International Rates of Breast Reconstruction After Prophylactic Mastectomy in BRCA1 and BRCA2 Mutation Carriers

Background

Breast reconstruction is an option for women with BRCA1 or BRCA2 mutations who elect to undergo prophylactic mastectomy to prevent breast cancer. We report on the uptake of breast reconstruction after prophylactic mastectomy in women with BRCA mutations from eight countries.

Methods

Women with a BRCA1 or BRCA2 mutation were questioned regarding their cancer preventive practices. Information was recorded on prophylactic mastectomy and breast reconstruction.

Results

A total of 1,635 women with a BRCA1 or BRCA2 mutation who elected to undergo prophylactic mastectomy from eight countries were included. A total of 1,137 women (69.5 %) had breast reconstruction after prophylactic mastectomy. A total of 58.7 % of women over the age of 45 years at the time of prophylactic mastectomy had breast reconstruction compared to 77.6 % of women 35 years of age or younger [odds ratio (OR) 0.36, 95 % confidence interval (CI) 0.26–0.50, p < 0.001]. In addition, 62.9 % of women with a breast cancer diagnosis (contralateral prophylactic mastectomy) had breast reconstruction after prophylactic mastectomy compared to 79.7 % of women without a previous breast cancer diagnosis (OR 0.48, 95 % CI 0.38–0.61, p < 0.001). A total of 66.9 % of women from Canada had breast reconstruction after mastectomy compared to 71.9 % of American women (OR 0.75, 95 % CI 0.59–0.96, p = 0.02).

Conclusions

The majority of women elect for breast reconstruction after prophylactic mastectomy. However, younger women and those without a previous diagnosis of breast cancer are more likely to have breast reconstruction than older women or those with a previous diagnosis of cancer.     

Utilization of Radiotherapy for Malignant Phyllodes Tumors: Analysis of the National Cancer Data Base, 1998–2009

Background

Malignant phyllodes tumors of the breast have traditionally been treated with surgical excision. Recently, the use of adjuvant radiotherapy has been advocated to reduce the risk of local recurrence; however, this recommendation is controversial in the absence of consistent outcome data. We hypothesize that there has been a trend toward increased utilization of adjuvant radiotherapy for malignant phyllodes tumors despite its uncertain effect on outcomes.

Methods

Using the National Cancer Data Base, predictors of radiotherapy utilization were examined for women with malignant phyllodes from 1998 to 2009. Kaplan–Meier and Cox regression models were generated to determine the effect of radiotherapy on local recurrence (LR), disease-free survival (DFS), and overall survival (OS).

Results

Of the 3,120 patients with malignant phyllodes, 57 % underwent breast conservation surgery and 42 % underwent mastectomy. Overall, 14.3 % of women received adjuvant radiotherapy. Utilization of radiotherapy doubled over the study period (9.5 % in 1998–1999 vs. 19.5 % in 2008–2009, p < 0.001). Women were significantly more likely to receive radiotherapy if they were diagnosed later in the study, were age 50–59 years old, had tumors >10 cm, or had lymph nodes removed. For the 1,774 patients with available recurrence data, overall recurrence was 14.1 %, and LR was 5.9 %. In adjusted models, adjuvant radiotherapy reduced LR (aHR 0.43, 95 % CI 0.19–0.95) but did not impact DFS or OS after 53 months’ median follow-up.

Conclusions

Utilization of adjuvant radiotherapy for malignant phyllodes doubled from 1998 to 2009. Radiotherapy significantly reduced LR but had no effect on DFS or OS.     

Breast Cancer Mastectomy Trends Between 2006 and 2010: Association with Magnetic Resonance Imaging, Immediate Breast Reconstruction, and Hospital Volume

Purpose

Analysis of mastectomy rates in breast cancer patients diagnosed between 2006 and 2010 in Germany with focus on impact of breast magnetic resonance imaging (MRI), immediate breast reconstruction (IBR) rates, and hospital volume as possible influencing factors of mastectomy rates.

Methods

Data of a voluntary monitored benchmarking project were used to evaluate mastectomy trends across time in an unselected cohort of breast cancer patients. We used univariate and multivariate logistic regression analysis to identify predictive factors of mastectomy.

Results

A total of 142.863 cases were included into the analysis. There was an overall decrease of 5.9 % (95 % confidence interval 5.1–6.7) in mastectomy trend from 36.5 % in 2006 to 30.6 % in 2010 (P < 0.0001). Known predictive factors were confirmed. Breast MRI (odds ratio 1.42, 95 % confidence interval 1.36–1.47) and small hospitals (<150 cases per year) seem to favor mastectomy. IBR was not associated with mastectomy rates.

Conclusions

Mastectomy rates in comparable health systems differ. Performance of preoperative breast MRI and hospital volume seem to be independent influencing factors for mastectomy rates.     

Impact of Routine Cavity Shave Margins on Breast Cancer Re-excision Rates

Purpose

Breast-conserving therapy (BCT) is an accepted method of treating early breast cancer. We hypothesized that routine excision of additional cavity shave margins (CSM) at time of initial partial mastectomy reduces the need for additional surgery.

Methods

A single-institution retrospective review was performed of women, 18 years or older, with a new diagnosis of breast cancer who underwent partial mastectomy between 1 January 2004 and 1 October 2009. Five hundred thirty-three charts were reviewed. Of those, 69 patients underwent CSM at time of initial operation. These 69 patients were matched with patients who had undergone partial mastectomy without CSM by tumor size, presence of extensive intraductal component, and primary histology.

Results

The two groups were well matched for age, nuclear grade, associated lymphovascular invasion (LVI), receptor status, and multifocality. We found that 31.9% (44/138) required return to the operating room (OR) for re-excision of margins. Rate of return to the OR was 21.7% (15/69) in the CSM group and 42.0% (29/69) in the matched group (p = 0.011). Multivariate analysis found factors significantly associated with need for additional operation included lack of CSM (odds ratio 9.2, 95% CI 2.8–30.5, p = 0.0003), larger extent of intraductal component (odds ratio 7.0, 95% CI 1.8–27.0, p = 0.005), and lack of directed re-excision (odds ratio 6.4, 95% CI 1.7–25.1, p = 0.007).

Conclusions

CSM at time of initial partial mastectomy decreases rate of re-excision by as much as ninefold. CSM should be considered at time of initial operation to reduce the need for subsequent reoperation.     

Outcomes of Partial Mastectomy in Male Breast Cancer Patients: Analysis of SEER, 1983–2009

Background

Although mastectomy is considered the gold standard for male breast cancer (MBC), the utilization of lumpectomy and its impact on outcomes in MBC patients has not been previously studied.

Methods

The Surveillance, Epidemiology and End Results (SEER) database was used to identify all MBC patients who underwent either mastectomy or less than mastectomy (i.e., lumpectomy) between 1983 and 2009.

Results

A total of 4707 (86.8 %) men underwent mastectomy and 718 (13.2 %) underwent lumpectomy. A greater proportion of patients underwent lumpectomy later in the study period (1983 to 1986, 10.6 %, vs. 2007 to 2009, 15.1 %). A greater percentage of lumpectomy patients were 80 years or older (21.3 % vs. 16.3 %), had stage IV disease (7.3 % vs. 3.1 %), and received no lymph node sampling (34.3 % vs. 6.9 %). Only 35.4 % of patients underwent adjuvant radiotherapy after lumpectomy. Ten-year breast cancer-specific survival and overall survival were 82.8 % and 46.9 %, respectively, in lumpectomy patients vs. 77.3 % and 46.4 %, respectively, in mastectomy patients. On Cox proportional hazards regression, lumpectomy was not independently associated with worse breast cancer-specific survival (odds ratio 1.09, 95 % confidence interval 0.87–1.37) or overall survival (odds ratio 1.12, 95 % confidence interval 0.98–1.27) after controlling for age, race, stage, and grade, as well as whether radiotherapy was received.

Conclusions

Lumpectomy is performed in a small but growing proportion of MBC patients. These patients are not only older and more likely to have advanced disease at the time of diagnosis, but they also are less likely to receive standard of care therapy, such as lymph node sampling and adjuvant radiotherapy. Despite these observations, breast cancer-specific survival is unaffected by the type of surgery.     

Increasing National Mastectomy Rates for the Treatment of Early Stage Breast Cancer

Background

To study national trends in the mastectomy rate for treatment of early stage breast cancer.

Methods

We analyzed data from the Surveillance, Epidemiology, and End Results database, including 256,081 women diagnosed with T1–2 N0–3 M0 breast cancer from 2000 to 2008. We evaluated therapeutic mastectomy rates by the year of diagnosis and performed a multivariable logistic regression analyses to determine predictors of mastectomy as the treatment choice.

Results

The proportion of women treated with mastectomy decreased from 40.1 to 35.6 % between 2000 and 2005. Subsequently, the mastectomy rate increased to 38.4 % in 2008 (p < 0.0001). Simple logistic regression models demonstrated that mastectomy rates between 2005 and 2008 were moderated by age (p < 0.0001), marital status (p = 0.0230), and geographic location (p < 0.0001). Multivariate logistic regression analysis found that age, race, marital status, geographic location, involvement of multiple regions of the breast, lobular histology, increasing T stage, lymph node positivity, increasing grade, and negative hormone receptor status were independent predictors of mastectomy. Additionally, multivariate analysis confirmed that women diagnosed in 2008 were more likely to undergo mastectomy than women diagnosed in 2005 (odds ratio 1.17, 95 % confidence interval 1.13 to 1.21, p < 0.0001).

Conclusions

There is evidence of a reversal in the previously declining national mastectomy rates, with the mastectomy rate reaching a nadir in 2005 and subsequently rising. Further follow-up to confirm this trend and investigation to determine the underlying cause of this trend and its effect on outcomes may be warranted.     

Increased Postoperative Complications in Bilateral Mastectomy Patients Compared to Unilateral Mastectomy: An Analysis of the NSQIP Database

Background

Recent studies indicate that women with unilateral breast cancer are choosing contralateral prophylactic mastectomy (CPM) at an increasing rate. There is limited literature evaluating the postoperative complication rates associated with CPM without breast reconstruction. The objective of this study was to compare postoperative complications in women undergoing unilateral mastectomy (UM) and sentinel lymph node biopsy (SLNB) to those undergoing bilateral mastectomy (BM) and SLNB for the treatment of their breast cancer.

Methods

The American College of Surgeons National Surgery Quality Improvement Program (ACS NSQIP) Participant Use Files between 2007 and 2010 were used to identify women with breast cancer undergoing UM or BM with SLNB. Individual and composite end points of 30-day complications were used to compare both groups by univariate and multivariate analyses.

Results

We identified 4,219 breast cancer patients who had a SLNB: 3,722 (88.2 %) had UM and 497 (11.8 %) had BM. The wound complication rate was significantly higher in the BM group versus the UM group, 5.8 % versus 2.9 % [unadjusted odds ratio (OR) 2.1, 95 % confidence interval (CI) 1.3–3.3, P < 0.01]. The overall 30-day complication rate in UM patients was 4.2 % versus 7.6 % in the BM group (unadjusted OR 1.9, 95 % CI 1.3–2.7, P < 0.01). The adjusted OR for overall complications adjusting for important patient characteristics was 1.9 (95 % CI 1.3–2.8, P < 0.01). Independent predictors of overall postoperative complications were body mass index (OR 1.1, P < 0.01) and smoking (OR 2.2, P < 0.01).

Conclusions

For patients with breast cancer, bilateral mastectomy is associated with an increased risk of wound and overall postoperative complications. Discussion of these outcomes is imperative when counseling women contemplating CPM.     

Effect of Delayed Autologous Breast Reconstruction on Breast Cancer Recurrence and Survival

Background

The goal of the present study was to evaluate the impact of delayed autologous breast reconstruction on disease relapse in breast cancer patients treated with mastectomy.

Material and methods

The study was based on 503 consecutive patients younger than 70 years of age who underwent mastectomy between January 2000 and December 2003. Overall, 391 (78 %) received mastectomy alone and 112 (22 %) underwent a delayed breast reconstruction. The median time from mastectomy to delayed breast reconstruction was 34 months. The median duration of follow-up was 102 months.

Results

There were no locoregional recurrences (LRR) in patients who underwent delayed reconstruction (0.0 %); 21 LRR developed in patients treated with mastectomy only (5.4 %), P = 0.011. Distant metastases occurred less frequently in the reconstruction group (12.5 %) than in the patients who underwent mastectomy alone (21.5 %); P = 0.0343. The 8-year breast cancer specific survival in the reconstruction group was 98.2 and 85.7 % for the mastectomy only group, P = 0.000.

Conclusions

Delayed autologous breast reconstruction does not appear to adversely influence disease progression when compared to patients treated with mastectomy only.     

Influence of Intraoperative Radiotherapy (IORT) on Perioperative Outcome after Surgical Resection of Rectal Cancer

Background

Intraoperative radiotherapy (IORT) for locally advanced or recurrent rectal cancer as an integral part of multimodal treatment might be an option to reduce local cancer recurrence. The aim of the present study was to determine the influence of IORT on the postoperative outcome and complications rates in the treatment of patients with adenocarcinoma of the rectum in comparison to patients with rectum resection only.

Methods

A total of 162 patients underwent operation for International Union against Cancer stage III/IV rectal cancer or recurrent rectal cancer at our surgical department between 2004 and 2012. They were divided into two groups depending on whether they received IORT or not. General patient details, tumor, and operation details, as well as perioperative major and minor complications, were registered and compared.

Results

Of the 162 patients treated for stage III/IV rectal cancer, 52 underwent rectal resection followed by IORT. Complication rates were similar in the two groups. Operative time was significantly longer in the IORT group (248 ± 84 vs 177 ± 68 min; p < 0.001). No significant differences were found concerning anastomotic leakage rate, hospital stay, or wound infection rate.

Conclusions

Intraoperative radiotherapy appears to be a safe treatment option in patients with locally advanced or recurrent rectal cancer with acceptable complication rates. The effect on local recurrence rate has to be estimated in long-term follow-up.     

Survival Analysis of Contralateral Prophylactic Mastectomy: A Question of Selection Bias

Background

Rates of contralateral prophylactic mastectomy (CPM) in women with breast cancer have increased, but most studies fail to show a survival benefit. We evaluated survival among CPM patients compared to patients undergoing single mastectomy (SM).

Methods

The Surveillance, Epidemiology, and End Results database was used to identify unilateral breast cancer patients who underwent mastectomy with/without CPM from 1998 to 2010. Case-control analysis was performed with CPM cases matched to SM controls on the basis of age group, race/ethnicity, extent of surgery, grade, T classification, N classification, estrogen receptor status, and propensity score. Survival analyses included Kaplan–Meier curves and univariate and multivariate proportional hazard models to determine factors associated with disease-specific (DSS) and overall survival (OS).

Results

A total of 26,526 CPM patients were identified. On multivariate regression analysis, increasing age, greater extent of surgery, increasing T and N stage, African American race, Hispanic ethnicity, poorly differentiated grade, and estrogen receptor negativity were associated with increased risk of death. CPM was associated with improved DSS (HR 0.86, 95 % CI 0.79–0.93) and even greater OS (HR 0.76, 95 % CI 0.71–0.81) compared with SM. Contralateral breast cancer (CBC) occurred in 1.6 % of women in the cohort. Removing CBC cases from analysis had little impact on CPM DSS (HR 0.86, 95 % CI 0.79–0.93) and OS (0.77, 95 % CI 0.72–0.82) suggesting that prevention of CBC by CPM does not explain the observed survival benefit.

Conclusions

CPM rates continue to rise. The improved DSS and OS observed with CPM support selection bias. Prospective trials are needed to determine cohorts of patients most likely to benefit from CPM.     

Use of MRI in Preoperative Planning for Women with Newly Diagnosed DCIS: Risk or Benefit?

Background

The role of magnetic resonance imaging (MRI) in preoperative planning for women diagnosed with breast cancer remains controversial. The risks and benefits in women with newly diagnosed ductal carcinoma in situ (DCIS) are largely unknown.

Patients and Methods

Retrospective chart review comparing women treated for DCIS who did and did not undergo MRI for preoperative planning. End points included number of additional biopsies prompted by MRI, surgical reexcision rates, weight of excisions, mastectomy rates, and conversion to mastectomy after attempted breast conservation.

Results

218 patients met study criteria. Sixty-four patients did not undergo preoperative MRI, and 154 patients did. There was no statistically significant difference (P = not significant, NS) in reexcision rates between the 34.1 % (42/123) of women who did and 20/51 (39.2 %) women who did not undergo MRI. Despite use of preoperative MRI, 11/123 women (8.9 %) were converted to mastectomy due to positive margins compared with 4/51 (7.8 %) in the women who did not undergo MRI (P = NS). In women undergoing MRI, average weight of excision at definitive surgery was 49.5 g, while in women who did not undergo MRI, average weight of excision at definitive surgery was 48.7 g.

Conclusions

Our data show that MRI does not significantly decrease reexcision rates or conversion to mastectomy after attempted breast-conservation surgery. Based on our findings, we do not believe preoperative MRI adds benefit to the care of this patient population. Prospective trials are necessary to further investigate the risks and benefits of preoperative MRI in women with DCIS.     

Intraoperative Radiation Therapy: A Critical Analysis of the ELIOT and TARGIT Trials. Part 1—ELIOT

Introduction

Two randomized intraoperative radiation therapy trials for early-stage breast cancer were recently published. The ELIOT Trial used electrons (IOERT), and the TARGIT-A Trial Update used 50-kV X-rays (IORT). These studies were compared for similarities and differences. The results were analyzed and used to determine which patients might be suitable for single-dose treatment.

Method

The primary sources of data were the ELIOT Trial and TARGIT-A Trial, as well as a comprehensive analysis of the peer-reviewed literature of accelerated partial breast irradiation (APBI) using 50-kV X-rays or electrons. Studies published or presented prior to March 2014 were analyzed for efficacy, patient restrictions, complications, and outcome.

Results

With a median follow-up of 5.8 years, the 5-year recurrence rates for ELIOT versus external beam radiation therapy (EBRT) patients were 4.4 % and 0.4 %, respectively, p = .0001. A low-risk ELIOT group was identified with a 5-year recurrence rate of 1.5 %. With a median follow-up of 29 months, the 5-year recurrence rates for the TARGIT-A versus EBRT patients were 3.3 % and 1.3 %, respectively, p = .042.

Conclusion

With 5.8 years of median follow-up, IOERT appears to have a subset of low-risk women for whom IOERT is acceptable. With 29 months of median follow-up the results of IORT with 50-kV devices are promising, but longer follow-up data are required. At the current time, single-fraction IOERT or IORT patients should be treated under strict institutional protocols.     

Chest and Upper Body Morbidity Following Immediate Postmastectomy Breast Reconstruction

Objective

The performance of a mastectomy for the treatment or prophylaxis of breast cancer may have long-term implications for both physical and mental well-being in women. The development of breast numbness and phantom breast sensations following mastectomy is well-known; however, relatively little is known about physical morbidity following postmastectomy breast reconstruction. The primary objective of this study was to evaluate the level of physical morbidity experienced following three surgical approaches: mastectomy alone, postmastectomy tissue expander/implant reconstruction, and postmastectomy autogenous tissue reconstruction.

Methods

We conducted a cross-sectional survey of a sample of women who had undergone mastectomy with or without reconstruction. Chest and upper body morbidity were evaluated using the BREAST-Q. Physical well-being was compared across three types of breast surgery.

Results

In total, 308 of 452 women who received a questionnaire booklet returned completed questionnaires. There was an overall difference in physical morbidity attributable to surgical treatment (P < 0.001). Patients who underwent autogenous tissue reconstruction had the highest (i.e., best) mean physical well-being score. Women who underwent expander/implant reconstruction also had less chronic physical morbidity than women who underwent mastectomy alone (P < 0.05).

Conclusions

Our findings suggest that women who undergo immediate autogenous tissue reconstruction experience significantly less chest and upper body morbidity than those who undergo either mastectomy with implant-based reconstruction or mastectomy alone. This information can be used to facilitate clinical decision-making, to validate individual experiences of breast cancer survivors, and to inform future innovations to decrease the long-term physical morbidity associated with breast cancer surgery.     

Residual Breast Tissue after Mastectomy: How Often and Where Is It Located?

Background

Residual breast tissue after a mastectomy can lead to a (second) primary breast cancer. The development of breast cancer after prophylactic mastectomy and the finding of normal breast tissue around a local recurrence support this assumption. The aim of the present study was to investigate the prevalence and localization of residual breast tissue after a mastectomy.

Methods

A series of 206 women who underwent a mastectomy between January 2008 and August 2009 in 11 hospitals were enrolled onto this study after written informed consent was obtained. From each mastectomy specimen, a total of 36 samples were obtained from the superficial dissection plane at predetermined locations. The biopsy samples were analyzed for the presence of benign breast tissue in the inked superficial area. Differences in percentage of positive samples were analyzed by generalized estimating equations to account for their interdependence.

Results

A total of 7,374 biopsy samples from 206 breast specimens of 206 patients were included in the analysis. In 76.2 % of the specimens (n = 157), one or more positive biopsy samples were found. The positive findings were found diffusely across the superficial dissection surface of the specimen with a significant predilection for the lower outer quadrant and the middle circle of the superficial dissection plane.

Conclusions

After a mastectomy, there is a high probability of residual breast tissue. This tissue is predominantly located in the middle circle of the superficial dissection plane and in the lower outer quadrant. Surgeons should be aware of these locations so they may remove as much of the benign breast tissue as possible.     

Intraoperative Radiation Therapy: A Critical Analysis of the ELIOT and TARGIT Trials. Part 2—TARGIT

Background

Two randomized intraoperative radiation therapy trials for early-stage breast cancer were recently published. The ELIOT Trial used electrons (IOERT), and the TARGIT-A Trial Update used 50-kV X-rays (IORT). These studies were compared for similarities and differences. The results were analyzed and used to determine which patients might be suitable for single-dose treatment.

Methods

The primary sources of data were the ELIOT Trial and TARGIT-A Trial, as well as a comprehensive analysis of the peer-reviewed literature of accelerated partial breast irradiation (APBI) using 50-kV X-rays or electrons. Studies published or presented prior to March 2014 were analyzed for efficacy, patient restrictions, complications, and outcome.

Results

With a median follow-up of 5.8 years, the 5-year recurrence rates for ELIOT versus EBRT patients were 4.4 and 0.4 %, respectively, p = 0.0001. A low-risk ELIOT group was identified with a 5-year recurrence rate of 1.5 %. With a median follow-up of 29 months, the 5-year recurrence rates for the TARGIT-A versus EBRT patients were 3.3 and 1.3 %, respectively, p = 0.042.

Conclusions

With 5.8 years of median follow-up, IOERT appears to have a subset of low risk women for whom IOERT is acceptable. With 29 months of median follow-up the results of IORT with 50-kV devices are promising, but longer follow-up data are required. At the current time, single-fraction IOERT or IORT patients should be treated under strict institutional protocols.     

Utilization of Sentinel Lymph Node Biopsy in Patients with Ductal Carcinoma In Situ Undergoing Mastectomy

Background

Current guidelines suggest consideration of sentinel lymph node biopsy (SLNB) for patients with ductal carcinoma in situ (DCIS) undergoing mastectomy. Our objective was to identify factors influencing the utilization of SLNB in this population.

Methods

We used the Surveillance Epidemiology and End Results database to identify all women with breast DCIS treated with mastectomy from 2000 to 2008. We excluded patients without histologic confirmation, those diagnosed at autopsy, those who had axillary lymph node dissections performed without a preceding SLNB, and those for whom the status of SLNB was unknown. We used multivariate logistic regression reporting odds ratios (OR) and 95 % confidence intervals (CI) to evaluate the relationship of patient- and tumor-related factors to the likelihood of undergoing SLNB.

Results

Of 20,177 patients, 51 % did not receive SLNB. Factors associated with a decreased likelihood of receiving a SLNB included advancing age (OR 0.66; 95 % CI 0.62–0.71), Asian (OR 0.75; CI 0.68–0.83) or Hispanic (OR 0.84; 95 % CI 0.74–0.96) race/ethnicity, and history of prior non-breast (OR 0.57; 95 % CI 0.53–0.61). Factors associated with an increased likelihood of receiving a SLNB included treatment in the east (OR 1.28; 95 % CI 1.17–1.4), intermediate (OR 1.25; 95 % CI 1.11–1.41), high (OR 1.84; 95 % CI 1.62–2.08) grade tumors, treatment after the year 2000, and DCIS size 2–5 cm (OR 1.54; 95 % CI 1.42–1.68) and >5 cm (OR 2.43; 95 % CI 2.16–2.75).

Conclusions

SLNB is increasingly utilized in patients undergoing mastectomy for DCIS, but disparities in usage remain. Efforts at improving rates of SLNB in this population are warranted.     

Locoregional Recurrence and Survival Outcomes by Type of Local Therapy and Trastuzumab Use Among Women with Node-Negative,HER2-Positive Breast Cancer

Background

While human epidermal growth factor receptor 2 (HER2) overexpression is an adverse breast cancer prognostic factor, it is unclear whether there are differences in outcomes between types of local treatment in this population. This retrospective study examined locoregional recurrence and survival in women with node-negative, HER2+ breast cancer treated with breast-conserving therapy (BCT) versus mastectomy.

Methods

Subjects were 748 patients with pT1–2, N0, M0 HER2+ breast cancer, treated with BCT (n = 422) or mastectomy (n = 326). Trastuzumab was used in 54 % of subjects. The 5-year Kaplan–Meier locoregional recurrence free survival (LRRFS), breast cancer specific survival (BCSS), and overall survival (OS) were compared between cohorts treated with BCT versus mastectomy. Subgroup analyses of LRR and survival were performed separately among patients treated with BCT or mastectomy to examine the effect of trastuzumab on outcomes in each group.

Results

Median follow-up was 4.4 years. Patients treated with mastectomy had higher proportions of grade 3 histology (69 vs 60 %, p = 0.004) and lower rates of hormone therapy (51 vs 64 %, p < 0.001) and trastuzumab therapy (50 vs 57 %, p = 0.04). The 5-year outcomes in women treated with BCT compared with mastectomy were: LRRFS 98.0 versus 98.3 % (p = 0.88), BCSS 97.2 versus 96.1 % (p = 0.70), and OS 95.5 versus 93.4 % (p = 0.19). Trastuzumab was associated with similar LRRFS and improved OS in both local treatment groups.

Conclusions

BCT is safe in the population of women with pT1–2, N0, HER2+ breast cancer, providing high rates of locoregional control and survival equivalent to mastectomy. Trastuzumab was associated with improved survival in both groups.     

Patient Age and Preoperative Breast MRI in Women With Breast Cancer: Biopsy and Surgical Implications

Background

The influence of patient age on multidisciplinary treatment planning after preoperative breast magnetic resonance imaging (MRI) and its influence on the surgical decision-making process are unclear.

Methods

We performed a retrospective review of 710 women with breast cancer who underwent preoperative MRI at our institution between January 2003 and December 2008. Analysis by patient age included the number of additional ipsilateral MRI findings, the number of biopsies recommended/performed, the number of additional cancers found, and the percentage of patients undergoing mastectomy.

Results

Of the 710 patients, 343 (48%) had additional ipsilateral MRI findings. After stratifying by age, the incidence of additional ipsilateral findings differed between decades (P = 0.004). However, fewer biopsies were recommended in older patients (P = 0.043). The number of women pursuing preoperative needle biopsy increased with age (P = 0.0018), while the incidence of a second focus of breast cancer did not change with age (P = 0.07). The mastectomy rate decreased from 65% in women younger than 50 to 40% in women older than 70 (P < 0.001).

Conclusions

In the setting of newly diagnosed breast cancer, the value of MRI is not influenced by patient age, with at least 40% of women in all age groups having additional findings on MRI. Insisting on preoperative needle biopsy of additional findings may decrease mastectomy rates. Further study is needed to determine the reasons for the increased percentage of mastectomies in younger women.     

Cosmesis Outcomes for Sector Resection for Ductal Carcinoma In Situ (DCIS)

Background

Oncoplastic surgery allows wide excision of pathology with greater margins in breast-conserving surgery (BCS) without compromising the shape of the breast. Oncoplastic techniques were used to remove a sector of tissue to fully excise ductal carcinoma in situ (DCIS) with a large margin, with relocation of the breast tissue to maintain normal shape. We assessed patient satisfaction with breast cosmesis after surgery as well as patients’ psychosocial well-being.

Methods

A retrospective study was conducted of patients who underwent BCS alone for pure DCIS between 1995 and 2009, performed by two surgeons. The BREAST-Q questionnaire was modified for partial mastectomy to gain patients’ perspectives on cosmetic outcomes and satisfaction after surgery. The questionnaire also assessed the emotional and sexual well-being of the patients.

Results

Overall, there was a high level of patient satisfaction, with 52 of 55 women (94 %) satisfied or very satisfied with their cosmetic outcome after partial mastectomy.

Conclusions

Oncoplastic techniques used for partial mastectomies to provide greater oncological clearance resulted in a high level of patient satisfaction after surgery.