A Population‐Based Cross‐Sectional Study Comparing Breast Cancer Stage at Diagnosis between Immigrant and Canadian‐Born Women in Ontario

There is limited information on stage at breast cancer diagnosis in Canadian immigrant women. We compared stage at diagnosis between immigrant women and Canadian‐born women, and determined whether ethnicity was an independent factor associated with stage. 41,213 women with invasive breast cancer from 2007 to 2012 were identified from the Ontario Cancer Registry. Women were classified as either immigrants or Canadian‐born by linkage with the Immigration, Refugees, and Citizenship Canada's Permanent Resident database. Women's ethnicity was classified as Chinese, South Asian, or remaining women in Ontario. Logistic regression was performed to calculate the odds ratio (OR) of being diagnosed at stage I breast cancer (versus stage II–IV). 4,353 (10.6%) women were immigrants and 36,860 (89.4%) were Canadian‐born women. The mean age at breast cancer diagnosis was 53.5 years for immigrants versus 62.3 years for Canadian‐born women (p < 0.0001). Immigrant women were less likely than Canadian‐born women to be diagnosed with stage I breast cancers (adjusted OR = 0.85; 95% CI: 0.79–0.91; p < 0.0001). The adjusted OR of being stage I was 1.28 (95% CI: 1.14–1.43; p < 0.0001) for women of Chinese ethnicity and was 0.82 (95% CI: 0.70–0.96; p = 0.01) for women of South Asian ethnicity, compared to the remaining women in Ontario. Canadian immigrant women were less likely than Canadian‐born women to be diagnosed with early‐stage breast cancers. Ethnicity was a greater contributor to the stage disparity than was immigrant status. South Asian women, regardless of immigration status, might benefit from increased breast cancer awareness programs.     

The Surgical Treatment of Breast Cancer in the Elderly: A Single Institution Comparative Review of 5235 Patients with 1028 Patients ≥70 years

Abstract: As the wave of the baby boomers shifts the age demographic of patients, the current surgical management of breast cancer in elderly women (≥70 years of age) becomes relevant because deviation from standard treatment often occurs in this group. The purpose of this study was to determine the operative mortality when treated with standard surgical procedures and to investigate trends in the surgical management of breast cancer in the elderly. A total of 5,235 patients undergoing either mastectomy or breast conservation surgery (BCS) for invasive and ductal carcinoma in situ (DCIS) were identified in a retrospective review of a prospectively accrued data base between the years of 1994 and 2007 at the Moffitt Cancer Center. Of the 5,235 patients, 1,028 (20%) patients were ≥70 years of age. The 30‐day and 90‐day mortality in the elderly group (age ≥70 years) was 0.2% (95% CI 0.02–0.7%) and 0.7% (95% CI 0.3–1.4%), respectively. The 30‐day and 90‐day mortality among patients <70 years was 0 and 0.05% (2 of 4,207 patients) (95% CI 0.005–0.2), respectively. BCS rates for invasive carcinomas were the highest for patients between 40 and 70 years of age, whereas the mastectomy rates were higher among patients <40 years of age (53%). Elderly women were as likely as women <40 years to have BCS for invasive carcinoma (OR 1.1, 95% CI 0.8–1.5), but more likely to have BCS for DCIS (OR 1.9, 95% CI 1.1–3.3). Surgical mortality in elderly women treated for breast cancer was extremely low and was related to the extent of surgery performed. Breast cancer treatment differed by age groups.     

Aromatase Inhibitor Associated Musculoskeletal Symptoms are associated with Reduced Physical Activity among Breast Cancer Survivors

Physical activity (PA) has numerous health benefits for breast cancer survivors. Recent data suggest that some breast cancer survivors treated with aromatase inhibitors may experience aromatase inhibitor associated musculoskeletal symptoms. It is unknown whether aromatase inhibitor associated musculoskeletal symptoms are associated with reduced PA and what other risk factors are associated with such PA reductions. We conducted a cross‐sectional study at a large university‐based breast cancer clinic among breast cancer survivors prescribed an aromatase inhibitor. At routine follow‐up, we surveyed participants about aromatase inhibitor associated musculoskeletal symptoms, as well as pre‐aromatase inhibitor, and current, PA levels. Among 300 participants, 90 (30%) reported a reduction of PA since the initiation of aromatase inhibitor therapy. Those with aromatase inhibitor associated musculoskeletal symptoms were more likely to report decreased PA (62% versus 38%, p = 0.001) compared with those without aromatase inhibitor associated musculoskeletal symptoms. In multivariate analyses, aromatase inhibitor associated musculoskeletal symptoms (odds ratio [OR] = 2.29 [95% confidence interval [CI]: 1.36–3.86]), and body mass index (OR = 1.06 [95% CI: 1.02–1.12]) were associated with reductions in PA. In subgroup analysis among breast cancer survivors with aromatase inhibitor associated musculoskeletal symptoms, self‐reported lower extremity joint pain (OR = 1.23 [95% CI: 1.00–1.50]) and impaired lower extremity physical function (OR = 1.07 [95% CI: 1.01–1.14]) were associated with reductions in PA. Breast cancer survivors with aromatase inhibitor associated musculoskeletal symptoms were more likely to report reductions in PA since initiating aromatase inhibitor therapy compared with those without aromatase inhibitor associated musculoskeletal symptoms. Our findings suggest that tailored interventions targeting lower extremity functional limitations are needed to enable breast cancer survivors with aromatase inhibitor associated musculoskeletal symptoms to participate in PA.     

A Contemporary, Population-Based Study of Lymphedema Risk Factors in Older Women with Breast Cancer

Background  We studied potential risk factors for lymphedema in a contemporary population of older breast cancer patients. Methods  Telephone surveys were conducted among women (65–89 years) identified from Medicare claims as having initial breast cancer surgery in 2003. Lymphedema was classified by self-report. Surgery and pathology information was obtained from Medicare claims and the state cancer registries. Results  Of 1,338 patients treated by 707 surgeons, 24% underwent sentinel lymph node biopsy (SLNB) and 57% axillary lymph node dissection (ALND). At a median of 48 months postoperatively, 193 (14.4%) had lymphedema. Lymphedema developed in 7% of the 319 patients who underwent SLNB and in 21% of the 759 patients who underwent ALND. When controlling for patient age, tumor size, type of breast cancer, type of breast and axillary surgery, receipt of radiation, chemotherapy, and hormonal therapy, and surgeon case volume, the independent predictors of lymphedema were removal of more than five lymph nodes [odds ratio (OR) 4.68–5.61, 95% confidence interval (CI) 1.36–19.74 for 6–15 nodes; OR 10.50, 95% CI 2.88–38.32 for >15 nodes] and presence of lymph node metastases (OR 1.98, 95% CI 1.21–3.24). Conclusions  Four years postoperatively, 14% of a contemporary, population-based cohort of elderly breast cancer survivors had self-reported lymphedema. In this group of predominately community-based surgeons, the number of lymph nodes removed is more predictive of lymphedema rather than whether SLNB or ALND was performed. As more women with breast cancer undergo only SLNB, it is essential that they still be counseled on their risk for lymphedema. Presented at the 61st Annual Society of Surgical Oncology Cancer Symposium, Chicago, IL, March 2008.     

Lymphedema: Knowledge, Treatment, and Impact Among Breast Cancer Survivors

Abstract: Lymphedema is an understudied consequence of surgery for breast cancer. It is estimated that as many as 60% of breast cancer survivors report symptoms of lymphedema. Few studies have examined the impact of lymphedema on the lives of women with breast cancer. The goal of this pilot study was to identify knowledge about, treatment received for, and the effect of lymphedema among a group of breast cancer survivors and physicians. Forty women with lymphedema and 10 physicians who treat breast cancer patients participated. Overall, women knew little to nothing about lymphedema before they developed it. After diagnosis, the primary source of information about lymphedema was a doctor or physical therapist. The majority of women received compressive garment therapy (75%), 46.9% received mechanical compressive therapy, 26% received bandaging, and 22% received physical therapy. More than half (55%) reported that clothing and appearance were affected by their condition and 48% reported that routine daily activities were impaired. Hot weather (58%) and regular arm use (40%) were reported to exacerbate the swelling. Most physicians reported that they did not routinely counsel women or provide written information on lymphedema prevention to their patients, and the extent to which women's daily living was affected by the condition was not always recognized. These findings have implications for interventions aimed at educating women and providers about lymphedema.     

Mammographic breast density in recent and longer‐standing ethiopian immigrants to israel

High breast density is associated with an increased risk of breast cancer development. Little is known concerning ethnic variations in breast density and its relevant contributing factors. We aimed to study breast density among Ethiopian immigrants to Israel in comparison with Israeli‐born women and to determine any effect on breast density of the length of residency in the immigrant population. Mammographic breast density using the BI‐RADS system was estimated and compared between 77 women of Ethiopian origin who live in Israel and 177 Israeli‐born controls. Logistic regression analysis was performed to estimate the odds ratios (OR) for high density (BI‐RADS score ≥ 3) vs low density (BI‐RADS score < 3) cases, comparing the 2 origin groups. Ethiopian‐born women had a crude OR of 0.15 (95% CI: 0.08‐0.26) for high breast density compared with Israeli‐born women. Adjustments for various cofounders did not affect the results. Time since immigration to Israel seemed to modify the relationship, with a stronger association for women who immigrated within 2 years prior to mammography (OR:0.07, 95% CI: 0.03‐0.17) as opposed to women with a longer residency stay in Israel (OR:0.23, 95% CI:0.10‐0.50). Adjustments of various confounders did not alter these findings. Breast density in Ethiopian immigrants to Israel is significantly lower than that of Israeli‐born controls. Our study suggests a positive association between time since immigration and breast density. Future studies are required to define the possible effects of dietary change on mammographic density following immigration.     

Survival after Breast‐Conserving Surgery with Whole Breast or Partial Breast Irradiation in Women with Early Stage Breast Cancer: A SEER Data‐base Analysis

Randomized clinical trials have demonstrated equivalency in survival outcomes for early stage breast cancer patients treated with either mastectomy or breast‐conserving surgery (BCS) with radiation. Recent, state‐level data confirm comparable survival outcomes. Using Surveillance Epidemiology and End Research (SEER) data, we sought to evaluate survival outcomes among patients with early stage breast cancer treated with mastectomy, BCS with whole breast irradiation (BCS + WBI), or BCS with accelerated partial breast irradiation (BCS + APBI). Data on women 50 years or older diagnosed with a node negative invasive breast cancer (≤3 cm in size) between 1995 and 2009 were extracted from the SEER data base. Women treated with mastectomy alone or BCS with radiation were eligible for analysis. Kaplan–Meier estimates and Cox proportional hazard models were used to compare overall survival (OS) and cancer‐specific survival (CSS) among the treatment groups. 150,171 women fulfilled inclusion criteria. OS was significantly improved among women treated with BCS and WBI or BCS and APBI compared to mastectomy alone. Adjusted hazard ratios for death in BCS with WBI or APBI (versus mastectomy alone) were 0.73 (95% CI: 0.71, 0.76) and 0.68 (95% CI: 0.58, 0.79), respectively. Adjusted CSS was also significantly improved in patients treated with BCS and WBI (HR 0.80, 95% CI: 0.76, 0.85) as compared to mastectomy. BCS with radiation (WBI or APBI) was associated with significantly improved OS and CSS, versus mastectomy alone. These results support the use of BCS with WBI or APBI (in well selected patients) for the treatment of breast cancer.     

Unequal access to breast-conserving surgery in Western Australia 1982-2000

BACKGROUND: The purpose of the present study was to examine the effects of demographic, locational and social disadvantage and the possession of private health insurance in Western Australia on the likelihood of women with breast cancer receiving breast-conserving surgery rather than mastectomy. METHODS: The WA Record Linkage Project was used to extract all hospital morbidity, cancer and death records of women with breast cancer in Western Australia from 1982 to 2000 inclusive. Comparisons between those receiving breast-conserving surgery and mastectomy were made after adjustment for covariates in logistic regression. RESULTS: Younger women, especially those aged less than 60 years, and those with less comorbidity were more likely to receive breast-conserving surgery (BCS). In lower socio-economic groups, women were less likely to receive BCS (OR 0.73; 95% CI 0.60-0.90). Women resident in rural areas tended to receive less BCS than those from metropolitan areas (OR 0.84; 95% CI 0.55-1.29). Women treated in a rural hospital had a reduced likelihood of BCS (OR 0.74; 95% CI 0.61-0.89). Treatment in a private hospital reduced the likelihood of BCS (OR 0.70; 95% CI 0.54-0.90), while women with private health insurance were much more likely to receive BCS (OR 1.39; 95% CI 1.08-1.79). CONCLUSION: Several factors were found to affect the likelihood of women with breast cancer receiving breast-conserving surgery, in particular, women from disadvantaged backgrounds were significantly less likely to receive breast-conserving surgery than those from more privileged groups.     

Family history of breast cancer,mammographic breast density and breast cancer risk: Findings from a cohort study of Korean women

BackgroundThis study investigated whether the association between family history of breast cancer in first-degree relatives and breast cancer risk varies by breast density.MethodsWomen aged 40 years and older who underwent screening between 2009 and 2010 were followed up until 2020. Family history was assessed using a self-reported questionnaire. Using Breast Imaging Reporting and Data System (BI-RADS), breast density was categorized into dense breast (heterogeneously or extremely dense) and non-dense breast (almost entirely fatty or scattered areas of fibro-glandular). Cox regression model was used to assess the association between family history and breast cancer risk.ResultsOf the 4,835,507 women, 79,153 (1.6%) reported having a family history of breast cancer and 77,238 women developed breast cancer. Family history led to an increase in the 5-year cumulative incidence in women with dense- and non-dense breasts. Results from the regression model with and without adjustment for breast density yielded similar HRs in all age groups, suggesting that breast density did not modify the association between family history and breast cancer. After adjusting for breast density and other factors, family history of breast cancer was associated with an increased risk of breast cancer in all three age groups (age 40–49 years: aHR 1.96, 95% confidence interval [CI] 1.85–2.08; age 50–64 years: aHR 1.70, 95% CI 1.58–1.82, and age ≥65 years: aHR 1.95, 95% CI 1.78–2.14).ConclusionFamily history of breast cancer and breast density are independently associated with breast cancer. Both factors should be carefully considered in future risk prediction models of breast cancer.     

The Role of Preoperative Magnetic Resonance Imaging in the Assessment and Surgical Treatment of Interval and Screen‐Detected Breast Cancer in Older Women

We describe the relationship between preoperative magnetic resonance imaging (MRI) and the utilization of additional imaging, biopsy, and primary surgical treatment for subgroups of women with interval versus screen‐detected breast cancer. We determined the proportion of women receiving additional breast imaging or biopsy and type of primary surgical treatment, stratified by use of preoperative MRI, separately for both groups. Using Breast Cancer Surveillance Consortium (BCSC) data, we identified a cohort of women age 66 and older with an interval or screen‐detected breast cancer diagnosis between 2005 and 2010. Using logistic regression, we explored associations between primary surgical treatment type and preoperative MRI use for interval and screen‐detected cancers. There were 204 women with an interval cancer and 1,254 with a screen‐detected cancer. The interval cancer group was more likely to receive preoperative MRI (21% versus 13%). In both groups, women receiving MRI were more likely to receive additional imaging and/or biopsy. Receipt of MRI was not associated with increased odds of mastectomy (OR = 0.99, 95% CI: 0.67–1.50), while interval cancer diagnosis was associated with significantly higher odds of mastectomy (OR = 1.64, 95% CI: 1.11–2.42). Older women with interval cancer were more likely than women with a screen‐detected cancer to have preoperative MRI, however, those with an interval cancer had 64% higher odds of mastectomy regardless of receipt of MRI. Given women with interval cancer are reported to have a worse prognosis, more research is needed to understand effectiveness of imaging modalities and treatment consequences within this group.     

Factors associated with breast MRI use among women with a family history of breast cancer

Although annual breast magnetic resonance imaging (MRI) is recommended for women at high risk for breast cancer as an adjunct to screening mammography, breast MRI use remains low. We examined factors associated with breast MRI use in a cohort of women with a family history of breast cancer but no personal cancer history. Study participants came from the Sister Study cohort, a nationwide, prospective study of women with at least 1 sister who had been diagnosed with breast cancer but who themselves had not ever had breast cancer (n = 17 894). Participants were surveyed on breast cancer beliefs, cancer worry, breast MRI use, provider communication, and genetic counseling and testing. Logistic regression was used to assess factors associated with having a breast MRI overall and for those at high risk. Breast MRI was reported by 16.1% and was more common among younger women and those with higher incomes. After adjustment for demographics, ever use of breast MRI was associated with actual and perceived risk. Odds ratios (OR) were 12.29 (95% CI, 8.85‐17.06), 2.48 (95% CI, 2.27‐2.71), and 2.50 (95% CI, 2.09‐2.99) for positive BRCA1/2 test, lifetime breast cancer risk ≥ 20%, and being told by a health care provider of higher risk, respectively. Women who believed they had much higher risk than others or had higher level of worry were twice as likely to have had breast MRI; OR = 2.23 (95% CI, 1.82‐2.75) and OR = 1.76 (95% CI, 1.52‐2.04). Patterns were similar among women at high risk. Breast cancer risk, provider communication, and personal beliefs were determinants of breast MRI use. To support shared decisions about the use of breast MRI, women could benefit from improved understanding of the chances of getting breast cancer and increased quality of provider communications.     

Frequent walking,but not total physical activity,is associated with increased fracture incidence: A 5‐year follow‐up of an Australian population‐based prospective study (AusDiab)

Current public health physical activity (PA) guidelines recommend that older adults accumulate ≥ 2.5 hours per week of moderate‐ to vigorous‐intensity PA to optimize health. The aim of this study was to examine (1) whether adults who meet the current PA guidelines are at reduced risk of fracture, (2) whether fracture risk varies by PA type/intensity and frequency, and (3) whether prolonged TV viewing, as a marker of sedentary behavior, is associated with fracture risk. This national, population‐based prospective study with a 5‐year follow‐up included 2780 postmenopausal women and 2129 men aged 50 years or older. Incident nontraumatic clinical fractures were self‐reported. Overall, 307 (6.3%) participants sustained at least one incident low‐trauma fracture (women 9.3%, men 2.3%). Multivariate logistic regression, adjusting for age, body mass index (BMI), physical function, previous fracture history, smoking, and dietary calcium and serum 25‐hydroxyvitamin D levels, showed that women who walked more than 3 hours per week or completed at least 6 weekly bouts of walking had a 51% and 56% increased fracture risk, respectively, compared with women who did no walking [odds ratio (OR) time = 1.51, 95% confidence interval (CI) 1.01–2.24; OR frequency = 1.56, 95% CI 1.07–2.27]. However, total and moderate to vigorous PA time and the accumulation of 2.5 hours per week or more of PA and TV viewing time were not associated with incident fractures. In men, there also was an increased fracture risk for those who walked more than 3 hours per week (OR = 2.30, 95% CI 1.06‐4.97) compared with those who reported no walking. In conclusion, older adults who adhered to the current PA guidelines were not protected against fragility fractures, but more frequent walking was associated with an increased fracture risk. © 2011 American Society for Bone and Mineral Research.     

Age- and treatment-related associations with health behavior change among breast cancer survivors

ObjectiveThe aim of this study was to identify demographic and treatment-related factors associated with health-promoting behavior changes after a breast cancer diagnosis. Changes in health behaviors were also evaluated according to weight, exercise, diet and alcohol consumption patterns before breast cancer diagnosis.Materials and methodsWe examined self-reported behavior changes among 1415 women diagnosed with breast cancer in the NIEHS Sister Study cohort. Women reported changes in exercising, eating healthy foods, maintaining a healthy body weight, drinking alcohol, smoking, getting enough sleep, spending time with family and friends, and participating in breast cancer awareness events.ResultsOn average, women were 3.7 years from their breast cancer diagnosis. Overall, 20–36% reported positive changes in exercise, eating healthy foods, maintaining a healthy weight, or alcohol consumption. However, 17% exercised less. With each 5-year increase in diagnosis age, women were 11–16% less likely to report positive change in each of these behaviors (OR = 0.84–0.89; p < 0.05), except alcohol consumption (OR = 0.97; CI: 0.81, 1.17). Women who underwent chemotherapy were more likely to report eating more healthy foods (OR = 1.47; 95% CI 1.16–1.86), drinking less alcohol (OR = 2.01; 95% CI: 1.01, 4.06), and sleeping enough (OR = 1.41; 95% CI: 1.04, 1.91). The majority of women (50–84%) reported no change in exercise, eating healthy foods, efforts to maintain a healthy weight, alcohol consumption, sleep patterns, or time spent with family or friends.ConclusionsMany women reported no change in cancer survivorship guideline-supported behaviors after diagnosis. Positive changes were more common among younger women or those who underwent chemotherapy.     

Optimism,Cynical Hostility,Falls, and Fractures: The Women's Health Initiative Observational Study (WHI‐OS)

Traits of optimism and cynical hostility are features of personality that could influence the risk of falls and fractures by influencing risk‐taking behaviors, health behaviors, or inflammation. To test the hypothesis that personality influences falls and fracture risk, we studied 87,342 women enrolled in WHI‐OS. Optimism was assessed by the Life Orientation Test–Revised and cynical hostility, the cynicism subscale of the Cook‐Medley questionnaire. Higher scores indicate greater optimism and hostility. Optimism and hostility were correlated at r = –0. 31, p < 0.001. Annual self‐report of falling ≥2 times in the past year was modeled using repeated measures logistic regression. Cox proportional hazards models were used for the fracture outcomes. We examined the risk of falls and fractures across the quartiles (Q) of optimism and hostility with tests for trends; Q1 formed the referent group. The average follow‐up for fractures was 11.4 years and for falls was 7.6 years. In multivariable (MV)‐adjusted models, women with the highest optimism scores (Q4) were 11% less likely to report ≥2 falls in the past year (odds ratio [OR] = 0.89; 95% confidence intervals [CI] 0.85–0.90). Women in Q4 for hostility had a 12% higher risk of ≥2 falls (OR = 1.12; 95% CI 1.07–1.17). Higher optimism scores were also associated with a 10% lower risk of fractures, but this association was attenuated in MV models. Women with the greatest hostility (Q4) had a modest increased risk of any fracture (MV‐adjusted hazard ratio = 1. 05; 95% CI 1.01–1.09), but there was no association with specific fracture sites. In conclusion, optimism was independently associated with a decreased risk of ≥2 falls, and hostility with an increased risk of ≥2 falls, independent of traditional risk factors. The magnitude of the association was similar to aging 5 years. Whether interventions aimed at attitudes could reduce fall risks remains to be determined. © 2016 American Society for Bone and Mineral Research.     

Association between mode of breast cancer detection and diagnosis delay

We investigated the association between mode of breast cancer (Bca) detection and diagnosis delay in a case-series of primary, histologically confirmed Bca patients from Southern Italy.Nine hundred and fifty nine women diagnosed with incident, primary Bca were recruited in two southern Italian regions. We grouped the mode of detection into two categories: Self-Detection (S-D) and Mammography (MG). Diagnosis delay was defined as the time between detection and a histologically confirmed diagnosis of invasive Bca.20.9% detected Bca with MG while 79.1% had S-D Bca. Women who detected Bca themselves (S-D) were more likely to delay breast cancer diagnosis than women who were diagnosed by a mammography (MG) (OR: 2.0; 95% CI: 1.39–2.87); when considering the model adjusted for health system-related characteristics, the risk increased (OR: 2.13; 95% CI: 1.47–3.09).Our study indicates a disadvantage in terms of diagnostic delay for women who were admitted and treated in community hospitals compared to women admitted and treated in breast health services.     

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 short‐ and long‐term mortality after lower limb amputation

Mortality after lower limb amputation is high, with UK 30‐day mortality rates of 9–17%. We performed a retrospective analysis of factors affecting early and late outcome after lower limb amputation for peripheral vascular disease or diabetic complications at a UK tertiary referral vascular centre between 2003 and 2010. Three hundred and thirty‐nine patients (233 male), of median (IQR [range]) age 73 (62–79 [26–92]) years underwent amputation. Thirty‐day mortality was 12.4%. On regression modelling, the risk of 30‐day mortality was increased in patients of ASA grade ≥ 4 (OR 4.23, 95% CI 2.07–8.63), p < 0.001 and age between 74 and 79 years (OR 3.8, 95% CI 1.10–13.13), p = 0.04 and older than 79 years (OR 4.08, 95% CI 1.25–13.25), p = 0.02. Peri‐operative (30‐day) mortality for these groups was 23.2%, 13.7% and 18.8%, respectively. Survival and Cox regression analysis demonstrated that long‐term mortality was associated with: age 74–79 years (HR 2.15, 95% CI 1.38–3.35), p = 0.001; age > 79 years (HR 2.78, 95% CI 1.82–4.25), p < 0.001; ASA grade ≥ 4 (HR 2.04, 95% CI 1.51–2.75), p < 0.001; out‐of‐hours operating (HR 1.51, 95% CI 1.08–2.10), p = 0.02; and chronic kidney disease stage 4–5 (1.57, 95% CI 1.07–2.30), p = 0.02. Anaesthetic technique was associated with long‐term mortality on survival analysis (p = 0.04), but not when analysed using regression modelling. Mortality after lower limb amputation relates to patient age, ASA, out‐of‐hours surgery and renal dysfunction. These data support lower limb amputations’ being performed during daytime hours and after modification of correctable risk factors.     

Comparative Diagnostic Utility of Low‐Dose Breast‐Specific Gamma Imaging to Current Clinical Standard

To retrospectively compare low‐dose (7–10 mCi) to high‐dose (15–30 mCi) breast‐specific gamma imaging (BSGI) in the detection of breast cancer. A retrospective review of 223 consecutive women who underwent BSGI exam between February 2011 and August 2013 with subsequent pathologic analysis was performed. Women were divided into low‐dose and high‐dose groups. The results of BSGI and pathology were compared, and the sensitivity, positive predictive value (PPV), and negative predictive value (NPV) were determined. A subgroup analysis was performed to evaluate specificity using benign follow‐up imaging to establish true‐negative results. There were 223 women who met inclusion criteria with 109 patients with 153 lesions in the low‐dose group and 114 patients with 145 lesions in the high‐dose group. Pathologic correlation demonstrates sensitivities of 97.6% (95% CI = 90.9–99.6%) and 94.6% (95% CI = 84.2–98.6%; p = 0.093), PPVs of 62.1% (95% CI = 53.2–70.3%) and 50.5% (95% CI = 40.6–60.3%, p = 0.089), and NPVs of 90.5% (95% CI = 68.2–98.3%) and 92.5% (95% CI = 78.5–98.0%, p = 0.781) in the low‐dose and high‐dose groups, respectively. Subgroup analysis included 72 patients with 98 lesions in the low‐dose group and 116 patients with 132 lesions in the high‐dose group, with a specificity of 53.7% (95% CI = 39.7–67.1%) and 66.3% (95% CI = 56.2–75.2%%, p = 0.143), respectively. Low‐dose BSGI demonstrated high sensitivity and NPV in the detection of breast cancer comparable to the current standard dose BSGI, with moderate specificity and PPV in a limited subgroup analysis, which was associated with a substantial number of false‐positives.     

Time-course of arm lymphedema and potential risk factors for progression of lymphedema after breast conservation treatment for early stage breast cancer

Abstract: The objective of this study was to describe the progression of arm lymphedema (ALE) after the initial presentation among patients receiving breast conservation therapy for early stage breast cancer and to identify potential risk factors contributing to ALE progression. The study sample was the 266 stage I or II breast cancer patients with documented ALE who underwent breast conservation therapy that included lumpectomy, axillary staging followed by radiation therapy. ALE were graded according to a difference of 0.5–2 cm (mild), 2.1–3 cm (moderate), and >3 cm (severe) in the circumference between the upper extremities for the treated and untreated sides. ALE at presentation was scored as mild, moderate, and severe in 109 (41%), 125 (47%), and 32 (12%) patients, respectively. One third of patients with ALE progressed to a more severe grade of lymphedema at 5 years of follow‐up. Age older than 65 years at the time of breast cancer treatment was associated with higher risk of ALE progression when compared 65 year age or younger (p = 0.04). The patients who had regional lymph node irradiation including posterior axillary boost were at higher risk of lymphedema progression than the patients treated with whole breast irradiation only (p = 0.001). Progression of ALE is a common occurrence. The current study provides support for the utility of routine arm measurements after breast cancer treatment to facilitate timely diagnosis and treatment of ALE.     

Mortality in Older Patients with Breast Cancer Undergoing Breast Surgery: How Low is “Low Risk”?

Background

Breast surgery carries a low risk of postoperative mortality. For older patients with multiple comorbidities, even low-risk procedures can confer some increased perioperative risk. We sought to identify factors associated with postoperative mortality in breast cancer patients ≥70 years to create a nomogram for predicting risk of death within 90 days.

Methods

Patients diagnosed with nonmetastatic invasive breast cancer (2010–2016) were selected from the National Cancer Database. Unadjusted OS was estimated using the Kaplan–Meier method. Multivariate logistic regression was used to estimate the association of age and surgery with 90-day mortality and to build a predictive nomogram.

Results

Among surgical patients ≥70 years, unadjusted 90-day mortality increased with increasing age (70–74 = 0.4% vs. ≥85 = 1.6%), comorbidity score (0 = 0.5% vs. ≥3 = 2.7%), and disease stage (I = 0.4% vs. III = 2.7%; all p < 0.001). After adjustment, death within 90 days of surgery was associated with higher age (≥85 vs. 70–74: odds ratio [OR] 3.16, 95% confidence interval [CI] 2.74–3.65), comorbidity score (≥3 vs. 0: OR 4.79, 95% CI 3.89–5.89), and disease stage (III vs. I: OR 4.30, 95% CI 3.69–5.00). Based on these findings, seven variables (age, gender, comorbidity score, facility type, facility location, clinical stage, and surgery type) were selected to build a nomogram; estimates of risk of death within 90 days ranged from <1 to >30%.

Conclusions

Breast operations remain relatively low-risk procedures for older patients with breast cancer, but select factors can be used to estimate the risk of postoperative mortality to guide surgical decision-making among older women.