Impact of Availability of Immediate Breast Reconstruction on Bilateral Mastectomy Rates for Breast Cancer across the United States: Data from the Nationwide Inpatient Sample

Background

Availability of immediate breast reconstruction (IBR) varies among institutions, yet the impact of IBR availability on the rates of bilateral mastectomy (BM) versus unilateral mastectomy (UM) for breast cancer is unknown.

Methods

From the 2002 to 2010 Nationwide Inpatient Sample, we identified women with breast cancer undergoing UM or BM with and without IBR using ICD-9 codes. Hospitals were classified as performing IBR if at least one hospitalization included both mastectomy and reconstruction and then by IBR volume. Statistical comparisons utilized Chi square tests, tests for trend, and multivariable logistic regression.

Results

We identified 130,420 women undergoing UM (76.9 %) or BM (23.1 %) for breast cancer. Of 6,579 hospitals, 3,358 (51.0 %) performed no IBRs, while in the remaining 3,221 hospitals, 1 to 638 IBRs were performed per year. Large, teaching, urban, and Northeastern hospitals were more likely to have higher IBR volumes. BM rates were significantly higher in patients treated at those hospitals with higher IBR volumes, from 33.1 % at hospitals performing ≥24 IBRs per year to 9.0 % at hospitals without IBR (p < 0.001). Upon adjusted analysis, patients who elected BM were more likely to be seen at hospitals performing ≥24 IBRs per year (odds ratio 1.69 vs. UM, p < 0.001).

Conclusions

In this analysis of national data, BM rates were higher in hospitals where IBR was available, suggesting a significant influence of institutional factors on treatment options for breast cancer patients. Efforts are needed to ensure patients have access to IBR when desired and to better understand the reasons for hospital variation in BM rates.     

Decreasing Use of Axillary Dissection in Node-Positive Breast Cancer Patients Treated with Neoadjuvant Chemotherapy

Background

Neoadjuvant chemotherapy (NAC) may downstage axillary disease in node-positive breast cancer. Several clinical trials have shown that sentinel lymph node (SLN) surgery after NAC is feasible for these patients. We sought to evaluate the use of SLN surgery and ALND in cN1 patients undergoing NAC.

Methods

We identified all patients with biopsy-proven cN1 breast cancer treated with NAC at our institution between January 2009 and December 2017. Approximated biologic subtype was determined by estrogen receptor (ER) and human epidermal growth factor receptor 2 (HER2) status. Cochran–Armitage trend and Chi square tests were used for statistical analysis.

Results

Of 430 cN1 patients treated with NAC, 93 (22%) underwent SLN surgery only, 100 (23%) underwent SLN and ALND, and 237 (55%) underwent ALND only. The use of SLN surgery (±?ALND) increased from 28% in 2009 to 86% in 2017 (p?<?0.001), while the performance of ALND decreased from 100% in 2009 to 38% in 2017 (p?<?0.001). Among SLN+ patients who underwent ALND, disease was limited to the SLNs in 25/73 (34%) patients. The nodal pathologic complete response rate was 46% and varied by tumor subtype (p?<?0.001). Among patients undergoing SLN surgery, ALND was avoided in 48% of patients overall and varied by biologic subtype: 55% ER?/HER2+, 61% ER+/HER2+, 62% ER?/HER2?, and 31% ER+/HER2? (p?=?0.001). With short-term follow-up, no nodal recurrences have occurred in patients without ALND.

Conclusions

We observed a significant shift in axillary surgery for cN1 breast cancer patients treated with NAC, with increasing use of SLN surgery to assess nodal treatment response, and decreasing use of ALND.

     

Axillary Ultrasound in the Management of the Newly Diagnosed Breast Cancer Patient

Axillary lymph node status remains an important prognostic factor in patients with breast cancer. Axillary ultrasound (AUS) is an important tool in the workup of patients with newly diagnosed breast cancer and also has an emerging role evaluating the axilla after neoadjuvant chemotherapy. This review discusses the value of AUS in the workup and management of patients with newly diagnosed breast cancer and describes its role given the recent changes in axillary management.     

Outcomes of > 1300 Nipple-Sparing Mastectomies with Immediate Reconstruction: The Impact of Expanding Indications on Complications

Annals of Surgical Oncology - The enhanced esthetics and demonstrated oncologic safety of nipple-sparing mastectomy (NSM) in selected patients have resulted in increased rates among patients with...     

Surveillance mammography after treatment for male breast cancer

Breast Cancer Research and Treatment - To identify the practice patterns related to use of surveillance mammography in male breast cancer (MaBC) survivors. Using administrative claims data from...     

Influence of Biologic Subtype of Inflammatory Breast Cancer on Response to Neoadjuvant Therapy and Cancer Outcomes

Background

Few data exist on the influence of tumor biologic subtype on treatment response and outcomes for inflammatory breast cancer (IBC). We examined a contemporary cohort of IBC patients treated with current targeted systemic therapies, selected on the basis of tumor biologic subtype, to evaluate pathologic treatment response and cancer outcomes across biologic subtypes.

Unilateral Arm Urticaria Presenting as a Paraneoplastic Manifestation of Metachronous Bilateral Breast Cancer

Various paraneoplastic syndromes (PNS) are reported to be associated with breast cancer and can range from mild dermatological symptoms to severe neurological complications. Neurological and dermatological manifestations tend to be the more commonly seen paraneoplastic manifestations, albeit both are relatively rare. Diagnosis of the underlying malignancy is often delayed since the presence and severity of paraneoplastic manifestations are not dependent on the tumor size or stage. Herein, we describe a unique case of unilateral arm urticaria presenting as a paraneoplastic manifestation of metachronous bilateral breast cancer. Similar reports and other PNS associated with breast cancer are described. Recognition of PNS associated with underlying malignancies and age-appropriate screening can facilitate diagnosis of the underlying occult malignancy. Resection of the underlying malignancy can lead to resolution and/or improvement of the PNS for some patients.Key Words: Paraneoplastic syndromes, Urticaria, Dermatological symptoms, Neurological complications, Breast cancer, Occult malignancy, Rash, Adenocarcinoma