Breast Cancer: Do Specialists Make a Difference?

Background: Many believe that breast cancer should be treated by specialists. We studied the effect of surgeon and hospital specialization on survival after breast cancer treatment in a large, well-defined patient population.Methods: The Cancer Surveillance Program database for Los Angeles County was reviewed. Between 1990 and 1998, 43,411 cases of breast cancer were diagnosed, of which 29,666 had complete data on surgeon, hospital, and staging information. Patients were stratified on the basis of surgeon and hospital specialization, as well as by age, race, stage, surgical procedure, and surgeon and hospital case volume. An analysis of survival and its dependence on these factors was performed.Results: Age, race, socioeconomic status, tumor size, nodal status, extent of disease, surgeon specialization, surgeon case volume, and hospital case volume were all associated with 5-year survival after diagnosis of breast cancer. Treatment at a specialty center did not affect survival. Multivariate analysis indicated that type of surgeon was an independent predictor of survival (relative risk, .77), as were both hospital and surgeon case volume.Conclusions: Treatment by a surgical oncologist resulted in a 33% reduction in the risk of death at 5 years. The effect of surgical specialization cannot be entirely attributed to volume effects.     

Can Sentinel Lymph Node Biopsy Be Omitted in Patients With Favorable Breast Cancer Histology?

Background The widespread use of sentinel lymph node biopsy (SLNB) to replace axillary dissection has broadened the indications for axillary staging in breast cancer. Recent studies have demonstrated a finite risk of lymphedema and sensory morbidity associated with SLNB. We undertook this study to determine whether SLNB could be omitted in clinically node-negative patients with favorable-histology breast cancer.Methods We conducted a retrospective review of a prospective database of SLNBs performed at Memorial Sloan-Kettering Cancer Center from 1996 to 2003 to determine the incidence of lymph node metastases by histological subtype. For the favorable subtypes, the patients age, tumor size, estrogen receptor status, lymphovascular invasion, nuclear grade, and histological grade were compared by nodal status to determine their predictive value.Results A total of 196 cases with favorable breast cancer subtypes were identified with a 4.1% (8 of 196) sentinel lymph node (SLN) positivity rate. Each of the histological subtypes included patients with positive SLNs, with the exception of adenoid cystic (n = 4) and secretory (n = 1) breast carcinoma, which were quite rare in our series. When compared by nodal status, the patients age, tumor size, estrogen receptor status, lymphovascular invasion, nuclear grade, and histological grade failed to predict those with positive SLNs.Conclusions Patients with favorable breast cancer histology have a small risk of axillary SLN metastases. The use of SLNB in these patients should be individualized, taking into consideration the small incidence of axillary metastases and the risks and benefits associated with the SLN procedure.     

Preoperative Chemotherapy for Breast Cancer: Do We Need to Redefine Our End Points?

Annals of Surgical Oncology -     

Axillary Lymph Nodes in Breast Cancer: Is Size Related to Metastatic Involvement?

Usually when using imaging procedures, such as axillary mammography or ultrasonography, a cutoff level of 5 mm for lymph node size is postulated to be not only the limit of lymph node visibility but also a sign of metastatic involvement. The aim of this study was to evaluate whether this assumption, used as a basic hypothesis in many reports, is true. A series of 72 axillary specimens from 71 breast carcinoma patients operated at the university hospital of Vienna were analyzed. A comparison of histologically noninvolved axillary specimens with those showing metastatic involvement revealed that the two groups did not differ significantly according to the number or size of lymph nodes per axilla. For lymph nodes <5 mm the probability of being metastatically involved was still 10%. Enlarged lymph nodes (5–20 mm) had a slightly higher risk of being malignant (20%). In contrast, the probability of metastatic involvement for lymph nodes >20 mm was only 40%. We suggest that many reports dealing with the prediction of malignancy in axillary lymph nodes may have used misleading basic assumptions, so the results of these studies must be viewed critically.     

Breast Cancer in the Elderly: Is MRI Helpful?

Appropriate use of magnetic resonance imaging (MRI) in elderly breast cancer (BC) patients remains unclear; we sought to identify the indications and implications of MRI use in our elderly BC population. Women 70 years of age or older at first BC diagnosis with an MRI performed at our institution either perioperatively or in follow‐up were included from a prospectively maintained database from 2000 to 2010. Univariate logistic regression was used to test associations with disease identified by MRI only (additional ipsilateral, contralateral, or new cancer) following perioperative MRI. 305 BCs were imaged in 286 patients. 133 were imaged with MRI in the perioperative setting alone, 88 had only follow‐up MRIs after BC treatment, and 65 had both. Indications for perioperative MRI include: extent of disease evaluation (181; 91%); occult primary (10; 5%); high‐risk screening (5; 3%); and abnormal physical exam with negative conventional imaging (2; 1%). Disease identified by MRI only for occult primary cases was 4/10 (40%; 95% confidence interval: 12.2–73.8%) and 14/181 (7.7%; 95% confidence interval: 4.3–12.6%) for perioperative MRIs performed for extent of disease evaluation. Analysis of imaging and tumor characteristics failed to find significant predictors of disease identified by MRI only. A total of 369 post‐treatment follow‐up MRIs were performed in 148 patients with a median of 2 MRIs per patient (range 1–8), with seven cases of disease identified by MRI only (1.9%; 95% confidence interval: 0.8–3.9%). MRI had the greatest benefit in women presenting with an occult primary cancer and minimal additional benefit in elderly patients with BC undergoing MRI imaging for extent of disease evaluation or in post‐treatment surveillance.     

Metaplastic Breast Cancer: To Radiate or Not to Radiate?

Background

The role of radiation therapy (RT) is unclear for metaplastic breast cancer (MBC). We hypothesized that RT would improve overall survival (OS) and disease-specific survival (DSS).

Materials and Methods

We used the Surveillance, Epidemiology, and End Results (SEER) database to identify MBC patients diagnosed from1988 to 2006. Univariate analyses of patient, tumor, and treatment-specific factors on OS and DSS were performed using the Kaplan–Meier method and differences among survival curves assessed via log rank. Variables assessed included patient age, race/ethnicity, histologic subtype, tumor grade, T stage, N stage, M stage, hormone receptor status, surgery type, and use of RT. Cox proportional hazards models used all univariate covariates. Risks of mortality were reported as hazard ratios (HR) with 95% confidence intervals (95% CI); significance was set at P ≤ 0.05.

Results

Among 1501 patients, RT was given to 580 (38.6%). Ten-year OS and DSS were 53.2, and 68.3%, respectively. In the overall analysis, RT provided an OS (HR 0.64; 95% CI, 0.51–0.82; P < 0.001) and DSS (HR 0.74; CI, 0.56–0.96; P < 0.03) benefit. When patients were stratified according to type of surgery, RT provided an OS but not a DSS benefit to lumpectomy (HR 0.51; CI, 0.32–0.79, P < 0.01) and mastectomy patients (HR 0.67; CI, 0.49–0.90; P < 0.01).

Conclusions

Our findings support the use of RT for patients with MBC following lumpectomy or mastectomy. These retrospective findings should be confirmed in a prospective clinical trial.     

Innate Immune Cells in Breast Cancer – From Villains to Heroes?

The innate immune system ensures effective protection against foreign pathogens and plays important roles in tissue remodeling. There are many types of innate immune cells, including monocytes, macrophages, dendritic cells, and granulocytes. Interestingly, these cells accumulate in most solid tumors, including those of the breast. There, they play a tumor-promoting role through secretion of growth and angiogenic factors, as well as immunosuppressive molecules. This is in strong contrast to the tumor-suppressing effects that innate immune cells exert in vitro upon proper activation. Therapeutic approaches have been developed with the aim of achieving similar suppressive activities in vivo. However, multiple factors in the tumor microenvironment, many of which are immunosuppressive, represent a major obstacle to effective treatment. Here, we discuss the potential of combating breast cancer through activation of the innate immune system, including possible strategies to enhance the success of immunotherapy.     

Stratifying Venous Thromboembolism Risk in Arthroplasty: Do High-Risk Patients Exist?

BackgroundWhile there are many possible complications associated with total joint arthroplasty (TJA), venous thromboembolism (VTE) is both frequent and potentially severe. Despite this importance, there are inconsistent recommendations for prophylaxis based on patient risk factors.MethodsA predictive model was constructed to compare low-molecular-weight heparin(LMWH) and aspirin (ASA) for prevention of VTE-associated complications following TJA.The model used risks from prior prophylaxis studies to estimate the risk of developing a symptomatic deep vein thrombosis, pulmonary embolism, thrombocytopenia, and operative or nonoperative site bleeding. We also evaluated the progression to 4 possible final health states: postphlebitis syndrome, intracranial hemorrhage, death, or baseline health. Within published ranges, we selected assumptions that were favorable to LMWH such that these analyses represent a best case scenario for LMWH or an alternative more aggressive low-molecular-weight heparin alternative (LMWHA). Events and outcomes were assigned quality-adjusted life-year (QALY) losses according to prior studies to determine the effect on patients’ outcomes for ASA and LMWHA prophylaxis.ResultsAssessing VTE risk populations from 0.2% to 2% with life expectancies ranging from 5 to 40 years postoperatively, patients with a risk ratio less than 3.7 showed increased expected QALY with ASA compared to LMWHA. For patients with a baseline VTE risk of 1% and a 15 year life expectancy, a risk ratio of 13.4 was needed to identify patients that would benefit from LMWHA. With life expectancy increased to 30 years, the risk ratio needed to idetify these patients was 7.4.ConclusionPatients undergoing TJA should receive ASA chemoprophylaxis in nearly all situations, unless the patient has a significantly increased VTE risk compared to the baseline population and a long life expectancy.     

Options in Breast Cancer Local Therapy: Who Gets What?

Today, women with primary breast cancer may consider three surgical options: breast-conserving surgery (BCS), mastectomy (MT), and mastectomy with contralateral prophylactic mastectomy (MT?+?CPM). In each case, the ipsilateral axilla is generally managed with a sentinel node biopsy and possibly an axillary lymph node dissection. BCS generally requires breast radiotherapy, except in older women having tumors with a favorable prognosis who will receive endocrine therapy. In contrast, women treated with MT generally do not require radiotherapy, except for those with large tumors or metastases to the axillary nodes. Moreover, MT and MT?+?CPM are usually undertaken with breast reconstruction. Yet, most patients today are suitable candidates for BCS, with a few relative contraindications. Thus, early pregnancy, previous radiotherapy to the breasts, active collagen vascular disease, multicentric breast cancer, large tumors (although neoadjuvant systemic therapy can often reduce tumor size), and the presence of the BRCA mutation are all relative contraindications to BCS. BRCA mutation carriers should consider MT?+?CPM because their risk of contralateral breast cancer is greatly increased. In the U.S., the use of MT for the treatment of primary breast cancer has declined in recent years, while MT?+?CPM rates have increased, and BCS rates have remained relatively stable. The underlying reasons for these trends are not fully understood. Local therapy options should be discussed with each patient in considerable detail, and more studies are needed to better elucidate which factors influence a woman's choice of local therapy following a breast cancer diagnosis.