Factors which affect the use of lumpectomy and mastectomy in an underinsured,safety net hospital population

Background

This study was performed to evaluate variables that affect the use of mastectomy and lumpectomy in an underinsured population.

Methods

A retrospective review of all patients who underwent breast cancer operations from July 2001 to February 2011 at a safety net hospital was performed. Univariate and multivariate analyses were performed to identify variables, which were associated with the type of operation.

Results

Of the 412 patients, 81% of the patients were underinsured or uninsured. Most patients (58%) presented with clinical stage 2A/B disease. Mastectomy was performed in 37% of patients and lumpectomy in 63%. In multivariate analysis, clinical tumor size (P = .035) and pathologic stage (P = .003) remained associated with mastectomy, while use of preoperative chemotherapy (P = .004) and type of surgeon (P = .001) was associated with lumpectomy.

Conclusions

Most patients underwent lumpectomy despite later stage at presentation. Preoperative chemotherapy was associated with increased likelihood of lumpectomy.     

Accelerated partial breast irradiation using external beam conformal radiation therapy: a review

Lumpectomy followed by whole breast radiation therapy (i.e. breast conservation therapy (BCT)) is the standard of care for management of early stage breast cancer. However, its utilization has not been maximized because of a number of reasons including the logistic issues associated with the 5-6 weeks of radiation treatment. Also, pathological and clinical data suggest that most ipsilateral breast cancer recurrences are in the vicinity of the lumpectomy. Accelerated partial breast irradiation (APBI) is an approach that treats only the lumpectomy bed plus a 1-2 cm margin, rather than the whole breast with higher doses of radiation in a shorter period of time. There has been growing interest for APBI and various approaches have been developed and are under phase I-III clinical studies. This paper reviews external beam conformal radiation therapy (EBCRT) as a possible technique to APBI. The various EBCRT approaches such as 3D conformal radiation therapy, IMRT, proton therapy, tomotherapy, and volumetric arc therapy are discussed. Issues with the implementation of these techniques such as target volume delineation and organ motion are also presented. It is evident that EBCRT has potential for APBI of a selected group of early breast cancer patient. However, issues with setup errors and breathing motions need to be adequately addressed.     

Experience with partial breast irradiation for treatment of breast cancer at a community-based cancer center

Background

Many patients after lumpectomy have barriers to whole breast radiation. Accelerated partial breast irradiation (APBI) was introduced at our institution as an alternative.

Methods

Retrospective review of patients who were treated with ABPI from March 2003 to December 2011 was conducted. Results of demographics, tumor pathology, infection, and recurrence were reviewed.

Results

Two hundred ninety-four patients received 298 treatments of APBI. The mean follow-up was 58.5 months. Using the American Society for Radiation Oncology criteria, 101 patients were suitable, 142 cautionary, and 52 patients were unsuitable. The average age was 65 with a range of 37 to 93. In our study, true local recurrence occurred in only 1.0% (n = 3). Patients recurring in the same breast elsewhere was 2% (n = 6).

Conclusions

Outcomes after treatment with APBI were excellent, and breast recurrence was similar to whole breast irradiation. It may safely be offered to patients with less than suitable criteria or barriers to whole breast radiation.     

Assessment of treatment for patients with primary ductal carcinoma in situ in the breast

Background: Current mammographic technology has resulted in increased detection of ductal carcinoma in situ (DCIS). It is necessary to assess which patients presenting with DCIS are good candidates for breast conservation and which of these patients should receive adjuvant radiation. Methods: We accrued clinical data for 124 patients with a primary diagnosis of DCIS from 1979 through 1994. Primary therapy was a mastectomy for 18 patients, and a lumpectomy for 106 patients. Only 18 of the latter group of patients received adjuvant radiotherapy. For the 88 lumpectomy-alone patients (median follow-up, 5.2 years), we evaluated the effects of clinical (age and initial presentation) and pathologic (nuclear grade, architecture, parenchymal involvement, calcifications, and measured margins) factors on recurrence of DCIS or the development of invasive breast cancer. Results: Patients who underwent lumpectomy with or without adjuvant radiotherapy (median follow-up, 5.0 years) were significantly more likely to have recurrence of DCIS (P=.05) than those who underwent mastectomy (median follow-up, 6.7 years): 18% (19/106) versus 0% (0/18), respectively; lumpectomy-alone patients experienced a 19% (17/88) rate of DCIS recurrence. All recurrent DCIS was ipsilateral. For lumpectomy-alone patients, the factors associated with ipsilateral recurrence of DCIS were extent of involvement of the parenchyma (P=.01, for univariate;P=.07, for multivariate) and initial presentation (P=.05, for univariate;P=.07, for multivariate). Eleven lumpectomy-alone patients developed invasive breast cancer (6 ipsilateral, 5 contralateral); none of the 18 lumpectomy patients who received adjuvant radiation developed invasive disease. None of the factors investigated, including primary surgery and adjuvant radiotherapy, were associated with a significant effect on the development of invasive disease. Conclusions: Longer follow-up is required to determine if the benefits of either mastectomy or radiotherapy following lumpectomy persist. There is a suggestion that patients under 40 years of age or women who present with nipple discharge might be considered for either adjuvant radiotherapy following lumpectomy or a simple mastectomy.     

早期乳腺癌肿瘤切除联合放射治疗12年随访结果

目的总结早期乳腺癌肿瘤切除联合放射治疗的12年随访结果. 方法 1988年11月～1990年6月,对31例早期乳腺癌施行肿瘤切除联合放疗(肿瘤切除组),35例施行改良根治术(改良根治组),比较2组病人术后12年复发率和生存率. 结果肿瘤切除组局部复发率6.5%(2/31),总生存率74.1%;改良根治组复发率2.9%(1/35),生存率为74.3%.2组的复发率及总生存率均无显著性差别(Logrank检验, χ2=1.04,P＞0.05; χ2=0.55,P>0.05). 结论对于早期乳腺癌,行肿瘤切除联合放疗是一种安全、可行的方法.     

The Consequence of Multiple Re-Excisions to Obtain Clear Lumpectomy Margins in Breast Cancer Patients

Background Microscopically clear lumpectomy margins are critical for optimizing local control with breast conservation for cancer. Re-excisions are often necessary to achieve clear surgical margins. Factors that contribute to nonnegative margins and necessitate re-excision may increase the risk of local recurrence. Methods Patients who were treated with breast conservation for breast cancers were identified from a prospective database maintained by one of the authors. Factors associated with local recurrence were evaluated in 459 consecutive patients with attention to the number of re-excisions required to obtain clear margins. Results Twenty-eight patients (5%) developed local recurrences at a mean follow-up of 78 months. In multivariate analysis, local recurrence was most significantly associated with the omission of radiotherapy (19% vs. 5%; relative risk [RR], 3.64; 95% confidence interval, 1.6–8.2), followed by young age (52 vs. 58; 95% confidence interval, −.83 to −10.6 years) and the number of re-excisions required to obtain clear margins (none, 4%; one, 7% [RR, 2.05; 95% confidence interval, .86–4.89]; two or more, 17% [RR, 5.20; 95% confidence interval, 1.44–18.8]). Tumor size, the number of involved nodes, pathology, and adjuvant chemotherapy were not significantly related to local recurrence. Conclusions The risk of local recurrence after breast conservation for breast cancer increases progressively with the number of re-excisions needed to achieve clear margins. Patients in whom the cancer is fully excised with clear margins in the first excision will have less of a chance of local recurrence compared with patients who need further re-excision to achieve clear margins.     

Acute Toxicity of High-Dose-Rate Intracavitary Brachytherapy With the MammoSite Applicator in Patients With Early-Stage Breast Cancer

Background: Intracavitary brachytherapy with the MammoSite applicator as the sole radiation treatment in breast-conserving therapy is an option for women with early-stage breast cancer; we evaluated the acute toxicities associated with this treatment method.Methods: Thirty-one patients with 32 stage I or II breast carcinomas underwent breast-conserving therapy, which included lumpectomy with negative margins, sentinel node biopsy, or axillary dissection, followed by brachytherapy with the MammoSite applicator. Acute radiation skin complications were graded on the day of radiotherapy completion and at weeks 2, 4, 6, and 12 after radiation treatment. Cosmesis was graded on the Harvard Scale at all follow-ups.Results: The median follow-up was 11 months (range, 4–15 months). Twenty-seven of the 31 patients were treated with the device as the sole method of radiotherapy. No acute toxicities occurred during the 5 days of treatment. Nineteen patients (68%) had no to mild acute skin reactions, and 25% developed bright erythema and patchy moist desquamation. Two patients (7%) developed confluent moist desquamation within the first 4 weeks (grade 3); this healed by week 12. All skin reactions were localized to the area overlying the balloon. Sixteen percent (5 of 32) of all breasts with implants developed infection. Cosmesis was good to excellent in 86% of cases.Conclusions: Most acute skin toxicities were mild. Our infection rate was higher than in prior studies that used interstitial brachytherapy. Cosmesis was good to excellent in most patients. Breast brachytherapy with the MammoSite catheter was well tolerated; further investigations of breast brachytherapy with this system are warranted.     

Avoidance of Adjuvant Radiotherapy in Selected Patients With Invasive Breast Cancer

Background: Current standard therapy for invasive breast carcinoma is mastectomy or breast conservation with adjuvant radiation. Data from randomized trials suggest no advantage for radiotherapy after lumpectomy in highly selected patients. Selective radiotherapy would make contemporary breast cancer therapy more rational with decreased morbidity and expense.Methods: A total of 163 patients were treated by breast conservation without adjuvant radiation between 1978 and June 2003. They declined radiation after discussion or had medical contraindications. The great majority were postmenopausal and had lower-grade T1 tumors with resection margins 1 cm and no nodal metastases. The goal was to identify patients with favorable prognostic features for omission of postsurgical irradiation without impaired local recurrence or survival.Results: Twenty patients (12%) had local recurrences; 17 (10%) were invasive, and 3 (2%) were ductal carcinoma-in-situ. An ideal patient subgroup >50 years of age with grade 1 or 2 cancers 1.5 cm in diameter and with surgical margins 1 cm was empirically defined. Of 80 such patients, 5 (6%) had local recurrence; 3 (3.5%) were invasive, and 2 (2.5%) were ductal carcinoma-in-situ.Conclusions: A defined ideal subset of older breast cancer patients with smaller, lower-grade cancers and adequate excision margins can be treated with lumpectomy without irradiation and with minimal local recurrence.     

Local recurrence in lumpectomy patients after imprint cytology margin evaluation

BACKGROUND: This is a follow-up study to our previously reported data on local recurrence rates in patients whose lumpectomy margins were evaluated by intraoperative imprint cytology (IIC(M)). The purpose of this study was to compare local recurrence rates for patients whose lumpectomy margins were evaluated with IIC(M) with local recurrence rates of those not evaluated by IIC(M). METHODS: A total of 1713 patients underwent lumpectomy treatment for breast cancer from 1988 to 2001 were prospectively entered into a computerized database and subsequently included in this study. Of the patients, 520 (group 1) had their surgery performed at an outside institution where conventional margin analysis was performed. Another 1193 (group 2) had their surgery performed at our institution where margins were evaluated by IIC(M). For each histologic type and for the overall sample, probabilities of recurrence with time were estimated using the method of Kaplan and Meier. RESULTS: IIC(M) overcomes sampling error inherent in the frozen section analysis and results in a diminished incidence of overall 5-year local recurrence from 8.8% to 2.8% (P <0.0001). The recurrence rates for each respective histologic subtype are reported for both absolute recurrences and probability of recurrence with time. CONCLUSIONS: IIC(M) provides an accurate evaluation of lumpectomy margins for patients undergoing breast-conservation treatment. IIC(M) was associated with an overall lower local recurrence rate. This series defined the utility of intraoperative imprint cytology for evaluation of margins in patients undergoing breast-conservation treatment.     

Prospective hospital-based survey of attitudes of Southern women toward surgical treatment of breast cancer

Background: Breast-conserving surgery is equivalent to total mastectomy in the treatment of breast cancer. The Southern part of the United States has a low rate of breast conservation. Methods: We surveyed 300 women: 100 hospital personnel, 100 cancer clinic patients, and 100 non-cancer clinic patients. The women were asked about their attitudes toward breast cancer, surgery preferences, and factors that might influence their decisions. Results: One hundred eighty-nine chose mastectomy as the best operation, 106 women chose lumpectomy, and five women were undecided. There was no difference in mean age, racial distribution, education level, income level, percentage of women who considered themselves Southern women, concerns about breast cancer, recent mammograms, previous breast surgery, previous breast cancer treatment, or acquaintances with breast cancer between the mastectomy and the lumpectomy groups. Women interested in saving the breast were more likely to pick lumpectomy (35 vs. 84%,p=0.001). A fear of cancer recurrence played a role in the decision (88 vs. 40%,p=0.001). Fear of radiation therapy (76 vs. 57%,p=0.002) and of the side effects (80 vs. 63%,p=0.005) was a significant factor. Conclusions: The choice of surgery for breast cancer is an individual process between a woman and her surgeon. Attitudes and fears regarding cancer recurrence and radiation therapy may make women select mastectomy over lumpectomy.Presented at the 47th Annual Cancer Symposium of The Society of Surgical Oncology, March 17–20, 1994, Houston, TX.