Impact of breast cancer treatment guidelines on surgeon practice patterns: results of a hospital-based intervention

BACKGROUND: Despite evidence regarding the effectiveness of post-surgical treatments for early-stage breast cancer, older women are less likely to receive appropriate therapy. We evaluated the impact of surgeon-specific "performance reports" on adherence to treatment guidelines among older women with breast cancer. METHODS: We obtained diagnostic and treatment data from hospital tumor registries supplemented with self-reported adjuvant therapy information on 1099 patients with stage I or II breast cancer diagnosed between November 1, 1992, and January 31, 1997, at 6 Rhode Island hospitals. We compared rates of appropriate treatment receipt before and after distribution of performance reports. Hierarchical analysis was used to account for the nesting of patients within surgeons. Separate analyses of mastectomy and breast-conserving surgery were performed. RESULTS: Age was negatively associated with post-surgical treatment, with patients who had breast-conserving surgery and who were older than 80 years significantly less likely to undergo radiation therapy (adjusted odds ratio = 0.08 [0.04, 0.14]) or appropriate adjuvant therapies (adjusted odds ratio = 0.14 [0.08, 0.22]) or both relative to 70- to 79-year-old patients. This effect did not improve post-intervention. While there was much variability in compliance with guidelines, surgeons' characteristics did not explain this variation. CONCLUSIONS: In Rhode Island, advanced age continues to be associated with less than adequate breast cancer therapy. Providing surgeons with "feedback" on the appropriateness of adjuvant treatment for older patients was insufficient to alter established practices. Using guideline compliance data as standard "quality indicators" of physician practice may be required.     

Incidence and severity of short-term complications after breast augmentation: results from a nationwide breast implant registry

The frequency and severity of local complications remain the primary safety issues with silicone breast implants. The Danish Registry for Plastic Surgery of the Breast (DPB), established in 1999, prospectively collects pre-, peri- and postoperative information regarding Danish women undergoing breast augmentation. Through DPB, we conducted a prospective follow-up study of short-term local complications among 1090 women who underwent cosmetic breast implantation from June 1999 through October 2002. Nineteen percent of women who underwent initial implantation developed at least 1 adverse effect. Forty percent of the adverse effects occurred within 3 months of implantation; 79%, within 6 months. Capsular contracture grade II-IV was observed among 4.1% of women in the 2-year follow-up period. Overall, 97 (29%) of the 344 adverse effects among 55 (6%) of the 971 women required surgical intervention. A higher incidence of adverse effects typically occurred after subsequent implantations. According to the DPB experience, we conclude that most short-term postoperative adverse effects following cosmetic implantation are clinically insignificant and do not require treatment and that short-term complications requiring adjuvant treatment are rare.     

Metastasectomy versus radiation of secondary sites in stage IV breast cancer: Analysis from a national cancer registry

PurposeLocoregional therapy at primary or secondary sites in breast cancer may be associated with improved survival as compared to systemic therapy alone. We explored the sociodemographic and clinicopathologic factors associated with the use of radiation versus surgical resection of metastatic sites (metastasectomy) in patients with de novo stage IV breast cancer, followed by the associated overall survival.MethodsWe sampled the National Cancer Database for patients with de novo stage IV breast cancer, (2010–2017) and described cohort's characteristics using univariate analyses. We identified 5 subgroups based on malignant site involvement: 1. Bone only, 2. Brain only, 3. Liver only, 4. Lung only, and 5. Metastasis involving >1 site. Kaplan-Meier modeling with log-rank testing and multivariate Cox Regression analysis were used to explore differences in overall survival between those that received radiation at secondary sites and those that underwent metastasectomy.ResultsN = 22,749patients were included in this analysis. Radiation (81.2%) was used more commonly than metastasectomy (28.8%). Metastasectomy was associated with better median overall survival across all 5 cohorts (p < .001), with the survival benefit being the most pronounced with lung only (OS: 56.9 months; HR 0.8, 95% CI 0.7–0.9, p = .032), or liver only (OS: 41.6 months; HR: 0.9; 95% CI: 0.7–1.1, p < .001) metastasis.ConclusionMetastasectomy in patients with de novo stage IV breast cancer may be associated with improved overall survival as compared to radiation of secondary lesions, particularly in those with only liver or lung involvement. Prospective randomized controlled trials investigating surgical resection of metastatic sites in patients with breast cancer are warranted.     

Pregnancy associated breast cancer (PABC): Report from a gestational cancer registry from a tertiary cancer care centre,India

BackgroundPregnancy associated breast cancer (PABC) is a rare entity and defined as breast cancer diagnosed during pregnancy or one-year post-partum. There is sparse data especially from low and middle-income countries (LMIC) and merits exploration.MethodsThe study (2013–2020) evaluated demographics, treatment patterns and outcomes of PABC.ResultsThere were 104 patients, median age of 31 years; 43 (41%) had triple-negative disease, 31(29.8%) had hormone-receptor (HR) positive and HER2 negative, 14 (13.5%) had HER2-positive and HR negative and 16(15.4%) had triple positive disease. 101(97%) had IDC grade III tumors and 74% had delayed diagnosis. 72% presented with early stage (24, EBC) or locally advanced breast cancer (53, LABC) and received either neoadjuvant (n = 49) or adjuvant (n = 26) chemotherapy and surgery. Trastuzumab, tamoxifen, and radiotherapy were administered post-delivery. At a median follow up of 27 (IQR:19–35) months, the estimated 3-year event-free survival (EFS) for EBC and LABC was 82% (95% CI: 65.2–100) and 56% (95% CI: 42–75.6%) and for metastatic 24% (95% CI: 10.1%–58.5%) respectively.Of the 104 patients, 34 were diagnosed antepartum (AP) and 15 had termination, 2 had preterm and 16 had full-term deliveries(FTDs). Among postpartum cohort (n = 70), 2 had termination, 1 had preterm, 67 had FTDs. 83(including 17 from AP) children from both cohorts were experiencing normal milestones.ConclusionData from the first Indian PABC registry showed that the majority had delayed diagnosis and aggressive features(TNBC, higher grade). Treatment was feasible in majority and stage matched outcomes were comparable to non-PABCs.     

Validation of the AJCC 8th prognostic system for breast cancer in an Asian healthcare setting

AimsWe aim to validate the AJCC 8th edition prognostic staging system for breast cancer in an Asian setting.MethodsClinico-pathologic information and cancer-specific survival (CSS) outcomes of 6287 stage I to III patients with invasive breast cancer who underwent upfront surgery at SingHealth institutions in Singapore from 2006 to 2014 were analyzed. Survival distributions for the different staging systems were estimated by the Kaplan-Meier method and compared using the log-rank tests. Multivariable Cox proportional hazards models were used, with Akaike Information Criterion (AIC) and Harrell's Concordance Index (C-index) to compare both staging systems.Among patients with positive hormone-receptor status, 84.8% received endocrine therapy. Among the cohort, 60.3% of received chemotherapy; 82.1% of node positive patients received chemotherapy and 86.0% of HER2-enriched patients in whom chemotherapy was also indicated received adjuvant HER2-targeted therapy. Ninety-seven percent of patients received anthracyclines and/or taxanes containing chemotherapy regime.ResultsThe median follow up was 64 months. 2921 patients (46.5%) were discordant between the anatomic and prognostic systems of which 363 (5.8%) were upstaged and 2558 (40.7%) were down-staged. For all patients, stages in both the prognostic and anatomic systems were discriminating for 5-year CSS. Controlling for age, ethnicity and receipt of chemotherapy, the prognostic staging system model (AIC = 7538.87, C = 0.79) presented slightly better explanation and concordance of survival times than the anatomic staging system model (AIC = 7607.31, C = 0.77).ConclusionThe prognostic staging system was better than the anatomic staging system in predicting outcomes but the anatomic system remains relevant due to its ease of use.     

Breast cancer presenting initially with urinary incontinence: a case of bladder metastasis from breast cancer

Bladder metastasis from breast cancer is rare. Patients with breast cancer, in particular patients with a lobular carcinoma subtype, who present with urinary symptoms including incontinence, hematuria, dysuria, and frequency should have the possibility of bladder metastases kept in mind and investigated with cystoscopy and imaging as necessary.     

Breast cancer in young Asian women: study on survival

BACKGROUND: Breast cancer in young patients is often associated with a poorer prognosis, but there has been a paucity of published data in an Asian population. METHODS: One hundred and six patients (12.6%) under the age of 40 years with breast cancer (group V) were compared with 737 patients with breast cancer aged 40 years or more (group W). Demographics, presentations, pathological profiles, treatment and survival measures were analysed. RESULTS: Median tumour size was similar in both groups. Group V had more patients with grade 3 tumours and nodal involvement compared to group W (51.5% vs 38.1%, P = 0.012 and 52.5% vs 41.8%, P = 0.045). The mean Nottingham prognostic index (NPI) score was significantly higher in group V compared to group W (4.75 vs 4.26, P < 0.001). The incidences of chemotherapy and radiotherapy in group V were higher than group W (69.2% vs 35.2%, P < 0.001 and 41.1% vs 24.4%, P = 0.002). There were no differences in overall survival and disease-free survival (local recurrence). CONCLUSION: Patients below 40 years with breast cancer have tumours with a poorer prognostic profile. However, this did not translate into a poorer overall survival, and this might be attributable to more aggressive adjuvant treatment of younger patients.     

Early technique failure in peritoneal dialysis patients in a multi-ethnic Asian country

International Urology and Nephrology - Early technique failure is a serious complication for peritoneal dialysis (PD) patients. The study aimed to examine the incidence, causes, and risk factors...     

Improving breast cancer screening rates in a primary care setting

Biannual mammogram has been recommended for all women aged 50‐74 years by USPSTF. Our aim was to improve the screening rates of biannual mammogram among women aged 50‐74 years in a primary care clinic. Medical records were reviewed. Patients who were not up‐to‐date with their breast cancer screening, were contacted by telephone or a letter was sent. Our screening rate was found to be 64.7%. After 6 months, 38.5% had undergone mammograms after our intervention. This improved the compliance rate from 64.7% to 76.6%. Hence discussion of breast cancer screening status between a patient and provider can significantly increase compliance.     

Targeted breast cancer screening in women younger than 40: results from a statewide program

BACKGROUND: Our state Breast and Cervical Cancer Program (BCCP) has previously reported a paucity of data supporting breast screening for asymptomatic women younger than 40 (cancer detection rate of .25% per screening-year). In partnership with the local Affiliate of the Susan G. Komen for the Cure Foundation, we began a targeted "screening" program to evaluate women younger than 40 referred for symptoms or other concerns. METHODS: Retrospective data review of program results, including demographics, symptoms, evaluations performed, and outcomes. RESULTS: A total of 176 women, ages 16 to 39 years, were referred to the BCCP/Komen program. Of the women with documented presenting symptoms, the most common was breast lump (81%). Evaluation triggered 75 surgical referrals and 69 biopsies, yielding 16 cancers (a biopsy positive rate of 23% and overall cancer detection rate from the program of 9%). CONCLUSIONS: For women younger than age 40, targeted breast cancer screening is a more efficient utilization of screening resources, with a higher cancer detection rate than asymptomatic screening.     

Treatment disparities in muscle-invasive bladder cancer: Evidence from a large statewide cancer registry

ObjectiveTo identify patient-level factors that can lead to treatment disparities for muscle invasive bladder cancer, we examine factors associated with receipt of definitive therapy, type of definitive therapy, and neoadjuvant chemotherapy administration in a statewide cohort of muscle-invasive bladder cancer patients.Materials and methodsWe identified 2,434 patients diagnosed with non-metastatic muscle-invasive bladder cancer between 2010 and 2015 using the Pennsylvania Cancer Registry. We divided the cohort into three subsamples to examine receipt of treatment: definitive therapy among all muscle-invasive bladder cancer patients (n = 1548), cystectomy (n = 1254) vs. trimodal therapy (n = 294), and neoadjuvant chemotherapy among radical cystectomy patients (n = 1156). Multivariable logistic regression models controlling for patient-level covariates, including insurance status, and socioeconomic disadvantage (based on Area Deprivation Index from census tract data) were estimated to examine factors associated with each treatment outcome.ResultsOnly 64% of muscle-invasive bladder cancer patients underwent definitive therapy. Those receiving trimodal therapy were more likely to be covered by Medicare than those undergoing cystectomy. Uninsured patients were less likely to undergo definitive treatment and Medicare-insured patients were less likely to undergo cystectomy as their definitive therapy. Patients with greater socioeconomic disadvantage were less likely to receive definitive treatment, undergo cystectomy, or receive neoadjuvant chemotherapy. Over the course of the study period, there was increased neoadjuvant chemotherapy use, but a persistent gap by neighborhood socioeconomic status.ConclusionsSocioeconomic disadvantage and insurance status are patient-level factors associated with suboptimal treatment for muscle-invasive bladder cancer.     

Breast cancer surgery in a day case setting: Where do the Netherlands stand in 2004?

To assess to what extent day case surgery for breast cancer is practised in the Netherlands a questionnaire was sent to 105 surgeons/hospitals. In 2004, 30% of the hospitals performed minor and 3% performed major breast cancer surgery in a day case setting. Sixteen percent of the hospitals indicated planning to introduce day case surgery for minor and major breast cancer surgery. The basic requirements for this development are widely available. Potential obstacles can be overcome by adjustments in organisation, logistics and financial reimbursement, thus making day case surgery available to more patients while reducing health care costs.     

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.     

Trends in management of ureteral urothelial carcinoma and effects on survival: a hospital-based registry study

BackgroundHigh-risk ureteral tumors represent an understudied subset of upper tract urothelial carcinoma, whose surgical management can range from a radical nephroureterectomy (NU) to segmental ureterectomy (SU).ObjectivesTo evaluate contemporary trends in the management of high-risk ureteral tumors, the utilization of lymphadenectomy and peri-operative chemotherapy, and their impact on overall survival (OS).Design, setting, and participantsWe performed a retrospective cohort study of patients in the National Cancer Database from years 2006 to 2013 with clinically localized high-risk ureteral tumors treated with NU or SU.Outcome measurements and statistical analysisChi-squared tests were utilized to assess differences in clinicodemographic features and peri-operative treatment delivery between SU and NU cohorts. Cochran-Armitage tests and linear regressions were performed to evaluate temporal trends in treatment utilization. Multivariable logistic regression models were employed to assess predictors of treatment delivery. Multivariable Cox proportional hazards models evaluated associations with OS.ResultsOf the 1,962 patients included, NU was more commonly performed than SU (72.4%, 1,421/1,962 vs. 27.6%, 541/1,962). Only 22.7% (446/1,962) of the population underwent lymphadenectomy, and 24.8% (271/1,092) of those with advanced pathology (≥pT2 or pN+) received adjuvant chemotherapy. Lymphadenectomy was associated with improved OS in NU patients when more than 3 nodes were removed (hazard ratio [HR] 0.58, 95% confidence interval [CI] 0.39–0.89). Receipt of adjuvant chemotherapy for advanced pathology had no impact OS in both the NU (HR 1.10, 95% CI 0.84–1.44) and SU (HR 0.94, 95% CI 0.61–1.46) cohorts. Performance of SU was not associated with poorer OS on multivariable analysis (HR 1.02, 95% CI 0.89–1.21, P = 0.83).ConclusionOur study suggests that SU may be an appropriate alternative to NU for the management of high-risk ureteral tumors. Further, lymphadenectomy may play an important role at the time of NU, and adjuvant chemotherapy is infrequently utilized in patients with advanced pathology.     

Breast cancer on the Internet: the quality of Swedish breast cancer websites

The aim of this study was to investigate the quality of Swedish-language breast cancer information available on the Internet. The questions explored were the extent and type of breast cancer information available, the coverage and correctness of that information, and whether the websites fulfilled the European Commission quality criteria for health-related websites. Three search engines were used to find websites containing medical information on breast cancer. An oncologist then evaluated the 29 relevant sites. Only seven of these were judged suitable for breast cancer patients. The coverage and correctness of the medical information varied considerably. None of the websites fulfilled the European Commission quality criteria. Therefore, considerable effort will be required before the Internet can serve as a valuable and up-to-date source of information on breast cancer for both professionals and laypersons. Our findings broadly match the results of earlier studies of English-language websites.