Neoadjuvant Chemotherapy of Breast Cancer: Tumor Markers as Predictors of Pathologic Response,Recurrence, and Survival

Abstract: This study reports the value of the tumor markers estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2) in predicting the response of breast cancer to neoadjuvant chemotherapy. A community cancer center prospectively maintained breast cancer database containing over 8,000 patient records was used. Since 1989, 464 patients were treated with neoadjuvant chemotherapy followed by surgical resection and were tested for ER and PR. Estrogen receptor and/or PR positive patients were considered hormone receptor (HR) positive. Human epidermal growth factor receptor 2 status was available on 368 patients. Total, breast, and nodal pathologic complete response (pCR) rates, recurrence, and overall survival were assessed. Total and breast pCR rates were higher in HR negative (HR?) patients (26% and 32%, respectively) than in HR positive (HR+) patients (4% and 7%, respectively; p < 0.001). Compared to HR+ patients, HR? patients had higher recurrence rates (38% versus 22%; p < 0.001), a shorter time to recurrence (1.28 versus 2.14 years; p < 0.001), and decreased overall survival (67% versus 81%; p < 0.001). Human epidermal growth factor receptor 2 positive patients treated with neoadjuvant trastuzumab (NAT) demonstrated higher total pCR (34% versus 13%; p = 0.008), breast pCR (37% versus 17%; p = 0.02), and nodal pCR rates (47% versus 23%; p = 0.05) compared to HER2+ patients not treated with NAT. Furthermore, HER2+ patients who received NAT had lower recurrence rates (5% versus 42%; p < 0.001) and increased overall survival (97% versus 68%; p < 0.001). In conclusion, breast cancer HR status is predictive of total and breast pCR rates after neoadjuvant chemotherapy. Although HR? patients derive greater benefit from neoadjuvant chemotherapy in terms of pathologic response, they have worse outcomes in terms of recurrence and survival. Hormone receptor positive patients demonstrate significantly less response to neoadjuvant chemotherapy, but significantly better overall outcome. For both HR? and HR+, addition of NAT for HER2+ tumors results in both a superior response and outcome.     

Impact of Oncotype DX on Treatment Decisions in ER‐Positive,Node‐Negative Breast Cancer with Histologic Correlation

Oncotype DX, a gene‐expression profiling assay, provides stratification of patients with estrogen‐receptor positive, lymph‐node‐negative early breast cancer into risk groups based on recurrence score, which are associated with distant recurrence and response to chemotherapy. This study aims to determine whether Oncotype DX influences clinicians' treatment decisions, and whether assay results correlate with histologic assessment. Fifty patients with estrogen‐receptor positive, node‐negative early breast cancer analyzed by Oncotype DX and operated on by two breast surgeons were included. To assess effect on treatment decisions, clinical vignettes were created by retrospective chart review. Physicians were then presented with the clinical vignettes and instructed to make a treatment decisions (i.e., hormone therapy alone versus hormone therapy combined with chemotherapy) both before and after knowledge of the recurrence score. To assess correlation with histologic assessment, a prospective, blinded review of tumor slides was performed by two pathologists. Based on this review, tumors were placed into low, intermediate and high risk groups for comparison with Oncotype DX assay results. Treatment decisions were changed based on Oncotype DX results in 36 and 18% of cases by breast surgeons and medical oncologists, respectively. All tumors categorized as high risk by Oncotype DX were categorized as high risk based on histologic assessment, and 96% of cases categorized as low risk by recurrence score were categorized as low or intermediate risk by histologic assessment. Oncotype DX significantly influences management of estrogen‐receptor positive, lymph‐node‐negative early breast cancer. Further studies are needed to assess association of histologic categorization to assay results.     

乳腺癌分子分型与预后关系的研究

目的 探讨乳腺癌分子分型与预后之间的关系.方法 回顾性分析2002年1月至2003年12月接受手术治疗的708例原发性乳腺癌患者的临床资料.患者均为女性,平均年龄53岁.根据雌激素受体(ER)、孕激素受体(PR)及人类表皮生长因子受体2(HER2)状态的免疫组织化学结果,将全组乳腺癌分型为:内分泌高反应型、内分泌反应不完全型、三阴型及HER2阳性型,观察不同分子分型乳腺癌的预后,比较各型患者术后的累计生存率,多因素分析筛选预后相关因素.结果 本组内分泌高反应型、内分泌反应不完全型、HER2阳性型及三阴型乳腺癌所占的比例分别为33.2%(235/708)、23.6%(167/708)、21.3%(151/708)和21.9%(155/708).随访3～69个月,中位随访时间40.2个月,100例患者复发或死亡.单因素分析示乳腺癌预后与肿瘤大小、腋窝淋巴结状态、分子分型、术后辅助放疗及内分泌治疗有关;多因素分析示分子分型和淋巴结状态为乳腺癌的独立预后因素;生存分析示内分泌高反应型乳腺癌的预后好于其他三型.结论 乳腺癌分子分型是预后的独立预测因素,内分泌高反应型乳腺癌预后最好.     

Casting-type calcifications with invasion and high-grade ductal carcinoma in situ: a more aggressive disease?

HYPOTHESIS: Women with breast cancer who have casting-type microcalcifications associated with multifocal invasion and extensive ductal carcinoma in situ (DCIS) form a subset of patients with a poor prognosis. Our study aims to identify the mammographic and pathologic features of this group. DESIGN: Women with casting-type microcalcifications, multifocal invasion, and extensive DCIS were identified from our tumor board registry. Mammographic features, tumor characteristics, treatment, and survival rates were evaluated. Invasive tumors were limited to 14 mm or smaller. SETTING: University medical teaching hospital and breast cancer specialty clinic. RESULTS: Of the 984 patients with breast cancer treated at our center, 15 patients were identified who had extensive casting-type calcifications and DCIS. Twelve of these patients also had multifocal invasive breast cancer. All had casting-type microcalcifications occupying more than 1 breast quadrant. All but 1 of the patients were treated using mastectomy with sentinel node biopsy or axillary node dissection. All but 1 patient had extensive grade 3 DCIS. Invasive tumors were negative for estrogen receptor and progesterone receptor expression in half of the patients, and 60% were positive for the HER-2-neu receptor. Positive axillary lymph nodes were found in 33% of patients, and 75% received adjuvant chemotherapy. After a median follow-up period of 20.5 months (range, 6-72 months), 1 patient had died and 1 had distant metastases. Of the 3 patients who had DCIS without invasion, 1 experienced a recurrence with infiltrating ductal carcinoma. CONCLUSIONS: In women with small multifocal breast cancers with extensive casting calcifications and DCIS, the incidence of positive lymph nodes was 33%, with a tendency for poor tumor markers. These women appear to be at substantial risk for systemic disease; lymph node sampling and adjuvant systemic therapy are recommended.     

Linkage disequilibrium between the androgen receptor gene CAG and GGC repeats in the African-American population

African-American men are at an increased risk of developing prostate cancer when compared with other racial and ethnic groups. In addition, African-Americans display a greater propensity for developing aggressive prostate cancer. There are multiple etiologic factors that likely contribute to the development of prostate cancer; however, one potential factor that may explain differences of prostate cancer risk among ethnic and racial groups is the androgen receptor (AR) gene. Studies have showed that there is correlation between two polymorphic microsatellite regions of the AR receptor gene and its transactivational activity. The CAG and GGC repeats both have been implicated as important loci for variation in differential androgen receptor activity. This review analyzes the available data regarding variation of the CAG and GGC repeat sequences among different racial and ethnic populations, and the implications of these variations for prostate cancer risk.     

Immunohistochemical and biochemical measurement of estrogen and progesterone receptors in primary breast cancer. Correlation of histopathology and prognostic factors.

OBJECTIVE: The authors investigated correlations of estrogen-receptor and progesterone-receptor with conventional risk factors as well as histopathology in patients with primary breast cancer. SUMMARY BACKGROUND DATA: Immunohistochemically determined hormone receptors have gained importance as prognosticators in primary breast cancer, but their definitive role has not yet been evaluated. METHODS: Tumor samples from 299 patients were examined for estrogen and progesterone receptors by biochemical and immunohistochemical assay. Correlations with established risk factors (tumor size, lymph node status, menopausal status, grading including subfactors) and histopathology were analyzed. RESULTS: The estrogen receptor, determined by immunohistochemical method revealed positivity in 80.6% of patients; biochemical measurement yielded 76.2% positive results. The progesterone receptor measured by immunohistochemistry yielded 61.3% positivity versus 55.8% detected by biochemical analysis. Invasive lobular, tubular, and ductal invasive carcinoma with prominent stroma content ("scirrhous carcinoma") rather than ductal invasive carcinoma was more frequently estrogen-receptor positive with immunohistochemistry than with biochemical assay. For progesterone receptor, the same pattern of positivity was seen with immunohistochemical assay. With progesterone receptor determined biochemically, "scirrhous" and lobular carcinoma showed positive results in a lower proportion than invasive ductal and tubular carcinoma. Significant correlations were observed between the estrogen-receptor status, the histologic grade of malignancy, nuclear polymorphism, and the rate of mitosis with both methods (p < 0.001 respectively). Different correlations were found between tumor size, menopausal status and estrogen receptor status with both assays respectively. For the progesterone receptor status, immunohistochemistry yielded significant correlations with the histologic grade of malignancy, nuclear polymorphism, rate of mitosis (p < 0.001 respectively) as well as growth pattern (p < 0.01), while biochemical analysis revealed a correlation with nuclear polymorphism (p < 0.05). The correlation analysis of both components of the immunoreactive score revealed a more significant impact of percentage of positive cells than of staining intensity. CONCLUSIONS: Immunohistochemistry detected a closer correlation between prognostic factors and receptor data than biochemical analysis.     

Indigent breast cancer patients among all racial and ethnic groups present with more advanced disease compared with nationally reported data

BACKGROUND: This study examines the epidemiologic and pathologic characteristics of indigent breast cancer patients followed up in a public city hospital in comparison to national standards. METHODS: A prospective oncology database was queried to identify all patients presenting with primary breast cancer. Medical records of 188 patients identified between March 1997 and May 2002 were retrospectively reviewed. Pathologic and epidemiologic data were compared with 1998 data reported by the Surveillance, Epidemiology, and End Results (SEER) program. RESULTS: Among the patient population 10% were Caucasian, 13% African-American, 49% Hispanic, 25% Chinese, and 6% were of other background. The majority of patients were uninsured. Indigent patients within each ethnic group presented with more advanced disease when compared with patients reported by SEER. CONCLUSIONS: Indigent patients among all ethnic and racial backgrounds present with more advanced disease when compared with national statistics reported by SEER. The majority of these patients is uninsured and would benefit from more aggressive education, screening, detection methods, and follow-up.     

The prognostic significance of Gail model risk factors for women with breast cancer

BACKGROUND: Because many risk factors for breast cancer are related to hormonal factors and hormonal factors influence breast cancer prognosis, risk factors may have prognostic value. In order to assess the prognostic value of risk factors for breast cancer we divided patients with breast cancer into those at high risk and low risk using the Gail model. METHODS: Patients with available follow-up and information concerning age, age at menarche, number of children, age at first birth, number of first degree relatives with breast cancer, and number of previous breast biopsies were divided into low and high-risk groups by the average relative risk calculated using the Gail model. Risk factors, clinical presentations, pathologic findings, tumor characteristics, extent of disease, treatment and outcomes for the 106 high-risk women were compared with the 206 low-risk women. Stage IV patients were excluded. RESULTS: The average relative risk of breast cancer was 2.09. The 106 high-risk women were significantly older (58 years versus 53 years; P = 0.001), older at first live birth (30 years versus 23 years; P <0.001), more likely to have a first degree relative with breast cancer (57% versus 0%; P <0.001), and more likely to have previously had a breast biopsy (19% versus 1%; P <0.001). There was no difference in the average age at menarche. Low-risk patients were significantly more frequently nulliparous (40% versus 22%; P = 0.002). Clinical presentation, pathologic findings, extent of disease, and treatment were comparable in high and low-risk patients. Cancers of low-risk patients were more frequently poorly differentiated (39% versus 25%, P = 0.044). Tamoxifen was used more frequently in high-risk patients (56% versus 41%; P = 0.012). High-risk patients exhibited significantly better 5-year (95% versus 88%; P = 0.047) and 10-year distant disease-free survival than low-risk patients (88% versus 79%; P = 0.050). In multivariate analysis only the number of involved lymph nodes was related to local (P = 0.001) and distant (P <0.001) disease-free survival. CONCLUSIONS: Breast cancer patients considered high risk by the Gail model have significantly better disease-free survival than low-risk patients. This study does not support the notion that risk factors for breast cancer are prognostic factors.     

Prognostic Factors for Metachronous Contralateral Breast Cancer: Implications for Management of the Contralateral Breast

The absolute number of breast cancer survivors who are at risk for metachronous contralateral breast cancer (mCBC) has dramatically increased. The objectives of this study were to identify factors predictive of survival for patients with mCBC and to determine clinicopathological factors predictive of advanced mCBC. Using the Surveillance, Epidemiology, and End Results data base, we identified women, ages 18–80, diagnosed with invasive breast cancer from 1992 to 2010. We excluded patients with bilateral and stage IV primary breast cancer. Patients who developed mCBC ≥12 months from initial diagnosis were identified. Kaplan–Meier methods and Cox proportional hazards modeling were used to determine survival of patients with mCBC. Multivariate logistic regression was utilized to determine factors associated with advanced mCBC. We identified 6,673 patients who developed mCBC during our study period. The median interval between initial breast cancer and mCBC was 5 years. The strongest predictor of overall survival was the nodal status of the mCBC. Other significant prognostic factors included patient age; race; size, nodal status, estrogen receptor status, grade, and type of surgery of the initial breast cancer; grade of the mCBC; and use of radiation therapy for the mCBC. Overall, 25% of mCBCs were node positive. Younger age, black race, and characteristics of the initial breast cancer (increased size, invasive lobular histology, mastectomy treatment, and node‐positivity) were significantly associated with node‐positive mCBC (all p < 0.0.05). The most powerful predictor of survival for patients with mCBC is the nodal status of mCBC. Patients with advanced initial breast cancers are more likely to develop node‐positive mCBC. Adherence to current surveillance and adjuvant therapy guidelines may minimize the risk and mortality of mCBCs.     

Comparative Long‐term Study of a Large Series of Patients with Invasive Ductal Carcinoma and Invasive Lobular Carcinoma. Loco‐Regional Recurrence,Metastasis, and Survival

Our aim was to compare histologic and immunohistochemical features, surgical treatment and clinical course, including disease recurrence, distant metastases, and mortality between patients with invasive ductal carcinoma (IDC) or invasive lobular carcinoma (ILC). We included 1,745 patients operated for 1,789 breast tumors, with 1,639 IDC (1,600 patients) and 145 patients with ILC and 150 breast tumors. The median follow‐up was 76 months. ILC was significantly more likely to be associated with a favorable phenotype. Prevalence of contralateral breast cancer was slightly higher for ILC patients than for IDC patients (4.0% versus 3.2%; p = n.s). ILC was more likely multifocal, estrogen receptor positive, Human Epidermal Growth Factor Receptor‐2 (HER2) negative, and with lower proliferative index compared to IDC. Considering conservative surgery, ILC patients required more frequently re‐excision and/or mastectomy. Prevalence of stage IIB and III stages were significantly more frequent in ILC patients than in IDC patients (37.4% versus 25.3%, p = 0.006). Positive nodes were significantly more frequent in the ILC patients (44.6% versus 37.0%, p = 0.04). After adjustment for tumor size and nodal status, frequencies of recurrence/metastasis, disease‐free and specific survival were similar among patients with IDC and patients with ILC. In conclusion, women with ILC do not have worse clinical outcomes than their counterparts with IDC. Management decisions should be based on individual patient and tumor biologic characteristics rather than on lobular versus ductal histology.     

Short-term survival in breast cancer: the experience of the University of Malaya Medical Centre

OBJECTIVE: To study the impact of various clinicopathological factors on short-term survival in a cohort of breast cancer patients treated at the University of Malaya Medical Centre (UMMC). METHODS: All cases of breast cancer treated at UMMC from January 1999 to June 2001, except for stage IV disease, were included in the study. Survival analysis was carried out using Kaplan-Meier for univariate analysis and Cox regression for multivariate analysis. The log-rank test was used to test the significance of differences between the different survival curves. RESULTS: A total of 385 patients were included. The mean patient age at presentation was 50.3 years (SD, 11.4); 198 (51.4%) patients had lymph node-positive disease, and 187 (48.6%) had node-negative disease. The mean follow-up period was 18.7 months (SD, 8.8). The Malay ethnic group, tumours of larger size, node-positive disease, more than five positive lymph nodes, oestrogen receptor (ER) negativity and the presence of lymphovascular invasion were significant prognostic factors for shorter recurrence-free survival (RFS) in the univariate analysis. In the multivariate analysis, ER negativity was the only independent adverse prognostic factor for RFS. For overall survival (OS), tumours of larger size, node-positive disease, more than five positive lymph nodes, ER negativity and high grade tumours were associated with significantly shorter OS. However, more than five positive lymph nodes was the only independent prognostic factor for shorter OS in the multivariate analysis. Further multivariate analysis of the patients with node-positive disease showed that the Malay ethnic group, ER negativity and more than five positive lymph nodes were independent prognostic factors for shorter RFS. On the other hand, ER negativity and more than five positive lymph nodes were independent negative prognostic factors for OS in this subgroup of patients. CONCLUSION: The evaluation of various prognostic factors would provide useful information on disease progression in local patients, especially for the planning of adjuvant therapies and follow-up protocols. Differences in the pattern of breast cancer among the different ethnic groups in Malaysia warrant further studies.     

男性乳腺癌：附17例报告

目的:探讨男性乳腺癌的诊断、治疗及预后。方法:回顾性分析17例男性乳腺癌患者的临床资料。结果:17例患者平均年龄为59.6岁。其中Ⅰ期3例，Ⅱ期5例，Ⅲ期7例，Ⅳ期2例。以典型浸润性导管癌为主，乳腺癌的雌、孕激素受体阳性率分别为82.4 %和72.5 %。均行根治性手术治疗，术后辅以放疗、内分泌治疗和（或）化疗。其中1例失访，2例术后8个月~3年死于其它疾病，余14例术后已生存1～12年。结论:男性乳腺癌发病率低，发病年龄偏大,易误诊;内分泌治疗首选他莫昔芬;影响其预后的因素很多，其中最重要的是诊断时肿瘤的分期和淋巴结受累情况。     

Prognostic value of insulin-like growth factor 1 and insulin-like growth factor binding protein 3 blood levels in breast cancer

High circulating insulin-like growth factor 1 (IGF-1) levels are firmly established as a risk factor for developing breast cancer, especially estrogen positive tumors. The effect of circulating IGF-1 on prognosis once a tumor is established is unknown. The authors explored the effect of IGF-1 blood levels and of it's main binding protein, IGFBP-3, on overall survival and occurrence of second primary breast tumors in breast cancer patients, as well as reproductive and lifestyle factors that could modify this risk. Patients were accrued from six hospitals in the Netherlands between 1998 and 2003. Total IGF-1 and IGFBP-3 were measured in 582 plasma samples.No significant association between IGF-1 and IGFBP-3 plasma levels and overall survival was found. However, in a multivariate Cox regression model including standard prognostic variables high IGF-1 levels were related to worse overall survival in patients receiving endocrine therapy (HR = 1.37, 95% CI: 1.11, 1.69, P 0.004). These data at least indicate that higher IGF-1 levels, and as a consequence most likely IGF-1-induced signaling, are related to a less favorable overall survival in breast cancer patients treated with endocrine therapy. Interventions aimed at reducing circulating levels of IGF-1 in hormone receptor positive breast cancer may improve survival.     

Position Paper of the American Council on Science and Health on Risk Factors for Breast Cancer: Established, Speculated, and Unsupported

Abstract: This article provides the position of the American Council on Science and Health regarding how breast cancer is defined and classified; the magnitude of the public health problem of breast cancer among women; the implications of variation in incidence of breast cancer internationally and with migration; access to health care as a factor in slight differences in incidence and mortality rates among African-American and white women; and the evidence concerning various proposed human-breast-cancer risk factors. The article classifies risk factors as either established, speculated, or unsupported on the basis of available evidence. Specific genes have been identified that may explain as much as 5–10% of new breast cancer cases. Inherited predispositions may be characterized by family history of breast or ovarian cancer, young age at diagnosis, breast cancer diagnosed in both breasts, and male breast cancer. Benign breast disease (BBD), particularly the subtypes of BBD involving atypical hyperplasia, and exposure early in life to ionizing radiation is an established risk factor for breast cancer. Several reproductive characteristics are established as risk factors for breast cancer: early age at menarche, first full-term pregnancy after age 35 years of late age, and late age of menopause. Obesity and low physical activity are established as risk factors for breast cancer and are modifiable. Speculated risk factors for breast cancer that are gaining scientific support include nulliparity, oral contraceptive use, and postmenopausal estrogen replacement therapy. Speculated risk factors for which there is conflicting or preliminary support include not breast feeding, postmenopausal estrogen/progestogen replacement therapy, prescribed diethylstilbestrol, low consumption of phytoestrogens, specific dietary practices, alcohol consumption, not using nonsteroidal antinflammatory drugs, abortion, and breast augmentation. Unsupported risk factors include higher than average consumption of phytoestrogens, premenopausal obesity, electromagnetic fields, and low-dose ionizing radiation after 40 years of age. There is only limited support for xenoestrogens and large breast size as risk factors for breast cancer.     

Clinical Observations from a Breast Cancer Registry in Asian Women

Background The incidence of breast cancer in Singapore, reflecting cancer trends of developed nations, is rising rapidly. It is the most common cancer in Singaporean women. Given the significant problem that breast cancer poses, this study reports the clinical-pathologic features of 1,165 women with invasive breast cancer managed at a university teaching hospital in Singapore. Methods All patients who were diagnosed, treated, and followed-up at this institution between 1990 and 2002 were analyzed. Data were obtained from the National University Hospital Breast Cancer Registry. Results Of our patients, 82% were ethnic Chinese. The median age of presentation was 49 years, and 24.5% of our patients presented with stage I disease. In addition, 51% of premenopausal and 60% of postmenopausal patients stained positive for estrogen receptor. Mastectomy was the most common surgical therapy, and about 90% of patients received adjuvant therapy. At a median follow-up of 81 months, the median 5-year survival was as follows: stage I, 97%, stage II, 78%, stage III, 52%, and stage IV, 13%. Conclusions This study supports what has been observed among breast cancer patients in this region and reflects a profile of breast cancer that differs from that seen in the West: patients present at a younger age, with more advanced stage and fewer estrogen-positive tumors. Most women in our series received systemic adjuvant therapy, and the 5-year overall survival rates are equivalent to published results from the West. The unique features of the disease in women in Singapore are important to recognize, as they may influence future prevention and management strategies for Asian women with breast cancer.     

The Identification of a Subset of Patients with Axillary Node-Negative Minimally Invasive Breast Cancer Who May Benefit from Adjuvant Systemic Therapy

Abstract: It is generally accepted that women with axillary node-negative minimally invasive breast cancers (≤1 cm) are not candidates for systemic therapy because of their low risk for distant metastases and excellent overall prognosis. However, recent studies have suggested that a subset of these patients may have a significant risk of failure. In this study, 188 women with axillary node-negative minimally invasive breast cancer (≤1 cm) were treated with conservative surgery and radiation. Their median age was 56 years. The median followup was 6.2 years. The following factors were analyzed for their ability to predict for freedom from distant metastases, distant disease-free survival, and cause-specific survival: patient age, method of detection of the primary, tumor size, estrogen and progesterone receptor status, and lymphatic invasion.
The ten year actuarial distant disease-free survival, cause-specific, and overall survival were 80%, 94%, 92% respectively. There were no significant prognostic factors for freedom from distant metastases or distant disease-free survival although young women and those with estrogen receptor negative tumors had a 20–25% risk of distant disease at ten years. The median interval to distant metastases was five years. Estrogen receptor negativity was a significant prognostic factor for cause-specific survival (ten year 81%).
We have identified a subgroup of patients with axillary node-negative minimally invasive breast cancer (≤ 1 cm) whose risk of distant failure at ten years is 20% or greater. These patients are characterized by young age and estrogen receptor negativity and may be candidates for adjuvant systemic therapy. We await confirmation of our results by others.     

Risk factors for estrogen receptor-positive breast cancer

HYPOTHESIS: Some risk factors associated with breast cancer may be more predictive of estrogen receptor (ER)- positive than ER-negative tumors. DESIGN: Survey of patients enrolled in a study of breast cancer risk factors. SETTING: Community population in a northern California county. PATIENTS: A total of 234 individuals diagnosed as having breast cancer between July 1, 1997, and June 30, 1999, reporting Marin County, California, residence and participating in a questionnaire regarding exposure to breast cancer risk factors. MAIN OUTCOME MEASURE: Diagnosis of ER-positive vs ER-negative breast cancer. RESULTS: Comparison between ER-positive and ER-negative cases showed several factors predictive of ER-positive tumors. In a multivariate model, years of hormone therapy use remained the most significant predictor of ER-positive disease. CONCLUSIONS: Patients diagnosed as having ER-positive breast cancer were more likely to have undergone hormone therapy. The excess of ER-positive breast cancers reported in Marin County could, therefore, in part, be related to hormone therapy.     

Outcomes in racial and ethnic minorities after revisional robotic-assisted metabolic and bariatric surgery: an analysis of the MBSAQIP database

BackgroundRobotic-assisted metabolic and bariatric surgery (MBS) is being performed with increased frequency in the United States, including for revisional MBS. However, little is known about perioperative outcomes between racial and ethnic cohorts after revisional robotic-assisted MBS.ObjectiveThe goal of our study was to determine if there are racial differences in outcomes after robotic-assisted revisional MBS.SettingUniversity Hospital, United States.MethodsUsing the 2015–2017 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, we identified patients undergoing revisional MBS by a robotic-assisted approach. Univariate analyses were performed of unmatched and matched racial and ethnic cohorts, comparing black versus white patients and Hispanic versus white patients.ResultsOf 2027 robotic-assisted revisional MBS cases in the database, 1922 were included in our analysis, including 67%, 22.6%, and 10.4% white, black, and Hispanic patients, respectively. At baseline, there were some differences in patient characteristics between racial and ethnic cohorts. After propensity matching, outcomes between black and white patients were similar, except for higher rates of superficial surgical site infection among white patients (P = .05) and higher rates of organ space surgical site infection in black patients (P = .05). Outcomes were also similar between matched white and Hispanic patients, except for a higher bleeding in white patients (2% versus 0%, P = .04). There were no mortality or morbidity differences between racial and ethnic cohorts.ConclusionMorbidity and mortality after robotic-assisted revisional MBS do not seem to be mediated by race or ethnicity.     

Patient age and positive margins are predictive factors of residual tumor on mastectomy specimen after conservative treatment for breast cancer

AimsTo determine factors predictive of the presence of residual tumor on the specimen from mastectomy performed after conservative treatment for breast cancer in order to limit potentially unnecessary mastectomies (free of residual lesions).Materials and methods294 patients treated in 2 expert centers for breast cancer with breast-conserving therapy (BCT) followed by mastectomy, according to French recommendations, were investigated between January 1, 1998 and January 1, 2005. Patients with residual tumor on the mastectomy specimen were compared with patients whose mastectomy specimens did not reveal any residual tumor. All the clinical risk factors (age, previous history of breast cancer, tumor focality) and histological risk factors (tumor size, histological type, positive margins, estrogen and progesterone receptor expression, histological grade) for residual tumor after BCT were compared between the 2 patient groups.ResultsOf the 294 patients studied, 202 (68.71%) mastectomies had residual tumor and 92 (31.29%) were tumor-free. Four predictive factors for residual tumor were found in the univariate analysis: age under 45 years (p = 0.01), absence of estrogen receptor expression (p = 0.05), positive margins (p = 0.01), and presence of lymph node metastases (p = 0.05). The multivariate analysis revealed only 2 independent risk factors that were significantly associated with increased risk of residual tumor on the mastectomy specimen: age under 45 years (p = 0.05) and presence of positive margins on the lumpectomy specimen (p = 0.05).ConclusionYoung age of patients (under 45-years-old) and presence of positive margins on the operative specimen are independent risk factors of residual tumor after conservative treatment of breast cancer.     

Socioeconomic Factors, not Ethnicity, Predict Breast Self-Examination

Abstract: The American Cancer Society has recommended monthly breast self-examinations (BSEs) to aid in the early detection of breast cancer. Compliance with BSE recommendations has been shown to be decreased in certain ethnic groups. This investigation evaluates relevant variables involved in BSE compliance in an urban breast cancer screening center. A survey over a 1-year period (June 1996–June 1997) was given to all patients on their initial visit to the Breast Health Center at Tulane University Medical Center. Demographic and socioeconomic factors associated with the compliance of BSE were explored. The overall rate of BSE was relatively high at 80%. There was no difference between ethnic groups in rates of BSE (Caucasians 21% versus African Americans 20%). Statistically significant variables associated with BSE noncompliance were high school education (did not complete high school 16% versus completed high school 33%; p < 0.0004), employment status (employed 16% versus unemployed 31%; p < 0.0004), and marital status (married 15% versus single/divorced 22%; p < 0.05). While the majority of women in our study practiced BSE and ethnicity did not predict BSE, several socioeconomic factors were predictive of BSE compliance. Efforts to increase community outreach to lower socioeconomic patients as well as efforts to ensure proficient BSE techniques by patients may help detect early breast cancer.