Does a dedicated program for young breast cancer patients affect the likelihood of fertility preservation discussion and referral?

PurposeTo assess whether a dedicated program for young breast cancer patients, including a nurse navigator, improves the frequency of: a) fertility discussion documentation and b) fertility preservation (FP) referrals.MethodsA retrospective chart review and prospective survey were undertaken of breast cancer patients diagnosed at age 40 or younger between 2011 and 2013 who received adjuvant or neo-adjuvant chemotherapy at two academic cancer centers in Toronto, Canada. The Odette Cancer Centre (OCC) has a dedicated program for young breast cancer patients while Princess Margaret Cancer Centre (PM) does not. Patient demographics, tumor pathology, treatment and fertility discussion documentation prior to systemic chemotherapy administration were extracted from patient records. Prospective surveys were administered to the same cohort to corroborate data collected.ResultsEighty-one patient charts were reviewed at both OCC and PM. Forty-seven and 49 at OCC and PM returned surveys for a response rate of 58% and 60% respectively. Chart reviews demonstrated no difference in the frequency of fertility discussion documentation (78% versus 75% for OCC and PM, p = 0.71); however, surveys demonstrated higher rates of recall of fertility discussion at OCC (96% versus 80%, p = 0.02). A greater proportion of women were offered FP referrals at OCC, as observed in chart reviews (56% versus 41%, p = 0.09), and surveys (73% versus 51%, p = 0.04). Time to initiation of chemotherapy did not differ between women who underwent FP and those who did not.ConclusionA dedicated program for young breast cancer patients is associated with a higher frequency of FP referrals without delaying systemic therapy.     

Outcomes among women younger than age 40 in a state breast cancer screening program

BACKGROUND: The value of entering women younger than age 40 in breast cancer screening programs (SPs) remains unclear. METHODS: Data from the Oregon Breast and Cervical Cancer Program (BCCP) for the period December 31, 2000 through July 1, 2003 were reviewed with a focus on women 39 years of age or younger. Information on cancers detected in this group was extracted from The Oregon State Cancer Registry. RESULTS: Of the 13,636 women screened, 797 (5.8%) were younger than 40 (mean age 31.9 years). A total of 20.6% of the women were asymptomatic and therefore represented true incidence screening, while 79.4% were referred to the program for symptoms (prevalence screen). A total of 125 biopsies were done out of 797 women, which yielded 5 cancers. All 5 of these patients were symptomatic at presentation and had a negative family history. CONCLUSIONS: There are as yet no data in our state breast cancer SP to support screening of asymptomatic women younger than 40.     

Strategies for fertility preservation in young early breast cancer patients

Diagnosis of breast cancer in young women poses a threat to fertility. Due to a recent trend of delaying pregnancy, an increasing number of breast cancer patients in reproductive age wish to bear children. Health care providers have the responsibility to know how to manage fertility issues in cancer survivors. Oncofertility counseling is of great importance to many young women diagnosed with cancer and should be managed in a multi-disciplinary background. Most of young breast cancer patients are candidate to receive chemotherapy, which could lead to premature ovarian failure. A baseline evaluation of ovarian reserve may help in considering the different fertility preservation options. The choice of the suitable strategy depends also on age, type of chemotherapy, partner status and patients' motivation. Various options are available, some established such as embryo and oocyte cryopreservation, some still experimental such as ovarian tissue cryopreservation and ovarian suppression with GnRHa during chemotherapy. An early referral to a reproductive specialist should be offered to patients at risk of infertility who are interested in fertility preservation.     

Unique challenges and outcomes of young women with breast cancers from a tertiary care cancer centre in India

BackgroundYoung (≤40 years) breast cancers (YBC) are uncommon, inadequately represented in trials and have unique concerns and merit studying.MethodsThe YBC treated with a curative intent between 2015 and 2016 at our institute were analysed.ResultsThere were 1228 patients with a median age of 36 (12–40) years; 38 (3.1%) had Stage I, 455 (37.1%) - II, 692 (56.3%) –III, and remaining 43 (3.5%) Stage IV (oligo-metastatic) disease; 927 (75.5%) were node positive; 422 (34.4%) were Triple negatives (TNBC), 331 (27%) were HER-2 positive. There were 549 (48.2%) breast conservations and 591 (51.8%) mastectomies of which 62 (10.4%) underwent breast reconstruction. 1143 women received chemotherapy, 617 (53.9%) received as neoadjuvant and 142 (23.1%) had pathological complete response; 934 (81.9%) received adjuvant radiotherapy. At the median follow-up of 48 (0–131) months, 5-year overall and disease-free survival was 79.6% (76.8–82.5) and 59.1% (55.8–62.6). For stage I, II, III and IV, the 5-year overall-survival was 100%, 86.7% (82.8–90.6), 77.3% (73.4–81.2), 69.7% (52.5–86.9) and disease-free survival was 94% (85.9–100), 65.9% (60.3–71.5), 55% (50.5–59.5), and 29.6% (14–45.2) respectively. On multivariate analysis, TNBC and HER-2+ subgroups had poorer survival (p = 0.0035). 25 patients had BRCA mutations with a 5-year DFS of 65.1% (95% CI:43.6–86.6). Fertility preservation was administered in 104 (8.5%) patients; seven women conceived and 5 had live births. Significant postmenopausal symptoms were present in 153 (13%) patients.ConclusionMore than half of the YBC in India were diagnosed at an advanced stage with aggressive features leading to suboptimal outcomes. Awareness via national registry and early diagnosis is highly warranted. Menopausal symptoms and fertility issues are prevalent and demand special focus.     

Prospective study to optimize care and improve knowledge on ovarian function and/or fertility preservation in young breast cancer patients: Results of the pilot phase of the PREgnancy and FERtility (PREFER) study

BackgroundDespite the availability of different strategies for ovarian function and/or fertility preservation in young breast cancer patients candidates for chemotherapy, limited data are available on patients’ actual need of these options.Patients and methodsThe PREFER study is a prospective cohort study including premenopausal women with newly diagnosed early stage breast cancer between the age of 18 and 45 years and candidates for chemotherapy. The study aimed to investigate patients' preferences and their choices of the different available strategies for ovarian function and/or fertility preservation (i.e. acceptance rate) and reasons for refusal.ResultsA total of 131 consecutive patients referred from a single breast unit were included. Median age was 38.9 years with 92 patients (70.3%) diagnosed at ≤ 40 years. The majority of patients (122, 93.1%) were concerned about the risk of treatment-induced premature ovarian insufficiency (POI) and/or infertility. A total of 120 (91.6%) patients underwent temporary ovarian suppression with gonadotropin-releasing hormone agonists during chemotherapy for ovarian function preservation. Among patients with ≤40 years, only 11 (12.0%) decided to access cryopreservation strategies for fertility preservation. The main reason for not accessing the fertility unit was completion of family planning before breast cancer diagnosis; for patients who accessed the fertility unit, fear of the procedure was the main reason to refuse the proposed cryopreservation strategies.ConclusionDespite the majority of young breast cancer patients are concerned about the risk of treatment-induced POI and/or infertility, only a limited number of them required to access the fertility unit to undergo cryopreservation strategies.     

Neuropathic pain after breast cancer treatment and its impact on sleep quality one year after cancer diagnosis

ObjectivesData regarding the impact of breast cancer treatment-related neuropathic pain (NP) on sleep quality are scarce. Therefore, we aimed to assess the impact of breast cancer treatment-related NP on patients' sleep quality, during the first year after cancer diagnosis.Materials and methodsA total of 501 breast cancer patients were followed prospectively. Incident NP was identified through systematic evaluations after treatments and one year after enrolment. NP severity was quantified using the Brief Pain Inventory severity subscale and sleep quality was evaluated through the Pittsburgh Sleep Quality Index (PSQI), at baseline and after one year. Adjusted regression coefficients (β) and 95% confidence intervals (95%CI) were used to quantify the relation between NP and the variation in the PSQI z-scores.ResultsThe occurrence of NP was associated with a deterioration in sleep quality during the first year of follow-up, more pronounced among those with good sleep quality (PSQI≤5) than those with poor sleep quality at baseline (PSQI>5) (β = 0.44, 95%CI: 0.11 to 0.77 versus β = 0.33, 95%CI: 0.08 to 0.59). These differences were accentuated when only the cases of NP with greater severity were considered (β = 0.86, 95%CI: 0.37 to 1.35 versus β = 0.31, 95%CI: −0.08 to 0.64). Within the PSQI components, daytime dysfunction and sleep duration were the most impaired by NP.ConclusionOur findings highlight the importance of the promotion of sleep hygiene among breast cancer patients diagnosed with NP, especially among those with good sleep quality before treatments.     

Genetic heterogeneity during breast cancer progression in young patients

BackgroundBecause a number of years may be required for normal cells to develop into carcinoma, genes involved in tumorigenesis and progression might differ among breast cancers in young women and those in older women. The present study sought to analyze subclonality during breast cancer evolution as well as diversity within each individual in our young patients’ cohort.MethodsA total of 13 women aged <35 years at diagnosis with early breast cancer were recruited. Serial sections of breast samples consisting of synchronous invasive carcinoma, adjacent ductal carcinoma in situ (DCIS), normal breast tissue, and metastatic lymph nodes were collected and prepared for immunohistochemical analysis of estrogen receptor, progesterone receptor, HER2, and Ki67, and for extraction of genomic DNA. Germline and somatic gene alterations of genomic DNA were examined by targeted sequencing.ResultsGenomic DNA from 13 blood samples and 36 breast tissues consisting of 14 invasive carcinomas, nine adjacent DCIS, 11 normal breast tissues, and two metastatic lymph nodes were successfully sequenced. Germline gene alterations including pathogenic variants and gene alterations that were not yet evaluated for their clinical significance were detected in all patients but one. Somatic gene alterations were identified in eight invasive carcinomas, five DCIS, and one metastatic lymph node. Different somatic gene alterations between invasive carcinoma and DCIS were detected in two patients. Somatic gene mutations were present in non-neoplastic tissues in three patients. No two patients had the same gene alterations.ConclusionOur results reveal diversity within each individual during breast cancer progression.     

Quality of life among a population-based cohort of older patients with breast cancer

BackgroundGrowing numbers of older women receive adjuvant breast cancer therapies, but little is known about the long-term effects of current therapies upon health-related quality of life outside of clinical trials.MethodsA population-based cohort of postmenopausal women with incident breast cancer aged sixty-five and older was identified from Medicare claims from four states and followed over five years. General health-related quality of life (HRQOL) was assessed using the Medical Outcomes Study SF-12 Health Survey, and breast cancer-related HRQOL was assessed using the breast cancer subscale of the functional assessment of cancer therapy (FACT-B BCS). The association of HRQOL with sociodemographic variables, comorbidity, and breast cancer variables (stage, treatments, and treatment sequelae) was examined in longitudinal models.ResultsAmong the 3083 older breast cancer survivors, general HRQOL as measured by SF-12 mental and physical component scores was similar to norms for non-cancer populations, and remained stable throughout follow-up. Breast cancer treatments, including surgery and radiation, adjuvant hormonal therapy, and cytotoxic chemotherapy were not associated with worsened general health scores. A similar pattern was seen for breast cancer-related HRQOL scores, except that chemotherapy was associated with slightly worse scores. Lymphedema occurred in 17% of the cohort, and was strongly associated with all measures of HRQOL. Reductions in general HRQOL with lymphedema development were larger than those with an age increase of 10 years.ConclusionsThere is little association of breast cancer treatment with HRQOL in older breast cancer patients followed for up to five years, but the development of lymphedema is associated with substantial reductions in HRQOL.     

乳腺癌病人生活质量及其影响因素现况调查

目的：了解乳腺癌病人的生活质量水平及其影响因素。方法：采用横断面研究设计,对上海3家综合性医院325例治疗期间的乳腺癌病人进行问卷调查。自行设计的一般资料问卷,欧洲癌症治疗研究组织针对肿瘤病人制定的生活质量核心问卷（EORTCQLQ-C30）及乳腺癌的特异性量表（EORTC-BR23）。结果：乳腺癌病人整体生活质量得分为（61.30±18.56）分,与EORTC提供的乳腺癌参考值比较无统计学差异（P〉0.05）,但国内、外病人在不同的生活质量子量表比较中仍存在一定差异。不同月收入组（P=0.030）和不同年龄组的乳腺癌病人间生活质量存在差异（P=0.038）;不同治疗方案组病人在躯体功能（P〈0.001）、社会功能（P=0.019）及恶心、呕吐、气促、经济困难、体形、系统治疗不良反应、手臂症状、脱发引起的烦恼这些症状比较上,差异有统计学意义;改良根治术与保乳术病人在体形得分上有显著差异（P〈0.001）。结论：乳腺癌病人的生活质量处于中等水平,影响其生活质量的主要因素有经济收入、年龄、治疗方案及具体的手术方式等。     

Ambulatory surgery for breast cancer patients

Background Less than two decades ago, early discharge of mastectomy patients was found to be possible while the drains were still in place, without noticeable consequences for patients. Most reported studies focused on surgical complication rates and found no significant evidence of it. The objective of the present study was to compare inpatient to same-day discharge surgery for breast cancer, on unselected patients. Methods All interviewed patients (n=90) had routine level I and II axillary lymph node dissection under general anesthesia, combined with breast surgery for most of them. The outpatient group comprised 55 patients and the inpatient group 35. Psychological distress was assessed, as well as pain, anxiety, quality of life, emotional adjustment, recovery, social relations, stressful life events, and so on. Results The sociodemographic characteristics of both surgery groups was quite similar, except that time from surgery to interview was about 1 year longer for inpatients. Outpatients and hospitalized patients report similar levels of pain, fear, anxiety, health assessment, and quality of life. Ambulatory patients manifest a significantly better emotional adjustment and fewer psychological distress symptoms. Inpatients reported that it took an average of 27 days to feel that they had recovered from surgery, about 10 days longer than outpatients. Inpatient return to usual activities was also about 11 days later. Conclusions Same-day discharge patients are not at a disadvantage compared to hospitalized patients; i.e., they report faster recovery and better psychological adjustment. Outpatient surgery may thus foster patient emotional well-being better than routine hospitalization.     

Fertility in Breast Cancer Survivors in the Middle East: A Retrospective Study

IntroductionBy the time they complete breast cancer therapy, many young patients are still of childbearing age. We aim to estimate the incidence of pregnancies in women who completed treatment and examine the percentage of patients who received fertility counseling before initiation of therapy.Material and methodsElectronic health records of breast cancer patients between 2008 and 2014 at AUBMC were screened for exclusion criteria of having metastatic disease or known infertility, still receiving therapy, and being above 42 years at diagnosis. Data about therapy and tumor characteristics was obtained for the included survivors who were interviewed as well via telephone for information about fertility preservation counseling, pregnancy occurrence, and delivery.Results451 breast cancer patients were identified. 39 patients remained after application of exclusion criteria. 30.76% (n = 12) wanted more children at the time of diagnosis. 10.25% (n = 4) of all 39 patients treated for breast cancer achieved one or more pregnancy after a median time of 3.83 years after completion of therapy. 25% (n = 3) of women who wanted more children at diagnosis (n = 12) were able to conceive. 23.07% (n = 9) of patients discussed fertility with their primary oncologist prior to treatment initiation. 35.89% (n = 14) of patients were aware of fertility preservation technique availability, but none of these patients used one.ConclusionsThe observed rate of pregnancy is comparable to the literature. There is a lack in fertility counseling of breast cancer patients, and the rate of use of fertility preservation techniques is very low despite prior knowledge about their availability.     

Local control in young women with early-stage breast cancer treated with hypofractionated whole breast irradiation

ObjectiveTo compare local control (LC) in young women with early-stage breast cancer (BC) treated with hypofractionated (HF) whole breast irradiation (WBI) vs conventional fractionation (CF) following breast-conserving surgery (BCS).Materials and MethodsWomen <50 years with pT1-2N0 BC following BCS treated with WBI, CF (50Gy/25 fractions) or HF (42.4Gy/16 fractions) followed by a tumor bed boost (10–16Gy/5–8 fractions) from 2009 to 2013 were identified from an institutional database. Median follow-up was 5.2 years (range 0.3–8.4). Kaplan-Meier analysis was used to estimate 5-year LC. Logistic regression identified factors associated with receipt of CF vs HF WBI.ResultsOf 270 eligible women, 227 (84%) were treated with HF and 43 (16%) with CF WBI. A tumor bed boost of 10 Gy/5 fractions was given in 97% of patients, 53% received adjuvant chemotherapy and 94% (225/239) with estrogen-positive disease received endocrine therapy. Median age was 45 years (range 30–49) in HF and 40 years (range 19–49) in the CF group. The 5-year LC rate was 99.3% (95% CI 97.9–100%, p = 0.495) in the HF and 97.5% (95% CI 92.8–100%) in the CF group. On univariate analysis, age ≤ 40 years or triple negative BC was associated with a decreased likelihood of receiving HF WBI. Only age remained significant on multivariate analysis [OR 2.82 (95% CI 1.45–5.48, p = 0.002)].ConclusionsHF WBI was associated with excellent LC rates in this study cohort, comparable to CF WBI. However, CF WBI was more likely to be recommended to women <40 years.     

乳腺癌手术后即刻乳房重建患者的生活质量评价

目的对乳腺癌手术后即刻乳房重建患者的生活质量进行评价。 方法收集2017年11月—2019年11月在海南医学院第一附属医院乳腺胸部肿瘤外科接受乳房改良根治术的乳腺癌患者150例，根据手术方式分为根治术后即刻乳房重建组(根治＋重建组，n＝25)和根治术后未行即刻乳房重建组(单纯根治组，n＝125)。术后6个月时，应用欧洲癌症研究与治疗组织乳腺癌生活质量量表(EORTC QLQ-BR45)调查两组患者的生活质量，采用自制乳腺癌配偶问卷调查两组患者配偶的生活满意度，并进行组间比较。分析患者手术方式选择的影响因素。 结果生活质量调查分析发现：根治＋重建组患者在身体形象、性欲、未来预期方面的得分优于单纯根治组，差异有统计学意义(P<0.05)。自制问卷分析结果显示：根治＋重建组配偶在身体形象、自身性功能和感情家庭方面的得分优于单纯根治组配偶，差异有统计学意义(P<0.05)。Logistics回归分析结果显示：患者的年龄和经济水平与手术方式的选择有关(P<0.05)。 结论乳腺癌手术后即刻乳房重建患者的生活质量优于未行即刻乳房重建的患者。年龄和经济水平可能是乳腺癌患者手术方式选择的影响因素。     

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目的 探讨乳腺癌保乳综合治疗的原则及近期疗效。方法 82例各期乳腺癌病例施保乳手术（局部乳腺切除 腋淋巴结清扫术）、术中或术后瘤床插植近距放疗 化疗。手术后2-4周再接受全乳腺外照射剂量为50Gy。激素受体阳性的病人均接受三苯氧胺治疗,随访时间中位数为42个月。结果 82例全部存活,无一例出现局部复发。1例出现骨转移。双乳对称。外形美观,其中1例为双侧乳癌,两侧病理类型不同,均做保乳手术。结论 早期乳腺癌病人接受保乳综合治疗可以取得满意的临床效果。可成为早期乳腺癌的首选治疗方法。     

Contraception counseling for young breast cancer patients: A practical needs assessment and a survey among medical oncologists

Background/methodsWe analyzed an unselected, consecutive cohort of young breast cancer (BC) patients (≤40 years, n = 100) with regard to the contraceptive methods used at the time of diagnosis. Based on this data, we assessed the individual need for contraceptive counseling before cancer therapy. Secondly, in a study-specific self-report questionnaire, we surveyed 101 medical oncologists with the aim of evaluating attitudes towards contraception and how young patients are being counseled in the practical clinical setting.ResultsIn 62% of our cohort of young BC patients, we identified situations in which contraceptive counseling was necessary at the time of BC diagnosis. The patients did not use contraception or used an ineffective method (TIER III/IV, 42%), or were using hormonal methods (12%) or IUDs (8%).Almost all respondents of the survey (99%) stated that contraception is an important aspect in the surveillance of young BC patients and the vast majority (90%) discussed this item before starting therapy. Only 20% of the respondents reported that they a) inform the patients that reliable contraception is necessary before starting therapy, b) ask whether contraceptive methods are used during ongoing therapy, and c) regularly refer their patients to specialist counseling by a gynecologist.ConclusionsA large proportion of young women require contraceptive counseling after newly diagnosed BC. Oncologists should be aware that the use of reliable contraceptive methods should not only be discussed before starting therapy, but also during ongoing therapy. Oncologists should consider actively referring their young patients to gynecologists to ensure proper contraceptive counseling.     

Fertility Preservation Methods in Breast Cancer

Thanks to the recent advances in reproductive medicine, more and more young women with breast cancer may be offered the possibility of preserving their fertility. Fertility can be endangered by chemotherapy, by treatment duration and by patient's age at diagnosis. The currently available means to preserve a young woman's fertility are pharmacological protection with gonadotrophin-releasing hormone analogues during chemotherapy, and ovarian tissue or oocyte/embryo freezing before treatment. New future venues, including in vitro maturation, will improve the feasibility and efficacy of the fertility preservation methods in breast cancer patients.     

Survival after surgical treatment of breast cancer

Background The principle objective of locoregional treatment in breast cancer is to eradicate local disease in the breast and local lymph nodes. Surgery in breast cancer provides locoregional control of the disease by resection appropriate to oncological principles, i.e. complete resection with tumour-free margins. Type and extent of breast surgery is dependent on tumour stage; beyond that and even more importantly, prognosis of an individual patient depends upon its stage at diagnosis.Method We reviewed the current literature, working out stage-specific survival and disease-free survival (DFS). The reported data were considered, according to stage and type of surgery, and a clear survey up to 20 years after surgery was depicted. Additionally, we assessed quality of life after breast cancer surgery.Results Overall survival (OS) rates after 5 years range from 93–84% in women diagnosed with stage I disease to 18% in women diagnosed with stage IV disease. In the management of stages I and II breast cancer, breast conservation with lumpectomy and radiation is a preferable alternative to mastectomy, with equivalent patient outcome. In stages III and IV breast cancer, surgery allows local control of the disease, but prognosis depends predominantly on the response to systemic treatment, as does prognosis in all breast cancer patients.Conclusion The reported data distributing patients outcome according to stage and surgical treatment provide a clear summary in order to estimate an individual patients risk.