Surgical management of breast cancer in the elderly patient.

BACKGROUND: Breast cancer in the older woman is a major health issue and therapeutic challenge. This study asked if presentation, surgical treatment, and outcome of breast cancer are different in elderly women compared with their younger counterparts. METHODS: There were 816 women < 70 years (younger) and 190 > or = 70 years (older) treated surgically for breast carcinoma between January 1992 and April 2000. Data for younger and older patients was analyzed from our prospective database. RESULTS: More older women had mammographic lesions (P < 0.006). Breast conservation was the treatment of choice for both groups. Stage, tumor size, histology and disease-specific survival were similar for both. There was no evidence of disease in 93% of cases in the < 70 years group at median follow-up of 38.4 months and 91% for the > or = 70 years group at 44.5 months. CONCLUSIONS: In our population the presentation, surgical treatment, and survival from breast cancer is similar in older and younger women.     

Clinical options for women at high risk for breast cancer

Women at hereditary risk of breast cancer face a difficult clinical decision. Each of the options available to them has unique advantages and disadvantages that are summarized in Table 9. Many components enter a high-risk woman's decision: her objective risk of breast cancer; clinical features, such as the consistency of breast tissue and resultant ease of examination; breast density on mammography; personal characteristics, including her experience with cancer within her family; her role and [table: see text] responsibilities within her own nuclear family; her values and goals; her experiences with the medical system; and her subjective assessment of risk. It is generally believed that women significantly overestimate their risk of breast cancer. Thus, it is vital that a woman at risk have access to a genetic counselor who can provide accurate assessment of her risk. Women should be encouraged to take time to understand their risk level and the advantages and disadvantages of the options before them.     

Identification and management of the patient at high risk for wound infection

Despite the use of perioperative antibiotics, wound infection remains a major source of morbidity after contaminated head and neck cancer surgery. Most adjunctive methods designed to control wound infection include techniques to reduce bacterial wound contamination. Additional methods include predicting the high risk patient and the bacteriology of subsequent wound infection, which allows antibiotic prophylaxis to be used on a selective basis. This article reviews relevant experimental and clinical data that evaluated these methods. Based on these results, as well as personal observations, guidelines are suggested for controlling wound infection in patients undergoing contaminated head and neck surgery.     

Surgical management of high risk prostate cancer: the Mayo Clinic experience

Although the prostate specific antigen (PSA) era has altered the clinical and demographic characteristics of men with newly-diagnosed prostate cancer, the impact on patients with high risk disease has been less predictable. We have long advocated aggressive surgical resection for patients with high risk prostate cancer at the Mayo Clinic, including patients with clinical T3 tumors, and have reported our results as well of radical prostatectomy with adjuvant hormonal therapy in the setting of lymph node positive disease. At the same time, multiple predictive models have been developed to assess the risk of disease progression following definitive therapy for prostate cancer. One such model is pretreatment risk group stratification, based on patients' PSA at diagnosis, biopsy Gleason score, and clinical stage. Here, we will review our institution's experience with surgical treatment for men with high risk prostate cancer, and will address the benefits and potential pitfalls of the pretreatment risk group classification model for high risk patients.     

Technical considerations for prophylactic mastectomy in patients at high risk for breast cancer

A study of 5 patients and 10 mastectomy specimens was performed to identify the extent of surgery necessary to completely remove all breast tissue in patients having prophylactic mastectomies. A standard total mastectomy performed for breast cancer was shown to frequently leave breast tissue within the superficial pectoralis major muscle and the lower skin flap. Frozen section analysis of margins was found to be essential to clear the axillary extension of the breast and lower skin flap in particular. The value of more extensive surgery to remove all glandular elements of the breast in the high-risk patient remains to be demonstrated.     

Current comprehensive assessment and management of women at increased risk for breast cancer

The potential for reducing the risk of breast cancer through selective estrogen receptor modulators, aromatase inhibitors, and surgery has generated interest in the use of quantitative models of risk assessment. With the addition of ductal lavage cytology to traditional epidemiologic risk factors, a discovery of cellular atypia can result in refinement of assigned risk values, while simultaneously optimizing patient selection for selective estrogen receptor modulators utilization. In view of increasing complexity in this arena, a Risk Assessment Working Group was formed to outline management strategies for the patient at an elevated risk for the development of breast cancer. No longer a statistical exercise, quantitative risk assessment is part of basic breast care and comprehensive management includes a discussion of the following: ductal lavage for improved risk stratification, multiple options for risk reduction, and high risk surveillance strategies that might incorporate investigational imaging protocols.     

Long-term outcomes of bilateral direct-to-implant breast reconstruction in women at high breast cancer risk

Introduction: Challenges of direct-to-implant breast reconstruction (BR) are to achieve sufficient implant coverage and lower pole projection. We assessed reoperation rates, long-term patient satisfaction and aesthetic outcome after direct-to-implant BR without acellular dermal matrix (ADM) in women with high breast cancer risk.

Methods: Women who underwent bilateral skin or nipple-sparing mastectomy and immediate direct-to-implant BR between 1994 and 2006 completed a survey on reoperations and the Breast-Q Reconstruction questionnaire. Photographs taken during follow-up were rated for long-term aesthetic outcome (scale 1–10) by five plastic surgeons. Outcomes were compared between women who never underwent unanticipated reoperations after immediate BR and women who underwent one or more reoperations, adjusted for potential confounders using multivariable linear regression.

Results: Of 143 women, 70 (49%) were never reoperated and 73 (51%) had undergone reoperations. Median follow-up was 12?years in both groups (range 7–17 and 6–19?years, respectively). Baseline characteristics were comparable except for history of prophylactic oophorectomy with 81% in the no-reoperations group versus 66% in the reoperated group (p?=?.03). Breast-Q scores were 59.7?±?17.3 versus 58.0?±?17.8 (p?=?.67) for ‘satisfaction with breasts’ and 71.1?±?20.3 versus 68.1?±?22.9 (p?=?.47) for ‘satisfaction with outcome’ in the no-reoperation versus reoperation group, respectively. Aesthetic outcome was scored 5.8?±?1.1 in the no-reoperation group versus 5.3?±?1.3 in the reoperation group (p?=?.01).

Conclusions: The single-stage intent did not prevent unanticipated surgical reinterventions in 51% of the patients. Long-term patient satisfaction was reasonable and not affected by reoperations. Aesthetic outcome, however, was only poor to reasonable and scores were significantly lower in the reoperated group.     

Practicalities of developing a breast magnetic resonance imaging screening service for women at high risk for breast cancer

Background: Demand for screening breast magnetic resonance imaging (MRI) for women with a hereditary predisposition to breast cancer has increased since the introduction of a medicare item number. To aid future service planning, we examined the practicalities of establishing and running a breast MRI screening programme for high risk women and to describe the early outcomes of our screening programme. Methods: We undertook a retrospective audit of prospectively collected data. Women <50 years of age with an inherited BRCA1 or BRCA2 gene mutation were invited to undergo annual breast screening with MRI in addition to mammography and clinical breast examination. We assessed process times for booking, performing and reporting MRIs; MRI findings and ease of interpretation; patient recall rate; MRI cancer detection rate; and patient satisfaction via questionnaire. Results: From 2006 to 2009, 82 women completed a round one screening MRI and 45, 21 and one women completed second, third and fourth round annual MRI studies, respectively. Median MRI process times were: booking 20 min; attendance in radiology department 90 min; imaging duration 45 min; reporting by one radiologist 30 min. Of the 82 round one studies, 23 (28%) were reported as ≥Breast Imaging Reporting and Data System three requiring further investigation. Of the round two and three studies completed, 13/45 (28%) and 2/21 (9%) have been recalled, respectively. Seven malignancies were detected. Questionnaires revealed women were satisfied with the service. Conclusions: Significant time, staff and equipment is required to run an effective breast MRI screening programme and this must be considered by future service providers.     

Management of women at high risk for breast cancer: new imaging beyond mammography

The management of women with an increased lifetime risk of breast cancer is a difficult task. This is especially true for women with a documented mutation in a breast cancer susceptibility gene (BRCA), and also for those who tested negative for a mutation, but have a family history that is suggestive of familial breast cancer. Primary prevention by prophylactic mastectomy has been shown to reduce breast cancer incidence in these women, but this intervention is still not considered a "first-line" option in the majority of guidelines. Instead, secondary prevention (intensified surveillance) is recommended. However, due to the early onset of familial breast cancer, screening must start at a substantially younger age than in women at average risk. This, together with the fact that familial breast cancers may differ from sporadic cancers in many aspects, will have a significant impact on the design and on the success rates of surveillance protocols. This article describes the different management options that exist for women at increased genetic risk and provides a survey of the current evidence regarding mammographic and non-mammographic imaging techniques. The conclusion is that mammographic screening, with or without concomitant ultrasound and clinical breast examination, is probably not sufficient to ensure an early diagnosis of familial breast cancer. If MRI is integrated in surveillance programs, early diagnosis seems to be possible. Still, the efficacy of screening even with MRI is unclear in terms of morbidity and mortality, and this lack of evidence must be communicated to women at high genetic risk.     

Populations at high risk for prostate cancer

Although prostate cancer tends to be a slow-growing neoplasm affecting older men, there is clearly a subset of patients at high risk for developing early and possibly more aggressive disease. This group of high-risk patients includes men with a family history of prostate cancer and various histologic features such as PIN and ASAP identified on an initial biopsy. Black American men have a much higher risk of developing prostate cancer when compared with white men and especially Asian men. This finding may reflect both genetic and environmental factors. Screening men at increased risk of developing prostate cancer appears to be a logical strategy, especially in light of recent reports that suggest a benefit to aggressive treatment.     

Efficacy of tamoxifen as the primary treatment of operable breast cancer in the high risk patient

An audit of 43 breast cancer patients, considered to be of high operative risk and treated only with Tamoxifen was performed. All cases were potentially operable. Good outcome was obtained in only one-third of patients. Salvage surgery had no operative mortality.     

Preoperative risk factors for carotid endarterectomy: defining the patient at high risk

PURPOSE: The efficacy of carotid endarterectomy (CEA) for prevention of stroke has been demonstrated in randomized trials; however, the optimal approach in patients excluded from these trials or who have other significant comorbid conditions remains controversial, particularly with the advent of percutaneous interventions. We examined the influence of putative risk factors on outcome of CEA in a single-center experience. METHODS: A retrospective analysis of 1370 consecutive CEA performed from 1990 to 1999 was undertaken. Preoperative risk factors examined included age older than 80 years, congestive heart failure, chronic obstructive pulmonary disease, renal failure (serum creatinine concentration > 2.0 mg/dL), contralateral carotid artery occlusion, recurrent ipsilateral carotid artery stenosis, ipsilateral hemispheric symptoms within 6 weeks, and recent coronary bypass grafting (CABG). The Fisher exact test was used to identify baseline variables associated with perioperative (30 days) risk for stroke or death. Multivariate analysis with Poisson regression was used to study the effect of all univariate criteria in combination. RESULTS: In the overall cohort, there were 32 adverse events (2.3%), including 11 deaths (0.8%), 6 disabling strokes (0.4%), and 10 nondisabling strokes (0.7%). There was no significant difference in incidence of perioperative stroke or death between patients with one or more risk factors (n = 689) and those with no risk factors (low risk, n = 681). Thirty-day mortality was significantly greater in patients with two or more risk factors compared with patients with no risk factors (2.8% vs 0.3%; P =.04), but no significant difference was noted in perioperative stroke rate (2.3% vs 1.0%). Univariate analysis demonstrated that contralateral carotid occlusion (n = 75) was the only significant predictor of adverse outcome (5 events, 6.7%) among the variables tested; this was confirmed with multivariate analysis (relative risk, 4.3; 95% confidence interval, 1.2-12.3; P =.01). Five-year survival for patients with two or more risk factors was notably diminished compared with that for patients with no risk factors (38.7% +/- 5.9% vs 75.0% +/- 2.6%; P <.001). Contralateral occlusion was also associated with reduced 5-year survival (38 +/- 11% vs 67 +/- 2%; P <.004). CONCLUSION: CEA can be safely performed in patients deemed at high risk, including those aged 80 years or older and others with significant comorbid conditions, with combined stroke and mortality rates comparable to those found in randomized trials, ie, the Asymptomatic Carotid Atherosclerosis Study and the North American Symptomatic Carotid Endarterectomy Trial. Contralateral occlusion may be a predictor for moderately increased perioperative risk and for reduced long-term survival. Caution may be warranted in asymptomatic patients with multiple risk factors, in whom presumed long-term benefit of CEA may be compromised by markedly reduced 5-year survival.     

Initial experience with surgical treatment planning in the newly diagnosed breast cancer patient at high risk for BRCA-1 or BRCA-2 mutation

Despite an abundance of information available for dealing with patients with BRCA-1 and BRCA-2 mutations, little guidance is available to assist the surgeon in dealing with the genetically high-risk patient recently diagnosed with breast cancer. A retrospective review was undertaken of 170 patients who underwent genetic counseling and testing over a 3-year period from March 2000 to March 2003. Forty-three of the 170 patients tested were diagnosed with breast cancer prior to genetic testing. Nine patients (20.9%) tested positive for a deleterious mutation. Fifty-eight percent underwent genetic counseling prior to definitive cancer surgery. Five of the 25 patients who underwent lumpectomy tested positive for a deleterious mutation. Testing results became available during systemic therapy or radiation was delayed until results were known. After counseling, all five patients testing positive went on to bilateral prophylactic mastectomy and reconstruction. None had radiation therapy. Because of a strong family history, eight patients elected to undergo prophylactic mastectomy and reconstruction prior to obtaining genetic test results; and despite compelling histories, all eight tested negative for a mutation. Treatment algorithms are developed to manage patients that are first discovered to be at high risk for a BRCA-1 or BRCA-2 mutation at the time they are diagnosed with breast cancer. Patients diagnosed with breast cancer who are discovered to be at high risk for a genetic mutation should undergo counseling prior to definitive surgery. This maximizes the time that patients have to consider options for prophylaxis and monitoring should their test be positive. It also prevents women who would otherwise be candidates for breast preservation from undergoing unnecessary radiation therapy should they chose prophylactic mastectomy in the face of a positive test.     

Man at risk. Preventive strategies and risk management for patient safety

Anaesthesia-related risk has been significantly reduced within the last decade. Nevertheless the risk and the possibility of dying or suffering permanent damage still exist. To improve patient safety, risk assessment and analysis must lead to the development of preventive strategies. For this purpose anaesthesia can rely on the concepts of other "high reliability" organisations such as aviation or nuclear power plants. Analyses of critical incidents in the different fields confirm that next to technical problems human factors account for most of the preventable mishaps. Human factors are responsible for individual mistakes as well as for organisational errors. Therefore besides traditional concepts of risk reduction (e.g. guidelines) new strategies (e.g. full-scale simulation) must be applied to minimise the negative impact of human factors on patient safety. Risk management has to consider technical, organisational and human factors to implement a higher standard of patient safety.     

The management of high risk prostate cancer

PURPOSE: A major problem that urologists encounter is the recurrence of prostate cancer after local therapy or the failure of primary therapy. There is no consensus on the treatment of these groups of patients. The role of radiotherapy, hormonal therapy or chemotherapy must be defined. MATERIALS AND METHODS: A comprehensive literature review of the current management of recurrence after primary therapy in prostate cancer was performed using MEDLINE, a review of current urology and oncology journals, and abstracts from recent urology meetings. The data collected focused on the role of radiotherapy, hormonal therapy and chemotherapy in this setting. RESULTS: Defining a high risk group of patients using Gleason score, seminal vesicle or pelvic lymph node involvement and prostate specific antigen recurrence time is important for treating the problem early in disease course. Adjuvant radiotherapy cannot offer a survival advantage but it provides longer biochemical recurrence-free survival. Early administration of salvage radiotherapy in adequate doses provides a success rate similar to that of adjuvant radiotherapy in patients with low prostate specific antigen. Although there is no good evidence that early androgen deprivation definitely prolongs patient survival, increased time to progression in addition to excellent palliation with early hormonal therapy was reported in the majority of trials. Early trials of the use of chemotherapy showed improved survival rates with adjuvant chemotherapy alone or with a combination of hormonal therapy, especially in patients with nonmetastatic disease. CONCLUSIONS: Although analysis of current literature revealed that patients who have recurrence after primary therapy would benefit from radiotherapy, hormonal therapy, chemotherapy or a combination of therapies, additional prospective randomized studies are needed to support these findings.