating an oncologic and reconstructive surgeon). Radiation therapy following reconstruction is believed to have negative aesthetic outcomes, and increase the need for revision surgery.ConclusionsUnfavourable beliefs about certain clinical actions do not align with recent provincial guideline recommendations. Insufficient healthcare resources are perceived to be a significant barrier to IBR and timely care.     

Decisional conflict in breast cancer patients considering immediate breast reconstruction

BackgroundBreast cancer (BC) patients who are treated with mastectomy are frequently offered immediate breast reconstruction. This study aimed to assess decisional conflict in patients considering immediate breast reconstruction, and to identify factors associated with clinically significant decisional conflict (CSDC).MethodsBaseline data of a multicenter randomized controlled trial evaluating the impact of an online decision aid for BC patients considering immediate breast reconstruction after mastectomy were analyzed. Participants completed questionnaires assessing sociodemographic and clinical characteristics, decisional conflict and other patient-reported outcomes related to decision-making such as breast reconstruction preference, knowledge, information resources used, preferred involvement in decision-making, information coping style, and anxiety. Multivariable logistic regression analysis was performed to identify factors associated with CSDC (score > 37.5 on decisional conflict).ResultsOf the 250 participants, 68% experienced CSDC. Patients with a slight preference for breast reconstruction (odds ratio (OR) = 6.19, p < .01), with no preference for or against breast reconstruction (OR = 11.84, p < .01), and with a strong preference for no breast reconstruction (OR = 5.20, p < .05) were more likely to experience CSDC than patients with a strong preference for breast reconstruction. Furthermore, patients with more anxiety were more likely to experience CSDC (OR = 1.03, p = .01).ConclusionA majority of BC patients who consider immediate breast reconstruction after mastectomy experience clinically significant decisional conflict. The findings emphasize the need for decision support, especially for patients who do not have a strong preference for breast reconstruction.     

Do surgeons convey all the details? A provincial assessment of operative reporting for breast cancer

IntroductionA breast cancer synoptic operative report was developed using a modified Delphi processMethodsData from the British Columbia Cancer Breast Cancer Outcomes Unit (BCOU) was used to analyze the association between the completion of a synoptic operative report and reporting of operative details and The American Society of Breast Surgeons quality indicators.Results3662 patients had surgery for breast cancer by 185 surgeons. 2281 reports were narrative and 1007 synoptic. Requested surgical details were more commonly reported with synoptic reports for both posterior (96 vs 58%, p < 0.0001) and anterior margins (96 vs 5%, p < 0.0001). This was true for high and low volume surgeons. Quality Indicators were higher in those cases with an associated synoptic report for high and low volume surgeons.ConclusionCommunication of operative details is improved with synoptic reporting. Investment in platforms to facilitate synoptic reporting could improve patient care through improved multidisciplinary communication.     

Who's talking about breast cancer? Analysis of daily breast cancer posts on the internet

ObjectiveBreast cancer is the cancer most commonly searched for on the internet. Our aim was to assess daily new breast cancer related posting on the internet.MethodsWe analyzed numbers of new daily posts for common cancers for one month and subsequently analyzed content of 1426 breast cancer related posts. We also assessed use of online discussion forums for breast cancer related dialogue.ResultsBreast related topics had significantly more posts per day compared to others (mean 66.7, p < 0.01). Most posts were on media sites (65.8%). Accuracy levels were high (87.5%) but significantly lower where posted on blogs and discussion forums (p < 0.001). Anonymous posts were common (55%) and less likely to be accurate (p < 0.001). Use of discussion forums has exponentially increased over the last five years (p < 0.001).ConclusionsThe internet has become a primary forum within which health information, particularly relating to breast cancer, is both sought and shared. Increasingly information is provided by patients themselves.     

Orthognathic surgery during breast cancer treatment—A case report

IntroductionIn recent years, patients with orthognathic surgery in middle-aged and elderly people have come to be a more frequent occurrence. Breast cancer is the most frequently diagnosed cancer in woman worldwide, and its prevalence rate is steadily increasing.Presentation of caseWe report a case of a 47-year-old Japanese woman in whom left-side breast cancer (Stage 1) was unexpectedly found just before orthognathic surgery in April 2012. Breast-conserving surgery was performed (estrogen receptor+, progesterone receptor+, HER2 −, surgical margin+, sentinel lymph node +) that May. From June to August docetaxel (75 mg/m²) and cyclophosphamide (600 mg/m²) were administrated four times every 21 days and thereafter radiotherapy (total 60 Gy) was completed. The cancer surgeon declared the prognosis good and the patient had a strong desire to undergo orthognathic surgery, so in November we performed a bimaxillary osteotomy, and administration of tamoxifen began 6 weeks after the osteotomy.DiscussionThere are breast cancer cases in which the prognosis is sufficiently good for a planned orthognathic surgery to proceed. Good communication among surgeons and the patient is important.ConclusionWe experienced a case in which breast cancer was found just before the orthognathic surgery; we performed a bimaxillary osteotomy, including follow-up tamoxifen administration, during breast cancer treatment.     

The role of the breast cancer surgeon in personalized cancer care: clinical utility of the 21-gene assay

BackgroundBreast cancer surgeons represent the first line of defense for many patients battling this disease. They often have the first contact to discuss treatment options with the patient after diagnosis. However, the potential impact of this consultation has evolved with the arrival of commercialized multigene prognostic and predictive tests that continue to reshape the landscape of breast cancer management, including modern surgical practice.MethodThis review was compiled from peer-reviewed literature indexed in PubMed.ConclusionsThe advent of genomic analysis has advanced the treatment and management of breast cancer toward the goal of personalized care. Therefore, the role of the surgeon now extends beyond extirpation of the tumor and includes an understanding of the biology of the disease as well as an appreciation of this new technology. Breast cancer surgeons should seize this opportunity to provide patients and colleagues with this information in an expeditious manner to optimize clinical outcomes.     

Management of breast cancer: basic principles

Breast cancer is the most common cancer in the UK predominately affecting women. The majority of breast cancer patients present with symptoms, but approximately 40% are diagnosed in asymptomatic women through the NHS Breast Screening Programme. Most breast cancers are now diagnosed non-operatively by triple assessment (the combination of clinical, radiological and pathological assessment) in specialist breast clinics. Breast cancer management is provided by a multidisciplinary team of breast specialists, including surgeons, radiologists, pathologists, breast care nurses and clinical/medical oncologists. Breast cancer patients now receive individualized treatment plans that may include surgery to both the breast and axilla (including breast reconstruction when appropriate), radiotherapy, endocrine treatment, chemotherapy and targeted treatments such as trastuzumab.     

Clinicopathologic characteristics of breast cancer in BRCA-carriers and non-carriers in women 35 years of age or less

PurposeBreast cancer diagnosed in women 35 years of age or less accounts for <2% of all breast cancer cases. Clinical and pathologic characteristics of early onset breast cancer are not well defined in BRCA mutation carriers and non-carriers.Methods194 women diagnosed with breast cancer at 35 years of age or less who had BRCA1/2 mutation testing were included in the study. Logistic regression models were fit to determine the associations between clinical variables and BRCA status.ResultsThirty-two (17%) and 12 (6%) patients had BRCA1 and BRCA2 mutations, respectively. BRCA1-carriers had a higher likelihood of a positive family history (FH) of breast and/or ovarian cancer (P = 0.001), or first-degree relatives diagnosed with breast cancer at <50 years old (P = 0.001) compared to non-carriers. BRCA2-carriers were more likely to have a FH of male breast cancer compared to noncarriers (P = 0.02). Among BRCA2-carriers, the age at first full-term pregnancy was younger in ER-negative cases compared with ERpositive cases (19.5 vs. 28.5 years old; P = 0.01). BRCA1-carriers with a later age at menarche were more likely to have a later stage at diagnosis (P = 0.04). Non-carriers with a lower BMI were more likely to have lymph node involvement (P = 0.03).ConclusionsSeveral associations were identified between reproductive risk factors or BMI and disease characteristics. Further characterization may result in a better understanding of the trends in young onset breast cancer in BRCA-carriers and non-carriers.     

Management of breast cancer: basic principles

Breast cancer is the most common cancer in the UK predominately affecting women. The majority of breast cancer patients present with symptoms, but approximately 40% are diagnosed in asymptomatic women through the NHS Breast Screening Programme. Most breast cancers are now diagnosed non-operatively by triple assessment (the combination of clinical, radiological and pathological assessment) in specialist breast clinics. Breast cancer management is provided by a multidisciplinary team of breast specialists including surgeons, radiologists, pathologists, breast care nurses and clinical/medical oncologists. Breast cancer patients now receive individualized treatment plans that may include surgery to both the breast and axilla (including breast reconstruction when appropriate), radiotherapy, endocrine treatment, chemotherapy and targeted treatments such as trastuzumab.     

Tamoxifen related side effects and their impact on breast cancer incidence: A retrospective analysis of the randomised IBIS-I trial

BackgroundStudies in the adjuvant setting have shown that endocrine therapy related side effects predict breast cancer recurrence risk. Here, we assess the relationship between early reported side effects and incidence of breast cancer in women randomised to tamoxifen for cancer prevention in the International Breast Intervention Study (IBIS)–I trial.MethodsWomen randomised to tamoxifen in the IBIS-I trial and for whom side effect status was known at the 6-month follow-up visit were included in this analysis. Side effects included in this analysis were hot flushes, vaginal discharge, and vaginal dryness. The primary endpoint was all breast cancer and secondary endpoint was oestrogen receptor (ER) positive breast cancer. Cox proportional hazard models were used to investigate breast cancer incidence in the tamoxifen group with and without side effects reported within 6 months of randomisation.ResultsWomen randomised to tamoxifen and reporting hot flushes at the 6-month follow-up visit had a non-statistically significant increase in breast cancer compared to those without hot flushes (HR = 1.26 (0.98–1.62), P = 0.08). A significant higher breast cancer risk was observed for postmenopausal women who reported hot flushes at the 6-month follow-up visit compared to those without hot flushes (HR = 1.59 (1.12–2.26), P = 0.01). A higher risk was observed for ER-positive breast cancer in postmenopausal women (HR = 1.81 (1.19–2.74), P = 0.01). No significant associations between gynaecological side effects and breast cancer occurrence was observed.ConclusionsOverall, no association between side effects reported at 6 months and subsequent breast cancer occurrence was observed. Some side effects might be useful markers for breast cancer occurrence in postmenopausal women.     

Patient surveillance after initial breast cancer therapy: variation by physician specialty

Background

American Society of Clinical Oncology (ASCO) guidelines recommend only office visits and mammograms as the primary modalities for patient surveillance after treatment for breast carcinoma. This study aimed to quantify differences in posttreatment surveillance among medical oncologists, radiation oncologists, and surgeons.

Methods

We e-mailed a survey to the 3,245 ASCO members who identified themselves as having breast cancer as a major focus of their practices. Questions assessed the frequency of use of 12 specific surveillance modalities for 5 posttreatment years.

Results

Of 1,012 total responses, 846 were evaluable: 5% from radiation oncologists, 70% from medical oncologists, and 10% from surgeons; 15% were unspecified. Marked variation in surveillance practices were noted within each specialty and among specialties.

Conclusion

There are notable variations in surveillance intensity. This suggests overuse or underuse or misuse of scarce medical resources.     

Adverse health effects after breast cancer up to 14 years after diagnosis

BackgroundThe number of breast cancer survivors increases, but information about long-term adverse health effects in breast cancer survivors is sparse. We aimed to get an overview of the health effects for which survivors visit their general practitioner up to 14 years after diagnosis.MethodsWe retrieved data on 11,671 women diagnosed with breast cancer in 2000–2016 and 23,242 age and sex matched controls from the PSCCR-Breast Cancer, a database containing data about cancer diagnosis, treatment and primary healthcare. We built Cox regression models for 685 health effects, with time until the health effect as the outcome and survivor/control and cancer treatment as predictors. Models were built separately for four age groups (aged 18/44, 45/59, 60/74 and 75/89) and two follow-up periods (1/4 and 5/14 years after diagnosis).Results229 health effects occurred statistically significantly more often in survivors than in controls (p < 0.05). Health effects varied by age, time since diagnosis and treatment, but coughing, respiratory and urinary infections, fatigue, sleep problems, osteoporosis and lymphedema were statistically significantly increased in breast cancer survivors. Osteoporosis and chest symptoms were associated with hormone therapy; respiratory and skin infections with chemotherapy and lymphedema and skin infections with axillary dissection.ConclusionsBreast cancer survivors may experience numerous adverse health effects up to 14 years after diagnosis. Insight in individual risks may assist healthcare professionals in managing patient expectations and improve monitoring, detection and treatment of adverse health effects.     

Attitudes of UK breast and plastic surgeons to lipomodelling in breast surgery

Lipomodelling is increasingly popular in breast surgery. The aims of this study were to elucidate the prevalence and practice of lipomodelling by surgeons in the UK and explore their attitudes and reservations to the technique.MethodologyA study specific questionnaire was circulated to Breast and Plastic Surgeons with an interest in breast reconstruction.Results228 surgeons responded. Lipomodelling in breast surgery was performed by 48/70 (69%) plastic surgeons and 17/158 (11%) breast surgeons (p < 0.0001). Most attitudes were positive with over 60% surgeons agreeing that the benefits of lipomodelling outweighed the risks. Critics cited the lack of prospective, long term follow up data (16%) in addition to oncological (4%), radiological (8%) and efficacy (4%) concerns.ConclusionsLipomodelling is performed by the majority of plastic surgeons who responded. Despite oncological, radiological and efficacy concerns, the majority of surgeons feel that the benefits of lipomodelling in the breast outweigh the risks.     

Targeted superparamagnetic nanoparticles coated with 2-deoxy-d-gloucose and doxorubicin more sensitize breast cancer cells to ionizing radiation

IntroductionNanoparticles are promising as a new approach to enhance chemo- radiotherapy efficiency in breast cancer mainly via targeted therapy.Materials & methodsSKBR3 and T47D breast cancer cells were treated with superparamagnetic mesoporous hydroxyapatite nanocomposites (SPmHANs)conjugated with 1 μM doxorubicin and 0.5 mM 2-Deoxy-d-Glucose and irradiated with 1 and 2 Gy gamma rays in vitro. The treatment toxicity and also the apoptosis/necrosis ratio were measured by MTT assay and also ELISA cell death detection PLUS, respectively.ResultsThe decreased cell viability with the combined treatment, with determined 42% loading efficiency for 200 ppm 2DG and 93% for5ppm doxorubicin on SPmHANs in PH about 7.4 and 5.5, were calculated to 60.9% and 68% compared to radiotherapy alone inT47D and SKBR3 cells (both with p < 0.05), respectively.ConclusionBreast cancer cure may boost from The combined targeted nanoparticle treatment with doxorubicin and 2-Deoxy-d-Glucose may boost breast cancer radiotherapy by improved chemodrug localization, increased cytotoxicity in tumor cells and decreased single modality treatment doses.     

Are males with early breast cancer treated differently from females with early breast cancer in Australia and New Zealand?

Breast cancer in males is much rare than in females so in practice, male breast cancer treatment is likely to follow the guidelines developed for female breast cancer patients. The objective of this study is to compare the characteristics and treatment pattern of male breast cancer patients with comparable subgroups of female breast cancer patients using data submitted to the National Breast Cancer Audit.This is a retrospective analysis of 151 male breast cancers diagnosed and treated between 2000 and 2008. Most of the male early breast cancer cases in this group were symptomatic ones in men aged > 50 years with one invasive tumour. There was a similar proportion of lymph node positive cancer among males and females, although male breast cancer was more likely to be unifocal (P = 0.007) and oestrogen receptor positive (P = 0.001). Male breast cancer patients almost always underwent mastectomy and a significant proportion of them (11%) received no surgical treatment. There were no differences in axillary surgery although males were more likely to undergo a level 2 axillary surgery and less likely to have sentinel node biopsy. Male patients were significantly less likely to undergo radiotherapy, chemotherapy or hormonal therapy for oestrogen receptor positive tumours.Conclusion: While the female oriented treatment guidelines are available, male patients with early breast cancer received different surgical and adjuvant treatment from comparable females.     

Multidisciplinary care for patients with breast cancer

Breast cancer management requires a multidisciplinary approach that is tailored to the patient's stage at presentation, desire for breast conservation or reconstruction, estimation of risk of recurrence, and assessment of the benefits and toxicities of potential adjuvant therapies. At the Lahey Clinic Medical Center, breast surgeons, plastic surgeons, radiation oncologists, and medical oncologists staff the Breast Cancer Treatment Clinic, and work closely together to formulate treatment plans that will optimize the likelihood for cure with an acceptable cosmetic result. This involves careful preoperative work-up, surgical axillary staging, breast irradiation in the setting of breast conservation, and selection of chemotherapy or hormonal therapy if appropriate. Newer aspects of breast cancer care, including sentinal lymph node biopsy, postmastectomy radiation therapy, expanded use of hormonal therapy in younger women, new agents and chemotherapy combinations, and autogenous reconstruction techniques, have become an essential part of the multidisciplinary clinic approach.     

Predictors of axillary lymph node metastases in early breast cancer and their applicability in clinical practice

PurposeLymph node involvement is the most important prognostic factor in breast cancer. It is a multifactorial event determined by patient and tumour characteristics. The purpose of this study was to determine clinical and pathological factors predictive for axillary lymph node metastasis (ALNM) in patients with early breast cancer and to build a model to portend lymph node involvement.MethodsWe evaluated 1300 consecutive patients surgically treated in our institution (2007–2009) for cT1-T2 invasive breast cancer. The patient and tumour characteristics evaluated included: age at diagnosis, number of foci, histologic grade, location, tumour size, histologic subtype, lymphovascular invasion (LVI), estrogen-receptor (ER), progesterone-receptor (PR) and Her-2 status. Univariate and multivariate analyses were performed. Factors significantly associated with ALNM by univariate analysis plus histologic subtype were included in the multivariate analysis.ResultsBy univariate analysis, the incidence of ALNM was significantly associated with the presence of LVI (P < 0.0001), larger tumour size (P < 0.0001), higher histologic grade (P < 0.0001), retroareolar or lateral location in the breast (P < 0.0001), multiple foci (P = 0.0002) and in patients who underwent an axillary lymph node dissection. We found no effect of age, ER?PR nor HER-2 status. By multivariate analysis, ALNM was significantly associated with the presence of LVI (P < 0.0001), larger tumour size (P < 0.0001), axillary lymph node dissection (P = 0.0003), retroareolar and lateral tumour location in the breast (P = 0.0019) and the presence of multiple foci (P = 0.0155).ConclusionsLVI and tumour size emerged as the most powerful independent predictors of ALNM, followed by the location of the tumour in the breast and the presence of multiple foci.