Age-related differences in breast cancer stage at diagnosis between black and white patients in an urban community hospital

Background: Breast cancer mortality is significantly higher among black patients compared to white patients. Black women are reportedly at increased risk for early-onset breast cancer. Our goal was to evaluate stage distribution relative to age among black and white breast cancer patients in an institution with a relatively high minority patient population. Methods: We evaluated 425 patients diagnosed with breast cancer between 1990 and 1994: 56% white, 34% black, the remainder were other ethnicities. Patients were stratified by age: under 50 years versus 50 and older. Socioeconomic status was estimated by utilization of medical care in the private-practice setting versus the public clinic. Results: Significantly more black patients were younger at diagnosis compared to white patients (32% vs. 20%; p=0.008). There was a significantly more advanced stage distribution among the younger black patients, but not among the older black patients. Most of the black and white patients received private-practice care. Conclusions: These age-related differences in breast cancer stage distribution between black and white patients (which appeared independent of socioeconomic status) indicate that more aggressive screening and public education progams directed toward younger black women is warranted, and they lend support to the possibility of ethnicity-related variation in primary tumor biology.     

Falls in older people: comparing older and younger fallers in a developing country

Purpose

While falls are common in older people, causing significant mortality and morbidity, this phenomenon has not been extensively studied in the Caribbean. This study aimed to compare falls in older and younger people in this setting.

Methods

We conducted a prospective observational study of older trauma patients in Trinidad, comparing older and younger patients sustaining falls.

Results

1432 adult trauma patients were included (1141 aged 18–64 years and 291 aged 65 years and older). Older fallers were more likely to be female (66.7 vs 47.2%; p < 0.001), suffer from multiple pre-existing diseases (24.7 vs 2.4%; p < 0.001) and take multiple medications (16.1 vs 0.8%; p < 0.001). They also sustained more severe injuries and presented with higher acuity than younger fallers. Admission rates were higher among older fallers (29.9 vs 13.1%; p < 0.001).

Conclusions

In our study, older patients who fell were a distinct group from younger falls victims, with unique demographic, clinical and injury related characteristics. Their increased risk of injury within the home, coupled with their propensity for more severe injuries made them a high risk patient group. More research is needed to better understand this patient group and plan specific preventive interventions.

     

Node Positivity Among Sonographically Suspicious but FNA-Negative Axillary Nodes

Background

Fine needle aspiration (FNA) of sonographically suspicious axillary lymph nodes is helpful to clinically stage patients and guide consideration of neoadjuvant therapy in breast cancer. However, data are limited for suspicious nodes that are FNA negative. Our goal is to compare the frequency of node positivity between patients with negative axillary ultrasound (AUSneg) versus suspicious AUS with negative FNA (FNAneg).

Methods

With IRB approval, we identified all clinically node-negative (cN0) patients with invasive breast cancer treated with upfront surgery at our tertiary care center between 2016 and 2021. AUS is routinely performed with FNA of suspicious lymph node(s). We compared clinicopathologic characteristics and nodal positivity rates between AUSneg and FNAneg groups.

Results

A total of 1580 cN0 patients with invasive breast cancer were analyzed, including 1240 AUSneg and 340 FNAneg patients. The FNAneg group was younger (median age 59.7 years versus 63.5 years, p < 0.001) and had higher clinical T (cT) category (29.1% versus 21.7% with cT2–cT4 disease, p = 0.005). Final axillary pathologic node positivity did not differ significantly between the AUSneg and FNAneg groups (16.5% versus 19.1%, p = 0.25). Among FNAneg patients, 58/340 (17.1%) had a clip placed, with retrieval confirmed in 28/58 (48.3%). Of the 28 retrieved clipped nodes, 27 were sentinel nodes. Final pathologic nodal status (pN+%) did not differ between patients in whom retrieval of the clipped node was confirmed versus not confirmed (28.6% versus 16.7%, p = 0.28).

Conclusions

Both patients with sonographically suspicious node(s) and negative FNA and patients with negative AUS have a similarly low chance of positive nodes. Additionally, routine targeted excision of FNA-negative clipped nodes is not warranted.

     

Primary Breast Neuroendocrine Tumors: An Analysis of the National Cancer Database

Background

Primary breast neuroendocrine tumors (BNETs) represent < 1% of breast cancers. Diagnosing BNETs can be challenging, and a limited amount of cohort data currently exists in literature. We aimed to describe primary BNET characteristics, treatment modalities, and survival outcomes through the National Cancer Database (NCDB).

Methods

A retrospective cohort analysis was performed using the NCDB from 2004 to 2017. BNET cases were compared with patients with invasive ductal carcinoma (IDC). A matched IDC cohort was created by matching patient age, race, and disease stage. Kaplan–Meier analysis was performed, and hazard ratios (HR) were calculated through the bootstrap sampling method.

Results

A total of 1389 BNET and 1,967,401 IDC cases were identified. When compared with IDC patients, BNET patients were older, had more comorbidities, and were more often male (p < 0.01). BNETs were larger, higher grade, and more frequently hormone receptor negative (p < 0.01). While BNET patients were treated with surgery and radiotherapy (p < 0.01) less often compared with IDC patients, they presented at later disease stage (p < 0.001) and received systemic treatment more frequently (53.5% vs. 40%, p < 0.01). Patients with BNET had increased mortality compared with the matched IDC cohort: stage 1 HR 1.8, stage 2 HR 2.0, stage 3 HR 1.8, and stage 4 HR 1.5 (p < 0.001 for all).

Conclusion

Patients with BNET tend to present at higher clinical stages, are more frequently hormone receptor negative, and have inferior overall survival compared with patients with IDC. Further treatment strategies and studies are needed to elucidate optimal therapies to maximize patient outcomes.

     

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.

     

Gender differences in interventional management of peripheral vascular disease: Evidence from a blood flow laboratory population

Recent studies of gender differences in the treatment of coronary artery disease have concluded that female patients often receive less aggressive care than male patients. This study compares rates of lower extremity surgical and endovascular procedures by gender for peripheral vascular disease patients seen in the blood flow laboratory at our institution in 1987. Revascularization rates were compared for 192 female and 218 male patients with abnormal blood flow examinations and no prior lower extremity procedures. Female patients were older (3.3 years; p < 0.02), had a lower prevalence of ankle/brachial indices greater than 0.5 (64.2% of males vs. 51.8% of females; p < 0.01), a higher prevalence of hypertension (p < 0.03), and a lower prevalence of smoking (p < 0.02). No significant baseline differences were found for the prevalence of limb salvage indications or other comorbid conditions. A total of 41 women (21.4%) and 64 men (29.4%) underwent subsequent lower extremity surgical or endovascular procedures in 1987 ( p =0.08). Men had a significantly higher procedure rate among the 311 patients without limb salvage indications ( p =0.03). When statistically significant covariates such as limb salvage, age, ankle/brachial index, comorbidity, and smoking are controlled for in logistic regression analysis, men were found to have more than twice the chance of being selected for procedures ( p =0.009). Although limited to practice patterns at one institution, these results suggest that other centers should examine criteria for interventional therapy in mild-to-moderate peripheral vascular disease.Supported by AHCPR grant HS07184-01 to Northwestern University Medical School.Presented at the Annual Midwest Regional Meeting of the Society for General Internal Medicine, Chicago, Ill., September 15, 1993.     

Reduced Postoperative Morbidity after Elective Laparoscopic Cholecystectomy: Stratified Matched Case-Control Study

p < 0.003); the difference was particularly significant for complications classified as grade I, in female patients, those younger than 70, those with low anesthesiologic risk (ASA), and those after cholecystectomy without surgical difficulties. Matched case–control analysis revealed that the complication rate in the LC group significantly decreases with experience ( p < 0.01). We conclude that LC is today the treatment of choice for symptomatic cholelithiasis and is replacing OC as the gold standard against which new therapies should be compared.     

Intraoperative vasopressors and thrombotic complications in free flap breast reconstruction

Objective: The purpose of this study was to critically examine intraoperative vasopressor usage as it relates to free flap perfusion and its effect on perioperative complications in autologous breast reconstruction.

Methods: A retrospective cohort study was performed involving all free autologous breast reconstructions at a single institution over a 5 year period. Data collection focused on perioperative care, specifically fluid administration, urine output (UOP), use of vasopressors, and case duration. Outcomes included major intraoperative and postoperative complications. Patients who received intraoperative vasopressors were compared to all patients who did not. The use, type, and timing of the vasopressor agent were assessed with standard statistical analyses and regression modelling.

Results: Six hundred and eighty-two patients reconstructed with 1039 flaps were included. Of these, 475 (69.6%) patients received vasopressors. The vasopressor cohort was older (p?=?0.001), with higher rates of hypertension (p?=?0.02). They had a greater number of hypotensive episodes (2.3 vs 0.8, p?p?=?0.004). Examining complications, no increase in intraoperative thrombotic events (arterial or venous) or flap loss was noted with vasopressor administration. A higher rate of minor complications was, however, noted (53.1% vs 43.0%, p?=?0.016).

Conclusions: This study demonstrates that the use of intraoperative vasopressor agents in the anaesthetic care of free flap breast reconstruction patients is common, but likely does not impact thrombotic events or flap loss. Minor complications may, however, be more common in these patients.     

Twenty-Three-Hour-Stay Colectomy Without Increased Readmissions: An Analysis of 1905 Cases from the National Surgical Quality Improvement Program

Background

Isolated case series from highly specialized centers suggest the feasibility of a 23-h hospital stay after colectomy. We sought to determine preoperative variables associated with discharge within 23 h after colectomy to identify patients best suited for a short-stay model.

Methods

The American College of Surgeons NSQIP Colectomy-Targeted database was used to identify patients who underwent elective colectomy from 2012 to 2017. All cases with missing length of stay or inpatient death were excluded. Patients with a postoperative hospital stay ≤1 day were identified. Univariate and multivariate analyses were conducted to identify factors associated with early discharge.

Results

A total of 1905 patients were discharged within 23 h after surgery (1.6%). These patients were noted to be younger (59 versus 61 years, p < 0.001) and less likely to have insulin-dependent diabetes (3.0 versus 4.4%, p < 0.001), preoperative dyspnea (2.2 versus 6.0%, p < 0.001), COPD (3.0 versus 4.2%, p = 0.011), and hypertension (40.7 versus 46.9%, p < 0.001) than patients who stayed longer. Shorter operative time (OR 0.986, 95% CI 0.985–0.987, p < 0.001), minimally invasive techniques (OR 2.969, 95% CI 2.686–3.282, p < 0.001), lack of ostomy (OR 0.614, 95% CI 0.478–0.788, p < 0.001), and lack of ureteral stenting (OR 0.641, 95% CI 0.500–0.821, p < 0.001) were associated with early discharge in multivariable analysis. There was no increased incidence of readmission in patients discharged within 23 h.

Conclusions

Twenty-three-hour-stay colectomy is feasible on a national level and does not result in an increased incidence of readmission. Patients undergoing elective procedures without significant medical comorbidities may be eligible for early discharge. Preoperative factors may be used to select patients best suited for this short-stay model.

     

Parathyroidectomy in the Elderly: Do the Benefits Outweigh the Risks?

n = 36) were compared to those from younger patients (< 70 years of age) ( n = 148). Preoperative symptoms of mental impairment, bone disease, and fatigue were more common in elderly patients ( p < 0.05), and nephrolithiasis was more frequent in younger patients ( p < 0.025). Elderly patients presented with more advanced disease, manifested by higher preoperative parathyroid hormone levels (301.9 ± 63.3 vs. 169.2 ± 14.3 pg/ml, p < 0.05). The cure rate (94.4%), morbidity (5.5%), and mortality (0%) in the elderly were indistinguishable from those of their younger cohorts (98%, 1.4%, and 0%, respectively). In conclusion, the more advanced disease seen in the elderly suggests that they are referred for surgery with a higher threshold than younger patients. Although several series of parathyroidectomy in elderly patients have reported high morbidity rates, significant mortality, and long length of stay (LOS), we found that parathyroidectomy in these patients can be performed with high cures, low morbidity, no mortality, short LOS, and high patient satisfaction. These data suggest that the benefits of surgery outweigh its risks and argue for a lower threshold for referral of elderly patients with primary HPT for surgical treatment.     

Prognostic factors in patients receiving surgery and radiation therapy for retroperitoneal sarcoma: A machine-learning analysis

BackgroundThe addition of radiation therapy to surgery for retroperitoneal sarcoma remains controversial. Improved patient selection may help identify optimal candidates for multimodality treatment. The aim of this analysis was to define prognostic factors among patients who receive radiation therapy and surgery to aid in patient selection for multimodal therapy.MethodsPatients who received radiation therapy and underwent curative-intent resection for retroperitoneal sarcoma between 2004 and 2016 were identified from a national cohort in the United States (National Cancer Database). A machine-based classification and regression tree model was used to generate similar groups of patients relative to overall survival based on preoperative factors.ResultsA total of 1,443 patients received radiation therapy in addition to surgery. Median age was 61 years old and 55.0% were female. Most patients (66%) received care at an academic or integrated network cancer program. With a median follow-up of 84 months, receipt of radiation therapy was not associated with improved overall survival (P = .81). Classification and regression tree analysis revealed a significant association between overall survival and American Joint Committee on Cancer stage group, age, tumor histology, and Charlson comorbidity score. Application of these parameters via machine learning stratified patients into 5 cohorts with distinct survival outcomes. In the most favorable cohort (Cohort 1: American Joint Committee on Cancer stage group ≤II, age ≤61, histology including fibrosarcoma, well differentiated liposarcoma, myxoid liposarcoma, and leiomyosarcoma), the 5-year overall survival was 81.7% and median overall survival was not reached; in the least favorable cohort (Cohort 6: American Joint Committee on Cancer stage group >II, age >68) where the 5-year survival was 41.3% and median overall survival was 45.2 months (P < .001 versus Cohort 1).ConclusionIn the absence of a defined survival benefit, patients with advanced American Joint Committee on Cancer stage group, older age, and medical comorbidities have relatively unfavorable overall survival after combined modality therapy and therefore stand the least to gain from the addition of radiation therapy to surgery. In contrast, younger patients with good performance status and retroperitoneal sarcoma histologies with a higher propensity for local recurrence may have the greatest opportunity to benefit from radiation therapy.     

Competing causes of death for primary breast cancer

Background: A patient's likelihood of dying from breast cancer or another cause can be assessed with competing risks analyses. Methods: Data for a cohort of 678 patients with primary invasive breast cancer accrued from 1971 to 1990, updated to 1995, included cause of death (e.g., breast cancer vs. other cause). We investigated the effects of age, tumor size, nodal status, ER, PgR, and adjuvant therapy (hormones, chemotherapy, radiotherapy) on type of death and time to death for patients of all ages and for those over the age of 65 years. Results: Although there were no significant univariate differences in breast cancer death rates by age group (P=0.94), more patients over the age of 65 years died from other causes (41/207 [20%] of those older than 65 years vs. 16/471 [3%] of those younger than 65 years;P<.001). In competing risks analyses, older age was associated with non-breast cancer death, whereas larger tumor size was associated with breast cancer death. PgR was positively, and nodal status negatively, associated with survival, regardless of type. In the older patient group, the competing risks analyses identified similar effects for age and tumor size; in addition, higher ER assay values were less likely to be associated with breast cancer death. Conclusions: With increased lifespan, there will be more breast cancer cases in women older than 65 years; we have shown that women in this group have more non-breast cancer deaths. It becomes important, then, to delineate differential effects of prognostic factors on competing causes of death. This research was funded by the E. B. Fish Research Fund.     

Breast Cancer in Chinese Women Younger than Age 40: Are They Different from Their Older Counterparts?

Background  Breast cancer in young women is uncommon, but when it does occur it has been reported to have aggressive biological characteristics. The incidence of breast cancer peaks at age 40 in Hong Kong Chinese women, earlier than in Caucasians. This study is the first to report the tumor characteristics and management of breast cancer in Chinese women younger than age 40 and a comparison with their older counterparts. Materials and methods  Demographic and clinicopathologic findings of 1,485 Chinese women with breast cancer seen during the period September 2003 to November 2006 were prospectively recorded, and comparisons were made between those who were under the age of 40 and those 40 years of age and older. These results were then compared with a reference population obtained from the Surveillance, Epidemiology and End Results (SEER) database between 2003 and 2004. Results  17.6% of the women were younger than 40 years old, and age distribution was significantly different from women in the SEER database. The mean age at menarche was lower in women under age 40 (p < 0.0005), and age at first live birth was also higher (p = 0.017). The rate of first detection by screening mammography was significantly higher among women who were 40 of age and older (p = 0.002). Breast conservation surgery was more commonly performed in the younger age group of Chinese women, particularly when tumor size was less than 2 cm (p = 0.001). A significantly higher proportion of women under age 40 had breast reconstruction (p < 0.001). The majority of women presented with stage 0-II disease, but in the Chinese groups the younger patients presented at a later stage (p = 0.04). Younger women had higher pathological grade and poorly differentiated tumors (p = 0.02), more nodal involvement (p = 0.024), and lymphovascular permeation involvement (p < 0.001). The majority of tumors were ER and PR positive in both groups, but younger women had a higher proportion of cerbB2-positive tumors. Conclusion  Chinese women present with breast cancer at an earlier age. Younger women present with more advanced disease and more aggressive tumor characteristics. More ethnic-specific screening protocols and treatment decisions may benefit this group of patients. This work was presented as an oral presentation at International Society Surgical Week, August 2007, Montreal, Canada and awarded the Best Paper Award.     

Neoadjuvant Chemotherapy and Radiation for Patients with Locally Unresectable Pancreatic Adenocarcinoma: Feasibility, Efficacy, and Survival

Abstract Background We evaluated the feasibility and efficacy of neoadjuvant chemotherapy and radiation for patients with locally unresectable pancreatic cancer. Materials and Methods From October 2000 to August 2006, 245 patients with pancreatic adenocarcinoma underwent surgical exploration at our institution. Of these, 78 patients (32%) had undergone neoadjuvant therapy for initially unresectable disease, whereas the remaining patients (serving as the control group) were explored at presentation (n = 167). All neoadjuvant patients received gemcitabine-based chemotherapy, often in conjunction with docetaxal and capecitabine in a regimen called GTX (81%). Seventy-five percent of neoadjuvant patients also received preoperative abdominal radiation (5,040 rad). Results Neoadjuvant patients were younger than control-group patients (60.8 vs 66.2 years, respectively, p < 0.002). Seventy-six percent of neoadjuvant patients were resected as compared to 83% of control patients (NS). Concomitant vascular resection was required in 76% of neoadjuvant patients but only 20% of NS (p < 0.01). Complications were more frequent in the neoadjuvant group (44.1 vs 30.9%, p < 0.05), and mortality was higher (10.2 vs 2.9%, p < 0.03). Among the neoadjuvant patients, all but one of the deaths were in patients that underwent arterial reconstruction. Mortality for patients undergoing a standard pancreatectomy without vascular resection was 0.8% in this series. Of patients resected, negative margins were achieved in 84.7% of neoadjuvant patients and 72.7% of NS. Within the cohort of neoadjuvant patients, radiation significantly increased the complication rate (13.3 vs 54.6%, p < 0.006), but did not affect median survival (512 vs 729 days, NS). Median survival for patients who received neoadjuvant therapy (503 days) was longer than NS that were found to be unresectable at surgery (192 days, p < 0.001) and equivalent to NS that were resected (498 days). Conclusions Resection rate, margin status, and median survivals were equivalent when neoadjuvant patients were compared to patients considered resectable by traditional criteria, demonstrating equal efficacy. Surgical resection with venous reconstruction following neoadjuvant therapy for patients with locally advanced pancreatic cancer can be performed with acceptable morbidity and mortality. This approach extended the boundaries of surgical resection and greatly increased median survival for the “inoperable” patient with advanced pancreatic cancer. This work was presented at the American Hepato-Pancreato-Biliary Association Conference in Las Vegas, NV, April 2007.     

Altered serum levels of insulin-like growth-factor binding proteins in breast cancer patients

Background: Insulin-like growth factor 1 (IGF-1) has mitogenic properties for breast cancer cell lines and has been proposed to be an important factor in breast carcinogenesis. We hypothesized that differences in IGF-1 or its binding proteins might increase susceptibility to breast cancer. This case-control study was designed to investigate whether patients with breast cancer have altered levels of either IGF-1 or its intermediary modulatory proteins, the IGF binding proteins (BP). Methods: Serum was collected from 90 patients (63 with breast cancer and 27 with benign breast disease) after an overnight fast and before surgery. IGF-1, BP1, and BP3 levels were determined by immunoradiometric assays. In a subset of 66 patients, Western ligand blots were also performed for a semiquantitative measurement of functioning BP levels. A forward stepwise logistic regression model to adjust for other confounding variables (age, menopausal status, parity, age at menarche, use of oral contraceptives, history of breast biopsy, family history of breast cancer, hormone replacement therapy, and body-mass index) was used in the multivariate analysis. Results: Serum IGF-1 levels were similar in cases and controls. However, levels of BP3 (p<0.001), BP4 (p<0.01), and BP1 (p<0.05) were significantly associated with risk of breast cancer. The level of BP3 was the most significant factor predictive of breast cancer. The odds ratio for breast cancer in women with BP3 levels >2066 ng/ml was 0.18 (95% CI, 0.05–0.55). Correspondingly, women with BP1 levels higher than 39 ng/ml had an odds ratio of 0.21 (95% CI, 0.07–0.68) for breast cancer. When considering only cancer patients (n=63), decreasing levels of BP4 (p<0.01) and increasing levels of BP1 (p<0.02) were significantly associated with progesterone receptor positivity (PR+) in the tumor. The odds ratio of PR+ in patients with BP1 levels higher than 34 ng/ml was 7.49 (95% CI, 1.5–37.4). Better grade of tumor (well and moderately differentiated) was observed in patients with higher levels of BP3 (p<0.03). Conclusions: Distinct differences in BP profiles exist among patients with breast cancer and also among those with high-grade, hormonal receptor-negative tumors. These findings suggest that the bioavailability of IGF-1 as mediated by its binding proteins may participate in both breast carcinogenesis and selection of more aggressive breast carcinomas.     

Outcomes of patients with invasive mucinous and tubular carcinomas of the breast

Invasive tubular carcinoma (ITC) and invasive mucinous carcinoma (IMC) of the breast are rare histologic subtypes of breast cancer associated with favorable prognoses. The aim of our study was to investigate the outcomes for these rare subtypes using the National Cancer Database. Female patients diagnosed with ITC or IMC between 2005 and 2014 were analyzed. The primary outcome was overall survival (OS), and we analyzed its association with adjuvant therapy. 2735 patients with ITC and 5602 patients with IMC were identified. ITC presented in younger patients (57 vs. 67 years), had smaller tumors (size <1 cm, 63.1% vs. 25.4%), earlier stage, and less node-positive disease (5% vs. 8.6%), compared with IMC. Older age, government insurance, lower income, treatment in a community cancer program, large tumor size, positive nodal status, and without endocrine therapy were associated with worse OS with either subtype on multivariate analysis. No OS benefit was found for node-positive ITC that received adjuvant chemotherapy compared with those who did not. (5-year OS of 96.0% vs. 91.3%, p = 0.17).OS was improved for IMC that received adjuvant chemotherapy (10-year OS: 82.5% vs. 60.1%, p = 0.008) and endocrine therapy (10-year OS: 86.6% vs. 81.2%, p < 0.001). We concluded that ITC has favorable clinicopathological characteristics and prognosis, even with node-positive disease. ITC and IMC may need to be evaluated independently when administering adjuvant treatment plans.     

The use of granulocyte colony stimulating factor (G-CSF) and management of chemotherapy delivery during adjuvant treatment for early-stage breast cancer—Further observations from the IMPACT solid study

ObjectiveTo investigate the use and impact of granulocyte colony-stimulating factors (G-CSF) on chemotherapy delivery and neutropenia management in breast cancer in a clinical practice setting.MethodsIMPACT Solid was an international, prospective observational study in patients with a physician-assessed febrile neutropenia (FN) risk of ≥20%. This analysis focused on stages I–III breast cancer patients who received a standard chemotherapy regimen for which the FN risk was published. Chemotherapy delivery and neutropenia-related outcomes were reported according to the FN risk of the regimen and intent of G-CSF use.Results690 patients received a standard chemotherapy regimen; 483 received the textbook dose/schedule with a majority of these regimens (84%) having a FN risk ≥10%. Patients receiving a regimen with a FN risk ≥10% were younger with better performance status than those receiving a regimen with a FN risk <10%. Patients who received higher-risk regimens were more likely to receive G-CSF primary prophylaxis (48% vs 22%), complete their planned chemotherapy (97% vs 88%) and achieve relative dose intensity ≥85% (93% vs 86%) than those receiving lower-risk regimens. Most first FN events (56%) occurred in cycles not supported with G-CSF primary prophylaxis.ConclusionPhysicians generally recommend standard adjuvant chemotherapy regimens and were more likely to follow G-CSF guidelines for younger, good performance status patients in the curative setting, and often modify standard regimens in more compromised patients. However, G-CSF support is not optimal, indicated by G-CSF primary prophylaxis use in <50% of high-risk patients and observation of FN without G-CSF support.     

Local Expansion of Donation After Circulatory Death Kidney Transplant Activity Improves Waitlisted Outcomes and Addresses Inequities of Access to Transplantation

In the United Kingdom, donation after circulatory death (DCD) kidney transplant activity has increased rapidly, but marked regional variation persists. We report how increased DCD kidney transplant activity influenced waitlisted outcomes for a single center. Between 2002–2003 and 2011–2012, 430 (54%) DCD and 361 (46%) donation after brain death (DBD) kidney‐only transplants were performed at the Cambridge Transplant Centre, with a higher proportion of DCD donors fulfilling expanded criteria status (41% DCD vs. 32% DBD; p = 0.01). Compared with U.K. outcomes, for which the proportion of DCD:DBD kidney transplants performed is lower (25%; p < 0.0001), listed patients at our center waited less time for transplantation (645 vs. 1045 days; p < 0.0001), and our center had higher transplantation rates and lower numbers of waiting list deaths. This was most apparent for older patients (aged >65 years; waiting time 730 vs. 1357 days nationally; p < 0.001), who received predominantly DCD kidneys from older donors (mean donor age 64 years), whereas younger recipients received equal proportions of living donor, DBD and DCD kidney transplants. Death‐censored kidney graft survival was nevertheless comparable for younger and older recipients, although transplantation conferred a survival benefit from listing for only younger recipients. Local expansion in DCD kidney transplant activity improves survival outcomes for younger patients and addresses inequity of access to transplantation for older recipients.     

Metabolic surgery in patients over 60 years old: short- and long-term results

Purpose: Laparoscopic Roux-en-Y gastric bypass can treat obesity related comorbidities and can prolong life expectancy. It remains unclear whether this type of surgery is also indicated in obese patients with advanced age.

Materials and methods: In this retrospective monocentric study, we investigated the morbidity and outcomes of weight and metabolic control of bariatric surgery in patients older than 60 years and compared these findings with those of younger patients.

Results: At 18 months after RY gastric bypass, weight losses of respectively 30?±?11% and 34?±?9% of total initial body weight were measured in the older and younger patients (p?p?=?0.11). There was no mortality in either group, but there were significantly more complications and there was a longer hospital stay in the older patients.

Conclusion: RY gastric bypass comes with a significantly higher morbidity and hospital stay in older patients, but weight loss and improvement of DM are similar as in the younger patients.