Trends in surgical treatment of younger patients with breast cancer in Australia and New Zealand

Background: The optimal surgical treatment of early breast cancer in young women is not fully determined, while past reports indicate a trend to the increased use of breast‐conserving surgery (BCS). This study aims to assess the trend in Australia and New Zealand of BCS use between 1999 and 2006 and to determine pathological factors associated with it. Methods: Data on cancer characteristics and surgical procedures in younger patients with early breast cancer reported to the National Breast Cancer Audit have been analysed. Results: There was little change in the rate of BCS over the last 7 years with an overall rate of 53%. The main factors associated with the use of BCS are low histological grade, absence of extensive intraductal carcinoma (EIC), negative lymph node involvement, unifocal tumour and small tumour size. Conclusion: Between 1999 and 2006, the use of BCS for early breast cancer treatment in younger women was stable. These results show that surgeons contributing data to the National Breast Cancer Audit appear to use pathological factors that are known to increase the risk of local recurrence after BCS, in selecting mastectomy for younger women.     

BREAST CANCER OUTCOMES AT THE STRATHFIELD BREAST CENTRE

Background: Breast cancer is the most commonly diagnosed cancer and the most common cause of cancer death in women. This report presents outcomes from a multidisciplinary breast clinic established in 1989 with the specific aim of providing a rapid, integrated assessment service for patients with breast disease. Methods: A prospective data collection and analysis using a Microsoft Access^TM (Microsoft Corp., North Ryde, NSW, Australia) database was established and has collected information on all patients presenting for diagnosis or ongoing management of breast cancer. Data on survival were obtained by routine follow-up visits or contact with the patient'general practitioner. Results: Patient age, mode of presentation and histopathology were similar to other population-based studies in Australia. Ninety-three per cent of the patients had a diagnosis confirmed on the day of consultation. The average time between diagnosis and surgery was 11.9 days. Breast preserving surgery was attempted in 68% and achieved in 50% of cases, 67% of patients had one stage surgery. Five-year disease-free survival was 74% and is comparable with other reports. Conclusions: The centralization of services and expertise has enabled us to provide efficient service and achieve internationally comparable outcomes.     

Surgical Treatment for Women with Breast Cancer in Relation to Socioeconomic and Insurance Status

Based on the National Breast Cancer Audit of the Royal Australasian College of Surgeons an association between patient age and type of breast cancer surgery received has already been demonstrated. The aim of this study is to assess the patterns of surgical treatment for women with early breast cancer in relation to socioeconomic and insurance status. Data on patient demographics, diagnostic, and surgical procedures and cancer characteristics in 115,872 episodes of early breast cancer reported to the National Breast Cancer Audit between 1998 and 2012 is used for this study. Tumor size, histologic grade, number of tumors, lymph node positivity, and lymphovascular invasion are the major prognostic factors adjusted for. Reconstruction following mastectomy is the most likely surgical procedure for the higher socioeconomic and privately insured patients. Mastectomy alone is the most likely surgical procedure for the lower socioeconomic and for public patients. No surgery is the most likely surgical outcome for the lower socioeconomic and the least likely for the higher socioeconomic population. Open biopsy is the most likely diagnostic procedure for the lower socioeconomic and fine needle aspiration for the higher socioeconomic population. Socioeconomic and insurance status, are both independently associated with the types of treatment and diagnostic procedure for women with breast cancer. Opportunities present to investigate an association of these factors with morbidity and survival outcomes.     

Patterns of Surgical Treatment for Women with Breast Cancer in Relation to Age

Abstract: Although treatment recommendations have been advocated for all women with early breast cancer regardless of age, it is generally accepted that different treatments are preferred based on the age of the patient. The aim of this study was to assess the pattern of breast cancer surgery after adjusting for other major prognostic factors in relation to patient age. Data on cancer characteristics and surgical procedures in 31,298 patients with early breast cancer reported to the National Breast Cancer Audit between 1999 and 2006 were used for the study. There was a close association between age and surgical treatment pattern after adjusting for other prognostic factors, including tumor size, histologic grade, number of tumors, lymph node positivity, lymphovascular invasion (LVI), and extensive intraduct component. Breast Conserving Surgery (BCS) was highest among women aged ≤40 years (OR = 1.140; 95% CI: 1.004–1.293) compared to women aged 51–70 years (reference group). BCS was lowest in women aged >70 years (OR = 0.498, 95% CI: 0.455–0.545). Significantly more women aged ≤50 years underwent more than one operation for breast conservation (20.4–24.8%) compared with women aged >50 years (11.4–17.0%). Women aged >70 years were more likely to receive no surgical treatment, 3.5% versus 1.0–1.3% in all other age groups (≤40, 41–50 51–70 years). There is an association between patient age and the type of breast cancer surgery for women in Australia and New Zealand. Women age ≤40 years are more likely to undergo BCS despite having adverse histologic features and have more than one procedure to achieve breast conservation. Older women (>70 years) more commonly undergo mastectomy and are more likely to receive no surgical treatment.     

Factors influencing the use of breast reconstruction postmastectomy: a National Cancer Database study

BACKGROUND: Advances in surgical techniques and changes in our understanding of the biology of breast cancer have made immediate or early breast reconstruction a viable option for the majority of women with breast cancer. Little is known about national patterns of use of reconstruction. This study was undertaken to determine national patterns of care and factors that influence the use of breast reconstruction. STUDY DESIGN: A large convenience sample reported to the National Cancer Data Base was studied. Patients coded as undergoing mastectomy between 1985 and 1990 (n = 155,463) and between 1994 and 1995 (n = 68,348) were evaluated. The use of reconstruction in the two time periods was compared, and patient and tumor factors influencing the use of the procedure were compared. RESULTS: Between 1985 and 1990, 3.4% of mastectomy patients had early or immediate reconstruction, increasing to 8.3% in 1994-5. Patient age, income, geographic location, type of hospital where treatment occurred, and tumor stage all influenced the use of reconstruction in univariate analysis. In multivariate analysis, patients age 50 or under had a 4.3-fold greater likelihood of having reconstruction than their older counterparts. Patients with ductal carcinoma in situ were twice as likely as those with invasive cancer to have reconstruction. Family income of $40,000 or more (Odds Ratio 2.0), ethnicity other than African-American (Odds Ratio 1.6), surgery in a National Cancer Institute-designated cancer center (Odds Ratio 1.4), and surgery in a geographic region other than the Midwest or South (Odds Ratio 1.3) remained significant predictors of the use of reconstruction in multivariate analysis. CONCLUSIONS: Breast reconstruction is an underused option in breast cancer management. Predictors of the use of reconstruction do not reflect contraindications to the procedure, and indicate the need for both physician and patient education.     

Evaluation of implementation of sentinel node biopsy in Australia

Background: Sentinel node biopsy (SNB) has been a major change in surgical technique for the management of early breast cancer. In June 2008, the National Breast and Ovarian Cancer Centre (NBOCC) released evidence-based guidelines for the use of SNB in Australia. During 2010, NBOCC undertook a cohort study to identify the extent to which clinical practice in Australia reflected the recommendations for use of SNB in the 6 months after release of the guidelines. Methods: Records obtained from four datasets, Royal Australasian College of Surgeons National Breast Cancer Audit, New South Wales Central Cancer Registry, Victorian Cancer Registry and Medicare Benefits Schedule records, were analysed to determine the extent to which the four key guideline recommendations had been implemented. This was supplemented by an audit of written SNB protocols of a sample of pathology laboratories in Australia. Results: Across all cohorts, between 78 and 83% of women in Australia with tumours ≤3?cm had an SNB. Data were not available to indicate whether nodes were clinically negative. The likelihood of women having an SNB decreased outside the metropolitan regions, for women treated as public patients compared with private patients and as the size of the tumour increased. In 90% of procedures both preoperative lymphoscintigraphy with isotope and blue dye were used. Conclusion: The findings from the study confirm that best practice recommendations from the NBOCC guidelines for SNB were largely being implemented for women with early breast cancer in Australia within 6 months of their release.     

Use of trastuzumab in Australia and New Zealand: results from the National Breast Cancer Audit

Background: Trastuzumab increases disease‐free and overall survival in HER‐2‐positive, early breast cancer. In 2007, the National Breast and Ovarian Cancer Centre recommended that patients with HER‐2 positive cancers (node positive or node negative tumours >1 cm) be offered adjuvant trastuzumab with chemotherapy. The aim of this study was to evaluate recent trends in trastuzumab therapy in Australia and New Zealand. Methods: Following data were obtained from the National Breast Cancer Audit for patients treated between 2006 and 2008: tumour size, number of cases recorded per surgeon per year, location of hospital, HER‐2 receptor status, age, lymph node status, chemotherapy and trastuzumab treatment. Results: Data were available from 23 290 patients. During the study period, the percentage of breast cancers tested for HER‐2 rose from 77% to 91%. Patients over 70 had fewer HER‐2 tests than their younger counterparts. Fourteen percent of tumours were HER‐2 positive; the proportion treated with trastuzumab in 2006, 2007 and 2008 was 50%, 66% and 74%, respectively. Significantly more node‐positive patients (77%) were given trastuzumab than node‐negative patients (52%). All the patients prescribed trastuzumab also received chemotherapy. Patients under 70 years, patients treated in Australia and patients treated by higher caseload surgeons were more likely to be prescribed trastuzumab than those over 70, patients in New Zealand and patients treated by lower caseload surgeons. Conclusions: Trastuzumab‐prescribing trends conform to the published guidelines. However, older patients and those with HER‐2 positive, node‐negative tumours >1 cm may be undertreated in some cases.     

Effectiveness of decentralized community-based screening, detection, and treatment of breast cancer in low-income, uninsured women

Different systems exist currently in the provision of breast care to low-income, uninsured women. We assessed the efficacy of screening, diagnosis, and treatment of breast cancer in this patient population through a decentralized network of providers. We retrospectively reviewed charts of all patients referred for evaluation and treatment under the Cancer Detection Program: Every Woman Counts (CDP:EWC), the California equivalent of the National Breast and Cervical Cancer Detection and Prevention Program, in a suburban area of Los Angeles County. A total of 972 CDP:EWC screening mammograms was performed in the Antelope Valley during a 7-year study period (2000 to 2007). Sixty-two screened women aged 40 to 64 years were referred for further evaluation. Breast cancer detection rate per screening mammogram was 0.8 per cent; 80 per cent were early-stage breast cancer. The majority of the women (nine of 15) underwent breast conservation surgery. The axilla was staged using sentinel lymph node dissection and/or axillary lymph node dissection. Adjuvant chemotherapy and radiation were administered to all eligible patients. Compliance with published practice guidelines was high. This suggests that a decentralized community-based network of providers may be an effective model to deliver breast care to a low-income, uninsured patient population.     

Validation of the electronic version of the BREAST-Q in the army of women study

Women undergoing surgery for primary breast cancer can choose between breast conserving therapy and mastectomy (with or without breast reconstruction). Patients often turn to outcomes data to help guide the decision-making process. The BREAST-Q is a validated breast surgery–specific patient-reported outcome measure that evaluates satisfaction, quality of life, and patient experience. It was originally developed for paper-and-pencil administration. However, the BREAST-Q has increasingly been administered electronically. Therefore, the aim of this study was to evaluate the psychometric properties of an electronic version of the BREAST-Q in a large online survey. Women with a history of breast cancer surgery recruited from the Love/AVON Army of Women program completed an electronic version of the BREAST-Q in addition to the Impact of Cancer Survey and PTSD Checklist. Traditional psychometric analyses were performed on the collected data. BREAST-Q data were collected from 6748 women (3497 Breast Conserving Therapy module, 1295 Mastectomy module, 1956 Breast Reconstruction module). Acceptability was supported by a high response rate (82%), low frequency of missing data (<5%), and maximum endorsement frequencies (<80%) in all but 17 items. Scale reliability was supported by high Cronbach's α coefficients (≥0.78) and item-total correlations (range of means, 0.65–0.91). Validity was supported by interscale correlations, convergent and divergent hypotheses as well as clinical hypotheses. The electronically administered BREAST-Q yields highly reliable, clinically meaningful data for use in clinical outcomes research. The BREAST-Q can be used in the clinical setting, whether administered electronically or using paper-and-pencil, at the choice of the patient and surgeon.     

Internet and information on breast cancer: an overview

In the past few years, many Internet breast cancer resources have appeared, including medical journals and clinical trial registries. Examples of online breast cancer journals are the The Breast, The Breast Journal, and the Breast Cancer Research and Treatment. These have replicated the experience of general medical and cancer journals such as the British Medical Journal and the Journal of Clinical Oncology. One of the most important cancer registries is the Physician Data Query, which provides information on the National Cancer Institute's clinical trials, most of which are related to breast cancer. Medical guideline databases, institutional websites, medical associations, and non-profit breast cancer organizations provide users with information including news, calendars of international breast cancer events, clinical guidelines and abstracts presented at cancer and breast cancer meetings. Finding high-quality breast cancer literature and websites is relatively easy using appropriate indexes such as Cancerlit, MedlinePlus, and Cancerlinks.     

The need for advanced breast cancer treatment guidelines: results of an internet-based survey

Although not curable, advanced breast cancer is treatable, however, treatment options are many and varied, and unlike early breast cancer (EBC), consistent guidelines are lacking. Breast cancer physicians were surveyed to assess the emotional impact of recurrence, factors affecting their treatment decisions, the role of guidelines in the management of advanced breast cancer and the need for new guidelines. Overall, distress levels were higher at recurrence than at first diagnosis of early breast cancer for both patients and physicians and the goal of treatment for this disease stage was to improve the patient's quality of life, delay disease progression and improve overall survival. While most respondents (96%) use the currently available guidelines, improvements are required, including the development of uniform global guidelines and recommendations for specific patient groups. Interactive computer programs and e-mail updates should also be utilised to ensure physicians are able to make fully informed decisions regarding optimum treatment.     

Documenting patterns of breast reconstruction in Australia: The national picture

IntroductionDifferences in national health data collection systems preclude accurate assessments of how much breast reconstruction (BR) is performed in Australia. This paper aims to quantitatively document and visually map the national prevalence and distribution of BR, using the best available evidence.Materials and methodsQuantitative analysis and spatial mapping of hospital-level data on BR prevalence in all six Australian states and two mainland territories. Data was extracted on 3786 women, under the care of members of Breast Surgeons of Australia and New Zealand Incorporated, who had mastectomy for breast malignancy with or without post-mastectomy BR in 2013.ResultsAnalysis revealed a national BR rate of 18.3%. Statistically significant differences in BR uptake (p < .0001) were found between jurisdictions [χ² (df = 7) = 284.29], with BR more likely in younger women [χ² (df = 14) = 395.62] and in private hospitals (χ² = 63.99) and less likely in remote areas [χ² (df = 4) = 66.49].ConclusionAnalysis of this substantial subset of Australian women requiring mastectomy for breast cancer has demonstrated significant variation in provision or uptake of BR across four important variables. As BR has been shown to provide long-term survivorship benefits for the growing number of women living longer following mastectomy for breast cancer, there is an urgent need to ensure BR is accessible and affordable for all women who choose this option.     

Increased Risk of Breast Cancer at a Young Age in Women with Fibrous Dysplasia

Fibrous dysplasia (FD) is a rare bone disorder caused by mutations of the GNAS gene, which are also identified in malignancies. We explored the potential relationship between breast cancer and fibrous dysplasia in two fibrous dysplasia cohorts from the Netherlands and the United States. Data on fibrous dysplasia and breast cancer diagnosis were retrieved from hospital records of 134 (Netherlands) and 121 (US) female patients. Results were validated with breast cancer data of 645 female fibrous dysplasia patients from the Dutch Pathology Registry (PALGA). Standardized morbidity ratios for breast cancer were estimated with data from Dutch and US general population registries. GNAS mutation was analyzed in 9 available breast cancer specimens. A combined total of 15 patients (6 polyostotic, 9 McCune‐Albright Syndrome) had breast cancer (87% thoracic localizations). In the Netherlands, a breast cancer incidence rate of 7.5% at median age of 46 years was validated in PALGA (6.5% at age 51 years). Breast cancer risk was 3.4‐fold increased (95% confidence interval [CI] 1.6–5.9) compared with the Dutch general population; OR 13.2‐fold (95% CI 6.2–22.8) in thoracic disease. In the US cohort, breast cancer incidence rate was 4.5% at a median age of 36 years. Breast cancer risk was 3.9‐fold increased (95% CI 1.2–8.2) compared with the general population; 5.7‐fold (95% CI 1.4–13.0) in thoracic disease. GNAS mutation was positive in 4 breast cancer specimens (44%). Risk of breast cancer is increased at a younger age, particularly in polyostotic FD, suggesting that screening for breast cancer should be considered in this particular group at a younger age than currently advocated by national guidelines. © 2017 American Society for Bone and Mineral Research.     

HOW SHOULD WE INTRODUCE HIGH-DOSE CHEMOTHERAPEUTIC STRATEGIES INTO THE ADJUVANT MANAGEMENT OF HIGH-RISK BREAST CANCER IN AUSTRALASIA?

Background : Development of bone marrow support techniques has altered the standard chemotherapeutic management of haematological malignancies, and these techniques are now being increasingly utilized in solid tumours. In breast cancer, survival benefits have resulted from conventional dose adjuvant chemotherapy, but outcomes remain poor in many women with high-risk disease. Improved response rates with high-dose chemotherapy (HDC) in metastatic disease have led to the investigation of these techniques in adjuvant therapy of high-risk localized disease. In some high-risk patient subgroups survival is extremely poor, with 5-year rates below 30%. Improved adjuvant strategies for patients in these subgroups are therefore urgently required. In Australasia, oncology departments are currently considering accrual of women with high-risk disease into the International Breast Cancer Study Group (IBCSG) 15–95 Trial investigating HDC/stem cell transplantation. Methods : The present paper reviews the available data on the efficacies and toxicities of currently available high-dose chemotherapeutic strategies; discussing methodological considerations relevant to their introduction and safe use in the adjuvant setting in Australia and New Zealand. Results : Although response rates with HDC in metastatic disease are encouraging, the clinical effectiveness of current HDC regimens in adjuvant management has not been established and is limited by significant toxicity. Conclusions : The introduction of HDC strategies for high-risk breast cancer in Australia encounters difficulties both in trial design and potential clinical practice.     

Trends in breast cancer at a county hospital

Breast cancer mortality has changed dramatically with improvements in screening techniques. Mammography is essential for early detection; however, its contribution to the survival benefit in young women is questionable. We report our experience in breast biopsies at a county teaching hospital with a traditionally younger patient population. Institutional review board approval was obtained prior to data collection. A total of 550 breast biopsies were conducted between 1995 and 2000. Data regarding age, method of breast biopsy, and pathology was reviewed. One hundred twenty of 550 patients (21.8%) had breast carcinoma detected on breast biopsies with the predominant histologic subtype being invasive ductal carcinoma. The mean age of patients with carcinoma was 52.8 years, whereas that of patients with benign breast disease was 43.6 years (P < 0.05). Forty-three per cent of all breast cancers occurred in women under the age of 50 years. During the study period, there was neither an increase in the number of breast biopsies performed per year nor a decrease in the average age of women with breast cancer. However, observing a significant percentage of breast cancer patients under 50 years old, our data suggest the importance of strict adherence to current screening recommendations including self-breast examination and yearly mammography.     

Standardized evaluation of regional and institutional breast cancer outcomes

BACKGROUND: Optimal breast cancer control outcomes include early diagnosis, thorough staging work-up, and lowest disease-related mortality. METHODS: The standardized case-mix index (SCI) for breast cancer was derived from the stage distribution of cases weighted for earlier diagnosis using the national stage 5-year mortality provided in the National Cancer Data Base expressed as an institution or region (observed) to national (expected) ratio (O/E). The standardized work-up index was the mean O/E mortality ratio for each stage. The standardized treatment index was the total O/E 5-year mortality corrected for the SCI. The overall performance evaluation (OPE) was SCI x standardized work-up index x standardized treatment index. Institutional data were acquired from a prospectively maintained breast cancer database. RESULTS: OPE scores for 42 states acquired from the National Cancer Data Base tended to be best for the northeast and northwest states. Washington and Oregon OPE scores were in the top 20%. The Swedish Cancer Institute OPE score improved steadily from 1990 to 2000 and was better than the Washington state score. CONCLUSIONS: By calibrating breast cancer stage of diagnosis and mortality to a national standard, regional and institutional breast cancer control programs can be compared objectively.     

National breast surgery audit

BACKGROUND: Surgical audit is routinely conducted throughout the surgical community in order to examine practice in a peer-review environment. A national audit for breast cancer surgery has been implemented in Australia and New Zealand. It aims to standardize the way in which surgical activities are recorded. The present paper describes the development and implementation of the audit project. METHODS: An audit kit including instruction manual, data dictionary and choice of two data collection instruments (paper or database) were distributed among participants. Surgeons record their patients prospectively, submit data to central office and provide feedback. RESULTS: Information on 3000 breast cancer patients has been collected within the first 6 months. CONCLUSION: The project has been successfully implemented and is continuing to develop. Many surgeons have incorporated the patient record forms in their routine case management activities. Comments and other submissions have been reviewed and changes incorporated into the second and subsequent releases of the kit.     

Early Data from the First Population-Wide Breast Cancer-Specific Registry in Hong Kong

Background

Current measures for breast cancer prevention and options for treatment adopted in Hong Kong are mainly based on research data and clinical evidence from overseas. It is essential to establish a cancer-specific registry to monitor the status of breast cancer in Hong Kong.

Objectives

We summarized the current status of breast cancer in Hong Kong based on the data collected from Hong Kong Breast Cancer Registry (HKBCR).

Methods

Prevalent and newly diagnosed breast cancers (including in situ and invasive breast cancers) were registered in the HKBCR. Information on patient demographics, risk factors, medical information, and survival were analyzed and reported in this study.

Results

Data of 2,330 breast cancer patients were analyzed. We observed an earlier median age at diagnosis in Hong Kong than those reported in other countries. Distribution of cancer stage was: stage 0 (11.4%), stage I (31.4%), stage II (41%), stage III (12.5%), stage IV (0.8%), and unclassified (2.9%). The percentages of patients who received surgery, chemotherapy, radiation therapy, and endocrine therapy were 98.7, 67.9, 64.8, and 64.1%, respectively. At a median follow-up of 1.2?years, locoregional recurrence was recorded at 2%, distant recurrence at 2.8%, and breast-cancer–related mortality at 0.3%.

Conclusions

The HKBCR serves as a surveillance program to monitor disease and treatment patterns. It is pivotal to support research for more effective breast cancer prevention and treatment strategies in Hong Kong.