Global Forum of Cancer Surgeons: Cancer Surgery During the COVID-19 Pandemic: Impact and Lessons Learned

Annals of Surgical Oncology - The purpose of this article is to summarize the opinions of the surgical oncology leaders from the Global Forum of Cancer Surgeons (GFCS) about the global impact of...     

Consensus Guidelines on Genetic` Testing for Hereditary Breast Cancer from the American Society of Breast Surgeons

Background

The purpose of this consensus guideline is to outline recommendations for genetic testing that medical professionals can use to assess hereditary risk for breast cancer.

Methods

Literature review included large datasets, basic and clinical science publications, and recent updated national guidelines. Genetic testing to assess hereditary risk of cancer is a complex, broad, and dynamic area of medical research. The dominant focus of this guideline is limited in scope to breast cancer.

Results

There is a lack of consensus among experts regarding which genes among many should be tested in different clinical scenarios. There is also variation in the degree of consensus regarding the understanding of risk and appropriate clinical management of mutations in many genes.

Conclusions

Genetic testing should be made available to all patients with a personal history of breast cancer. Recent data are reviewed that support genetic testing being offered to each patient with breast cancer (newly diagnosed or with a personal history). If genetic testing is performed, such testing should include BRCA1/BRCA2 and PALB2, with other genes as appropriate for the clinical scenario and family history. For patients with newly diagnosed breast cancer, identification of a mutation may impact local treatment recommendations. Patients who had genetic testing previously may benefit from updated testing. Genetic testing should be made available to patients without a history of breast cancer who meet National Comprehensive Cancer Network guidelines. Finally, variants of uncertain significance are not clinically actionable and these patients should be managed based on their individual risk factors.

     

Impact of the COVID-19 Pandemic on Lung Cancer Screening Program and Subsequent Lung Cancer

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Reasons for Re-Excision After Lumpectomy for Breast Cancer: Insight from the American Society of Breast Surgeons MasterySM Database

Background

There is marked variability of re-excision rates after initial lumpectomy for breast cancer. Reasons for re-excision and variability across surgeons have not been well documented. We hypothesized the American Society of Breast Surgeons (ASBrS) Mastery^SM Program can identify reasons for re-excision.

Methods

Data from January 1 to 7 November 2013 were evaluated in the ASBrS Mastery^SM Program to determine re-excision lumpectomy rate (RELR). On 1 June 2013, a tool to track reasons for re-excision was developed. Variation in re-excision rate by surgeon and patient characteristics was performed by Chi square test and Fisher’s test for univariate analysis, then logistic regression with backwards elimination method for multivariate analysis.

Results

For 6,725 patients undergoing initial lumpectomy for cancer, 328 surgeons reported 1,451 (21.6 %) patients had one or more re-excisions. The most common reasons for re-excision were ink positive margins in 783 (49.7 %), margin <1 mm (34.3 %), and margin 1–2 mm (7.2 %). By multivariate analysis, re-excision rates were lower in patients aged less than 35 years, with White (non-) Hispanic ethnicity, and, among surgeons in solo practice, more years in practice and higher-volume practice.

Conclusion

Half of re-excisions after initial lumpectomy were performed for margins that are positive. Most of the remainder were for negative close (<1–2 mm) margins. This information corroborates surgeon survey data regarding reasons for re-excision and provides proof of concept the Mastery^SM Program can capture surgical outcome data in real time, providing opportunity and a method for future performance improvement.     

Comprehensive Breast Care for the Future from the American Society of Breast Surgeons

Annals of Surgical Oncology -     

COVID-19 Pandemic and the Lived Experience of Surgical Residents,Fellows, and Early-Career Surgeons in the American College of Surgeons

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Perspectives on the Costs of Cancer Care: A Survey of the American Society of Breast Surgeons

Annals of Surgical Oncology - Cancer treatment costs are not routinely addressed in shared decisions for breast cancer surgery. Thus, we sought to characterize cost awareness and communication...     

Global Impact of the COVID-19 Pandemic on Solid Organ Transplant

BackgroundCOVID-19 has drastically affected transplant services, but there is limited understanding of the discrepancy of COVID-19 effects on various regions of the world.MethodsWe have explored the Global Observatory for Organ Donation and Transplantation data for assessing the transplant number changes between the calendar year 2019 (n = 157,301) and 2020 (129,681).ResultsThere was a disproportionate impact of COVID-19 on different areas of the world. Globally, there was a decline of 17.5%, in which deceased donation, kidney (20.9%), pancreas (16.2%), lung (12.7%), liver (11.3%), and heart (8%) transplant declined disproportionally in different regions of the world. The pandemic affected almost all geographic regions and nations, but China and the United States were mostly able to recover from the initial halt of the transplant practices by the pandemic so that there was a cumulative increase in transplant numbers.ConclusionsOur data show that developing nations lagged behind, whereas developed nations have been able to recover their transplantation programs during the pandemic. Further policy making and preparedness is required to safeguard the most vulnerable areas of the world to minimize the impact of any future pandemic on transplantation practices.     

Update on DCIS Outcomes from the American Society of Breast Surgeons Accelerated Partial Breast Irradiation Registry Trial

Background

Since the initial reports on use of MammoSite accelerated partial breast irradiation (APBI) for treatment of ductal carcinoma in situ (DCIS), additional follow-up data were collected. We hypothesized that APBI delivered via MammoSite would continue to be well tolerated, associated with a good cosmetic outcome, and carry a low risk for recurrence in patients with DCIS.

Materials and Methods

From 2002–2004, 194 patients with DCIS were enrolled in a registry trial to assess the MammoSite. Follow-up data were available for all 194 patients. Median follow-up was 54.4 months; 63 patients had at least 5 years of follow-up. Data obtained included patient-, tumor-, and treatment-related factors, and recurrence incidence.

Results

Of the 194 patients, 87 (45%) had the MammoSite placed at lumpectomy; 107 patients (55%) had the device placed postlumpectomy. In the first year of follow-up, 16 patients developed a breast infection, though the method of device placement was not associated with infection risk. Also, 46 patients developed a seroma that was associated with applicator placement at the time of lumpectomy (P = 0.001). For patients with at least 5 years of follow-up, 92% had favorable cosmetic results. There were 6 patients (3.1%) who had an ipsilateral breast recurrence, with 1 (0.5%) experiencing recurrence in the breast and axilla, for a 5-year actuarial local recurrence rate of 3.39%.

Conclusions

During an extended follow-up period, APBI delivered via MammoSite continued to be well tolerated for patients with DCIS. Use of this device may make lumpectomy possible for patients who would otherwise choose mastectomy because of barriers associated with standard radiation therapy.     

Four-year clinical update from the American Society of Breast Surgeons MammoSite brachytherapy trial

Background

We present a 4-year update on the efficacy, cosmetic results, and complications of MammoSite breast brachytherapy in patients enrolled in the American Society of Breast Surgeons registry trial.

Methods

A total of 1,449 breasts in 1,440 patients with early stage breast cancer undergoing breast-conserving therapy were treated with adjuvant, accelerated partial breast irradiation (APBI) (34 Gy in 3.4-Gy fractions) delivered with the MammoSite device. The median follow-up period for the entire group was 36.1 months.

Results

The 3-year actuarial rate of ipsilateral breast tumor recurrence was 2.15%. The 3-year actuarial rate of axillary recurrence was .36%. Complication rates were as follows: infection, 9.5%; seroma, 26.8% (symptomatic seroma, 12.7%); and fat necrosis, 2.0%. The percentages of breasts with good or excellent cosmetic results were as follows: 12 months, 95%; 24 months, 94%; 36 months, 94%; and 48 months, 91%.

Conclusions

Locoregional control, complications, and cosmetic outcomes from MammoSite APBI at the 4-year update are acceptable and similar to results seen with other forms of APBI.     

Margins: A Status Report from the Annual Meeting of the American Society of Breast Surgeons

Since the emergence of breast conserving surgery (BCS) as an alternative to mastectomy in the 1980’s, there has been little consensus on what constitutes acceptable margins for cases of invasive breast cancer, how best to evaluate margins in the operating room, or an understanding of the challenging process of margin assessment by pathologists. The program committee for the 15th Annual Meeting of The American Society of Breast Surgeons organized a plenary session to discuss the latest thinking and guidelines for these important issues. The SSO/ASTRO Consensus Guideline on Margins for BCS was an important focus of discussion. The SSO/ASTRO consensus panelists concluded that "no ink on tumor" is an adequate surgical margin for BCS in patients with invasive breast cancers. Intraoperative strategies to decrease the incidence of positive margins include intraoperative localization techniques (wire-localization, ultrasound, radioactive seed) and intraoperative margin assessments with specimen radiography, imprint cytology, and frozen section. Studies also demonstrate the positive effect of shave margins with or without intraoperative margin assessment. The College of American Pathologists protocols for breast specimen margin evaluation consider multiple variables that can impact the proper assessment of margins. These variables include: tissue fixation time, specimen orientation, cold ischemia time, leaking ink, specimen pancaking and others that surgeons need to be aware of. Determining when "enough is enough" should not only be the application of guidelines and national standards, but also a multidisciplinary discussion between breast cancer specialists for what is right for the individual patient's unique circumstances.     

The 2018 Compensation Survey of the American Society of Breast Surgeons

Annals of Surgical Oncology - There is limited compensation data for breast surgery benchmarking. In 2018, the American Society of Breast Surgeons conducted its second membership survey to obtain...     

Full Abstract to Published Manuscript: Evaluation of the Scientific Impact of the American Society of Breast Surgeons Conference

Annals of Surgical Oncology - The scientific rigor of the abstracts presented at the American Society of Breast Surgeons (ASBrS) annual meeting has not been recently evaluated. In this study, we...     

Margin Management and Adjuvant Therapy for Phyllodes Tumors: Practice Patterns of the American Society of Breast Surgeons Members

Background

Phyllodes tumors (PTs) are rare breast neoplasms with variable clinical behavior by histologic type: benign, borderline, or malignant. Until recently, management guidelines recommended one approach for all subtypes.

Methods

A 21-question survey was sent to American Society of Breast Surgeon members to evaluate management patterns by subtype. Surgeon demographics, decisions regarding management of margins, re-excision, surveillance, and synoptic reporting were collected. Chi-square or analysis of variance (ANOVA) were used as appropriate, with significance set at p < 0.05.

Results

A total of 493 of 2969 surveys were completed for a response rate of 18.3%. Among the survey takers, 55% were fellowship trained, 72% were in practice > 10 years, and 82% performed > 100 breast cases per year. Although 25% of respondents enucleate a mass with clinical suspicion of a PT alone, this decreased to 18% if a preoperative core biopsy performed was suggestive of PT. For margin management, 47% do not re-excise positive margins for benign PTs, but 96% would for a borderline or malignant PTs (p < 0.001). Only 2% perform axillary staging for malignant PTs, and 90% refer borderline or malignant PTs for radiation. Two-year surveillance was performed by about half of respondents for benign PT. However, two-thirds of respondents would increase surveillance to 5 years for borderline or malignant PTs. Only 38% report a templated synoptic pathology report at their institution.

Conclusion

PT management patterns are evolving but still variable when looking at initial margin intent, decision for re-excision, radiation referral, pathologic reporting, and surveillance. This suggests the need for more specific management guidelines by subtype given differences in clinical behavior.