Care For Early-stage Breast Cancer Research Articles

BREAST EDEMA AFTER CONSERVATIVE SURGERY FOR EARLY-STAGE BREAST CANCER: A RETROSPECTIVE SINGLE-CENTER ASSESSMENT OF RISK FACTORS

Breast-conserving surgery (BCS) is the standard of care for early-stage breast cancer. We retrospectively enrolled 530 patients (mean age: 62.96 ± 12.69 years) undergoing BCS between January 1, 2018, and December 31, 2019. During the COVID-19 pandemic, all patients with at least 1 year of follow-up were telephonically asked after surgery to provide clinical signs and symptoms attributable to postoperative breast cancer-related lymphedema of the breast (BCRL-B). Thirty-one (5.8%) patients reported breast edema and were visited to measure the tissue dielectric constant (TDC) and to assess the induration of the skin. There was a difference seen in treatment with lumpectomy + ALND performed more frequently in patients with (29%) than without (12%) BCRL-B. In the subgroup of patients with BCRL-B (n=31), significantly higher values of local total water were calculated in the nine patients who underwent Lump + ALND procedure (1.86 ± 0.48 vs. 1.48 ± 0.38; p = 0.046). Among patients with BCRL-B (n=31), in eight patients (25.8%) tissue induration measured with SkinFibroMeter was >0.100 N, thus suggesting tissue fibrosis. Cumulative survival probability at 1-year after surgery was 0.992. No statistical differences in 1-year survival after surgery were found for type of surgery (p = 0.890) or absence/presence of BCRL-B (p = 0.480). In univariate logistic regression, only lumpectomy + ALND surgery (p = 0.009) and any subsequent axillary lymph node removal surgery (p = 0.003) were associated with BCRL-B. Both of these variables were also found to be statistically significant in the multivariate regression model. Further prospective research is warranted to analyze potentential predictors of BCRL-B and to reduce/ prevent this complication.

Real-world, single-center experience on the outcomes of neoadjuvant chemotherapy and trastuzumab alone or in combination with pertuzumab in human epidermal growth factor receptor-2 breast cancer patients.

e12589 Background: Neoadjuvant chemotherapy (NACT) is the standard of care for early-stage breast cancer (BC). Human epidermal growth factor receptor 2 (HER2) positive disease constitutes a large proportion of BC patients, and HER2 overexpression is associated with poor prognosis. The introduction of HER2+ targeted therapies, such as trastuzumab and pertuzumab, has resulted in improved outcomes in HER2+ BC. NACT in combination with HER2 targeted therapies aims at achieving pathological complete response (pCR) and an improved survival rates. Methods: We performed a retrospective review of HER2+ BC patients who were treated at Medanta – The Medicity Hospital, Gurugram, Haryana, India, between 2011 and 2021. A total of 108 HER2+ BC patients who received NACT with platinum, anthracycline or taxane-based regimens, along with trastuzumab alone or in combination with pertuzumab, were included. Results: Of 108 enrolled patients, 66 and 42 patients received neoadjuvant single-blockade (trastuzumab) and dual-blockade (trastuzumab and pertuzumab) anti-HER2 therapy, respectively. The majority of patients were aged < 60 years. The patient populations were comparable in terms of clinical stage, hormone receptor status, histopathology category [Invasive ductal carcinoma (IDC) being most common] and Ki67 status for both groups. All patients had IHC3+/FISH+ HER2 expression. No significant (p = 0.896) difference was observed for breast conserving surgery between the groups. A higher pCR rate after surgery was reported in the dual-blockade versus single-blockade group (50% vs. 39.2%; p = 0.271). The median follow-up duration was 21.9 and 15.2 months in the single-blockade and dual-blockade groups, respectively. For dual- vs. single- blockade groups, the 1-year OS rates were 100% each, and 3-year OS rates were 100% vs. 98.48%. For dual- vs. single- blockade groups, the 1-year DFS rates were 100% vs. 95.45%, and 3-year DFS rates were 92.85% vs. 80.3% respectively. Conclusions: Neoadjuvant chemotherapy with dual HER2-blockade had higher pCR and survival rates compared with the single HER2-blockade strategy in HER2 positive breast cancer. [Table: see text]

Safety of Reduction Mammaplasty and Mastopexy After Breast Conservation Therapy and Radiation Therapy: A Case Series.

Conservative surgery and radiotherapy (CS + RT) have become the standard of care for early-stage breast cancer as an alternative to mastectomy. With the increasing rate of obesity and incidence of macromastia, surgeons increasingly encounter patients with a history of breast radiation desiring breast reduction. However, elective breast surgery after irradiation remains to be controversial due to known adverse effects of radiation, especially on wound healing, and unknown effects of lumpectomy on traditional pedicle choices. Herein, we present our experiences and outcomes of reduction mammaplasties and mastopexies in patients with breast cancer previously treated with CS + RT. Between 2009 and 2020, 13 patients undergoing reduction mammaplasty or mastopexy, who have previously underwent CS + RT with or without axillary surgery, were included in this study. Surgical techniques and complications, including delayed wound healing, infection, fat necrosis, and nipple-areolar necrosis, were recorded and analyzed based on the irradiated versus nonirradiated sides. Of the 13 patients, delayed wound healing occurred in 7% on the irradiated side and 15% on the nonirradiated sides (P > 0.05). No significant correlation was observed between the number of complications and time of elective breast surgery from the last radiation therapy. Complications between irradiated and nonirradiated breasts did not significantly differ in both the reduction mammaplasty and mastopexy groups. Reduction mammaplasty and mastopexy in patients with a history of lumpectomy and breast irradiation can be safely performed and should be considered in those experiencing macromastia or asymmetry post-CS + RT.

Single fraction ablative preoperative radiation treatment for early-stage breast cancer: the CRYSTAL study \u2013 a phase I/II clinical trial protocol

BackgroundBreast-conserving surgery (BCS) and whole breast radiation therapy (WBRT) are the standard of care for early-stage breast cancer (BC). Based on the observation that most local recurrences occurred near the tumor bed, accelerated partial breast irradiation (APBI), consisting of a higher dose per fraction to the tumor bed over a reduced treatment time, has been gaining ground as an attractive alternative in selected patients with low-risk BC. Although more widely delivered in postoperative setting, preoperative APBI has also been investigated in a limited, though increasing, and number of studies. The aim of this study is to test the feasibility, safety and efficacy of preoperative radiotherapy (RT) in a single fraction for selected BC patients.MethodsThis is a phase I/II, single-arm and open-label single-center clinical trial using CyberKnife. The clinical investigation is supported by a preplanning section which addresses technical and dosimetric issues. The primary endpoint for the phase I study, covering the 1st and 2nd year of the research project, is the identification of the maximum tolerated dose (MTD) which meets a specific target toxicity level (no grade 3–4 toxicity). The primary endpoint for the phase II study (3rd to 5th year) is the evaluation of treatment efficacy measured in terms of pathological complete response rate.DiscussionThe study will investigate the response of BC to the preoperative APBI from different perspectives. While preoperative APBI represents a form of anticipated boost, followed by WBRT, different are the implications for the scientific community. The study may help to identify good responders for whom surgery could be omitted. It is especially appealing for patients unfit for surgery due to advanced age or severe co-morbidities, in addition to or instead of systemic therapies, to ensure long-term local control. Moreover, patients with oligometastatic disease synchronous with primary BC may benefit from APBI on the intact tumor in terms of tumor progression free survival. The study of response to RT can provide useful information about BC radiobiology, immunologic reactions, genomic expression, and radiomics features, to be tested on a larger scale.Trial registrationThe study was prospectively registered at clinicaltrials.gov (NCT04679454).

Breast Reconstruction Using the Lateral Thoracic, Thoracodorsal, and Intercostal Arteries Perforator Flaps.

Background:Breast-conserving surgery followed by radiotherapy represents the standard of care for early-stage breast cancer. The aim of this article was to provide a review of the literature about the use of the lateral thoracic artery perforator (LTAP) flap, the lateral thoracodorsal (LTD) flap, and the lateral intercostal artery perforator (LICAP) flap in lateral partial breast defect.Methods:A literature search was performed via PubMed, Medline, and Cochrane. Patient’s characteristics, topography and size of breast defect, flap size and design, number of perforators, and operative time were analyzed. Aesthetic and patient-reported outcomes, postoperative complications, and donor site morbidity were also registered.Results:Thirteen articles fulfilled inclusion criteria, and 432 patients were included. Different flap designs and flap combinations were described. Satisfactory outcomes were reported for between 78% and 100% of cases. Patient satisfaction ranged from 75.8% to 92.5% of cases. The overall complication rate was 9.25%, and donor site morbidity was very low (3.7%).Conclusions:A distinct advantage of LTAP, LTD, and LICAP flap reconstruction is that the thoracodorsal pedicle is not sacrificed, not compromising eventual delayed breast reconstruction with TDAP or latissimus dorsi flaps. This staged approach to partial breast reconstruction is especially useful in cases where the oncological margins are uncertain and wider resections (or mastectomies) are secondly required.

Preoperative radiotherapy: A paradigm shift in the treatment of breast cancer? A review of literature.

The standard of care for early-stage breast cancer (BC) consists of breast-conserving surgery followed by postoperative irradiation. Recently, the concept of changing the usual sequence of treatment components in BC RT has been investigated. Potential advantages of preoperative RT in BC include a possible tumor downstaging with improved surgical cosmetic outcomes, accurate tumor site identification and better target volume delineation. Furthermore, preoperative RT could serve as a tool for treatment stratification for de-escalation of treatments in the event of pathological complete response. The present literature review analyzed the available clinical data regarding the potential impact of preoperative RT. Overall, available clinical evidence of preoperative RT in BC remains limited, deriving mostly from retrospective case series. Nevertheless, the experiences prove the feasibility of the preoperative RT approach and confirm the efficacy in almost all analyzed studies, including experiences using higher prescription RT doses or RT in combination with systemic therapy.

Predictors of Residual Disease After Breast Conservation Surgery.

Breast-conserving therapy is the standard of care for early-stage breast cancer. In the era of multimodality therapy, the debate on the value of revision surgery for compromised margins continues, and high re-excision rates persist despite updated guidelines. Our study sought to identify the local re-excision rate for compromised margins after lumpectomy, and identify predictors of residual disease at re-excision. This population-based retrospective cohort study included women with breast cancer who underwent a lumpectomy between 2009 and 2012 in Manitoba, with close (≤2mm) or positive margins that led to re-excision. Patient demographics and tumor characteristics were identified through provincial cancer registries and chart reviews. For patients with invasive cancer, the six anatomical margins were reported for margin status, width, and pathology type at the margin. Of the 2494 patients identified, 556 women underwent re-excision, yielding a re-excision rate of 22.29%. Of our 311 patients with invasive cancer who underwent re-excision, 62.7% had residual disease identified on revision. On univariable analysis, the size and grade of the invasive component, nodal stage, and the number of positive margins were associated with residual disease on re-excision (p<0.05). With the exception of nodal stage, the same variables remained statistically significant on multivariable analysis. Our results suggest that even in the absence of 'no ink on tumor', the cancer size and grade in lumpectomy specimens are high-risk factors for residual disease, and this subgroup of patients may benefit from re-excision. Long-term follow-up of this cohort is required to determine their risk of recurrence after adjuvant treatment.

Variation in guideline-concordant care for elderly patients with metastatic breast cancer in the United States.

Prior studies have identified shortcomings in the quality of care for early-stage breast cancer. Guidelines recommend systemic therapy for metastatic breast cancer (MBC), but few studies have examined guideline concordance for these patients. We used Surveillance, Epidemiology, and End Results (SEER)-Medicare data to identify patients aged ≥66 diagnosed in 2010-2011 with de novo MBC who were continuously enrolled in fee-for-service Medicare. We described initial care (within 6months of diagnosis) for hormone receptor (HR)-positive/human epidermal receptor-2 (HER2)-negative, HER2-positive, and triple-negative (TN) tumors. We identified factors independently associated with receiving no initial systemic therapy, and compared hospice and hospital utilization for treated versus untreated patients. Among 446 patients, 65% were HR-positive, 21% were HER2-positive, and 14% were TN. Most patients (76.9%) received initial systemic treatment. Among treated HR-positive patients, 15% received chemotherapy as initial treatment; among treated HER2-positive patients, 34% did not receive HER2-targeted initial therapy. Factors independently associated with receiving no initial systemic therapy included older age (ORage continuous/year=1.08, 95% CI 1.04-1.11), being not married (ORnot married vs. married=2.87, 95% CI 1.42-5.81), and subtype (ORTN vs. HR+=4.95, 95% CI 2.53-9.71). Of patients who did not receive initial systemic therapy, 41.1% did not receive hospice services. In this population-based MBC cohort, almost one quarter did not receive initial systemic therapy and a substantial proportion of treated patients did not receive guideline-concordant first-line therapy. Further research should explore underuse of chemotherapy and HER2-targeted therapies, investigate whether patterns of care are consistent with patient preferences, and identify opportunities to optimize hospice utilization for patients not receiving treatment.

Institutional variation in surgical care for early-stage breast cancer at community hospitals

BackgroundThere is significant institutional variation in the surgical care of breast cancer, and this may reflect access to services and resultant physician practice patterns. In previous studies, specialty care has been associated with variation in the operative treatment of breast cancer but has not been evaluated in a community setting. This study investigates these issues in a cohort of 59 community hospitals in the United States. Materials and methodsData on patients receiving an operation for breast cancer (2006-2009) in a large, geographically diverse cohort of hospitals were obtained. Administrative data, autoabstracted cancer-specific variables from free text, and multiple other data sets were combined. Polymotous logistic regression with multilevel outcomes identified associations between these variables and surgical treatment. ResultsAt 59 community hospitals, 4766 patients underwent breast conserving surgery (BCS), mastectomy, or mastectomy with reconstruction. The older patients were most likely to receive mastectomy alone, whereas the younger age group underwent more reconstruction (age <50), and BCS was most likely in patients aged 50-65. Surgical procedure also varied according to tumor characteristics. BCS was more likely at smaller hospitals, those with ambulatory surgery centers, and those located in nonmetropolitan areas. The likelihood of reconstruction doubled when there were more reconstructive surgeons in the health services area (P = 0.02). BCS was more likely when radiation oncology services were available within the hospital or network (P = 0.04). ConclusionsInterpretation of these results for practice redesign is not straightforward. Although access to specialty care is statistically associated with type of breast surgical procedure, clinical impact is limited. It may be more effective to target other aspects of care to ensure each patient receives treatment consistent with her individual preferences.

Bilateral mastectomy and the retreat from breast-conserving surgery.

The purpose of this study is to assess the consequences for breast cancer patients of the trend away from breast conservation in favor of bilateral and contralateral mastectomy. The methods are followed from the review of the literature from 1991 to 2015. Breast-conserving surgery and sentinel lymph node biopsy, introduced into mainstream practice in the 1980s and 1990s, respectively, are now the standard of care for early-stage breast cancer. Disruptive change has unexpectedly supervened in the guise of bilateral mastectomy for cancer or prophylaxis and contralateral prophylactic mastectomy. These operations are now being resorted to at a rate which cannot be explained by any of the biological imperatives related to breast cancer and related diseases. This phenomenon extends across the Western world and beyond, driven by patients' cancer concern, a misunderstanding of what surgery can and cannot achieve and preserve, and the current popular media/cultural environment. These developments and their consequences for patients are reviewed. Surgical complications, especially those related to reconstruction, are unusually common. Of equal or greater concern are the physical, esthetic, psychosocial, psychosexual morbidities, and other adverse sequelae of these operations.

10-Year follow-up of 621 patients treated using high-dose rate brachytherapy as ambulatory boost technique in conservative breast cancer treatment

PurposeBreast conserving treatment, consisting of lumpectomy followed by whole-breast irradiation, is considered the standard of care in early-stage breast cancer. Randomized studies have reported that delivering boost doses to tumor bed improves local control rates, particularly in young women. This study sought to evaluate local control and cosmetic results of delivering boost doses using a high-dose-rate (HDR) brachytherapy (HDRBT) in breast cancer conservative treatment. MethodsWe included 621 T1–T2, N0–N1 breast cancer patients who underwent lumpectomy, external irradiation (44Gy over 5weeks), and a boost dose of two fractions of 5Gy to the tumor bed by means of HDR iridium brachytherapy. Implantation was performed during the lumpectomy or 2–3weeks after external irradiation. Population characteristics were as follows: pTis=11.6%; pT1=63.4%; pT2=25.0%; median tumor size=1.5cm; histology: ductal carcinoma in situ (DCIS): 72 (11.6%); infiltrative ductal carcinoma (IDC): 471 (75.8%); other: 78 (12.6%). For IDCs, the surgical margins were positive in 38cases (6.2%) and an extensive intraductal component was present in 254 cases. ResultsWith a median follow-up of 10.3years, 47 local relapses were observed (10-year local relapse rate: 7.4%). Small-volume implantation (V100<45cc) and ductal carcinoma in situ histology both significantly correlated with local relapse. The 10-year overall survival was 91%. Cosmetic results were evaluated in 264patients, proving excellent in 58 (22%), good in 153 (58%), fair in 40 (15%), and poor in 13 (5%). ConclusionsSmall implant volume and ductal carcinoma in situ histology significantly correlated with local relapse following HDR brachytherapy dose boost in breast cancer conservative treatment. Modern image-guided breast brachytherapy techniques using surgical clips as a guide may decrease potential treatment targeting errors, consequently improving local control without increasing toxicity.

Radiation Induced Angiosarcoma of the Breast: Case Series - Review at a Single Breast Screening Institution and Review of the Literature

Introduction: Breast conserving surgery with radiotherapy has replaced mastectomy as the standard care for earlystage breast cancer in the last few decades. Angiosarcoma (AS) arising in the irradiated breast after breastconserving therapy (BCT) is being reported in the literature with increasing frequency. In our study, we have reviewed cases of breast AS at our institution that have occurred in the last two years; we report the clinical presentation, histopathology and their management outcome and have performed a thorough literature review for this condition. Method: Patients with angiosarcoma of breast in patients who had breast cancer surgery followed by radiation were identified during the breast multi-disciplinary meeting in a single breast screening unit from 2013-2015. Literature search of electronic databases via Pub Med and the search engines Google/Google Scholar were used. Emphasis on keywords with the varying combination of the search terms ‘breast’, ‘angiosarcoma’, ‘radiotherapy’, ‘trauma’, ‘secondary’, ‘primary’, ‘metastasis’ was performed. Results: Case 1: A 59-year-old female developed BAS 8 years following breast-conserving surgery and radiotherapy (BCS and RT). Microscopically, irregular dissecting vascular channels lined by pleomorphic, mitotically active cells are seen. Immunohistochemistry revealed that tumour cells express CD34 with weak, minimal expression of Factor VIII. Patient then proceeded to having a radical mastectomy and latissimus dorsi flap. Patient is currently alive. Case 2: A 56-year-old female developed right BAS 3 months following a normal mammogram. Right breast was wholly bruised and discolored. New 18 mm mass suspicious of malignancy (MRI4) was seen on MRI. Patient previously had BCS and RT 5 years prior. Case 3: A 79-year-old female with angiosarcoma over 15 years after BCS and RT. Conclusion: We conclude that with increasing use of radiotherapy for breast conserving surgery will result in a growing number of cases of secondary angiosarcoma for which early detection is important and requires a high index of clinical and pathological suspicion. Patient education is the key and they need to be advised to remain vigilant of any skin changes for early detection and prompt treatment for this condition.

Comorbidity Burden and Guideline‐Concordant Care for Breast Cancer

To explore the relationship between level and type of comorbidity and guideline-concordant care for early-stage breast cancer. Cross-sectional. National Program of Cancer Registry (NPCR) Breast and Prostate Cancer Patterns of Care study, which re-abstracted medical records from 2004 in seven cancer registries. Individuals with stage 0-III breast cancer. Multicomponent guideline-concordant management was modeled based on tumor size, node status, and hormone receptor status, according to consensus guidelines. Comorbid conditions and severity were measured using the Adult Comorbidity Evaluation Index (ACE-27). Multivariate logistic regression models determined factors associated with guideline-concordant care and included overall ACE-27 scores and 26 separate ACE comorbidity categories, age, race, stage, and source of payment. The study sample included 6,439 women (mean age 58.7, range 20-99; 76% white; 44% with no comorbidity; 70% estrogen- or progesterone-receptor positive, or both; 31% human epidermal growth factor receptor 2 positive). Care was guideline concordant in 60%. Guideline concordance varied according to overall comorbidity burden (70% for none; 61% for minor; 58% for moderate, 43% for severe; P < .05). In multivariate analysis, the presence of hypertension (odds ratio (OR) = 1.15, 95% confidence interval (CI) = 1.01-1.30) predicted guideline concordance, whereas dementia (OR = 0.45, 95% CI = 0.24-0.82) predicted lack of guideline concordance. Older age (≥ 50) and black race were associated with less guideline concordance, regardless of comorbidity level. When reporting survival outcomes in individuals with breast cancer with comorbidity, adherence to care guidelines should be among the covariates.

Freehand SPECT for image-guided sentinel lymph node biopsy in breast cancer

Sentinel lymph node biopsy (SLNB) is standard of care in early-stage breast cancer. Freehand SPECT (FhSPECT) is a system generating 3-D images for intraoperative visual detection of radioactivity in the body. The aim of our study was to evaluate the sensitivity of this technology for sentinel lymph node (SLN) detection and SLNB guidance. In 40 patients, FhSPECT was additionally used after planar imaging and probe localization for SLNB. The number of SLNs detected was compared with the number detected by planar scintigraphy (reference method) and the conventional acoustic gamma probe (standard alternative). The sensitivity of FhSPECT was compared with that of the conventional gamma probe (McNemar's test). FhSPECT mapped the SLNs in 92.3 % of the basins (36/39) intraoperatively in identical positions to those seen on planar scintigrams. The conventional gamma probe correctly detected the SLNs in 35 of 39 basins (89.7 %). After SLNB, remaining radioactivity was detected by FhSPECT in nine patients, resulting in additional resection of SLNs in four patients. FhSPECT is a highly sensitive modality for intraoperative detection of SLNs, resulting in the identification of a higher number of SLNs than conventional gamma probe detection.

A retrospective evaluation of chemotherapy dose intensity and supportive care for early-stage breast cancer in a curative setting

Early-stage breast cancer (ESBC) is commonly treated with myelosuppressive chemotherapy, and maintaining full-dose chemotherapy on the planned schedule is associated with improved patient outcome. Retrospective analysis of patients with ESBC treated from 1997 to 2000 showed that 56% of patients received a relative dose intensity (RDI) <85% (Lyman et al., J Clin Oncol 21(24):4524-4531, 2003). To determine current practice, we evaluated treatment patterns at 24 US community- and hospital-based oncology practices, 79% of which participated in the previous study. Data were abstracted from medical records of 532 patients with surgically resected ESBC (stage I-IIIa) treated from 2007 to 2009, who were ≥18years old and had completed ≥1 cycle of one of the following regimens: docetaxel+cyclophosphamide (TC); doxorubicin+cyclophosphamide (AC); AC followed by paclitaxel (AC-T); docetaxel+carboplatin+trastuzumab (TCH); or docetaxel+doxorubicin+cyclophosphamide (TAC). Endpoints included RDI, dose delays, dose reductions, grade 3/4 neutropenia, febrile neutropenia (FN), FN-related hospitalization, granulocyte colony-stimulating factor (G-CSF) use, and antimicrobial use. In this study, TC was the most common chemotherapy regimen (42%), and taxane-based chemotherapy regimens were more common relative to the previously published results (89 vs <4%). Overall, 83.8% of patients received an RDI≥85%, an improvement over the previous study where 44.5% received an RDI≥85%. Other changes seen between this and the previous study included a lower incidence of dose delays (16 vs 25%) and dose reductions (21 vs 37%) and increased use of primary prophylactic G-CSF (76 vs ~3%). Here, 40% of patients had grade 3/4 neutropenia, 3% had FN, 2% had an FN-related hospitalization, and 30% received antimicrobial therapy; these measures were not available in the previously published results. Though RDI was higher here than in the previous study, 16.2% of patients still received an RDI<85%. Understanding factors that contribute to reduced RDI may further improve chemotherapy delivery, and ultimately, patient outcomes.

Predictors of care for early-stage breast cancer in Appalachia.

6558 Background: We studied care for early-stage breast cancer in Appalachia, a region with health infrastructure, socioeconomic (SES) and geographic disparities. Methods: Cases of stage I-III breast cancer diagnosed 2006-2008 were identified from cancer registries of KY, NC, OH, and PA and linked to Medicare data. Guideline concordance was studied in eligible groups, as follows: endocrine therapy for hormone receptor positive cancer (n=1429); and radiation (RT) use after breast conserving surgery (BCS) divided into two groups - age 70 years and older with ER/PR+, &lt;2 cm, node negative tumors where it may have been acceptable to forgo RT (OptRT, n=1108) and all other cases (IndRT, n=1422). Multivariate (MV) and univariate analyses were performed. Covariates included age, state, Appalachian Regional Commission (ARC) economic status, Commission of Cancer (CoC) status, state, access to care, number of beds, surgery facility ownership, volume, and chemotherapy/radiation offered, provider graduation year and volume, Charlson comorbidity, diagnosis year, Medicaid/Medicare dual status, histology, tumor size, tumor sequence, positive lymph nodes, ER/PR status, stage, herceptin use, and BCS/mastectomy indicator. Results: Mean age was 74 years and 97% were white. Guideline-concordance was 76% for endocrine therapy, 83% for IndRT, and 77% for OptRT. Younger age predicted higher concordance in all groups. Endocrine therapy use was lower in NC vs PA (OR 0.60; 95% CI 0.41-0.88) and greater for cases whose provider graduated in years 1984-1988, vs. 1989+ (1.55; 1.06-2.29). In IndRT, provider volume in the 3rdquartile vs. highest quartile predicted increased radiation use (2.36; 1.46-3.81). In OptRT, less receipt of radiation was predicted by residence in NC vs. PA (0.26; 0.18-0.48), and competitive ARC class vs. transitional (0.60; 0.36-0.99). Conclusions: Within Appalachia, there are SES and provider characteristics that are associated with use of guideline concordant care.

Current patterns of chemotherapy and supportive care for early-stage breast cancer (ESBC).

1062 Background: ESBC is commonly treated with myelosuppressive chemotherapy, and high relative dose intensity (RDI) correlates with improved overall survival. A retrospective analysis of patients with ESBC treated from 1997–2000 showed that 56% received an RDI &lt; 85% (Lyman et al. JCO. 2003;21:4524-4531). To determine current practice, we evaluated ESBC treatment patterns at 24 US community- and hospital-based oncology practices. Methods: Data were abstracted from medical records of 532 patients with ESBC treated from January 2007–December 2009. Inclusion criteria included surgically resected ESBC (stage I-IIIA); ≥ 18 years old; and completion of at least 1 standard chemotherapy cycle on an every 2 or 3 week schedule. The primary endpoint was RDI over planned cycles. Other endpoints were incidence of dose delays ≥ 7 days, dose reductions ≥ 15% from standard, grade 3/4 neutropenia (SN), febrile neutropenia (FN), FN-related hospitalization, granulocyte-colony stimulating factor (G-CSF) use, and antimicrobial therapy. Descriptive statistics were generated for all endpoints. Results: In this study, mean (range) age was 55 (29–85) years. Relative to previously published results, chemotherapy regimens have shifted from mainly doxorubicin + cyclophosphamide (AC) (previously 35%) to docetaxel + cyclophosphamide (TC; n = 221; 42%) and AC followed by paclitaxel (AC-T; n = 163; 31%). Mean RDI is now higher (93% for both TC and the most common AC-T schedule [dose dense AC-T; n = 84] vs 79% previously); the incidence of dose delays (16% vs 25% previously) and dose reductions (21% vs 37% previously) have decreased; and primary prophylactic use of G-CSF has increased (76% vs 3% previously). In this study, 40% of patients had SN, 3% had FN, 2% had an FN-related hospitalization, and 30% received antimicrobial therapy. These measures were not available in the previously published results. Conclusions: The observed changes between the two studies are noteworthy though inferential comparisons are limited by changes in treatments and other factors. RDI has improved over time, but 16% of patients in this study received an RDI &lt; 85%. Further evaluation is needed to identify factors associated with lower RDI and determine outcomes for these patients.

A randomized trial evaluating the integration of online questionnaires into follow-up (FU) care for early-stage breast cancer (ESBC).

9107 Background: Large numbers of cancer survivors have led to the need for FU care addressing lasting effects of BC and its treatment. We conducted a trial evaluating formats of FU care to determine if integration of remote electronic questionnaire FU provides for timely symptom management and more efficient care than routine clinic visits alone. Methods: Patients (pts) with ESBC were randomized to either usual care (UC, frequency of visits determined by oncology providers) with completion of an optional online health and symptom questionnaire (Q) before each clinic visit, or to SIS.NET FU care, in which pts were scheduled for up to 3 routine oncology related clinic visits over 18 mos and completed the online Q every 3 mos. Qs were reviewed by a survivorship nurse practitioner (NP) with pt phone contact for symptoms requiring urgent attention. We recorded the time between electronic symptom reporting and FU for pts in the SIS.NET arm. Data included the number of oncology related clinic visits, total number of physician visits, and number of medical tests including labs and imaging studies ordered. Kolmogorov-Smirnov tests for equal distributions were used to determine if there were any significant differences between SIS.NET and UC. Results: 100 pts were enrolled, 75 completed the 18 month study and 25 pts remain in FU. For the 75 pts, 85% received chemotherapy and 77% received hormone therapy. Pts in the SIS.NET arm completed an average of 3.8 out of 7.2 emailed surveys (52.6%), and pts in the UC arm completed an average of 2.2 out of 3.4 (69.1%) routine pre-clinic surveys. For pts in the SIS.NET arm, 75% of reported symptoms were reviewed by a NP in &lt; 3 days. There was no significant difference between SIS.NET and UC FU for oncology related clinic appointments, total number of physician visits, or number of medical tests performed. Conclusions: Use of on-line health and symptom surveys with remote NP review provided timely symptom FU but did not reduce clinic visits or medical testing in pts with ESBC. Further analyses of these data as well as additional studies are necessary to understand the barriers to integration of web-based tools to achieve more efficient FU care for BC survivors.

The Impact of Diabetes Mellitus on Prognosis of Early Breast Cancer in Asia

Diabetes mellitus (DM) has been implicated in influencing the survival duration of patients with breast cancer. However, less is known about the impact of DM and other comorbidities on the breast cancer-specific survival (BCS) and overall survival (OS) outcomes of Asian patients with early-stage breast cancer. The characteristics of female patients with newly diagnosed, early-stage breast cancer were collected from the Taiwan Cancer Registry database for 2003-2004. DM status and other comorbidities were retrieved from Taiwan's National Health Insurance database. The BCS and OS times of patients according to DM status were estimated via the Kaplan-Meier method. Cox's proportional hazard model was used to estimate adjusted hazard ratios (HRs) for the effects of DM, comorbidities, and other risk factors on mortality. In total, 4,390 patients were identified and 341 (7.7%) presented with DM. The 5-year BCS and OS rates were significantly greater in DM patients than in non-DM patients (BCS, 85% versus 91%; OS, 79% versus 90%). Furthermore, after adjusting for clinicopathologic variables and comorbidities, DM remained an independent predictor of shorter BCS (adjusted HR, 1.53) and OS (adjusted HR, 1.71) times. Subgroup analyses also demonstrated a consistent prognostic influence of DM across different groups. In Asian patients with early-stage breast cancer, DM is an independent predictor of lower BCS and OS rates, even after adjusting for other comorbidities. The integration of DM care as part of the continuum of care for early-stage breast cancer should be emphasized.

Mastectomy and contralateral prophylactic mastectomy rates: an institutional review.

Background. Breast conservation surgery (BCS) followed by radiation is as effective as mastectomy for long-term survival and is considered standard of care for early-stage breast cancer. An increasing number of patients are opting for cancer-side mastectomies (CM) and often contralateral prophylactic mastectomies (CPM). Our study investigates if there are increasing trends in our patient population toward CM and CPM and identifies common factors associated with those electing to have more extensive surgery.Methods. A retrospective analysis was performed on 812 breast cancer surgeries between January 2001 and December 2009 at The George Washington University Breast Care Center. BCS-eligible patients who elected to have BCS were compared with those who chose CM. Patients who underwent CM were compared with patients undergoing CM and CPM.Results. A personal or family history of breast cancer and larger tumor size were positively associated with choosing CM in BCS-eligible patients. A nonstatistically significant trend toward CM was seen in younger patients. Age, family history, fewer children, Caucasian race, and reconstructive surgery were positively associated with choosing CPM.Conclusion. Mastectomy rates at this institution have not shown the recent sharp increase observed by some authors. The association of age, race, family history, and parity with CPM has been corroborated in multiple studies. However, there is disagreement between statistically significant findings among investigators evaluating factors associated with CPM, and there is limited data in the literature characterizing BCS-eligible patients who chose CM. Larger prospective studies are necessary to further evaluate CM and CPM rates.