The effect of immediate breast reconstruction with Becker-25 prosthesis on the preservation of proper body posture in patients after mastectomy

Purpose

This was a prospective study comparing coronal, sagittal and transverse plane body posture parameters in women after radical mastectomy and women after radical mastectomy with immediate breast reconstruction (IBR) for stage I and II breast cancer.

Methods

The three studied groups were one that underwent Madden’s radical mastectomy (n = 38), a second with skin sparing mastectomy with IBR with expander-prosthesis Becker-25 (n = 38), and the control (n = 38). All the women were examined to determine their body posture in the coronal, sagittal and transverse planes using three-dimensional (3D) body surface analysis before and 6, 12, 18 and 24 months after surgery.

Results

There is a significant difference body posture in the coronal, sagittal and transverse planes between groups of patients after mastectomy with IBR comparing with patients after mastectomy alone. The women after radical mastectomy demonstrated the greatest postural changes in particular parameters of body posture in postsurgical months 18 and 24. The IBR group only demonstrated significant postural changes in one parameter, though as time after surgery increased, these changes decreased.

Conclusions

IBR after mastectomy has an impact on proper body posture. Photogrammetric examination revealed important body posture disturbances only in the radical mastectomy group. It gives useful information on body posture parameters in the evaluation of quality of life in breast cancer survivors. It appears that immediate breast reconstruction helps to preserve proper body posture after mastectomy.     

Neoadjuvant bevacizumab,docetaxel and capecitabine combination therapy for HER2/neu-negative invasive breast cancer: Efficacy and safety in a phase II pilot study

Purpose

To evaluate the triplet combination of bevacizumab, capecitabine and docetaxel (XTA) as neoadjuvant therapy for breast cancer.

Experimental design

Patients with invasive, HER2-negative, nonmetastatic breast cancer (T2–4c >2 cm) and no prior systemic therapy received six 21-day cycles of XTA (bevacizumab 15 mg/kg, day 1, cycles 1–5; docetaxel 75 mg/m², day 1 of each cycle; capecitabine 950 mg/m² twice daily for 14 days of each cycle). Patients underwent surgery 2–4 weeks after completing XTA, followed by radiotherapy, chemotherapy and hormone therapy according to institution guidelines. Pathologic complete response (pCR), the primary endpoint, was defined as no evidence of invasive tumour in the final surgical sample. Secondary endpoints included rates of clinical response and breast-conserving surgery and safety.

Results

Median age of the 18 enrolled patients was 48 years (range 34–69). Most patients (72%) received six cycles of neoadjuvant therapy. pCR rate was 22% (95% confidence interval [CI]: 6–48). Nine of the patients without pCR achieved clinical partial response, giving a 72% overall clinical response rate (95% CI: 47–90). Fifteen patients underwent breast-conserving surgery (83%; 95% CI: 59–96). One additional patient had breast-conserving surgery, followed by mastectomy 1 month later. The remaining 2 patients underwent modified radical mastectomy. XTA was reasonably well tolerated, with no unexpected toxicities or treatment-related deaths.

Conclusions

The 22% pCR rate in a HER2-negative population suggests that addition of bevacizumab increases the activity of neoadjuvant capecitabine–docetaxel. Further evaluation of this regimen in early breast cancer is recommended.     

Uptake and predictors of post-mastectomy reconstruction in women with breast malignancy – Systematic review

Purpose

There is enormous range in the reported rates of breast reconstruction. This study explored reasons for this variation by reviewing the published literature to examine rates of reconstruction, factors associated with uptake, and possible barriers.

Methods

A systematic review of the literature was performed. Eligible studies reported rates of breast reconstruction and variables associated with uptake in women undergoing mastectomy for early invasive or in situ breast malignancy.

Results

Twenty-eight eligible studies were included, reporting 159,305 cases of breast reconstruction in 940,678 women. In these studies 16·9% of women underwent immediate or delayed reconstruction (range 4·9–81·2%, median 23·3%). Variables associated with reconstruction were: patient/tumour factors (early stage, no adjuvant therapy, young age, white race, private insurance, higher education/income), surgeon/hospital factors and psychological/other factors (including patient choice).

Conclusion

Rates of breast reconstruction were highly variable. Reconstruction appeared to be offered to a minority of women; around half took up the offer. The main reasons reported for no reconstruction included patient-related and adjuvant therapy-related factors. Clinicians' beliefs about reconstruction may be an important factor. Rates of reconstruction could be increased with early discussion of the options when mastectomy is chosen or required.     

Histopathological findings and follow-up after prophylactic mastectomy and immediate breast reconstruction in 100 women from families with hereditary breast cancer

Aim

To survey the histopathological abnormalities in breasts of women who have undergone risk reducing mastectomy and to evaluate the effect of this measure on future breast cancer development.

Patients/methods

Between August 1995 and October 2006 100 consecutive women with a hereditary increased risk of breast cancer underwent prophylactic mastectomy (PM) at Malmö University Hospital. Fifty of the 100 women had no previous breast cancer. Fifty were BRCA1 or BRCA2 mutation carriers. All breast specimens have been examined histopathologically according to a prospective protocol. Follow-up data was collected from medical records and data in the Regional Cancer Registry.

Results

In the PM specimens abnormal lesions were found in 18 women (three with invasive cancers, eight in situ cancers and seven atypical hyperplasia). In previously healthy women lesions were more frequent after the age of 40 than among younger women (p = 0.03). BRCA mutation carriers were more likely to present with ADH (atypical ductal hyperplasia)/ALH (atypical lobular hyperplasia) compared to the non-carriers/untested cases (p = 0.01). After a median follow-up of 52 months (range 1–136 months) none of the women have developed breast cancer in the area of the prophylactically removed breast.

Conclusions

Prevalent atypical or malignant lesions are relatively a common finding in PM specimens in asymptomatic women with hereditary increased risk of breast cancer. Such findings were significantly more common above age 40 in women without previous breast cancer. The risk of newly formed breast cancer after PM is small. The clinical importance of detecting a premalignant or preinvasive lesion in the breast at PM is still unclear.     

Pre-hepatectomy portal vein embolization: Single center experience

Aim

To evaluate the feasibility and the effectiveness of portal vein embolization (PVE) as preoperative treatment in patients scheduled to undergo right hepatectomy, when the volume of the future remnant liver (FRL) appears to be insufficient to prevent the risk of post-surgical hepatic failure.

Materials and Methods

Thirty-one consecutive patients (19 men, 12 women; age range: 54–77 years; mean age: 66.2 years) with liver malignancy (7 hepatocellular carcinoma, 13 metastases, 9 cholangiocarcinoma, and 2 gallbladder carcinoma) were selected after clinical–radiological evaluation for PVE. After the embolization changes in volume of FRL, portal pressure, liver enzymes, and complications before and after hepatectomy were assessed.

Results

PVE was successful in all patients without major complications. The mean volume of FRL, calculated before and 4 weeks after PVE, increased from 319.2 ± 45.1 to 460.2 ± 27.7 cm³ (+44.2%) in the non-cirrhotic group and from 458.4 ± 38.3 to 605.2 ± 27 cm³ (+32.1%) in the cirrhotic group. The FRL/TELV ratio increased by 9%.

Conclusion

In our experience, PVE resulted feasible, safe, with a very low rate of complications, and effective to induce liver regeneration before right hepatectomy in patients with liver malignancy.     

Positive or close margins in breast conserving surgery: Is re-excision always necessary?

Background

More than half of re-excision specimens after breast conserving surgery (BCS) are found to be free of residual tumor at definitive histology. The aim of this study was to identify clinicopathological factors along with intrinsic subtypes of the tumor (luminal A, luminal B, HER2-overexpressing, triple-negative) associated with residual tumor in re-excision or mastectomy specimen.

Methods

Two hundred forty-eight patients with initial BCS, who underwent one or more re-excisions or mastectomy because of close or positive margins were reviewed.

Results

Residual cancer was found in 50% of re-excision(s) or mastectomy specimens. Patients with multifocality (vs unifocality; OR = 5.2; 95% CI, 2.6–10.4) or positive nodes (vs negative nodes; OR = 2.5; 95% CI, 1.4–4.4), or positive margins (vs close margins; OR = 1.7; 95% CI = 1.0–2.9) were more likely to have residual tumor in re-excision or mastectomy specimen compared to others.

Conclusion

Our results suggest that further surgery is often indicated in patients with node positive or multifocal cancers or positive margins after BCS since residual disease cannot be ruled out. Re-excision or mastectomy could be omitted in patients with close margins with favorable factors such unifocal tumor or node negative disease.     

A population based study of variations in operation rates for breast cancer,of comorbidity and prognosis at diagnosis: Failure to operate for early breast cancer in older women

Background

Older women are less likely to have surgery for operable breast cancer. This population-based study examines operation rates by age and identifies groups which present with early or late disease.

Methods

37 000 cancer registrations for 2007 were combined with Hospital Episode Statistics comorbidity data for England. Operation rates were examined by age, ethnicity, deprivation, comorbidity, screen-detection, tumour size, grade and nodal status. Early and late presentation were correlated with Nottingham Prognostic Index (NPI) groups and tumour size.

Results

The proportion of women not having surgery increased from 7–10% at ages 35–69 to 82% from age 90. From age 70, the proportion not having surgery rose by an average of 3.1% per year of age. Women with a Charlson Comorbidity Index score of ≥1 (which increased with age), with tumours >50 mm or who were node positive, were less likely to have surgery. Although women aged 70–79 were more likely to have larger tumours, their tumours were also more likely to have an excellent or good NPI (p < 0.001). Good prognosis tumours were more likely to be screen-detected, and less likely in women aged 0–39, the deprived and certain ethnic groups (p < 0.02).

Conclusions

From age 70 there is an increasing failure to operate for breast cancer. Younger women and certain ethnic groups presented with more advanced tumours. Older women had larger tumours which were otherwise of good prognosis, and this would not account for the failure to operate which may in part be related to comorbidity in this age group.     

Local treatment options for ipsilateral breast tumour recurrence

Purpose

In case of ipsilateral breast tumour recurrence (IBTR), radical mastectomy represents the treatment option frequently proposed. A second conservative treatment (2ndCT) has been proposed using either lumpectomy alone or associated with a re-irradiation of the tumor bed. However, in both clinical situations, the proof level of such therapeutic approaches remains low, based on cased-series or retrospective studies (level C).

Material and methods

In order to assess the different strategies of local treatment proposed in case of IBTR, a PubMed literature review was performed using the following keywords: breast cancer, ipsilateral recurrence, mastectomy, radiation therapy, brachytherapy. Four different salvage options were analyzed: (a) salvage mastectomy alone; (b) salvage mastectomy with postoperative re-irradiation; (c) 2ndCT with surgery alone; (d) 2ndCT with re-irradiation.

Results

The rate of second local recurrence is about 10% [3–32%], about 25% [7–36%] and about 10% [2–26%], after salvage mastectomy, salvage lumpectomy alone or combined with a re-irradiation of the tumor bed respectively.However, the 5-year overall survival rates after salvage mastectomy and 2ndCT seem to be equivalent (≈75%) mainly influenced by distant metastatic progression.

Conclusion

In terms of Evidence Based Medicine, different options can be discussed such as Phase III or II randomized trials comparing salvage mastectomy versus 2ndCT, retrospective studies based on a matched-pair analysis or observatory studies. Those study designs need to be carefully analyzed to be able to propose new treatment options for women who experience an IBCR.     

Ductal carcinoma in situ of the breast. Long-term follow-up of health-related quality of life,emotional reactions and body image

Aims

To investigate and compare long-term health-related quality of life (HRQoL), body image, and emotional reactions in women with ductal carcinoma in situ of the breast (DCIS) treated with different surgical methods.

Patients and Methods

A total of 162 women were included in the study (47 had mastectomy and immediate breast reconstruction (IBR), 51 sector resection alone and 64 sector resection and postoperative radiotherapy). All women included in the study were asked to complete three questionnaires 4–15 years after surgery: the SF-36 for HRQoL, the Hospital Anxiety and Depression (HAD) scale, and the Body Image Scale (BIS). The response rate was 81%.

Results

Women in all three study groups had, overall, a very satisfactory HRQoL in the long term, similar to women in the general population. Women who underwent mastectomy and IBR scored significantly higher on physical functioning and bodily pain than the other two study groups as well as their age-adjusted norm groups. The addition of radiotherapy to breast-conserving therapy did not seem to have any negative impact on long-term HRQoL. Our results show significant differences between the three study groups for six of ten BIS items, with a greater proportion of women in the mastectomy and IBR group reporting problems.

Conclusions

Women treated for DCIS have a very satisfactory long-term HRQoL. However, body image appeared to be negatively affected in mastectomy and IBR patients. Our results indicate that these women need more preoperative information about what changes in body image to expect after surgery.     

Parity in relation to survival following breast cancer

Aim

The present study examines the association between parity and survival following breast cancer diagnosis.

Methods

Medical records of 4453 women diagnosed with breast cancer in Malmö, Sweden, between 1961 and 1991 were analysed. All women were followed until 31 December 2003, using the Swedish Cause-of-Death Registry. Breast cancer specific mortality rate was calculated in different levels of parity. Corresponding relative risks, with 95% confidence intervals (CI), were obtained using Cox's proportional hazards analysis. All analyses were adjusted for potential prognostic factors and stratified for age, menopausal status and diagnostic period.

Results

As compared to women with one child, nulliparity (RR 1.27: 95% CI 1.09–1.47), and high parity (four or more children) (1.49: 1.20–1.85) were positively associated with a high mortality from breast cancer. When adjusted for potential confounders, the association was only statistically significant for high parity (1.33: 1.07–1.66). In the analyses stratified on age and menopausal status, there was a similar positive association between high parity and breast cancer death in all strata, although only statistically significant among women older than 45 years of age or postmenopausal. Nulliparity was associated with breast cancer death in women that were younger than 45 years of age (1.28: 0.79–2.09) or premenopausal (1.30: 0.95–1.80), but these associations did not reach statistical significance. There was no association between nulliparity and breast cancer death in women older than 45 years of age or postmenopausal. All associations were similar in analyses stratified for diagnostic period.

Conclusion

Women with four or more children have a poor breast cancer survival as compared to women with one child.     

Factors correlating with reexcision after breast-conserving therapy

Aim

The aim of this study was to evaluate factors affecting the risk for reexcision following breast-conserving surgery. Positive tumor margins are critical for local disease control following surgery for breast cancer. Several factors, including tumor size, multifocality, and an extensive in situ component, may be associated with a higher rate of repeat operations due to positive margins. This study included mammographic density in the analysis.

Methods

A total of 565 breast cancer patients were considered eligible for breast-conserving therapy after a core biopsy had confirmed malignancy. The patients’ mammographic findings were reviewed, and mammographic density was documented in addition to the histopathological features of the lesions. Associations between these factors and the risk for a second operation were analyzed using the chi-squared test, and a model was developed for multivariate analysis.

Results

At least one repeat operation was necessary in 121 patients (21.4%), and mastectomy was ultimately necessary in 54 patients (9.6%). Tumor size, multifocality, and the presence of an in situ component were identified as risk factors. A mammographic density of category 4 was associated with a need for further surgery (OR 3.2; 95% CI, 1.2–11).

Conclusions

Mammographic density is an additional risk factor for a second operation following breast-conserving procedures, and it may make radiographic and intraoperative localization of the tumor technically difficult. Using mammographic density to define a group of patients with a higher risk of reexcision might allow these patients to benefit from more sophisticated methods of localization and margin assessment.     

Quality of life in patients with peritoneal surface malignancies after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

Background

An increasing number of patients are presenting with peritoneal carcinomatosis and more centers are performing cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). While morbidity and mortality are shown to be acceptable, quality of life after surgery should be assessed.

Methods

63 patients who had CRS and HIPEC from 2001 to 2012 and who were still alive and on follow up were included. The EORTC-QLQ-C30 was administered to the patients.

Results

Median age was 53 years (14–71). 44% had ovarian primaries, 21% had appendicael primaries and 19% had colorectal primaries. Median follow-up was 1.08 years (0.06–9.8). The median time from surgery to the questionnaire was 1.3 years (0.24–10.18). There was no statistical difference in scores when comparing by age, gender, recurrence, gender, PCI score, presence of a complication and type of primary cancer. Scores were highest less than 6 months after surgery, dropped subsequently but rose again after 2 years. Our patients had better scores compared to a control group of outpatient cancer patients at our institution as well as the reference EORTC group.

Conclusions

In keeping with previous quality of life studies done for CRS and HIPEC patients, we have shown that our patients can achieve a good quality of life after CRS and HIPEC even with recurrent disease.     

Radiologic assessment of earliest,best, and plateau response of gastrointestinal stromal tumors to neoadjuvant imatinib prior to successful surgical resection

Background

To determine the timing of earliest, best and plateau response to neoadjuvant imatinib in patients with GIST.

Materials and methods

In this IRB-approved retrospective study, we included all 20 patients (10 women; mean age 61 years, range 30–83 years) with KIT-positive primary GIST who received neoadjuvant imatinib and underwent surgery between January 2001 and December 2012. Earliest (earliest time to partial response), best (percentage reduction in longest axial diameter [LAD] and volume correlated with RECIST 1.1 and volumetric criteria) and plateau (time point when there was <10% change in treatment response between two consecutive scans beyond best response) responses were analyzed on review of imaging.

Results

Median tumor size at baseline was 7.2 cm (range, 3.0–31.4 cm). Median duration of neoadjuvant imatinib was 32 weeks (IQR, 16–36 weeks). Partial response was noted in 16/20 patients (median interval = 16 weeks; IQR, 7–26 weeks); 4/20 had stable disease. Median time to earliest PR was 16 weeks (IQR, 7–26 weeks). At best response, median decrease in LAD and volume were 43% (IQR, 31–48%) and 83% (IQR, 63–87%), (median interval = 28 weeks; IQR, 18–37 weeks), at which point 10 tumors were resected. Plateau response (45% [IQR, 35–45%] LAD reduction) was noted in the remaining 10 patients (median interval = 34 weeks; IQR, 26–41 weeks) before resection. Tumor size, location or risk category did not correlate with best response or time to best response.

Conclusion

Best response to neoadjuvant imatinib was seen at 28 weeks irrespective of tumor size and location. Plateau response was seen at 34 weeks, beyond which further treatment may not be beneficial.     

The oncological safety of nipple-sparing mastectomy – A Swedish matched cohort study

Purpose

The oncological safety of nipple-sparing mastectomy in the context of immediate breast reconstruction is debatable. Previous studies report wide variations in local recurrence rates and randomised or matched cohort study designs are lacking. The aim of this study is to compare the local recurrence rate after nipple-sparing mastectomy to that after conventional mastectomy. Further, to compare the disease-free, overall and breast cancer-specific survival rates.

Methods

A retrospective review of all patients undergoing nipple-sparing mastectomy with immediate implant-based breast reconstruction at Karolinska University Hospital, Sweden, in the years 2000–2012 was conducted. These were matched 1:3 to patients operated by conventional mastectomy. Matching variables were age, tumour stage and year of surgery.

Results

Sixty-nine nipple-sparing mastectomies in 67 patients (study group) and 206 conventional mastectomies in 203 patients (control group) were included in the study. Median follow-up was 36 and 35 months for the study and control group, respectively. No local recurrence occurred in the study group, while seven local recurrences were observed in the control group (p = 0.197). The estimated 5-year figures were 100% and 95.8% (local recurrence-free survival), 94.1% and 82.5% (disease-free survival), 96.2% and 91.3% (overall survival) and 98.0% versus 94.8% (breast cancer-specific survival). Survival rates did not differ significantly between groups.

Conclusions

Nipple-sparing mastectomy may be offered to selected breast cancer patients without any negative impact on oncological safety.     

Massive endoprosthetic replacement for bone metastases resulting from renal cell carcinoma: Factors influencing patient survival

Background

Surgery remains the main treatment of bone metastases due to renal cell carcinoma (RCC). We reviewed 135 patients treated with resection and endoprosthetic replacement (EPR) and examined clinico-pathological factors predicting survival.

Methods

Surgical and oncological outcomes were examined using a prospectively maintained database between 1976 and 2012. Survival rates were calculated by Kaplan–Meier method. Multivariate analyses were performed to investigate factors predictive of increased survival.

Results

At diagnosis, 81 patients had synchronous RCC and bone metastases and the remaining developed metachronous metastases after primary treatment for RCC. The majority were solitary tumours (75%) and 77% had ≥ one concurrent visceral metastases. The median age at surgery was 61 years old (IQR 53–69). The median follow-up was 20 months (IQR 10–43) and the overall survival was 72% at one-year. This declined to 45% and 28% at three and five-years, respectively. After adjustments for prognostic factors, there was an increased risk of death in patients with multiple skeletal metastases (HR = 2), ≥one visceral metastases (HR = 3) and local recurrence (HR = 3) (all p ≤ 0.01). Ten patients required revision (7%) and the risk of revision was 4% at one-year and remained low at 8% from two years postoperatively.

Conclusion

Patients with solitary bone lesions and no visceral metastases should be considered for bone resection and EPR. As survival beyond one-year can be expected in a majority of patients and the risk of further surgery after EPR is low, patients with multiple skeletal metastases and visceral metastases should also be considered.     

Intensity-modulated radiation therapy for head and neck cancer: Systematic review and meta-analysis

Background and purpose

Intensity-modulated radiation therapy (IMRT) provides the possibility of dose-escalation with better normal tissue sparing. This study was performed to assess whether IMRT can improve clinical outcomes when compared with two-dimensional (2D-RT) or three-dimensional conformal radiation therapy (3D-CRT) in patients with head and neck cancer.

Methods and materials

Only prospective phase III randomized trials comparing IMRT with 2D-RT or 3D-CRT were eligible. Combined surgery and/or chemotherapy were allowed. Two authors independently selected and assessed the studies regarding eligibility criteria and risk of bias.

Results

Five studies were selected. A total of 871 patients were randomly assigned for 2D-RT or 3D-CRT (437), versus IMRT (434). Most patients presented with nasopharyngeal cancers (82%), and stages III/IV (62.1%). Three studies were classified as having unclear risk and two as high risk of bias. A significant overall benefit in favor of IMRT was found (hazard ratio – HR = 0.76; 95% CI: 0.66, 0.87; p < 0.0001) regarding xerostomia scores grade 2–4, with similar loco-regional control and overall survival.

Conclusions

IMRT reduces the incidence of grade 2–4 xerostomia in patients with head and neck cancers without compromising loco-regional control and overall survival.     

Locoregional recurrence in breast carcinoma patients

Aims

To assess the risk of locoregional recurrence (LRR) after mastectomy and to identify predictive and treatment factors that affect the risk of LRR.

Methods

The primary endpoint was local recurrence. Univariate and multivariate Cox regression analyses were carried out in the data from 1217 patients.

Results

The median follow-up was 74 months, and 63 (5.2%) patients experienced a LRR in their follow-up period. In the multivariate analysis, age group (≤35 years vs. >35 years, p < 0.0001; Hazard Ratio [HR], 5.0; 95% Confidence Interval [95% CI], 3.0–8.3), tumour size (>2 cm vs. ≤2 cm, p = 0.03; HR, 2.2; 95% CI, 1.2–4.7) and LVI (yes vs. no, p < 0.0001; HR, 3.2; 95% CI,1.9–5.2) were the independent prognostic factors for LRR. This analysis, in the final model, indicated that adjuvant radiotherapy and adjuvant tamoxifen were associated with a reduced risk of LRR by 90% and 75%, respectively, across the follow-up period, whereas age group remained as an important risk factor (p = 0.002; HR, 3.0; 95% CI, 1.5–6.2).

Conclusions

Although adjuvant therapies reduce the risk of LRR, young age is an independent risk factor for LRR.     

Smoky coal,tobacco smoking,and lung cancer risk in Xuanwei,China

Objectives

Lung cancer rates in Xuanwei are the highest in China. In-home use of smoky coal has been associated with lung cancer risk, and the association of smoking and lung cancer risk strengthened after stove improvement. Here, we explored the differential association of tobacco use and lung cancer risk by the intensity, duration, and type of coal used.

Materials and methods

We conducted a population-based case-control study of 260 male lung cancer cases and 260 age-matched male controls. Odds ratios (OR) and 95% confidence interval (CI) for tobacco use was calculated by conditional logistic regression.

Results

Use of smoky coal was significantly associated with an increased risk of lung cancer, and tobacco use was weakly and non-significantly associated with lung cancer risk. When the association was assessed by coal use, the cigarette-lung cancer risk association was null in hazardous coal users and elevated in less hazardous smoky coal users and non-smoky coal users. The risk of lung cancer per cigarette per day decreased as annual use of coal increased (>0–3 tons: OR: 1.09; 95% CI: 1.03–1.17; >3 tons: OR: 0.99; 95% CI: 0.95–1.03). Among more hazardous coal users, attenuation occured at even low levels of usage (>0–3 tons: OR: 1.02; 95% CI: 0.91–1.14; >3 tons: OR: 0.94; 95% CI: 0.97–1.03).

Conclusion

We found evidence that smoky coal attenuated the tobacco and lung cancer risk association in males that lived in Xuanwei, particularly among users of hazardous coal where even low levels of smoky coal attenuated the association. Our results suggest that the adverse effects of tobacco may become more apparent as China's population continues to switch to cleaner fuels for the home, underscoring the urgent need for smoking cessation in China and elsewhere.     

Effect of local therapy on locoregional recurrence in postmenopausal women with breast cancer in the Tamoxifen Exemestane Adjuvant Multinational (TEAM) trial

Background and purpose

The TEAM trial investigated the efficacy and safety of adjuvant endocrine therapy consisting of either exemestane or the sequence of tamoxifen followed by exemestane in postmenopausal hormone-sensitive breast cancer. The present analyses explored the association between locoregional therapy and recurrence (LRR) in this population.

Material and methods

Between 2001 and 2006, 9779 patients were randomized. Local treatment was breast conserving surgery plus radiotherapy (BCS + RT), mastectomy without radiotherapy (MST-only), or mastectomy plus radiotherapy (MST + RT). Patients with unknown data on surgery, radiotherapy, tumor or nodal stage (n = 199), and patients treated by lumpectomy without radiotherapy (n = 349) were excluded.

Results

After a median follow-up of 5.2 years, 270 LRRs occurred (2.9%) among 9231 patients. The 5-years actuarial incidence of LRR was 4.2% (95% CI 3.3–4.9%) for MST-only, 3.4% (95% CI 2.4–4.2%) for MST + RT and 1.9% (95% CI 1.5–2.3%) for BCS + RT. After adjustment for prognostic factors, the hazard ratio (HR, reference BCS + RT) for LRR remained significantly higher for MST-only (HR 1.53; 95% CI 1.10–2.11), not for MST + RT (HR 0.78; 95% CI 0.50–1.22).

Conclusion

This explorative analysis showed a higher LRR risk after MST-only than after BCS + RT, even after adjustment for prognostic factors. As this effect was not seen for MST + RT versus BCS + RT, it might be explained by the beneficial effects of radiation treatment.     

Survival outcome of operated and non-operated elderly patients with rectal cancer: A Surveillance,Epidemiology, and End Results analysis

Background

With an ageing population, surgery is increasingly offered to elderly patients with rectal cancer, although outcomes for the oldest patients remain poorly defined. This study aimed to determine whether operative intervention improves outcome in elderly patients.

Method

Patients aged 18+ years diagnosed with rectal adenocarcinoma between 1998 and 2009 were identified from the Surveillance, Epidemiology, and End Results database. The primary endpoint was adjusted hazard ratios (HR) for 5-year cancer specific survival (CSS); the secondary endpoint was 5-year overall survival (OS).

Results

With increasing age, patients were less likely to undergo surgery, receive a complete stage or receive neoadjuvant radiotherapy. CSS and OS increasingly diverged with age in patients undergoing surgery. Those aged 80+ had reduced CSS compared to those aged 70–79 years (stages I–III, respective adjusted HR 2.14, 1.58, 1.48, all p < 0.001). However, stage II patients aged 80+ treated with resection and neoadjuvant therapy had similar survival to those aged 70–79 years (adjusted HR 1.26, p = 0.149). For only patients aged 80+ years, those treated non-operatively had lower survival than those undergoing surgery, who in turn had the best survival when treated with neoadjuvant radiotherapy (adjusted HR 0.74, p = 0.001).

Conclusion

Contrary to common expectation, in patients aged over 80 with rectal cancer, surgery with or without other modalities was associated with better survival than non-operative treatment. Despite selection bias in this observational study, these findings support consideration of maximal therapy regardless of age in selected patients deemed to be fit, since this leads to outcomes equivalent to younger patients.