Do breast implants after a mastectomy affect subsequent prognosis and survival?

In a large study, published in this issue of Breast Cancer Research, Le and colleagues report that women receiving implants after mastectomies for early-stage breast cancer experience lower breast cancer mortality than women not receiving implants. Assessment of survival patterns among women receiving reconstructive implants is complex given unique patient characteristics, disease attributes, and treatment patterns. The interpretation of reduced mortality from breast cancer must be assessed in light of significantly reduced risks of death from most other causes. In contrast, patients receiving post-mastectomy implants had elevated rates of suicide, consistent with findings among women with cosmetic implants. Additional well-designed investigations are needed to clarify survival patterns among women receiving reconstructive implants.     

Do radiation use disparities influence survival in patients with advanced breast cancer?

BACKGROUND:

The authors previously identified racial/ethnic disparities in the use of radiation therapy (RT) in patients with advanced breast cancer (BC). They hypothesized that disparities in the use of RT were associated with survival differences favoring white patients.

METHODS:

The authors used the Surveillance, Epidemiology, and End Results database to identify white, black, Hispanic, and Asian patients with BC associated with ≥10 metastatic lymph nodes diagnosed between 1988 and 2005. Multivariate analyses of overall survival (OS) and disease‐specific survival (DSS) assessed age, sex, race, tumor size, histology, estrogen receptor status, progesterone receptor status, RT, and type of surgery. The authors further stratified for use of RT and type of surgery. Risk of mortality was reported as hazard ratios (HRs) with 95% confidence intervals (CIs).

RESULTS:

Of 15,895 patients with advanced BC, 12,653 met entry criteria. On multivariate analysis, RT was associated with a decreased risk of all‐cause (HR, 0.78; 95% CI 0.74‐0.83; P < .001) and disease‐specific (HR, 0.81; 95% CI, 0.76‐0.86; P < .001) mortality; black race was associated with an increased risk of all‐cause (HR, 1.54; 95% CI, 1.42‐1.68; P < .001) and disease‐specific (HR, 1.53; 95% CI, 1.39‐1.68; P < .001) mortality. After stratifying by type of surgery and use of RT, blacks demonstrated poorer survival than their white counterparts, regardless of surgery type or receipt of RT.

CONCLUSIONS:

Only black patients had poorer OS and DSS relative to whites. When stratified by type of surgery and use of RT, blacks continued to demonstrate poorer survival. This survival disparity is unlikely to be because of lack of RT. Cancer 2012;. © 2011 American Cancer Society.     

Does multicentric/multifocal breast cancer differ from unifocal breast cancer? An analysis of survival and contralateral breast cancer incidence

Purpose we evaluated whether patients with multifocal/multicentric (M/M) breast cancer have different outcomes compared to unifocal (U) disease in terms of survival and the development of contralateral breast cancer (CBC) disease. Methods women diagnosed with stage I–III breast cancer were classified as having U or M/M disease. Prognostic factors were prospectively collected and obtained from the breast cancer outcome unit database. Univariate and multivariable analyses for the incidence of CBC were performed as well as Kaplan–Meier plots. Results 25,320 women met inclusion criteria. The 5-year cumulative incidence of CBC in the U versus M/M group was 2.3% (95% CI 2.1, 2.5) versus 2.4% (95% CI 1.6, 3.4) (P = 0.349). Breast cancer specific survival (BCSS) rate revealed a slightly worse outcome with M/M disease, RR = 1.174 (95% CI 1,004, 1.372). Conclusions M/M breast cancer did not increase the risk of metachronous CBC, but was associated with inferior BCSS.     

Do bowel cancer patients participate in treatment decision‐making? Findings from a qualitative study

The views of bowel cancer patients towards treatment decision-making and the extent to which they participate in this process were investigated. A prospective longitudinal qualitative study was conducted based on 55 new consultations between oncologists and bowel cancer patients and interviews with 37 recently diagnosed patients, 28 of whom were re-interviewed after 6 months. The interview and consultation data were transcribed verbatim and coded. Theoretical comparisons were made between the interviews and themes emerging from the consultation narratives. The analysis revealed that most bowel cancer patients preferred a limited role in the treatment decision-making process, preferring to delegate the responsibility to the clinician. However, they did not always consider themselves as 'passive' participants within the consultation and many felt that they had made the final decision to accept or refuse treatment. The consultation data shows that when a treatment recommendation was not forthcoming from the oncologist, patients became more proactive in the consultation, often taking the initiative to participate. It is concluded that patients who indicate a desire to participate in these types of consultations should be encouraged to do so and oncologists should try to identify those patients who could benefit from a greater role in treatment decision-making.     

Lunar phases and survival of breast cancer patients – a statistical analysis of 3,757 cases

The potential influence of lunar phases on human life has been widely discussed by the lay press. The purpose of this study was to find out whether the timing of surgery during particular lunar phases influences the survival of breast cancer patients. It has been postulated that breast cancer surgery performed during the waxing moon, or particularly at full moon, is associated with a poorer outcome. We tested this hypothesis by evaluating the overall survival for 3,757 consecutive patients with invasive breast cancer. All patients underwent either modified radical mastectomy or breast conserving surgery plus radiotherapy, followed by adjuvant cytotoxic or hormonal therapy. The date of definitive surgery was allocated to the lunar phases. 1,904 (50.7%) patients were operated on during the waxing moon and 1,853 (47.3%) during the waning moon. The median follow-up was 74 months (range 1–372 months). The mean age at primary surgery did not differ significantly in the two groups 58.39 (SD 13.14) versus 58.34 (12.75) (p>0.05, t-test). Breast cancer stages at initial diagnosis were evenly distributed according to the lunar phases (p=0.325; chi-square). Survival curves were plotted according to the method of Kaplan–Meier. No significant differences were observed when timing of surgery was allocated to the lunar phases (p=0.4841, log-rank). Subgroup analysis of premenopausal patients revealed similar results (p=0.2950, log-rank; n=1072). Using multivariate Cox modelling, we found a significant association between the patient's age, stage of disease and survival, whereas no association with survival was observed for the timing of surgery (RR=1.062; 95% CI, 0.970–1.163; p=0.1937). No significant differences in overall survival of breast cancer patients were observed when timing of breast cancer surgery during the lunar cycle was considered. Although this was not a prospective randomized trial, the statistical magnitude of the results do not support any recommendations for scheduling patients for surgery at any particular day of the lunar phase.     

Does postoperative chemotherapy have a survival benefit for patients with pancreatic cancer?

In our study, we investigated whether postoperative chemotherapy improved survival in patients with invasive ductal carcinoma of the pancreas. Between 1987 and 2004, 111 patients underwent pancreatic resection against invasive ductal carcinoma of the pancreas in Wakayama Medical University Hospital. Median survival time (MST) was 19.4 months, 8.6 months, and 7.2 months, in JPS Stage III (UICC Stage IIA and IIB), JPS Stage IVa (UICC Stage IIA and IIB), and JPS Stage IVb (UICC Stage IV), respectively (P < 0.01). The MST of the chemotherapy group was 12 months, and the MST of the non-chemotherapy group was 8.4 months (P < 0.05). Moreover, in JPS Stage IV (UICC Stage IIA, IIB, III, and IV) highly advanced pancreatic cancer, the MST of the chemotherapy group was 10.9 months, and the MST of the group without chemotherapy was 6.6 months (P < 0.01). Since pancreatic cancer is characterized by an aggressive tumor with a high recurrent rate, postoperative chemotherapy is effective for an improvement of survival.     

Improved survival time: What can survival cure models tell us about population‐based survival improvements in late‐stage colorectal,ovarian, and testicular cancer?

BACKGROUND: The objective of the current study was to investigate the long-term impact of treatment advances on the survival of patients with late-stage ovarian, colorectal (American Joint Committee on Cancer stage III, men), and testicular cancers by estimating the increase in the percentage cured from their disease and the change in survival time of uncured patients. METHODS: Cause-specific survival data from 1973 to 2000 were obtained from the Surveillance, Epidemiology, and End Results Program. Survival cure models were fit and were used to estimate the gain in life expectancy (GLE) attributed to an increase in the fraction of cured patients and to prolonged survival among noncured patients. RESULTS: Treatment improvement for ovarian cancer resulted in a total GLE of 2 years, and 80% of that GLE was because of an extension of survival time in uncured patients (from 0.9 years to 2.1 years) rather than an increased cure fraction (from 12% to 14%). In contrast, the cure rate rose from 29% to 47% for colorectal cancer, representing 82% of a 2.8-year GLE, and from 23% to 81% for testicular cancer, representing 100% of a 24-year GLE. CONCLUSIONS: The current results suggested that treatment benefits for testicular and colorectal cancer in men with late-stage disease primarily are the result of increases in cure fraction, whereas survival gains for ovarian cancer occur despite persisting disease. Cure models, in combination with population-level data, provide insight into how treatment advances are changing survival and ultimately impacting mortality. Survival patterns reflect the underlying biology of response to cancer treatment and suggest promising directions for future research.     

Does inverse‐planned intensity‐modulated radiation therapy have a role in the treatment of patients with left‐sided breast cancer?

Introduction: The purpose of the study was to determine if multi‐field inverse‐planned intensity‐modulated radiation therapy (IMRT) improves on the sparing of organs at risk (heart, lungs and contralateral breast) when compared with field‐in‐field forward‐planned RT (FiF). Methods: The planning CT scans of 10 women with left‐sided breast cancer previously treated with whole‐breast RT on an inclined breast board with both arms supported above the head were retrieved. The whole breast planning target volume (PTV) was defined by clinical mark‐up and contoured on all relevant CT slices as were the organs at risk. For each patient, three plans were generated using FiF, five‐ and nine‐field inverse‐planned IMRT, all to a total dose of 50 Gy to the whole breast. Mean and maximum doses to the organs at risk and the homogeneity index (HI) of the whole‐breast PTV were compared. Results: The mean heart dose for the FiF plans was 2.63 Gy compared with 4.04 Gy for the five‐field and 4.30 Gy for the nine‐field IMRT plans, with no significant differences in the HI of the whole‐breast PTV in all plans. The FiF plans resulted in a mean contralateral breast dose of 0.58 Gy compared with 0.70 and 2.08 Gy for the five‐ and nine‐field IMRT plans, respectively. Conclusions: FiF resulted in a lower mean heart and contralateral breast dose with comparable HI of the whole‐breast PTV in comparison with inverse‐planned IMRT using five or nine fields.     

Do anthracyclines still have a role in adjuvant chemotherapy of breast cancer?

Anthracycline-based regimens became the standard of care for early breast cancer patients based on the survival advantage they provide over nonanthracycline-containing regimens. The addition of taxanes, and subsequently trastuzumab in HER2-overexpressing patients, to anthracyclines further improved their efficacy in several studies involving high-risk early breast cancer patients. Concern over toxicity initially surfaced after anthracyclines were reported to carry an increased risk of cardiotoxicity and secondary leukemia. Trastuzumab has since been shown to compound the risk of cardiotoxicity in patients who have received an anthracycline. This has led to the development of regimens featuring a taxane without an anthracycline; these protocols vary in design and have different toxicity and efficacy profiles. Ongoing investigations are centered on the optimization of nonanthracycline regimens, prospective exploration of molecular markers to identify populations of patients who will derive maximal benefit from anthracycline-based chemotherapy, and the identification of less cardiotoxic formulations of existing anthracycline agents. Perhaps most importantly, a rapidly growing understanding of the biological heterogeneity of breast cancer is likely to lead to an individualized standard of care guided by particular patient and tumor characteristics.     

Do patients benefit from participating in medical decision making? Longitudinal follow‐up of women with breast cancer

This study sought to examine the relationships between decisional role (preferred and assumed) at time of surgical treatment (baseline), congruence between assumed role at baseline and preferred role 3 years later (follow-up), and quality of life at follow-up. Two hundred and five women diagnosed with breast cancer completed the decisional role preference scale at baseline and follow-up, and the EORTC QLQ-C30 at follow-up. A statistically significant number of women had decisional role regret, with most of these women preferring greater involvement in treatment planning than was afforded them. Women who indicated at baseline that they were actively involved in choosing their surgical treatment had significantly higher overall quality of life at follow-up than women who indicated passive involvement. These actively involved women had significantly higher physical and social functioning and significantly less fatigue than women who assumed a passive role. Quality of life was significantly related to reports of experienced involvement in treatment decision making, but not to reports of preferred involvement, or congruence between preferred and experienced involvement.     

Do metastatic colorectal cancer patients who present with late relapse after curative surgery have a better survival?

Background:

Patients who relapse after potentially curative surgery for colorectal cancer tend to relapse within 5 years. There is, however, a group of patients who relapse beyond 5 years after resection and this late relapsing group may have a different behaviour and prognosis.

Methods:

We analysed data from a prospective population-based registry to compare the characteristics and survival of relapsed patients with metachronous mCRC. Patients were categorised into relapse at <2, 2–5 and >5 years following their initial surgery. Univariate log-rank tests and multivariate Cox regression was performed to determine whether time to relapse (TTR) and other factors were associated with overall survival (OS).

Results:

A total of 750 metachronous mCRC patients were identified. In all, 56% relapsed ⩽2 years, 32.4% at 2–5 years and 11.6% >5 years. Median survival time from the time of diagnosis of mCRC for the three groups was 17.6, 26.1 and 27.5 months, respectively. Short TTR (<2 years) was significantly associated with survival (HR=0.75, 95% confidence interval (CI)=0.60–0.93 and HR=0.73, 95% CI=0.53–1.01, respectively, for 2–5 and >5 years vs <2 years, P<0.05). However, there was no significant difference in survival between patients who relapsed at 5 years or later compared with those who relapsed between 2 and 5 years (HR=0.98, 95% CI=0.69–1.38, P=0.90).

Conclusion:

TTR within 2 years is an independent predictor of shorter survival time for mCRC patients who experience a relapse. These data do not support the hypothesis that patients who have late relapse late (>5 years) have a ‘better'' biology or survival compared with patients with a TTR of 2–5 years.