Breast-conserving Therapies Research Articles

Prognostic Factors Associated with Breast Cancer-Specific Survival from 1995 to 2022: A Systematic Review and Meta-Analysis of 1,386,663 Cases from 30 Countries.

Breast cancer is the fifth-ranked cancer globally. Despite early diagnosis and advances in treatment, breast cancer mortality is increasing. This meta-analysis aims to examine all possible prognostic factors that improve/deteriorate breast cancer-specific survival. MEDLINE, PubMed, ScienceDirect, Ovid, and Google Scholar were systematically searched until September 16, 2023. The retrieved studies from 1995 to 2022 accumulated 1,386,663 cases from 30 countries. A total of 13 out of 22 prognostic factors were significantly associated with breast cancer-specific survival. A random-effects model provided a pooled estimate of the top five poorest prognostic factors, including Stage 4 (HR = 12.12; 95% CI: 5.70, 25.76), followed by Stage 3 (HR = 3.42, 95% CI: 2.51, 4.67), a comorbidity index ≥ 3 (HR = 3.29; 95% CI: 4.52, 7.35), the poor differentiation of cancer cell histology (HR = 2.43; 95% CI: 1.79, 3.30), and undifferentiated cancer cell histology (HR = 2.24; 95% CI: 1.66, 3.01). Other survival-reducing factors include positive nodes, age, race, HER2-receptor positivity, and overweight/obesity. The top five best prognostic factors include different types of mastectomies and breast-conserving therapies (HR = 0.56; 95% CI: 0.44, 0.70), medullary histology (HR = 0.62; 95% CI: 0.53, 0.72), higher education (HR = 0.72; 95% CI: 0.68, 0.77), and a positive estrogen receptor status (HR = 0.78; 95% CI: 0.65, 0.94). Heterogeneity was observed in most studies. Data from developing countries are still scarce.

Lessons learned from the COVID-19 pandemic: Using telemedicine for pre-operative surgical evaluation in breast disease.

The COVID-19 pandemic motivated telemedicine care to decrease potential exposures for both patients and staff. We hypothesized that select breast surgical patients can be successfully evaluated pre-operatively with telemedicine. With institutional review board approval, patients with telemedicine surgical consults between 1 March 2020 and 31 August 2020 were identified retrospectively from our prospective breast surgical registry. The frequency of successful pre-operative evaluation using telemedicine alone was assessed, defined as cases in which surgery was completed on the planned day without changes to the surgical plan after physical examination in the pre-operative area. Differences in disease presentation, patient characteristics, and complications were evaluated by whether the first in-person visit occurred on the day of surgery versus the prior. A total of 374 patients underwent breast surgery between 1 March 2020 and 31 August 2020, of which 96 (25.7%) had a telemedicine consultation. After the telemedicine visit, 38 patients (39.6%) had additional in-person visits with the breast surgeon prior to their operative date, and 58 patients (60.4%) did not. Forty-five patients underwent breast-conserving therapies, 41 mastectomies (25 with reconstruction), two axillary dissections, and eight excisional biopsies. All surgeries were completed on the planned operative day, with no changes in surgical plans. Patients with telemedicine only prior to surgery were more likely to speak English (100% vs. 92.1%, p = 0.02) and have lower body mass index (median 24.9 vs. 29.2, p = 0.01). The frequency of in-person pre-operative visits varied significantly by surgeon (p < 0.001). Age, American Society of Anaesthesiologists score, distance from facility, clinical T/N category, surgery type, and complications did not differ between groups. Telemedicine can be utilized successfully for select breast surgical patients, with the ability to proceed to surgery in the majority of patients without additional in-person visits.

Lessons Learned in Breast-Conserving Therapy

Since the introduction of breast-conserving therapies (BCTs) in the 1970s, considerable changes have occurred in the treatment of early-stage breast cancer. Prospective studies and especially major phase III clinical trials have yielded a wealth of information, allowing us to currently achieve very high local control rates in BCT. This progress has been very well demonstrated in a few European BCT trials; each succeeding trial obtained significant higher local control rates (Fig 1). These trial results also formed a stimulus for new approaches aimed at limiting the side effects while obtaining high local control rates.

The prognostic relevance of the mitotic activity index in axillary lymph node-negative breast cancer.

The aim of the present study is to look at the mitotic activity index (MAI) as a prognostic factor in a prospective population-based cohort of lymph node-negative invasive breast cancer patients. Analyses were based on 2,048 breast-conserving therapies in 1,971 patients, node-negative, and without any form of adjuvant systemic therapy with long-term follow-up. The 15-year distant metastases-free survival (DMFS) for women ≤55 years was 88.3 % for low MAI values (≤12) versus 73.4 % for high MAI values (>12); (HR 2.8; 95 % CI 1.8-4.4; p < 0.001). Multivariate analyses for DMFS showed significance for MAI. For MAI and Bloom-Richardson grading, by performing a likelihood ratio test, we showed the statistical significance for both. For women >55-years, the MAI was not an independent significant factor. We also confirmed the above findings for disease-specific survival. When multi-gene assays are not available, the MAI remains a robust prognostic marker in women younger than 55 years of age with early node-negative breast cancer.

Oncoplastic surgery in breast conservation: a prospective evaluation of the patients, techniques, and oncologic outcomes

BackgroundThe oncologic efficacy of breast-conserving therapies has been established in recent decades. Oncoplastic breast surgery (OBS), as a leap forward in breast conservation, offers concomitant techniques of oncologic and plastic surgeries that grant better esthetic results. The outcomes of our oncoplastic surgeries from 2007 to 2012 are reported. MethodsA series of 258 cases with breast masses (18 benign and 240 carcinomas) were operated on by OBS techniques and prospectively followed. Neoadjuvant and adjuvant oncologic treatments were also delivered as indicated. ResultsFree margins were obtained in 95% of cancer patients. During the 26 months of follow-up, local recurrence happened in 7 (2.9%) patients, of which 1 underwent oncologic therapies and 6 underwent completion mastectomy. Complications postponed adjuvant therapies in 3 (1.2%) patients. Postsurgically, metastases were diagnosed in 8 (3.3%) patients. Two patients (.8%) died of cancer. ConclusionsOutcomes of OBS are oncologically acceptable with low frequencies of positive margins and recurrence, while cosmetic results are much improved by OBS.

Timing of radiotherapy in breast-conserving therapy: a large prospective cohort study of node-negative breast cancer patients without adjuvant systemic therapy

Background:To investigate the issue of timing of radiation therapy (RT) after lumpectomy in relation to recurrences and outcome.Methods:Analysis was done on 1107 breast-conserving therapies (BCT) with 1070 women, all without lymph node metastasis and without any adjuvant systemic therapy. Timing was defined as time from lumpectomy till RT. Patients were categorised into tertiles: <45 days, 45–56 days, and 57–112 days.Results:Local control did not show a difference between the tertiles. The distant metastasis-free survival as well as the disease-specific survival showed a decreased outcome starting the RT to early after the lumpectomy.Conclusion:The results of this cohort study further refines the hypothesis that timing of RT in BCT might have an impact on outcome. It suggests that a randomised trial in timing of RT in BCT seems necessary to give a definite answer.

Current Considerations for Breast Reconstruction in Breast Cancer Patients

In the next year, approximately 250,000 women will be diagnosed with breast cancer in the United States [1]. The majority of these women will be recommended partial or total mastectomy as a component of their cancer treatment. The goal of breast reconstruction is to rebuild and/or reshape the breast mound to correct the mastectomy defect for physical and psychological reasons. There are a number of reconstructive options available to patients who desire breast reconstruction, including implant-based procedures, autologous tissue reconstructions, or a combination. Additionally, oncoplastic procedures are a recent advance in the field of breast-conserving therapies that further refines our ability to resect breast cancer while preserving the form of the breast. Because planning the reconstruction depends on the type of resection performed and the amount of tissue remaining after mastectomy, the breast surgeon, reconstructive surgeon, and the patient collectively should discuss reconstructive goals and how these can be achieved after the patient’s oncologic surgery.

Temporal trends in the surgical outcomes of patients with breast cancer

BackgroundThe incidence of breast cancer has been increasing in Japan over the past three decades, and it is the currently the most common malignancy in Japan. This study investigated the temporal trends of the surgical outcomes in patients with breast cancer.MethodsWe evaluated 543 consecutive patients who underwent breast-cancer resection between 1980 and 2009. The temporal trends in the surgical outcome and clinicopathological features were evaluated separately for the periods covering 1980 to 1989, 1990 to 1999, and 2000 to 2009.ResultsThe number of patients who underwent resection during these three respective periods were 133, 176, and 234, respectively. All patients were women. The percentage of patients at stages 0 or 1 was 63.2%, 58.5%, and 43.6%, respectively, during the three periods. The mean diameter of tumors in each period was 38, 29, and 30 mm, respectively. The percentage of tumors with positive ER expression was 62.5%, 64.3%, and 69.7%, respectively. In terms of surgical procedures, the use of Halsted’s radical mastectomy decreased during each period: from 40.6% of cases to 8.5% and then to 0.4%, while the proportion of breast-conserving therapies increased, from 0% to 12.5%, and finally to 35.9%. The postoperative 10-year survival rates during the three periods were 75.9%, 83.5%, and 84.9%, respectively. The 10-year survival rates of patients with stage II disease during the three periods were 66.2%, 75.7%, and 90.7%, respectively. The prognosis of stage III disease in the three periods also showed a tendency toward improvement, increasing from 37.8% to 64.2%, and finally to 84.5%.ConclusionThe survival of patients with stage II and III disease has improved during the past 30 years. Along with the recent advances in drug therapy, the surgical treatment has become less invasive, often because of drug therapy-related modifications.

Effect of External Boost Volume in Breast-Conserving Therapy on Local Control With Long-Term Follow-Up

To determine the effects of boost volume (BV) in relation to margin status and tumor size on the development of local recurrence with breast-conserving therapy. Between 1983 and 1995, 1,073 patients with invasive breast cancer underwent 1,101 breast-conserving therapies. Of these 1,101 BCTs, 967 were eligible for analysis. The BV was categorized into tertiles: <66 cm(3) (n = 330), 66-98 cm(3) (n = 326), and >98 cm(3) (n = 311). The median follow-up was 141 months. Separate analyses were done for women < or =40 years and >40 years. No significant difference in local recurrence was shown between the tertiles and the recurrence site. The 15-year local recurrence-free survival rate was 87.9% for the first tertile, 88.7% for the second, and 89% for the third. For women < or =40 years old, the corresponding 15-year local recurrence-free survival rate was 80%, 74.5%, and 69.2%. For women >40 years old, the corresponding rate was 88.7%, 89.5%, and 90.9%. At 5 years, women >40 years old had significantly more local failures in the first tertile; this difference disappeared with time. A test for trend showed significance at 5 years (p = 0.0105) for positive margins for ductal carcinoma in situ in women >40 years of age. The results of this study have shown that the size of the external BV has no major impact on local control. For women >40 years old, positive margins for ductal carcinoma in situ showed a trend with respect to BV at 5 years. The BV had no influence on local control in the case of positive margins for invasive carcinoma.

Neoadjuvant treatment: the MD Anderson experience

Adjuvant chemotherapy has traditionally been administered in the postoperative setting. However, numerous studies have evaluated its use preoperatively. The potential benefits of neoadjuvant chemotherapy (NACT) include downstaging the primary tumor to allow breast-conserving surgery and assessment of a tumor's in vivo sensitivity to individual chemotherapeutic regimens. Our group at the MD Anderson Cancer Center initiated clinical trials with neoadjuvant chemotherapy in 1974, and over the past three decades we have treated several thousand patients in prospective clinical trials. Initially, NACT was reserved for the treatment of patients with locally advanced and/or inflammatory breast cancers. These studies clearly demonstrated that most patients had a marked reduction in tumor volume with anthracycline–cyclophosphamide–fluorouracil based regimens. Inoperable tumors became operable for most patients, and later studies indicated that even large tumors became candidates for breast-conserving therapies. We described 20 years ago the prognostic value of pathological complete remission (pCR), and subsequent studies included pCR as a surrogate end-point for long-term efficacy. These findings were later confirmed by the largest study evaluating the impact of neoadjuvant chemotherapy, the NSABP B-18. In this study, 1523 women were randomized to receive four cycles of doxorubicin and cyclophosphamide either prior to or after surgical resection. Another large study of similar design was performed by the EORTC, with similar results. The timing of chemotherapy did not affect the disease-free or overall survival for the entire cohort, although more patients who received preoperative therapy were able to undergo breast conservation rather than mastectomy in comparison to those treated postoperatively. These studies confirmed the clear correlation of pathological complete response (pCR) in the breast (absence of invasive cancer cells) with survival. Using a single, anthracycline-containing chemotherapy regimen, a pCR rate of about 10–13% can be obtained. The definition of pCR used by our group includes the absence of lymph node involvement, in contrast to the definitions used by NSABP and other groups. The pCR rate has become one of the most important intermediate trial endpoints in assessing the efficacy of new adjuvant chemotherapy regimens. Published studies of anthracycline-based preoperative chemotherapy demonstrate pCR rates of up to 17%. Several recently reported studies including the sequential use of anthracycline-based regimens and taxanes have achieved significantly higher pathologic responses, ranging from 25% to 34%. Our studies focused on the sequential use of anthracyclines and taxanes, showing excellent tolerance and efficacy of this strategy. In addition, we demonstrated the therapeutic superiority of weekly paclitaxel in this setting. These findings were subsequently confirmed by much larger, randomized trials conducted by another cooperative group. We used the neoadjuvant strategy for the initial evaluation of trastuzumab in patients with primary breast cancer. That small randomized trial indicated an almost threefold increase in pCR with the addition of trastuzumab to chemotherapy. Currently, we conduct studies with gene profiling in the neoadjuvant setting to determine predictors of pCR, and therefore long-term prognosis, and to develop individualized medicine for patients with primary breast cancer. There are multiple remaining questions related to the use of this strategy, however. Some pertain to optimal local-regional therapies: when should axillary assessment be performed in relation to NACT, what should be the criteria for administration of postmastectomy radiation therapy following NACT, and how to optimally perform breast-conserving surgery following NACT. The role and relative timing of neoadjuvant hormone therapy (NAHT) is also under intensive evaluation at this time. This is solely relevant to the group of patients with hormone receptor-positive tumors, but has potential impact on the type and sequence of local, regional and systemic therapies.

Oncoplastic techniques for immediate reconstruction with nipple-areolar preservation following radical resection of a centrally located breast cancer

There are few breast-conserving therapies (BCT) for centrally located breast cancer. The present paper describes a BCT for breast cancers in such a location, which permits conservation of the nipple-areola complex (NAC), provided this has not been infiltrated. After histological detection of the breast cancer by punch biopsy, a central segmental mastectomy and an axillary dissection are performed. An immediate reconstruction of the subareolar defect is carried out by means of a local flap technique, thus conserving the NAC.

. . . and Breast-Conserving Therapy

Breast-conserving local therapies are widely accepted as alternatives to radical mastectomy for early-stage breast cancer. This report from the U.S. National Cancer Institute provides 10 …

LONG-TERM FOLLOW-UP OF BREAST-CONSERVATION THERAPY.

Breast-conserving local therapies are widely accepted as alternatives to radical mastectomy for early-stage breast cancer. This report from the U.S. National Cancer Institute provides 10 years of …