Breast Care Center Research Articles

Abstract P1-02-07: Adherence to breast cancer screening recommendations among underserved participants in an urban safety net mammography clinic

Abstract Background: The Georgetown Lombardi Comprehensive Cancer Center's Capital Breast Care Center (CBCC) is a safety net mammography screening center that uses a community-based patient navigation program to provide underserved minority women guidelines-concordant mammography screening. Given that screening navigation is designed to eliminate some established barriers such as, access, transportation, and cost, we retrospectively examined patient adherence rates to regular (annual/biennial) mammography screening. We also investigated whether patient demographics are associated with adherence to breast cancer screening. Methods: Data were derived from medical records of patients that received a baseline mammogram at CBCC in 2011 (n = 1,637) and were followed up for 4 years. Within the study time period of 2011-2015, patients were of age 40-74 and had not received a prior breast cancer diagnosis. 10 definitive cases of breast cancer were newly diagnosed in this population during the follow-up period and were excluded from the analysis. Adherence was then calculated based on the American College of Radiology (annual screening starting at 40) and the United States Preventive Services Task Force guidelines (biennial screening starting at 50). Results: In 2011, the mean age of women screened at CBCC was 51.25 years with 45% being 40-50 years of age. CBCC has a predominantly minority population with 48% of the women identifying as Black/African American (AA) and 41% identifying as Hispanic in 2011. Over the 4 year follow up period, 41.11% of the patients screened in 2011 did not return for another screen. The adherence rate for annual screening in the 40-74 age group was 3.3% (3.0% in Black/AA; 4.2% in Hispanic) over the 4-year follow-up. The adherence rate for biennial screening among the 50-74-year-old age group was 21% overall (20% among Black/AA; 26% among Hispanics). Approximately 40% of the participants with baseline screenings in 2011 received at least one additional screening over the 4 year follow up but their mammography schedules were not guidelines concordant and they were labeled as “partially adherent” for this analysis. Conclusion: While the number of partially adherent patients was consistent with previous population-based adherence studies, the proportion of non-adherent patients was higher compared with other population-based studies in primarily Non-Hispanic White populations. Our analysis highlights the importance of focusing on adherence to guidelines and not just mammography initiation in underserved minority populations through educational interventions targeted to patients and providers. Citation Format: McClenathan MM, Lu J, Oppong BA, Adams-Campbell LL, Dash C. Adherence to breast cancer screening recommendations among underserved participants in an urban safety net mammography clinic [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-02-07.

Abstract P4-10-03: Tobacco exposure and breast cancer

Abstract Background: Smoking is a known risk factor for various types of cancer, and breast cancer patients who smoke are known to have higher breast cancer mortality. However, few studies have found an association between smoking and breast cancer incidence or tumor biology. The Athena Breast Health Network distributes an intake questionnaire at the UCSF and UCSD breast care centers which can be used to investigate links between tobacco exposure and the characteristics of incident breast cancer. Methods: Intake questionnaires were distributed to all new patients at the UCSF and UCSD breast care centers from December 2012 to May 2018. Patients who completed the questionnaire with a known diagnosis of breast cancer were compared to those without in a case-control study. Breast cancer diagnoses were determined by ICD9 diagnosis codes from the patients' medical records. The association of smoking and breast cancer prevalence and biology was analyzed using generalized linear models and Fisher tests in R. Results: Of the 7727 patients who completed the Athena intake questionnaire at UCSF and UCSD, 5499 consented to have their data used for research. A first analysis was conducted on 4175 UCSF patients alone: 2186 of the UCSF patients who had completed the questionnaire had a documented breast cancer diagnosis, vs 1989 with no known diagnosis at the time of this analysis. 1096 of the 4175 UCSF patients reported having ever smoked, including 73 who had accrued 30 or more pack years. Complete pathology data was available for 1120 cancer patients. Controlling for age, more patients with invasive breast cancer reported having ever smoked, with an odd's ratio (OR) of 2.32 (p = .0043). By including DCIS, the OR drops slightly to 2.26 (p = .0058). Taking alcohol consumption into account as a confounder lowered the OR to 2.19 (p = .0454). Overall, the risk of breast cancer increases with each additional pack year (OR = 1.08, p = .0211), independent of age. There are no significant differences in tumor biology for any smoking group. Conclusions: A history of smoking is associated with an increased risk of developing breast cancer and is directly related to cumulative pack years exposure. This association should be further validated in cohort studies. Citation Format: Dreher N, Layton TM, Parker BA, Shibley WP, Acerbi I, Wallace AM, Blair S, Pierce JP, Glantz S, Guydish J, Hiatt R, van 't Veer L, Esserman L, Athena Breast Health Network Investigators and Advocate Partners. Tobacco exposure and breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-10-03.

Nurse-led coaching of shared decision-making for women with ductal carcinoma in situ in breast care centers: A cluster randomized controlled trial

BackgroundWomen with breast cancer demand informed shared decision-making. Guidelines support these claims. ObjectivesTo investigate whether an informed shared decision-making intervention for women with ‘ductal carcinoma in situ’ comprising an evidence-based decision aid with nurse-led decision coaching enhances the extent of the mutual shared decision-making behavior of patients and professionals regarding treatment options, and to analyze implementation barriers. DesignCluster randomized controlled trial with accompanying process evaluation. SettingCertified breast care centers in Germany. ParticipantsWomen with ductal carcinoma in situ and no previous history of breast cancer facing a primary treatment decision. MethodsSixteen breast centers were randomized to intervention or standard care to recruit 192 patients (partially-blinded). All coaching sessions and physician consultations were videotaped to assess the primary outcome ‘extent of patient involvement in shared decision-making’ using the MAPPIN-Odyad observer instrument (scores 0 to 4). Secondary endpoints included the sub-measures of the MAPPIN-inventory (MAPPIN-Onurse, MAPPIN-Ophysician, MAPPIN-Opatient, MAPPIN-Qnurse, MAPPIN-Qpatient and MAPPIN-Qphysician), ‘informed choice’, ‘decisional conflict’ and ‘duration of consultations’. Primary intention-to-treat analyses were on cluster level comparing means of cluster values using t-tests. An accompanying process evaluation was conducted comprising 1) analysis of all video recordings with focus on procedures and intervention fidelity and 2) field notes of researchers and feedback from professionals and patients assessed by questionnaires and interviews with focus on barriers and facilitators for implementation at different time points. ResultsDue to protracted recruitment, the study was terminated after 14 centers had included 64 patients (intervention group 36, control group 28). Patient participation in informed shared decision-making was significantly higher in the intervention group (mean (SD) score 2.29 (0.56) vs. 0.42 (0.51) in the control group; difference 1.88 (95% CI 1.26–2.50, p < 0.0001). 47.7% women in the intervention group made informed choices, but none in the control group, difference 47.7% (95% CI 12.6–82.7%, p = 0.016). In the intervention group physician consultations lasted 12.8 (6.6) min. vs. 24.3 (6.3) min. in the control group. Physicians’ attitudes, false incentives and structural barriers hindered implementation of informed shared decision-making. Nurses appreciated their new roles. ConclusionsInformed shared decision-making is not yet implemented in German breast care centers. Nurse-led decision coaching grounded on evidence-based patient information enhances informed shared decision-making.Trial registration No. ISRCTN46305518.

Differences in Perceived Waiting Time by Health Insurance Type in the Inpatient Sector: An Analysis of Patients With Breast Cancer in Germany.

Although the relationship between health insurance and waiting time has been established in the ambulatory sector in Germany, research in the inpatient sector is limited. This study aims to contribute to previous work through analyzing differences in perceived waiting time by health insurance type during the inpatient stays of patients with breast cancer in Germany. This study utilizes cross-sectional data from 2017 of patients with breast cancer (N = 4626) who underwent primary breast cancer surgery in a certified breast care center in Germany. Results from multilevel logistic regression models indicate a significant effect of health insurance status on perceived waiting time, net of other relevant factors (patient’s sociodemographic background, Union for International Cancer Control stage, grading, self-reported and classified health, type of surgery, and chemotherapy). Patients with statutory insurance were significantly more likely than privately insured patients to report long waiting times for examinations/procedures, discharge, and to speak with the physician. There were no significant differences in waiting time for nursing staff between private and statutory insurance holders. Results align with previous findings in the ambulatory sector and suggest a private health insurance advantage, with private patients receiving priority to some health care services. Disparities in health care accessibility and quality need to continue to be addressed and discussed, as well as the impact of health insurance type on other indicators of health.

Estrogen Receptor, Progesterone Receptor, and Human Epidermal Growth Factor Receptor-2 Testing in Breast Cancer: Assessing the Value of Repeated Centralized Testing in Excision Specimens.

At some tertiary breast care centers, where many patients are referred from other institutions, it is routine to repeat testing for estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor-2 (HER2/neu) in excision specimens if these tests were performed on the preceding biopsy at the referring facility. The goal of this study is to assess the value of this practice. We documented results from ER, PR, and HER2 testing in 541 consecutive invasive breast cancers excised over a 2.5-year period and analyzed the subset (n=153) for which testing was performed on the excision specimen solely due to the fact that testing on the preceding biopsy was performed at an outside institution. The rates and directions of biopsy-to-excision change were as follows: ER [1.3% (2/153), 100% from (+) to (-)]; PR [4% (6/153), 83% from (+) to (-)]; HER2/neu assessed by immunohistochemistry [21% (29/137)]; HER2/neu assessed by fluorescence in situ hybridization [3.3% (2/61); 50% from amplified to nonamplified and 50% vice versa]. There were no ER(-) and PR(-) biopsy cases that became ER and/or PR(+) in the excision. By coordinate analysis for the hormone receptors [ie, ER and/or PR(+) being indicative of "hormone receptor" (HR) positivity], there were no cases that changed from HR(+) in the biopsy to HR(-) in the excision (or vice versa), which suggests that repeat testing for ER and PR in this setting is of limited value. In an analysis that incorporated both immunohistochemistry and in situ fluorescence hybridization results, there were 2 cases with a clinically significant biopsy-to-excision change in HER2/neu status in which that change was detected primarily because the excision was retested. These findings provide baseline data for formulating policies on whether repeat testing should routinely be performed in the described scenario.

Integration of Health Questionnaire Systems to Facilitate Supportive Care Services for Patients at an Academic Breast Care Center.

This study evaluated the use of an electronic Health Questionnaire System (HQS) within the University of California San Francisco Breast Care Center as a screening and triage tool to proactively recognize patients' supportive care needs during new patient consultations and identify demographic characteristics associated with referrals to three supportive care services. A total of 428 patients with and without breast cancer between the ages of 18 and 84 years completed HQS intake forms before appointments at the University of California San Francisco Breast Care Center between November 2014 and May 2015 and agreed to participate in this study. Patient HQS responses triggered referrals to supportive care services, and a review of electronic health records was conducted to determine the outcomes of these referrals. A total of 242 patients (56.5%) met criteria for at least one supportive care referral. Women with invasive breast cancer or ductal carcinoma in situ met criteria for supportive services more frequently than women without breast cancer diagnoses (76.9% v 23.8%; P < .001) and were most likely to receive referrals for genetic counseling (67.0%), psychological services (32.2%), and social services (12.1%). Multivariable logistic regression analysis showed that being married was associated with fewer referrals to social work (OR, 0.42; 95% CI, 0.21 to 0.81) and that those between 45 and 54 years of age were less likely to receive referrals to genetic counseling than those ≥ 55 years of age (OR, 0.41; 95% CI, 0.23 to 0.73). Among all referrals (n = 369), 26.8% resulted in completed appointments. Using an automated intake form is an efficient way to identify and triage individuals in need of supportive care services and can provide insight into the populations with supportive care needs for targeted outreach.

Alexithymia in Breast Cancer Patients and Their Sisters in Seoul

Background: The incidence of breast cancer has more than doubled in South Korea since 1999. Breast cancer in the family affects other members such as first degree relatives. Alexithymia is a psychological construct related to an inability to express ones feelings and has been found to be useful in identifying individuals who might benefit from targeted counseling to address distress. Aim: The purpose of this study was to examine the levels of alexithymia in breast cancer patients, their sisters and healthy controls in South Korea with the aim of identifying individuals who will benefit from targeted counseling. Methods: The Korean version of the alexithymia questionnaire was used to compare the groups. The study group consisted of 98 breast cancer in-patients, out-patients, follow-up cases and lymphedema clinic attendees undergoing treatment at the Breast Care Center, Seoul National University Cancer Hospital, 50 sisters and 43 healthy controls. Results: The highest level of alexithymia was reported in patients, followed by their siblings. Healthy controls reported the lowest level of alexithymia. Difficulty in describing feeling scores has shown significant negative correlation with age and marital status among women with breast cancer. Women 51 years and above and married women have lower scores than those below 50 years aged women and those who are single, in a live-in relationship, widowed or divorced. No such significant correlation was observed among siblings and control group. The intensity of cancer was a significant predictor of the alexithymia score. Patients with T4 stage disease reported the highest levels of alexithymia. No significant differences were found among patients with lower staging. Conclusion: Not only breast cancer patients, but also their sisters show significantly more alexithymia than their healthy counterparts. Counselors can use the alexithymia questionnaire to identify persons who require support to prevent or reduce psychological problems in patients and siblings.

Differences in Breast Cancer Characteristics by Mammography Screening Participation or Non-Participation.

The goal of the German Mammography Screening Program (MSP) is to enable the early detection and less intensive treatment of breast cancer. We compared tumor characteristics and prognostic markers in breast cancers that were detected by screening in the MSP, in the interval after a negative screening, or among non-participants in screening. This retrospective series includes all of the 1531 cases of invasive and in situ breast cancer (DCIS, ductal carcinoma in situ) that were newly diagnosed in two certified breast care centers in Münster in the period 2006-2012 among women in the MSP target population. Complete information on the tumor characteristics, tumor biology, and primary surgical treatment were available for all cases. The mode of cancer detection was determined from the state cancer registry of North Rhine-Westphalia. Due to the retrospective design of this case series, there was no randomized allocation. The 874 cases of breast cancer among MSP participants (714 detected by screening, 160 in the interval after a negative screen) and the 657 cases among non-participants arose in women of similar age (mean, 60.2 versus 59.3 years). MSP participants with breast cancer had DCIS more commonly than non-participants did (23% versus 13%); invasive carcinomas were smaller (74% versus 55% in the T1 stage), less commonly node-positive (25% versus 31%), less commonly high-grade (19% versus 27%), and less commonly triple-negative (7% versus 12%); MSP participants received neoadjuvant treatment less frequently (2% versus 8%) and more frequently underwent breast-conserving surgery (75% versus 62%). They less commonly had a guideline-based indication for adjuvant chemotherapy (46% versus 52%). MSP participants with invasive breast cancer can generally be treated with less intensive surgical and systemic therapy than non-participants, even if interval cancers are also taken into account. Future studies should also investigate quality of life after a diagnosis of invasive carcinoma in screening participants.

Abstract C12: Cancer navigation programs: Identifying barriers and addressing health disparities in Appalachia

Abstract The Appalachian region includes 13 states comprising 420 counties, beginning in the north in southern New York and following the Appalachian Mountains to Mississippi. The region has unique natural beauty and a heterogeneous population that shares distinct cultural characteristics but with high rates of unemployment, low income, and high rates of chronic disease, including cancer. Patient Navigation (PN) can address barriers and enhance access to cancer screening and care through the use of individual navigators who are sensitive to the needs, interests, and values of the community. Although there are numerous PN training programs available, there are no known programs specific to the Appalachian population. An electronic survey was distributed in 2011 and again in 2015/16 to better understand the cancer navigation programs in all 13 states of the Appalachian states and how they serve the regional population. In both waves of the survey over 150 responses were received from navigators, program directors, and supervisors. Survey results identify where cancer navigation programs take place (hospitals, health centers, and cancer centers), which health professionals fill the role of navigators (social workers, nurses, health educators), where navigation programs reside in health organizations (breast care centers, infusion centers, social services, and cancer centers), what aspects of the cancer continuum are addressed (prevention, screening, treatment to survivorship), and what range of services are provided by navigation programs (from education, referrals, to financial and spiritual support). A summary and comparison of quantitative data will be reported supplemented with qualitative findings and open-ended responses. Citation Format: Sharon Dwyer, Elizabeth Rohan, Dana White, Eric Stockton, Georgina Castro, Reda Wilson, Carol White, Mark Dignan. Cancer navigation programs: Identifying barriers and addressing health disparities in Appalachia [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr C12.

Abstract B22: Trends in mammography utilization at a safety net breast cancer screening center

Abstract Background: Breast cancer screening uptake patterns vary based on race and ethnicity, insurance status, socioeconomic status, and age. Among uninsured and resource-poor populations, community-based safety net clinics have emerged as important providers of these breast cancer screening services. The Capital Breast Care Center (CBCC) was established in 2004 to deliver breast and cervical cancer screening to all women in the District of Columbia (DC) metropolitan region. CBCC serves a large Black and Hispanic population with representation of many diverse ethnic groups within these racial categories. Here, we examine the population of women presenting to CBCC for screening mammograms from 2010 to 2016, evaluating patterns of changes in utilization of the services along sociodemographic and economic lines among the women. Methods: Prospectively collected demographic data were abstracted from the electronic medical records including age, race, menopausal status, insurance status, highest education attainment, and screening outcome. Percentages of women who sought mammography screening were computed for each year by categories of selected characteristics. Time trends in screening were tested with the Cochran-Armitage trend test. Results: From 2010 to 2016, 8448 women were screened at CBCC with 106 diagnoses of breast cancer. African-American and Hispanic women accounted for about 90%. Trends in the racial/ethnic composition of the women screened shifted, with African American women decreasing while the proportion of Latina patients increased (p-value &amp;lt;0.0001). The uninsured population increased covered under the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) as decreases were seen in women with private commercial insurance, Medicaid, and Medicare (p-value &amp;lt;0.0001). The number of DC residents decreased as more patients traveled from Maryland and Virginia (p-value &amp;lt;0.0001). There was no significant trend in proportion of women who had screening and were diagnosed with breast cancer. Conclusion: In this analysis of asymptomatic women presenting for breast cancer screening, over a 7-year period there were significant trends in an increase in Hispanic women, those residing in Virginia, and those screened using the NBCCEDP. These analyses of the population of women selecting CBCC for mammography screening may reflect both local and national demographic shifts. Assessment of patient trends can improve preventative/public health efforts and intervention services offered at community clinics. Citation Format: Bridget A. Oppong, Holly Greenwald, Chiranjeev Dash, Kepher Makambi, Tesha Coleman, Lucile Adams-Campbell. Trends in mammography utilization at a safety net breast cancer screening center [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr B22.

Adherence to aromatase inhibitors (AIs) in Hispanic patients with early stage breast cancer.

70 Background: Adherence to Aromatase Inhibitors (AIs) is essential for the effective prevention of breast cancer recurrence. We sought to evaluate adherence to AIs as well as possible factors behind non-adherence in a large American-Mexican border city with predominantly Hispanic population. Methods: After IRB approval, women with Stages I-III breast cancer treated at the Texas Tech breast care center in El Paso, TX were included if they were receiving adjuvant AI therapy. We utilized the validated Morisky Medication Adherence Scale (MMAS-8) to determine AI compliance. In addition, a question to indicate reasons for noncompliance was added. Results: 87 patients were enrolled, median age was 61 years; 78 (90%) were identified as Hispanic. The majority of participants were women of low socioeconomic status 53 (61%) with an annual income of &lt; $15,000. MMAS-8 results showed 35 (40%) patients admitted to forgetting to take their AI pill. Additionally, 71 (82%) of the patients denied forgetting to take the AI pill within the past two weeks. 11 (13%) patients admitted to sometimes having difficulty remembering to take their AI medication, and 74 (85%) stated never or rarely having difficulty remembering to take their AI medication. 50 (57.5%) patients provided a reason why they did not take their AI pill, 35 (40%) cited forgetfulness, 14 (17%) cited other reasons including cost, limited insurance coverage, lack of transportation involved in obtaining the medication and timely prescription refills, and only 1(1%) due to side effects. Conclusions: Non-adherence to AI appears to be prevalent among Hispanic patients with breast cancer. Main causes of noncompliance are forgetfulness and financial reasons. Healthcare providers could reinforce educating patients about the importance of compliance. Financial assistance may also be helpful in improving AI compliance. Clinical trial information: NCT03144037.

Abstract P6-12-10: The importance of a survivorship coordinator role in the creation of survivorship care plans and maintaining compliance with new accreditation standards

Abstract Background: Froedtert Hospital and the Medical College of Wisconsin's Breast Care Center (F&amp;MCWBCC), is a Commission on Cancer (CoC) and National Accreditation Program for Breast Centers (NAPBC) accredited facility providing care to over 500 patients a year. The F&amp;MCWBCC recognized the importance of following the IOM survivorship recommendations and in 2014 began providing a survivorship care plan (SCP) to patients completing radiation therapy. In 2015, SCP standards for both CoC and NAPBC were established. A redesign of the process was necessary to meet these new requirements. Methods: A review of accreditation standards was conducted along with an examination of staff availability. A collaborative team of content experts was gathered who worked with an informatics nurse to design content and a template in the EHR that met the elements outlined by the accreditation standards. Initially, treating physicians and advanced practice nurses were responsible for creating the SCP. However, these providers found it to be increasingly difficult to manage on top of their other responsibilities. In May 2015, an experienced breast cancer technician was identified for the survivorship data coordinator role. The coordinator used available sources, patient lists and clinic schedules, to case find. She developed spreadsheets to assist in tracking patients and measuring compliance. The coordinator communicated with providers to alert them to populate and review the SCP and coordinated the survivorship appointment with the nurse. Once the SCP is completed, a dedicated RN position is utilized for a survivorship visit with patients. During this visit, the RN reviews the care plan and provides education on follow up care guidelines and overall health and wellness concepts. Assessments for further supportive services are performed, and appropriate referrals made. The RN shares the SCP with the primary care provider. Results are tracked and reported to Cancer Service Line Leadership and the Breast Steering and Cancer Committees. Results: During the implementation phase, completion of SCPs by physicians and advance practice nurses was inconsistent. Once the survivorship coordinator role was created and implemented, compliance with NAPBC standards improved as SCP delivery numbers increased 141%. The survivorship coordinator improved delivery of SCPs. In 2014, 130 plans were delivered, and 185 in 2015. In 2016, 314 were delivered, achieving 100% compliance to the NAPBC survivorship standard. Conclusion:Compliance with NAPBC and CoC standards to deliver SCPs to patients and primary care providers is labor intensive and requires a large number of resources. Use of a survivorship data coordinator has proven successful in determining and tracking eligible patients and ensuring timely delivery of SCPs to patients. The monitoring of new patients through this process has enabled this center to go from estimates of analytic cases, to a current real-time numbers. This is necessary to provide a comprehensive review of care and survivorship guidelines to cancer survivors and meeting accreditation standards. Further work is needed to assess the impact of the SCPs on patient outcomes and satisfaction. Citation Format: Blissitt J, Scalio R, Myers KB, Sweeney K, Kelly TR, Kong A, Chitambar C, Currey AD. The importance of a survivorship coordinator role in the creation of survivorship care plans and maintaining compliance with new accreditation standards [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-12-10.

Role of postoperative radiotherapy in reducing ipsilateral recurrence in DCIS: an observational study of 1048 cases

BackgroundThe objective of the present study was to evaluate the effectiveness of postoperative radiotherapy after breast conserving surgery (BCS) in DCIS in a large patient population treated in clinical practice.MethodsData were provided by the population-based Munich Cancer Registry. Between 1998 and 2014, 1048 female patients with diagnosis of DCIS and treated at two Breast Care Centres were included in this observational study. The effectiveness of postoperative radiotherapy and variables predicting the use of radiotherapy were retrospectively analysed.ResultsAfter adjusting for age, tumour characteristics and therapies, Cox regression analysis for local recurrence-free survival identified RT as an independent predictor for improved local control (HR: 0.579; 95%CI: 0.384–0.872, p = 0.008). Ten-year cumulative incidence of in-breast recurrences was 20.0% following BCS, compared to 13.6% in patients receiving postoperative radiotherapy (p = 0.012). As an estimate for disease-specific survival, 10-year relative survival was 105.4% for patients receiving postoperative radiotherapy and 101.6% without radiotherapy. On multivariate analysis, postoperative radiotherapy was not associated with improved overall survival (HR 0.526; 95%CI: 0.263–1.052, p = 0.069). Over time, a significant increase of RT was registered: while 1998 only 42.9% of patients received postoperative radiotherapy, the proportion rose to 91.2% in 2014. Women aged < 50 years (OR: 2.559, 95%CI: 1.416–4.625, p < 0.001) or with negative hormone receptor status (OR: 2.625, 95%CI: 1.458–4.728, p = 0.001) or receiving endocrine therapy (OR: 1.762, 95%CI: 1.060–2.927, p = 0.029) were more likely to receive postoperative radiotherapy after BCS.ConclusionsIn conclusion, this study provides insights regarding the adoption and treatment pattern of postoperative RT following BCS for DCIS in a large cohort reflecting “real-life” clinical practice in this setting. Postoperative RT was found to be associated with a reduced risk of ipsilateral recurrence and no survival benefit compared to observation alone.

Implementation of shared decision-making in oncology: development and pilot study of a nurse-led decision-coaching programme for women with ductal carcinoma in situ

BackgroundTo implement informed shared decision-making (ISDM) in breast care centres, we developed and piloted an inter-professional complex intervention.MethodsWe developed an intervention consisting of three components: an evidence-based patient decision aid (DA) for women with ductal carcinoma in situ, a decision-coaching led by specialised nurses (breast care nurses and oncology nurses) and structured physician encounters.In order to enable professionals to gain ISDM competencies, we developed and tested a curriculum-based training programme for specialised nurses and a workshop for physicians. After successful testing of the components, we conducted a pilot study to test the feasibility of the entire revised intervention in two breast care centres. Here the acceptance of the intervention by women and professionals, the applicability to the breast care centres’ procedures, women’s knowledge, patient involvement in treatment decision-making assessed with the MAPPIN’SDM-observer instrument MAPPIN’Odyad, and barriers to and facilitators of the implementation were taken into consideration. We used questionnaires, structured verbal and written feedback and video recordings. Qualitative data were analysed descriptively, and mean values and ranges of quantitative data were calculated.ResultsTo test the DA, focus groups and individual interviews were conducted with 27 women. Six expert reviews were obtained. The components of the nurse training were tested with 18 specialised nurses and 19 health science students. The development and piloting of the components were successful. The pilot test of the entire intervention included seven patients. In general, the intervention is applicable. Patients attained adequate knowledge (range of correct answers: 9–11 of 11). On average, a basic level of patient involvement in treatment decision-making was observed for nurses and patient–nurse dyads (M(MAPPIN-Odyad): 2.15 and M(MAPPIN-Onurse): 1.90). Relevant barriers were identified; physicians barely tolerated women’s preferences that were not in line with the medical recommendation. Classifying women as inappropriate for ISDM due to age or education led physicians to neglect eligible women during the recruitment phase.ConclusionDecision-coaching is feasible. Nevertheless, there are some indications that structural changes are needed for long-term implementation. We are currently evaluating the intervention in a cluster randomised controlled trial in 16 breast care centres.

Reply: Direct-to-Implant Breast Reconstruction without the Use of an Acellular Dermal Matrix Is Cost Effective and Oncologically Safe.

Sir: We thank Dr. Parisi and colleagues for their interesting response to our article.1 Conceptually, we completely agree that it is always better to have as much coverage of the implant as possible. In our practice, this is muscle, a deepithelialized dermal flap, or even potentially an acellular dermal matrix or mesh. This will provide potentially less rippling in the long term, as there is thicker coverage of the implant. However, it may not necessarily decrease the complication rates as far as sepsis and seroma are concerned, especially if an acellular dermal matrix or mesh is used. Coverage of the implant by whatever manner also does not necessarily change the perfusion of the mastectomy flaps, although tension in the repair may. Well established is the practice that unless an acellular dermal matrix or mesh is used, the surgeon is limited to using a skin-reducing mastectomy pattern with inferior deepithelialized dermocutaneous flap to cover the lower pole of the implant. If total muscular coverage is desired, a combination of the pectoralis major and the serratus anterior muscle is used. This will obviously limit the size of the prosthesis that can be placed in this relatively small pocket, as described in Dr. Parisi et al.’s letter. From a postoperative cosmetic point of view, in the lazy-S approach, the upper two-thirds of the implant is covered by the mastectomy flap and the pectoralis major muscle; thus, it is uncommon to have postoperative rippling in this area. If the lower mastectomy flap is very thin (<1 cm) then, not uncommonly, there will be some rippling in this area. This is usually corrected at the time of nipple-areola complex reconstruction with lipofilling of the lower mastectomy flap. It is also vital that the inframammary fold is retained during the mastectomy and that a tight snug pocket is reconstructed around the implant; otherwise, there is a high chance that the patient may end up with implant malposition or implant rotation. Mastectomy flap necrosis is one of the major concerns of which any breast reconstructive surgeon is acutely aware. The mastectomy needs to be performed in the mastectomy plane, and this can be vague; however, with appropriate traction on the skin and countertraction on the breast organ itself, the avascular white line can be seen and the mastectomy needs to be performed in this plane. If the mastectomy is performed in the correct plane, all that remains is the subcutaneous fat and the overlying skin. Although the patient’s body habitus often dictates the flap thickness, this is not always the case. The premise that the more weight the patient is carrying, generally the thicker the flap, cannot solely predict mastectomy flap. The blood supply to the mastectomy flaps after mastectomy is provided by the subdermal plexus, and if it is removed or damaged at the time of mastectomy, the surgeon should expect to have mastectomy flap necrosis. We do not routinely evaluate the mastectomy flap thickness before surgery and therefore there is no absolute number to use for the thickness of the mastectomy flap, as it varies from patient to patient. The most accurate way to determine perfusion and viability of the mastectomy flaps is to use intraoperative laser angiography [such as the SPY system (LifeCell Corp., Branchburg, N.J.)],2 which we do not use. If this is not available, débridement of the edges of the mastectomy flap will indicate the perfusion of that specific flap, and if there is doubt about the perfusion, the flaps can be trimmed back until the surgeon is happy with the perfusion. If there is not enough remaining skin to cover a large enough implant, the patient can then be converted to an expander prosthesis reconstructive pathway. Some patients are prone to wound healing problems, such as those with a high body mass index, diabetic patients, poorly controlled human immunodeficiency virus–positive patients, previously irradiated patients, and smokers. These women may have a higher postoperative complication rate in relation to wound healing and minor flap necrosis and should be approached and counseled with care. The reconstructive surgeon should have a much lower threshold to use an expander prosthesis reconstructive pathway for these high-risk patients. ACKNOWLEDGMENT The study received ethics approval from the Human Research Ethics Committee of the University of the Witwatersrand (M111121). DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. L. Charles J. Serrurier, F.C.S.Plast.Surg.(C.M.S.A.)Sarah Rayne, B.Sc.(U.C.L.), M.R.C.S.(Eng.), F.C.S.(S.A.)Marisse Venter, F.C.S.Plast.Surg.(C.M.S.A.)Carol-Ann Benn, F.C.S.(S.A.)University of the Witwatersrand and Milpark Breast Care Centre of ExcellenceJohannesburg, South Africa

Abstract A02: Comparative analysis of breast density among Black, White, and Hispanic women presenting for screening mammography

Abstract Background: Data on ethnic variations in breast density are limited and often not inclusive of underrepresented minorities, including Black and Hispanic women. As breast density is associated with elevated breast cancer risk, investigating racial and ethnic difference may elucidate the observed differences in breast cancer risk among different populations. Methods: We reviewed breast density recorded at the initial mammographic screening study in women presenting to the Capital Breast Care Center (CBCC) and Georgetown University Hospital (GUH) from 2010 to 2014. Patient demographics including race, age at screening, education and menopausal status were abstracted in addition to body mass index (BMI). From imaging reports, we recorded the BI-RADS density categories: 1-fatty, 2-scattered fibroglandular densities, 3-heterogeneously dense and 4-extremely dense. Multivariable unconditional logistic regression was used to identify predictors of breast density. Results: Density categorization was recorded for 2,146 women over the five-year period, with 940 (43.8%) Black, 893 (41.6%), Hispanic and 314 (14.6%) White. Analysis of subject characteristics by low density (categories 1 and 2) and high density (categories 3 and 4) show that high category is observed in younger, Hispanic, nulliparous, premenopausal and non-obese women (P-values &amp;lt;.0001). Obese women are 70% less likely to have high breast density compared to non-obese women. Being Hispanic, premenopausal, and non-obese were predictive of high mammographic density on logistic regression. Conclusion: In this analysis of density distribution in a diverse sample of women presenting for mammography, Hispanic women have the highest breast density, followed by Black women with Whites having the lowest. Unique in our findings is women who identify as Hispanic having the highest breast density and lower rates of obesity. Further investigation of the impact of obesity on breast density in minority women, especially in the understudied Hispanic group is needed. Citation Format: Bridget A. Oppong, Chiranjeev Dash, Suzanne Oneill, Kepher Makambi, Tesha Coleman, Lucile L. Adams-Campbell. Comparative analysis of breast density among Black, White, and Hispanic women presenting for screening mammography [abstract]. In: Proceedings of the AACR International Conference: New Frontiers in Cancer Research; 2017 Jan 18-22; Cape Town, South Africa. Philadelphia (PA): AACR; Cancer Res 2017;77(22 Suppl):Abstract nr A02.

Breast density in multiethnic women presenting for screening mammography.

Data on ethnic variations in breast density are limited and often not inclusive of underrepresented minorities. As breast density is associated with elevated breast cancer risk, investigating racial and ethnic difference may elucidate the observed differences in breast cancer risk among different populations. We reviewed breast density from initial screening of women from the Capital Breast Care Center and Georgetown University Hospital from 2010 to 2014. Patient demographics including race, age at screening, education, menopausal status, and body mass index were abstracted. We recorded the BI-RADS density categories: (1) "fatty," (2) "scattered fibroglandular densities," (3) "heterogeneously dense," and (4) "extremely dense." Multivariable unconditional logistic regression was used to identify predictors of breast density. Density categorization was recorded for 2146 women over the 5-year period, comprising Blacks (n=940), Hispanics (n=893), and Whites (n=314). Analysis of subject characteristics by breast density showed that high category is observed in younger, Hispanic, nulliparous, premenopausal, and nonobese women (t-test or chi-square test, P-values <.0001). Obese women are 70% less likely to have high density. Being Hispanic, premenopausal, and nonobese were predictive of high density on logistic regression. In this analysis of density distribution in a diverse sample, Hispanic women have the highest breast density, followed by Blacks and Whites. Unique in our findings is women who identify as Hispanic have the highest breast density and lower rates of obesity. Further investigation of the impact of obesity on breast density, especially in the understudied Hispanic group is needed.

Guideline adherence and clinical outcome in vulnerable and healthy breast cancer patients: Results of a prospective cross-sectional study in Germany.

e18132 Background: In 2003 the German Cancer Society and the German Society for Breast Disease introduced a number of Quality Indicators (QIs) to improve standards of breast cancer care. Although QIs should be based on clinical evidence, evidence for important subpopulations (i.e. vulnerable patients) is often limited. In this prospective cross-sectional study we assessed conformity and non-conformity of guidelines and their impact on clinical outcome in a real-world setting. Methods: This prospective analysis included patients with primary breast cancer. Patients with stage IV and recurrent breast cancer were excluded. Data was collected from 2012-2016 in six certified breast care centers using a personal questionnaire and data from the patients' medical records. Guideline adherence to a set of 11 QIs was explored. Overall survival (OS) and disease free survival (DFS) were correlated with fulfillment of QIs and tumor characteristics. Results: Survival analysis was conducted in 2390 patients with a median follow-up of 16 months. 88 (4%) patients had a recurrent disease. 31 (1.3%) patients died of breast cancer. Tumor stage, grading, Her2- and hormone receptor status and Ki-67 correlated with DFS and OS. 1725/1907 patients (90.5%) received a guideline adherent treatment. The most prevalent reasons for non-conformity were old age (24.7%) and/or comorbidity (20.9%). Breast cancer specific DFS and OS were not significantly different between patients treated adherent or not adherent to the guidelines. In contrast, survival analysis of death other than breast cancer showed a significantly worse OS (p = 0.006) for patients not treated according to guideline recommendation. Conclusions: Conformity of clinical guidelines was observed in the majority of patients including healthy and vulnerable patients. These patients tended to have a longer breast cancer specific survival. Patients who were not considered suitable for guideline-adherent therapy died more often from other medical reasons rather than from breast cancer. In our study 10% of the patients had a limited life expectancy due to old age and co-morbidities with no assumed benefit from guideline adherence.

Oral vitamin B12 to improve aromatase inhibitors (AI)-associated musculoskeletal symptoms (AIMSS).

e21679 Background: Breast cancer patients undergoing Aromatase Inhibitor (AI) therapy often experience many side effects, which include musculoskeletal and joint pain. Vitamin B12 has often been used as a naturopathic supplement to relieve joint pain that is caused by arthritis. The purpose of this study was to evaluate the effect of Vitamin B12 supplements on musculoskeletal pain and arthralgias induced by aromatase inhibitors (AI) therapy. Methods: After approval by Institutional Review Board (IRB), we enrolled consecutive patients treated at the Texas Tech Breast Care Center who had a diagnosis of invasive breast cancer, Stages I-III, and were taking an AI and experiencing significant musculoskeletal symptoms assessed by the Brief Pain Inventory-Short Form (BPI-SF) questionnaire. Participants received 2500 mcg of sublingual vitamin B12 daily for 90 days. Assessments included improvement in BPI-SF pain scores at 3 months, the impact on quality of life determined by the Functional Assessment of Cancer Therapy–Endocrine Symptoms, FACT-ES and correlative serum markers. Results: A total of forty-one patients were enrolled, five patients withdrew, leaving thirty-six patients to complete the study. Analysis of the data collected indicate a 34% average pain improvement (P-value = 0.0001) as reported by patients at baseline and at the end of treatment in the BPI-SF questionnaire. Additionally, a 23 % worst pain improvement (P-value = 0.0003) was obtained for worst pain scores evaluated similarly, at baseline and at the end of treatment. Analysis of the results for the FACT-ES scoring showed improvement on all scales. No significant adverse events were observed. Additionally, decrease in pain score was correlated with increased serum B12 levels. A paired t-test was used to assess the mean difference between baseline and endpoint. Conclusions: This study suggests that vitamin B12 reduces pain and improves quality of life for patients taking AIs who experienced AI-related musculoskeletal symptoms. If confirmed in large randomized prospective trials, Vitamin B12 would be a safe and cost effective option for the treatment of AI -related musculoskeletal symptoms.

Triple negative breast cancer in a South African urban breast care centre.

e13067 Background: Triple negative breast cancer (TNBC) is associated with advanced stage at presentation, aggressive tumour biology and poor outcomes. There is no published data for South Africa. Methods: A retrospective file review of TNBC cases at the Milpark Breast Care Unit in Johannesburg, South Africa, data were collected on presentation, treatment and outcomes. A prospective file review and telephonic interview were done for further follow up. Results: There were 196 patients with TNBC identified out of 1407 patients (13.9%), 135 patients were analysed. Stage at presentation was IIa and IIb in approximately half (46.7%) of the patients and IIIa, IIIb and IV in a third (31.8%). Patients presented with large tumours -71.8% were T2 to T4; and lymph node positive disease (55.6%). The majority of patients had high-grade, poorly differentiated tumours. The challenges when treating TNBC were reflected in the use of multimodality therapy; 92.2% of patients had chemotherapy, as neoadjuvant (59.3%), adjuvant or both. There were 93 (68.9%) patients treated with adjuvant radiation therapy. If neoadjuvant chemotherapy was given 91.2% had a response. Recurrences occurred in 33 patients, with a 5-year disease free survival of 72.5%, and preponderance to visceral metastases (45.2%). Recurrences occurred early, the median was 23.1 months and all had occurred within eight years. Younger patients (HR 1.58), tumour size and lymph node positivity (HR 4.42) were associated with increased risk of recurrence, but only lymph node positivity was significant (HR 4.42). Complete pathological response to neoadjuvant chemotherapy was associated with fewer recurrences if no tumour was found in either the breast or the lymph nodes (HR 0.33). The 5-year overall survival was 76.4%. There was no significant difference in survival for age, node status, nuclear grade, or complete pathological response, only tumour size at presentation was significantly associated. Conclusions: The prevalence of triple negative breast cancer in a South African breast care unit was similar to some European studies but less than studies in West and East Africa. Patients presented at an advanced stage and had poorer outcomes than luminal breast cancers.