Between Breast-conserving Surgery Research Articles

Impact of surgical types on overall survival in patients with ductal carcinoma in situ: an analysis based on the SEER database.

Breast cancer, as one of the most common malignancies among women globally, presents a concerning incidence rate, underscoring the importance of addressing the treatment of its precursor lesion, ductal carcinoma in situ (DCIS). Treatment decisions for DCIS, involving the balance between breast-conserving surgery (BCS) and mastectomy, remain an area requiring further investigation. This study aimed to compare influence of different surgical types on overall survival (OS) of patients with DCIS and identify specific subgroups with improved OS to develop an effective survival nomogram for patients. Patient data from the Surveillance, Epidemiology, and End Results (SEER) database for DCIS cohort from 2010 to 2020 were retrieved. Kaplan-Meier (K-M) survival curves were utilized to compare prognostic OS of patients with different surgical methods. Cox regression analysis was employed to determine prognostic factors and establish a nomogram to predict 3-, 5-, and 10-year survival rates. The model was confirmed by Concordance Index (C-index), calibration curves, and receiver operating characteristic (ROC) curves. A total of 71,675 patients with DCIS were included. Patients who underwent subcutaneous mastectomy (SM) demonstrated the best OS compared to other surgical types. Additionally, adjuvant radiotherapy or chemotherapy in combination with surgery significantly improved OS compared to surgery alone. Among DCIS patients aged ≤74 years, those who underwent SM benefited the most in terms of OS, while in the age group of 63-74 years, patients who underwent BCS had significantly higher OS than those who underwent total (simple) mastectomy (TM)/modified radical mastectomy (MRM). Multiple factors were associated with improved OS in DCIS patients, and these factors were integrated into the nomogram to establish OS predictions. The C-index, calibration curves, and ROC curves indicated that the nomogram was suitable for assessing patient prognosis. This study demonstrated that SM treatment yielded the best survival rates for DCIS patients, providing important guidance for future surgical decision-making. Moreover, identifying multiple independent factors related to survival and establishing reliable survival nomograms can assist physicians in developing personalized treatment plans and prolonging patient survival.

Unlocking the Power of the Homing Phenomenon: Why Breast Conserving Surgery Outshines Mastectomy in Overall Survival

Breast cancer stands as the most frequently diagnosed malignancy in women, holding a prominent position among the leading causes of cancer-related fatalities on a global scale. Despite significant advances in treatment modalities, approximately 20% of patients experience relapses after the first 5 years of postdiagnosis surveillance. While initial investigations from the 1970s indicated comparable survival rates between breast-conserving surgery (BCS) coupled with radiation therapy and mastectomy, recent research suggests that, within the context of modern systemic and radiation therapy, BCS followed by radiation may offer an improved overall survival benefit. Nevertheless, extended follow-up studies have unveiled a notable increase in the risk of locoregional recurrence associated with breast conserving therapy in contrast to mastectomy. This article introduces a novel hypothesis rooted in the biological phenomenon of homing to elucidate this intriguing clinical observation. We postulate that a breast homing mechanism of reactivated circulating and disseminated tumor cells mediated by chemotaxis involving at least the CXCR4-SDF-1 axis may provide a biological rationale for this clinical phenomenon.

Breast-conserving surgery versus mastectomy for treatment of breast cancer after neoadjuvant chemotherapy.

To compare recurrence and survival outcomes between breast-conserving surgery (BCS) and mastectomy after neoadjuvant chemotherapy (NACT). The data of 730 patients who underwent NACT between 2000 and 2014 were retrospectively reviewed. A total of 104 (14.2%) patients received BCS and 626 (85.8%) received mastectomy. Locoregional recurrence (LRR), distant metastases (DM), disease-free survival (DFS), breast cancer-specific survival (BCSS), and overall survival (OS) were analyzed using the Kaplan-Meier method. The impact of BCS versus mastectomy on outcomes was assessed by multivariate Cox models. Inverse probability of treatment weighting (IPTW) was used to balance covariates between the two groups. The median follow-up of BCS and mastectomy groups were 86.5 and 87.4 months, respectively. There were significant differences in distribution of most baseline characteristics between two groups. Compared with those who underwent mastectomy, the patients with BCS had similar 5-year LRR, DM, and DFS rates, but had significantly higher 5-year BCSS (98.9% vs. 90.4%, P = 0.005) and OS (98.9% vs. 90.1%, P = 0.003) rates. Multivariate analysis also showed that BCS significantly improved BCSS (HR = 0.27, 95% CI: 0.08-0.85, P = 0.025) and OS (HR = 0.25, 95% CI: 0.08-0.79, P = 0.018). After IPTW adjustment, the LRR, DM, DFS, BCSS and OS between two groups had no significant differences. The recurrence and survival outcomes are comparable with BCS and mastectomy. Thus, BCS is a safe treatment option for selected breast cancer patients after NACT.

Better survival was found in patients treated with breast-conserving surgery compared with mastectomy in malignant phyllodes tumor of the breast.

Malignant phyllodes tumor of the breast (MPTB) is a rare type of breast cancer. The prognosis between breast-conserving surgery (BCS) and mastectomy remains unclear in MPTB. Therefore, long-term survival was investigated between BCS and mastectomy in MPTB via the Surveillance, Epidemiology, and End Results (SEER) database. MPTB patients with T1-2/N0 stage between 2000 and 2015 from SEER database were retrospectively reviewed. Prognosis between different surgical approaches was assessed by Kaplan-Meier curves and Cox proportional hazards analysis. A total of 795 patients were enrolled with a median follow-up of 126months. BCS was associated with significantly increased 10-year overall survival (OS) (89.2% vs. 81.1%, p = 0.002) and breast cancer-specific survival (BCSS) (95.2% vs. 90%, p = 0.004) compared with mastectomy. Multivariate analysis showed better OS (HR = 0.587, 95% CI 0.406-0.850, p = 0.005) and BCSS (HR = 0.463, 95%CI 0.267-0.804, p = 0.006) in the BCS group than the mastectomy group. After 1:1 propensity score matching (PSM), improved 10-year OS (89.2% vs.81%, p = 0.023) and BCSS (95.8% vs. 90.1%, p = 0.033) were observed in BCS compared with mastectomy. This study found the survival benefit of BCS over mastectomy in patients with early-stage MPTB. BCS should be recommended as a priority in MPTB patients when both surgical approaches are feasible.

Local Treatment of Triple-Negative Breast Cancer: Is Mastectomy Superior to Breast-Conserving Surgery?

Triple-negative breast cancer (TNBC) is an aggressive type of breast cancer that lacks the expression of estrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2). TNBC accounts for about 15% of breast cancers and has a poorer prognosis as compared with other subtypes of breast cancer. The more rapid onset of this cancer and its aggressiveness have often convinced breast surgeons that mastectomy could provide better oncological results. However, there is no relevant clinical trial that has assessed differences between breast-conserving surgery (BCS) and mastectomy (M) in these patients. This population-based study aimed to investigate the distinct outcomes between conservative treatment and M in a case series of 289 patients with TNBC treated over a 9-year period. This monocentric study retrospectively evaluated patients with TNBC who underwent upfront surgery at Fondazione Policlinico Agostino Gemelli IRCCS, in Rome, between 1 January 2013 and 31 December 2021. First, the patients were divided in two groups according to the surgical treatment received: BCS vs. M. Then, the patients were stratified into four risk subclasses based on combined T and N pathological staging (T1N0, T1N+, T2-4N0 and T2-4N+). The primary endpoint of the study was to evaluate locoregional disease-free survival (LR-DFS), distant disease-free survival (DDFS) and overall survival (OS) in the different subclasses. We analyzed 289 patients that underwent either breast-conserving surgery (247/289, 85.5%) or mastectomy (42/289, 14.5%). After a median follow-up of 43.2 months (49.7, 22.2-74.3), 28 patients (9.6%) developed a locoregional recurrence, 27 patients (9.0%) showed systemic recurrence and 19 patients (6.5%) died. No significant differences due to type of surgical treatment were observed in the different risk subclasses in terms of locoregional disease-free survival, distant disease-free survival and overall survival. With the limits of a retrospective, single-center study, our data seem to indicate similar efficacy in terms of locoregional control, distant metastasis and overall survival with the use of upfront breast-conserving surgery as compared with radical surgery in the treatment of TNBC. Therefore, TNBC should not be considered to be a contraindication for breast conservation.

Comparison of Breast-Conserving Surgery vs. Mastectomy for Patients with Breast Cancer after Neoadjuvant Chemotherapy

<h3>Purpose/Objective(s)</h3> To compare recurrence and survival outcomes between breast-conserving surgery (BCS) and mastectomy after neoadjuvant chemotherapy (NACT). <h3>Materials/Methods</h3> A total of 730 eligible patients who underwent NACT between 2000 and 2014 were retrospectively reviewed. Of those, 104 (14.2%) patients received BCS and 626 (85.8%) patients received mastectomy. Locoregional recurrence (LRR), distant metastases (DM), disease-free survival (DFS), Breast cancer - specific survival (BCSS) and overall survival (OS) were estimated using the Kaplan-Meier method. The impact of BCS versus (vs) mastectomy on outcomes was assessed by multivariate Cox models and inverse probability of treatment weighting (IPTW) method by adjusting for age, clinical T stage, clinical N stage, NACT cycles, histological grade, lymphovascular invasion (LVI), molecular subtype/trastuzumab, ypT (pathologic tumor stage after NACT), ypN (pathologic lymph node stage after NACT), endocrine therapy, and adjuvant chemotherapy. Recurrence and survival curves before or after weighting were compared with the log rank test. <h3>Results</h3> The median follow-up was 87.4 months. The 5-year LRR, DM, DFS, BCSS and OS rates after BCS and mastectomy were 6.9% vs 7.6% (P = 0.805), 10.8% vs 19.9% (P = 0.145), 83.4% vs 78.2% (P = 0.514), 98.9% vs 90.4% (P = 0.005) and 98.9% vs 90.1% (P = 0.003), respectively. There were significant differences in distribution of most baseline characteristics between the BCS and mastectomy group. After IPTW adjustment, the clinical characteristics between two groups were comparable. Multivariate analysis showed that BCS had no significant impact on LRR (HR 1.08, 95% CI 0.48-2.43, P = 0.849), DM (HR 0.82, 95% CI 0.49-1.40, P = 0.473) and DFS (HR 1.12, 95% CI 0.70-1.80, P = 0.626) compared with mastectomy, but BCS significantly improved BCSS (HR 0.29, 95% CI 0.09-0.92, P = 0.035) and OS (HR 0.27, 95% CI 0.08-0.86, P = 0.027) compared with mastectomy. After IPTW adjustment, the results of 5-year LRR, DM, DFS remained the same, which were 10.0% vs 7.3% (P = 0.598), 11.7% vs 19.0% (P = 0.341), 78.6% vs 79.1% (P = 0.908) for BCS and mastectomy groups, respectively. The 5-year BCSS and OS were better in the BCS group than in the mastectomy group, but the difference was no longer statistically significant (BCSS: 99.7% vs. 90.8%, <i>P</i> = 0.095 and OS: 99.7% vs. 90.6%, <i>P</i> = 0.083). <h3>Conclusion</h3> Locoregional and distant control and DFS are comparable with BCS and mastectomy, but BCSS and OS may be better with BCS. Thus, BCS is a safe treatment option for selected breast cancer patients after NACT.

Surgical management in phyllodes tumors of the breast: a systematic review and meta-analysis.

Information is still controversial in the studies regarding the current optimal surgical management of phyllodes tumors (PTs) of the breast. Local recurrence (LR) may occur with an upgraded in the pathological grade, influencing the prognosis of patients with PT. This systematic review and meta-analysis aimed to investigate the association of LR risk with margin status and margin width which could have significant implications on the surgical management of PT. Independent and comprehensive searches were performed by two authors through five databases including PubMed, Medline, Embase, ScienceDirect and Cochrane Library from January 1990 to October 2021. Studies investigating the association between margin width, margin status and LR rates were considered for inclusion. Study quality was evaluated using the Newcastle-Ottawa Scale (NOS). Meta-analysis was performed using RevMan5.3 software, and statistical heterogeneity was assessed using the Chi-square test and quantified using the I2 statistic. Visual inspection of funnel plots was used to judge publication bias. A total of 34 articles were included in this article, all of which with NOS scores above 5. Regardless of the PT grade, positive margin significantly increased the risk of LR [odds ratio (OR) 3.64, 95% confidence interval (CI): 2.60-5.12]. No significant difference was found in the risk of LR between the margins <1 and ≥1 cm (OR 1.39, 95% CI: 0.67-2.92). For benign and borderline PTs, there were no significant differences of the LR risk between breast-conserving surgery (BCS) and mastectomy (benign OR 0.68, 95% CI: 0.12-3.78; borderline OR 1.14, 95% CI: 0.29-4.51). While the LR risk was significantly increased by BCS for malignant PT (OR 2.77, 95% CI: 1.33-5.74). Different surgical management strategies should be considered for different PT grades. BCS was a feasible option and margins <1 cm was not significantly associated with LR risk for all grade of PT. After BCS, benign PT with positive margin could adopt the "wait and watch" strategy with regular follow-up, while borderline and malignant PTs were expected to underwent re-excision to ensure negative margins. More studies are still needed to clarify and update the existing conclusions and improve the prognosis of PT patients.

Mastectomy with immediate breast reconstruction: Results of a mono-centric 4-years cohort

IntroductionOncological safety, quality of life and cosmetic outcomes seems to be similar between breast conserving surgery (BCS) and mastectomy with immediate breast reconstruction (IBR). We report our experience of IBR for consecutive mastectomies realized in a recent period of four years in order to determined immediate surgical results according to type of mastectomy and type of reconstruction, as mains objectives. MethodsAll mastectomies with IBR during years 2016–2019 were included. A retrospective analysis with prospective data collection was performed. ResultsWe analyzed 748 IBR: 353 nipple-sparing mastectomies (NSM), 391 skin-sparing mastectomies (SSM) and 4 standard mastectomies, 551 with definitive implant or expanders and 196 with latissimus dorsi-flap (LDF). More NSM were performed during the 2 last years and more LDF were performed for high BMI, high breast cup-size, neo-adjuvant chemotherapy and radiotherapy and local recurrence. We realized 111 robotic NSM and 125 robotic LDF. Longer duration of surgery was significantly associated with the robotic procedures.The overall complications crude rate was 31.4% with 9.9% of re-operations and 5.8% of implant loss. Grade 2–3 complications were significantly associated with smoking. Breast complications occurred in 32.9% of mastectomies with principally skin or nipple-areola-complex suffering or necrosis, hematomas and infections. A predictive score was determined to evaluate risk of complications before surgery. ConclusionMastectomy with IBR seems to be a safe technique with an acceptable complication rate which is increased by tobacco use, high breast cup-size and IBR-type.

Radiotherapy plays an important role in improving the survival outcome in patients with T1\u20132N1M0 breast cancer \u2013 a joint analysis of 4262 real world cases from two institutions

BackgroundTo compare the survival outcomes between breast-conserving surgery (BCS) and modified radical mastectomy (MRM), and to investigate the role of radiotherapy (RT) in patients with pT1–2N1M0 breast cancer.MethodsA total of 4262 women with T1–2N1M0 breast cancer treated at two institutions were retrospectively reviewed. A total of 3858 patients underwent MRM, and 832 (21.6%) of them received postoperative RT (MRM + RT). A total of 404 patients received BCS plus postoperative RT (BCS + RT). All patients received axillary lymph node dissection, while 3.8% of them had upfront sentinel node biopsy. The association of survival outcomes with different surgical modalities (BCS vs. MRM) and the role of RT were evaluated using multivariable proportional hazards regression and confirmed by the propensity score-matching (PSM) method.ResultsAt a median follow-up of 71 months (range of 6–230 months), the 5-year overall survival (OS) rates of the BCS and MRM groups were 96.5 and 92.7%, respectively (P = .001), and the corresponding 5-year disease-free-survival (DFS) and locoregional recurrence (LRR) rates were 92.9 and 84.0%, and 2.0 and 7.0% (P = .001), respectively (P < .001). Multivariate analysis revealed that RT was an independent prognostic factor for improved OS (P = .001) and DFS (P = .009), and decreased LRR (P < .001). However, surgery procedure was not independently associated with either OS (P = .495), DFS (P = .204), or LRR (P = .996), which was confirmed by PSM analysis.ConclusionPostoperative radiotherapy rather than the surgery procedures was associated with superior survival outcomes in patients with T1–2N1M0 breast cancer.

A randomized controlled trial of a self-administered, online decision-aid (“Navya Patient Preference Tool”) to reduce decisional conflict in women with early breast cancer.

7033 Background: Shared decision making to confront choices with clinical equipoise, has been the privilege of those patients with access to time intensive consults with oncologists. We conducted a randomized controlled trial for breast cancer patients to use an online, self-administered, out-of-the-medical-encounter decision aid (DA) to choose between breast conserving surgery (BCS) and mastectomy. Methods: Navya Patient Preference Tool (Navya PPT) is a multilingual DA based on adaptive conjoint analysis of tradeoffs between cost, adverse effects of radiation, and breast conservation. Prior analysis established high internal reliability and external validity of the Navya PPT. Eligible cT1/2, cN0 breast cancer patients planned for surgery were block randomized, in 1:1:1 ratio, to receive the research questionnaire (RQ) to measure decisional conflict on choice of surgery (control, arm 1), Navya PPT followed by RQ (experimental, arm 2) or Navya PPT followed by RQ administered with key male family member (experimental, arm 3). Groups were stratified with respect to age, socio-economic status (SES) and educational level. The study was powered to detect a decrease in Decisional Conflict Index (DCI) by 0.25 (β-0.8, two sided α- 0.01). Results: Between June 2017 and December 2019, 247/255 patients were randomized to arm 1 (83), arm 2 (84), and arm 3 (80). Median age was 48 years (IQR 23-76), and median pT size was .5 cm (0.5-6 cm). 59% of patients were middle or lower SES and 46.2% had ≤ 12th grade education. DCI was significantly reduced in arm 2 as compared with arm 1 (1.34 vs. 1.65, Cohen’s d 0.49 (± 0.31) p&lt;0.05) as well as in arm 3 as compared with arm 1 (1.30 vs. 1.65, Cohen’s d 0.54 (± 0.31) p&lt;0.05). 80% (± 6%) of patients underwent surgery of choice as determined by Navya PPT. BCS rate was similar in all three arms (85.2, 88.9 and 86.5% respectively (p=0.779). Conclusions: Online, self-administered, adaptive DAs used out of the medical encounter can reduce decisional conflict and increase access to shared decision making for every patient; especially in practices with low doctor to patient ratios. Clinical trial information: IEC/0116/1619/001 .

Association between initiation of adjuvant chemotherapy beyond 30 days after surgery and overall survival among patients with triple-negative breast cancer.

Delayed time to chemotherapy (TTC) is associated with decreased outcomes of breast cancer patients. Recently, studies suggested that the association might be subtype‐dependent and that TTC within 30 days should be warranted in patients with triple‐negative breast cancer (TNBC). The aim of the current study is to determine if TTC beyond 30 days is associated with reduced 10‐year overall survival in TNBC patients. We identified all TNBC patients diagnosed between 2006 and 2014 who received adjuvant chemotherapy in the Netherlands. We distinguished between breast‐conserving surgery (BCS) vs. mastectomy given the difference in preoperative characteristics and outcomes. The association was estimated with hazard ratios (HRs) using propensity‐score matched Cox proportional hazard analyses. In total, 3,016 patients were included. In matched patients who underwent BCS (n = 904), 10‐year overall survival was favorable for patients with TTC within 30 days (84.4% vs. 76.9%, p = 0.001). Patients with TTC beyond 30 days were more likely than those with TTC within 30 days to die within 10 years after surgery (HR 1.69 (95% CI 1.22–2.34), p = 0.002). In matched patients who underwent mastectomy (n = 1,568), there was no difference in 10 years overall survival between those with TTC within or beyond 30 days (74.5% vs. 74.7%, p = 0.716), nor an increased risk of death for those with TTC beyond 30 days (HR 1.04 (95% CI 0.84–1.28), p = 0.716). Initiation of adjuvant chemotherapy beyond 30 days is associated with decreased 10 years overall survival in TNBC patients who underwent BCS. Therefore, timelier initiation of chemotherapy in TNBC patients undergoing BCS seems warranted.

Radiotherapy Plays an Important Role in Improving the Survival Outcome in Patients with T1-2N1M0 Breast Cancer – A Joint Analysis of 4209 Real-world Cases from Two Institutions.

To compare the survival outcomes between breast-conserving surgery (BCS) and mastectomy, and investigate the role of radiotherapy (RT) in patients with T1-2N1M0 breast cancer in a real-world setting. There were 4209 women with T1-2N1M0 breast cancer treated in two institutions between 1999 and 2014 were retrospectively reviewed. All had received lumpectomy or mastectomy and axillary lymph node dissection without neoadjuvant chemotherapy. 3858 patients underwent modified radical mastectomy (MRM), 832 (21.6%) of them received postoperative RT (MRM + RT). 351 patients received BCS, all of them received postoperative RT (BCS + RT). Overall survival (OS) and disease-free survival (DFS) rates were calculated by using the Kaplan-Meier method and compared by log-rank test. The association of survival outcome with choice of different surgical modalities (BCS vs. MRM) and the role of RT were evaluated using multivariable proportional hazards regression and further confirmed with propensity score-matching (PSM) methods. At a median follow-up of 70 months (range, 6-226 months), the 5-year OS rates of the BCS and MRM group were 96.0% and 92.7% (p=0.005), and the corresponding 5-year DFS rates were 92.8% vs 84.0% (p<0.001). Multivariate analysis revealed that T stage, the number of positive axillary lymph node, histological grade, molecular subtype, Her2 status & target therapy, and RT were all independent prognostic factors for OS (p<0.05) and DFS (p<0.05). However, the type of breast surgery was not independently associated with either OS (p=0.788) or DFS (p=0.088). Between 326 pairs of patients (BCS + RT vs. MRM without RT) matched by PSM, BCS + RT group enjoyed significantly higher 5-year OS (96.0% vs. 94.0%, p=0.045) and DFS (92.8% vs. 87.0%, p=0.018). In further analysis of 1116 pairs of patients (BCS or MRM + RT vs. MRM without RT) matched by PSM, BCS or MRM + RT group had significantly higher 5-year OS (94.3% vs. 87.3%, p<0.001) and DFS (86.4% vs. 78.0%, p<0.001) than MRM without RT group. Based on this real-world-case analysis, we find that breast conserving surgery had superior survival outcomes to mastectomy in patients with T1-2N1M0 breast cancer, in which postoperative radiotherapy plays an important role. These findings need further validation.

Effect of 21-gene recurrence score in decision-making for surgery in early stage breast cancer.

AimWe aimed to assess the role of 21-gene recurrence score (RS) in the decision-making for surgical treatment in early stage breast cancer and compared the outcomes between breast-conserving surgery (BCS) and mastectomy (MAST) among various 21-gene RS groups.MethodsWe included patients with stage T1-2M0M0 and estrogen receptor-positive breast invasive ductal carcinoma who underwent BCS + radiotherapy or MAST between 2004 and 2012 as part of the Surveillance, Epidemiology, and End Results program. Data were analyzed using binomial logistic regression, multivariate Cox proportional hazards models, and propensity score matching (PSM).ResultsWe enrolled 34,447 patients including 22,681 (65.8%) and 11,766 (34.2%) who underwent BCS and MAST, respectively. Patients with high-risk RS were more likely to receive MAST. Multivariate analysis indicated that patients with intermediate-risk (P<0.001) and high-risk (P<0.001) RS had poor breast cancer-specific survival (BCSS), as compared to those with low-risk RS. Moreover, patients who underwent MAST also exhibited poor BCSS (P<0.001), as compared to those who underwent BCS. In low-risk (P<0.001) and intermediate-risk (P=0.020) RS groups, patients who underwent MAST had poor BCSS, as compared to those treated with BCS. However, BCSS was comparable between patients who underwent MAST and BCS (P=0.952); similar trends were also observed after PSM.ConclusionThe 21-gene RS may impact the decision-making for surgery in early stage breast cancer. Our study provides additional support for a shared decision-making process for BCS when both local management options are appropriate choices regardless of the 21-gene RS.

A preliminary prediction model for potentially guiding patient choices between breast conserving surgery and mastectomy in early breast cancer patients; a Dutch experience

PurposeTo guide early stage breast cancer patients to choose between breast conserving surgery (BCS) and mastectomy (MST) considering the predicted cosmetic result and quality of life (QoL).MethodsA decision model was built to compare QoL after BCS and MST. Treatment could result in BCS with good cosmesis, BCS with poor cosmesis, MST only, and MST with breast reconstruction. QoL for these treatment outcomes were obtained from a previous study and the literature and translated into EuroQoL-5D derived utilities. Chance of good cosmesis after BCS was predicted based on tumor location and tumor/breast volume ratio. The decision model determined whether the expected QoL was superior after BCS or MST based on chance of good cosmesis.ResultsThe mean utility for the treatments such as BCS with good cosmesis, BCS with poor cosmesis, MST only, and MST with breast reconstruction were 0.908, 0.843, 0.859, and 0.876, respectively. BCS resulted in superior QoL compared to MST in patients with a chance of good cosmesis above 36%. This 36% threshold is reached in case the tumor is located in the upper lateral, lower lateral, upper medial, lower medial, and central quadrant of the breast with a tumor/breast volume ratio below 21.6, 4.1, 15.1, 3.2, and 14.7, respectively.ConclusionsBCS results in superior QoL in patients with tumors in the upper breast quadrants or centrally and a tumor/breast volume ratio below 15. MST results in superior QoL in patients with tumors in the lower breast quadrants and a tumor/breast volume ratio above 4.

Abstract P2-13-03: Variation in the use of mastectomy (MAST) in women with small node negative breast cancer (BC) treated at US academic institutions

Abstract Background: More than two decades ago several trials have shown equivalent survival between breast conserving surgery (BCS) and MAST. Among a contemporary cohort of patients (pts) with Stage I BC who would be expected to be candidates for BCS; we examined the initial choice of surgery and factors associated with it. Pts and methods: Prospective cohort study including pts with clinical Stage I BC treated at a National Comprehensive Cancer Network center that participated in the BC outcomes database from 2000-09. Descriptive analyses were performed examining the proportion of pts who initially underwent MAST vs BCS. Factors associated with initial surgery were analyzed using multivariable logistic regression. Results: Of 10,249 pts with clinical Stage I BC, 2,361(23%) underwent MAST as the initial surgery and 7,888 (77%) BCS. Of those, 8% were ultimately converted to MAST. The median time from diagnosis to initial surgery was longer among the MAST group (4 vs. 6 weeks). Patient, tumor, care and institutional factors were associated with higher rates of initial MAST: 30% of pts with &amp;lt;50 years of age had a MAST vs. 17% of those ≥70; 41% of pts with body mass index (BMI) &amp;lt; 18.5 kg/m2 (underweight) had a MAST vs. 20% of those with a BMI &amp;gt;30 kg/m2 (obese). There was significant institutional variation, with rates of initial MAST ranging from 14-30%. The use of preoperative magnetic resonance imaging (MRI) was associated with a higher rate of initial MAST (32% vs.22%). Differences by tumor subtype were observed, 38% of pts with HER2+/HR- tumors had initial MAST vs. 22-28% among other subtypes. In the multivariate model, age, BMI, comorbidity, income, center, stage, tumor subtype, grade, histology and preoperative MRI were associated with the choice of initial surgery. Multivariate logistic model to investigate factors associated with initial MAST MAST vs BCS OR95%CIPAge &amp;lt;0.01&amp;lt;501 50-590.70.6 - 0.8 60-690.70.6 - 0.8 70+0.60.5 - 0.7 BMI (kg/m2) &amp;lt;0.01&amp;lt;18.51.81.3 - 2.6 18.5-&amp;lt;251 25-&amp;lt;300.80.7 - 0.9 ≥300.70.6 - 0.8 Unknown0.80.6 - 1.0 Comorbidity 0.0501 1+1.11.0 - 1.3 Race 0.8Non Hispanic white1 Non Hispanic black10.8-1.2 Hispanic10.8-1.3 Other1.10.9-1.4 Insurance 0.16Manged care/ Indemnity1 Medicare10.9-1.2 Self-pay/Medicaid1.31-1.6 Other10.6-1.6 Median Household income 0.021 (low)1 20.90.8-1.1 30.90.8-1.1 40.90.8-1.0 5 (high)0.80.6-0.9 Year of diagnosis11-10.35Center &amp;lt;0.01A1 B0.90.7-1.1 C0.70.6-0.9 D1.41.1-1.7 E0.40.3-0.6 F0.80.6-1.1 G1.31-1.6 H0.60.4-0.8 Clinical Stage &amp;lt;0.01T1a1 T1b0.80.6-0.9 T1c10.8-1.2 T1NOS1.10.9-1.4 Tumor Subtype &amp;lt;0.01HER2+HR+1 HER2+HR-1.51.1-1.9 HER2-HR+0.90.7-1.0 HER-HR-0.70.6-0.9 Grade &amp;lt;0.01Low Intermediate1 High1.21.1-1.4 Histology Ductal1 &amp;lt;0.01Lobular1.41.2-1.7 Mixed1.31.1-1.5 Other0.70.5-0.8 Preoperative MRI No1 &amp;lt;0.01Yes1.81.6-2.1 Conclusions: Among a cohort of pts with small node negative BC, 23% elected to have MAST with significant variation associated with choice of treatment, while some of this variation is likely appropriate and clinically indicated, further studies to assess pt understanding of the tradeoffs between BCS and MAST is warranted. These findings need to be considered in light of the increasing number of pts who are choosing MAST/bilateral MAST. Citation Format: Ines Vaz Luis, Melissa E Hughes, Angel Cronin, Hope S Rugo, Stephen B Edge, Beverly Moy, Richard Theriault, Michael J Hassett, Eric P Winer, Nancy U Lin. Variation in the use of mastectomy (MAST) in women with small node negative breast cancer (BC) treated at US academic institutions [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P2-13-03.

Changing trends in the decision-making preferences of women with early breast cancer.

Previous studies have indicated a predominance of passive decision-making styles among women with early-stage breast cancer in the UK offered a choice between breast-conserving surgery (BCS) and mastectomy. The aim of this study was to determine current decision-making styles and establish their association with operation choice and breast unit mastectomy rate. A questionnaire survey was conducted among women from three specialist breast units representing high, medium and low case mix-adjusted mastectomy rates. Of 697 consecutive patients, 356 (51.1 per cent) completed the questionnaire, a mean of 6.9 (range 1.3-48.6) weeks after surgery. Some 262 women (73.6 per cent) underwent BCS and 94 (26.4 per cent) had a mastectomy. Some 218 patients (61.2 per cent) achieved their preferred decision-making style. The proportions of women achieving an active decision-making style were high, particularly for those choosing mastectomy (83 versus 58.0 per cent for BCS; P < 0.001) and in the high mastectomy rate unit (79.6 versus 53 and 52.2 per cent for medium and low rate units respectively; P < 0.001). More women chose an active decision-making style than in previous UK studies. The provision of greater treatment selection autonomy to women suitable for BCS may not reduce mastectomy rates.

Patterns of Surgical Treatment for Women Diagnosed with Early Breast Cancer in Queensland

Australian women with early breast cancer should be given the choice between breast-conserving surgery (BCS) or mastectomy. This is the first Australian study to report on patterns of surgical care specifically for early breast cancer at a population level. Two population-based routine data collections were linked to obtain surgical treatment information for breast cancer cases diagnosed in 2004 in Queensland, from which we identified 1274 cases of early female breast cancer. Logistic regression was used to assess the likelihood of female breast cancer patients having mastectomy, BCS, and axillary node dissection, after adjusting for patient and hospital demographics, tumor size, and comorbidities. Three-quarters (77%) of women had BCS, 29% had a mastectomy, and 86% had dissection of the axillary lymph nodes. The likelihood of women having mastectomy was higher among women living in rural areas, those treated in public hospitals, and women who had comorbidities of anemia or heart failure. In contrast, BCS was more likely for women treated in private hospitals or hospitals with high surgical caseload. Heart failure decreased the likelihood of BCS. Having an axillary node dissection was more likely among younger women and those treated in high caseload hospitals. The observed differentials in surgical treatment for early breast cancer patients suggest that access issues may have contributed to the decision-making process. Understanding the reasons why women with early breast cancer choose a certain treatment strategy should be a focus of future research.

Effect of time interval between breast-conserving surgery and radiation therapy on ipsilateral breast recurrence

Purpose: To examine the effect of the time interval (interval) between breast-conserving surgery (BCS) and the start of radiation therapy (RT) on the subsequent risk of ipsilateral breast cancer recurrence (IBR). Methods and Materials: We reviewed interval and a number of prognostic and treatment factors among 1,962 women treated with BCS and RT for invasive breast cancer diagnosed between January 1, 1989 and December 31, 1993 in British Columbia, Canada. Subjects were female, less than 90 years old at diagnosis, not treated with chemotherapy, not stage T4 or M1, and had survived more than 30 days from diagnosis. The cumulative incidence of IBR was estimated in four interval groups: 0–5, 6–8, 9–12, and 13+ weeks. Only 23 women had an interval of greater than 20 weeks between BCS and start of RT. To assess whether an imbalance of prognostic and treatment factors could be obscuring real differences between the interval groups, Cox proportional hazards regression analyses were conducted. Results: Median follow-up was 71 months. The crude incidence of IBR for the entire sample was 3.9%. The cumulative incidence of IBR in the 6–8, 9–12, and 13+ week groups was not statistically significantly different from the cumulative incidence of IBR in the 0–5 week group. Multivariate analyses demonstrated that patients not using tamoxifen ( p = 0.027) and those with grade 3 histology ( p = 0.003) were more likely to recur in the breast. Interval between BCS and RT was not a statistically significant predictor of breast recurrence when entered into a model incorporating tamoxifen use and tumor grade (0–5 vs. 6–8 weeks, p = 0.872; 0–5 vs. 9–12 weeks, p = 0.665; 0–5 vs. 13+ weeks, p = 0.573). Conclusions: We found no univariate or multivariate difference in ipsilateral breast cancer recurrence between intervals of 0 to 20 weeks from breast conserving surgery to start of radiation therapy, in a population-based, low risk group of women not receiving adjuvant chemotherapy, after controlling for other factors important in predicting ipsilateral breast cancer recurrence.

Clinicopathologic factors and patient perceptions associated with surgical breast-conserving treatment

Clinical studies have shown equivalent survival rates between breast-conserving surgery (BCS) and mastectomy in early breast cancer; however, rates for BCS remain low. The purpose of this study was to determine (a) the prevalence of BCS in a regional medical center, (b) clinicopathologic factors associated with BCS, and (c) patient perceptions of the treatment decision-making process. We retrospectively reviewed 251 consecutive breast cancer cases during January 1990-December 1991; 77 patients were ineligible for BCS because of unfavorable pathology. We then interviewed 118 of the 160 women available for interview. BCS was performed in 31 of the eligible patients (18%). Multivariate analysis revealed that tumor size < 10 mm (p = 0.03) was the only significant predictive variable for BCS. Patient interviews revealed that 93% said their surgeon was the primary source of information regarding treatment options. Among 69% of the women whose surgeons reportedly recommended a particular option, 89% recommended mastectomy with 93% compliance, and 11% recommended BCS with 89% compliance. The BCS group more often obtained a second opinion (p = 0.04) and 60% said they made the decision themselves compared with only 37% of the mastectomy group (p = 0.05). Limiting BCS to women whose tumor size is < 10 mm is too restrictive; this excludes a large number of women who are clinically eligible for BCS. The surgical decision-making process for early-stage breast cancer is very much surgeon-driven, with a high degree of patient compliance.