Multidisciplinary Breast Cancer Clinic Research Articles

Evaluating Patient Experience in a Multidisciplinary Breast Cancer Clinic: A Prospective Study.

Background: Multidisciplinary clinics (MDCs) are a care model in which patients see several physicians across specialties and/or other allied health professionals in a single appointment in a shared space. This study sought to better understand patients' experiences with breast cancer (BC) MDC. Methods: A total of 429 patients diagnosed with BC and seen in a MDC between November 2020 and November 2021 were invited to participate in a patient experience survey. Results: In total, 116 patient respondents (27%) with representative demographics described their experience. Most patients report feeling "somewhat prepared" for the BC MDC experience (67%, median = 3.7, interquartile range [IQR] = 1.9), but with variability. The major areas of positive feedback were that the MDC was convenient (89.3%), efficient use of time (65.2%), and a good way to get questions answered (65.2%). Major criticisms included that the MDC was overwhelming (16.1%) and/or too long (4.5%). When asked to rate the top three satisfaction areas of MDCs, patients chose seeing multiple providers during a single visit (80.4%), communication about the process before and throughout the MDC (48.2%), and inclusivity of their support system (38.4%). The highest rated dissatisfiers were the volume of information presented (42.9%) and patients' emotional comfort (anxiety/stress) during MDC appointment (30.2%). Overall, 83% of patients with BC rate the MDC experience as excellent (median = 4.8, IQR = 0.9) and would be "very likely" to recommend BC MDC (median = 4.8, IQR = 0.9). Conclusion: Patients value seeing multiple providers simultaneously in an environment inclusive of their support systems, which is described as convenient and efficient. Improving emotional distress is a key opportunity to improve patient experience.

Multidisciplinary Breast Cancer Clinic: A Novel Approach to Decrease Time to Intervention.

Multidisciplinary clinics (MDCs) were created at high-volume surgical oncology centers to optimize breast cancer care, in which patients are seen by multiple subspecialists at one visit. We aim to evaluate our experience with this novel approach. We examined 492 patients with newly diagnosed invasive breast cancer from January 1, 2020, to September 1, 2022. Patients seen at our MDC had a decreased time to intervention across all measured intervals: 3days faster (10 vs 13days) from biopsy to clinic visit [t Sat 2.09 > t critical two tail 1.99], 5days faster (23 vs 28days) from diagnosis to initiation of neoadjuvant chemotherapy [t Sat 5.12 > t critical two tail 2.019], and 21days faster (24 vs 45days) from surgery clinic visit to operation [t Sat 5.12 > t critical two tail 2.019]. Although early in our experience, we have initiated a strategy for improved breast cancer care.

Rate of breast biopsy referrals in female BRCA mutation carriers aged 50 years or more: a retrospective comparative study and matched analysis

PurposeTo evaluate the total biopsy and positive biopsy rates in women at high risk of breast cancer compared to the general population.MethodsThe study group consisted of 330 women with pathogenic variants (PVs) in BRCA1/2 attending the dedicated multidisciplinary breast cancer clinic of a tertiary medical center in Israel. Clinical, genetic, and biopsy data were retrieved from the central healthcare database and the medical files. Patients aged 50 years or older during follow-up were matched 1:10 to women in the general population referred for routine breast cancer screening at the same age, as recommended by international guidelines. The groups were compared for rate of biopsy studies performed and percentage of positive biopsy results. Matched analysis was performed to correct for confounders.ResultsThe total biopsy rate per 1000 follow-up years was 61.7 in the study group and 22.7 in the control group (p < 0.001). The corresponding positive biopsy rates per 1000 follow-up years were 26.4 and 2.0 (p < 0.001), and the positive biopsy percentages, 42.9% and 8.7% (p < 0.0001).ConclusionWomen aged 50 + years with PVs in BRCA1/2 attending a dedicated clinic have a 2.7 times higher biopsy rate per 1000 follow-up years, a 13.2 times higher positive biopsy rate per 1000 follow-up years, and a 4.9 times higher positive biopsy percentage than same-aged women in the general population.

Abstract P2-11-16: Rate of breast biopsy referrals in BRCA mutation carriers: A retrospective comparative study and matched analysis

Abstract Purpose: To evaluate the total biopsy and positive biopsy rates in women at high risk of breast cancer compared to the general population. Methods: The study group consisted of 330 BRCA mutation carriers attending the dedicated multidisciplinary breast cancer clinic of a tertiary medical center in Israel. Clinical, genetic, and biopsy data were retrieved from the central healthcare database and the medical files. Patients who were at age 50 years or older during follow-up were matched 1:10 to women in the general population referred for routine breast cancer screening at the same age, as recommended in the international guidelines. The groups were compared for rate of biopsy studies performed and percentage of positive biopsy results. Matched analysis was performed to correct for confounders. Results: The matched analysis revealed that the total biopsy rate per 1000 follow-up-years was 61.7 in the study group and 22.7 in the control group (p &amp;lt;0.001). The positive biopsy rates per 1000 follow-up-years were 26.4 and 2.0, correspondingly (p &amp;lt;0.001), and the positive biopsy percentages were 42.9% and 8.7% correspondingly (p &amp;lt;0.0001).Conclusions: BRCA mutation carriers who attend a dedicated clinic, have a 2.7 times higher biopsy rate per 1000 follow-up-years, a 13.2 times higher positive biopsy rate per 1000 follow-up-years, and a 4.9 times higher positive biopsy percentage compared with women in the general population. Keywords: Biopsy, BRCA, breast cancer, screening, high risk Citation Format: Adi Pomerantz, Daliah Tsoref, Ahuva Grubstein, Sonya Wadhawker, Yael Rapson, Itay Gadiel, Hadar Goldvaser, Ariel Hammerman, Tzipora Shochat, Eran Sharon, Rinat Yerushalmi. Rate of breast biopsy referrals in BRCA mutation carriers: A retrospective comparative study and matched analysis [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P2-11-16.

Barriers to eliciting patient goals and values in shared decision-making breast cancer surgery consultations: An ethnographic and interview study.

Previous research has demonstrated the importance of eliciting patients' goals and values during shared decision-making (SDM), but this does not occur in most SDM conversations. Understanding challenges to eliciting patients' goals and values is crucial. This study assessed how clinicians balanced sharing medical information and considering patients' goals and values during breast cancer surgery consultation in an integrated health care system. We conducted interviews with clinicians (n = 6) and patients (n = 11) and conducted naturalistic, ethnographic observations of eight surgical consultations in a multidisciplinary breast cancer clinic. We analyzed the data following the template method using the qualitative software NVivo 10. Clinicians prioritized sharing medical information. We identified four patient factors necessary to integrate patients' values and goals into the conversation in addition to sharing medical information: ability to process large quantities of information quickly, willingness to embrace swift decision-making, ability to quickly formulate one's values, and prioritization of surgical choice as the goal of the conversation. We found that SDM implementation results in practices that emphasize information and choice, with less focus on patient goals and values. More research is needed to explore factors that may encourage the elicitation of patients' goals and values.

The impact of a coordinated joint multidisciplinary breast cancer clinic.

IntroductionTimely access to cancer treatment is expected to improve patients’ satisfaction and treatment outcome. A joint multidisciplinary breast cancer clinic (JMDBCC) was developed in January 2011 which aimed to accelerate access to breast cancer care. Here, we assess the efficacy of this approach.MethodsMetric data of access to care in 2010 represent the pre-JMDBCC era while those during the subsequent 5 years (2011–2015 inclusive) represent the post-JMDBCC era. The JMDBCC is comprised of three separate but closely adjacent subclinics conducted at the same time representing the three main relevant clinic-based disciplines supported by a breast cancer coordinator. The primary aim of the clinic is to provide service to new patients within 7 days at each of the following stages: acceptance to first clinic visit (S1), first clinic visit to completion of appropriate investigations (S2), and completion of investigations to start of active treatment (S3). Thus, the total duration from acceptance to treatment (S1-3) is aimed to be within 21 days.ResultsFive hundred and fifty visits to the relevant clinics were recorded at the pre-JMDBCC era. Mean time metrics for new patients were as follows: 13, 18, 21, and 46 days for S1, S2, S3, and S1-3, respectively. The JMDBCC achieved reduction in all time metrics from the first year of implementation, reaching 3.6, 4.9, 7.3, and 15.9 days for S1, S2, S3, and S1-3, respectively, in year 2015. The number of new patients and total recorded clinic visits increased from 49/550, respectively, in the pre-JMDBCC era to 92/654, 183/1816, 158/2797, 174/4426, and 180/5883 in subsequent years.ConclusionsA JMDBCC dramatically accelerates access to specialist multidisciplinary care. All institutions managing patients with breast cancer are encouraged to adopt such a coordinated service. The impact of an effective JMDBCC on disease-specific outcome should be addressed in future studies.

Breast Cancer Management with Melanie E Royce: BOLERO-4 Phase II Trial of First-Line Everolimus Plus Letrozole in ER + , HER2 - Advanced Breast Cancer

Melanie E Royce* speaks to Roshaine Wijayatunga, Managing Commissioning Editor: Melanie E Royce is a Professor in the Department of Internal Medicine, Division of Hematology/Oncology at the University of New Mexico Comprehensive Cancer Center (UNM CCC) in Albuquerque, NM, USA. She received her PhD and MD degrees at the University of Cincinnati, Ohio; then completed her Internal Medicine Residency at Yale University-New Haven Hospital in Connecticut and Medical Oncology Fellowship at The University of Texas MD Anderson Cancer Center in Houston, Texas where she subsequently joined the faculty until she moved to Albuquerque, to be one among the first batch of oncology faculty recruits to help establish an National Cancer Insititute (NCI)-designated CCC in the state of NM. At UNM CCC, she serves as the Director of the Multidisciplinary Breast Cancer Clinic and Programs and Co-Leader of the Women’s Cancer Program. She is engaged in the care of breast cancer patients and is the Principal Investigator for several breast cancer clinical trials at the UNM CCC. On a national level, she serves on the Breast Cancer Committee of the Southwest Oncology Group and the NCI Breast Oncology Local Disease Task Force. Beyond breast cancer, she has a wider involvement in clinical research being the Director of the Clinical Protocol and Data Management of the UNM CCC and the contract Principal Investigator for the NM Minority/Underserved NCI Community Oncology Research Program, a grant that enhances patient and provider access to NCI-led clinical trials. The NM NCI Community Oncology Research Program in partnership with the NM Cancer Care Alliance, a state-wide clinical trials consortium, facilitates access to an expansive array of clinical trials to virtually all cancer patients statewide.

Impact of early engagement of patients with clinical trial information in a system-based multidisciplinary breast cancer clinic on clinical trial enrollment.

149 Background: Cancer clinical trial enrollment is low at approximately 3% in the U.S., and there is an urgent need for improvement. Informing patients clinical trial information early at their initial appointment after the diagnosis of cancer may improve clinical trial enrollment. To this goal, we have developed a system-based multidisciplinary breast cancer clinic (MDBCC) that evaluates all newly diagnosed breast cancer cases and discuss with all patients eligible clinical trials at their initial appointment. Methods: Our MDBCC team consists of a medical and radiation oncologist, breast surgeon, mammographer, pathologist, geneticist, and breast cancer coordinators, who review all newly diagnosed cases in the tumor board (multidisciplinary breast cancer tumor board) prior to patient’s MDBCC appointment. During the MDBCC visit, each individual patient meets separately with a medical oncologist, a radiation oncologist, and a surgeon to discuss their treatment options. Eligible clinical trials are discussed and presented to patients with informed consent. Clinical trial nurses are dedicated for patients to call and meet for further discussion on the eligible trials after the MDBCC visit. Results: The average annual clinical trial enrollment for breast cancer was 9 cases (approximately 3%) between 2000 and 2006 prior to initiating the MDBCC, improved to 53 (approximately 17%) between 2007 and 2011 after the MDBCC was formed. The enrollment into the NSABP and SWOG trials accounts for the large portion of the accrual. Conclusions: Early engagement of patients with clinical trial information in a system-based MDBCC for all newly diagnosed breast cancer patients dramatically improves clinical trial enrollment.

P1-11-09: Effects of a Multidisciplinary Breast Cancer Clinic in an Appalachian Based Medical Center.

Abstract Background: Adena Health System is a not for profit 250 bed institution that provides health care for a 13 county region in southeast, Appalachia Ohio. Access to health care in rural setting is an ongoing challenge. Several barriers to health care access affect this region. Socioeconomic burden and lack of higher education are two of the most dominant barriers. The age-adjusted beast cancer rates are 5.3% higher in the Appalachian region and the stage at presentation is more advanced. In December of 2009, we held our first Multidisciplinary Breast Cancer Clinic (MDBCC). The goal of the MDBCC is to facilitate prompt diagnosis and effective treatment. The MDBCC is staffed by a team of physicians consisting of surgeons, medical oncologists, and radiation oncologists. The team meets with the patient in a one on one setting. That same day the patients are discussed by the team with input from pathology and radiology in order to tailor a treatment plan specifically for each patient. After the conference, the recommendations are discussed with the patient before treatment is initiated. Material and Methods: In a retrospective review, we evaluated the effect of a MDBCC on days to diagnosis, days from diagnosis to treatment, percentage of patients receiving neoadjuvant chemotherapy, and stage at diagnosis. Since December 2009, there have been over 90 breast cancer patients evaluated in the MDBCC. We randomly selected 60 breast cancer patients treated prior to MDBCC between 2008–09 and 66 patients evaluated at the MDBCC between December 2009–2011 from the tumor registry database. Results: The average number of days to diagnosis pre-MDBCC was 15.5 days as compared to 4 days post-MDBCC. In 2008–09, the average days to treatment (pathology result to a-port placement, surgery or chemotherapy) was 18 days as compared to 12 days post-MDBCC. The percentage of patients receiving neoadjuvant chemotherapy has not changed significantly, however, there is an upward trend approaching statistical significance (10% per-MDBCC vs. 12% post-MDBCC). The stage at presentation has not changed significantly since the start of the MDBCC. Discussion: The development of the MDBCC has proven to be a successful team oriented approach to breast cancer diagnosis and treatment. Time to diagnosis and initiation of treatment has improved. Providing patients with access to multiple specialists and forming a treatment plan the same day improves quality of care and lessens economic burden. The MDBCC is clearly feasible and particularly suited to the rural hospital setting. System wide, we hope to see a decrease in the stage at presentation and are confident based upon our current data that this in a realistic goal. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-11-09.

P2-08-09: The Impact of Preoperative Breast MRI in Newly Diagnosed Breast Cancer. A Prospective Study of Treatment Outcome in Patients Selected for Breast-Conserving Surgery in a Norwegian Multidisciplinary Breast Cancer Clinic.

Abstract Background: The aim of the study was to evaluate the impact of preoperative breast MRI on primary surgical treatment in a specialized multidisciplinary breast cancer clinic. The diagnostic tools routinely used are conventional mammography, ultrasound with core needle biopsy, and clinical examination including palpation of breast and axillary nodes. If indicated, the examination includes ultrasound examination and fine needle biopsy of axillary glands. We offer all patients selected for breast-conserving surgery preoperative breast MRI. Material and methods: We included consecutively 145 breast cancer lesions in 143 women (two had bilateral cancer) aged 35–75 in a prospective study, collecting data from January 2009 to December 2010. The patients were all selected for breast-conserving surgery based on the criteria recommended by the Norwegian Breast Cancer Group. That is, tumor ≤ 4 cm, or acceptable tumor:breast ratio, and age &amp;gt; 35. Multifocal lesions, defined as more than one tumor &amp;gt; 1 cm apart, size of tumor &amp;gt; 4 cm, or a large tumor:breast ratio, extensive ductal carcinoma in situ (DCIS), or known genetic disposition for breast cancer, indicates mastectomy according to these criterias. In addition, when postoperative radiation therapy is contraindicated, mastectomy is indicated. If the patients filled the criteria for breast-conserving surgery, they were offered preoperative breast MRI and included in the study. Patients who either choose mastectomy, or did not get a breast MRI for technical reasons, were excluded from the study. Two experienced breast radiologists evaluated the breast MRIs, and three experienced breast radiologists studied the mammographies and did the ultrasound examinations and biopsies. All additional MRI findings were examined by ultrasound-guided biopsy and given a histological diagnose before it influenced the surgical method. Results: We excluded 28 patients from the study; 10 patients choose mastectomy, 13 patients were excluded due to problems with the MRI technology, and 5 patients were excluded for other reasons. Among the remaining 117 patients, 96 were treated by breast-conserving surgery, and 21 by mastectomy. The change of operative method was induced by the preoperative breast MRI in 16 patients, because of multifocality in 11 patients, and because of a more extensive tumor than discovered by conventional diagnostic tools, in 5 patients. Five patients had a secondary mastectomy, due to histopathological findings in the lump. In one patient preoperative MRI revealed cancer in the contralateral breast, and in one patient the additional findings on MRI resulted in preoperative systemic chemotherapy. The multifocality diagnosed on the preoperative MRI was confirmed on histopathological examination of the breast in 10/11 patients. In one patient who received preoperative systemic chemotherapy, the removed breast was without sign of malignant cells on microscopic examination. Discussion: In this prospective study preoperative breast MRI give additional information that have impact on the primary surgical treatment in 16/117 or 13,7% of the patients selected for breast-conserving surgery. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-08-09.

Abstract P5-14-15: Contralateral Prophylactic Mastectomy: Clinical and Pathological Features of Women Treated at the University of Louisville

Abstract Objective: To evaluate the clinical and pathological features of women who underwent contralateral prophylactic mastectomy (CPM) as a component of breast cancer therapy. Materials &amp; Methods: This is a retrospective review of a prospectively-maintained database of patients treated at the multi-disciplinary breast cancer clinic at the University of Louisville from 2003-2009. Patientswith unilateral pre-invasive and invasive adenocarcinoma who underwent mastectomy as primary surgical treatment for the involved breast with CPM were included. All information from surgical, medical and radiation oncology records were reviewed for this analysis. Results: A total of 107 patients are included in this analysis. The median age was 48 years (range 26-80). A previous history of breast cancer was noted in 8% of patients, all of whom received lumpectomy and whole-breast radiotherapy. A family history of breast cancer was identified in 46% of patients and 4% of patients possessed a germline BRCA mutation. Ninety-three percent of tumors were invasive. Evaluation of the pathological tumor (T) stage yielded 7% Tis, 48% T1, 36% T2, 3% T3, and 3% T4. Four percent of tumors were pathologically T0 after a complete response to neoadjuvant chemotherapy. Pathological node (N) staging yielded 56% N0, 23% N1, 14% N2, and 7% N3. Two percent of patients had distant metastasis at diagnosis. Twenty-two percent of tumors were negative for the estrogen, progesterone, and HER2/neu receptors (triple negative). Lobular carcinoma in situ was found in 10% of tumors. Five occult tumors were detected in the contralateral breast, of which 4 were carcinoma in situ and 1 was invasive mucinous carcinoma. With a median follow-up of 27 months (range 7-83), 9 treatment failures have been noted. Four patients failed locoregionally, 3 failed distantly, and 2 failed both locoregionally and distantly. Five patients have died of metastatic disease. No contralateral chest wall failures have occurred. Conclusions: CPM has become more popular over the past 6 years and patients present with a diverse array of clinical and pathological features. Occult disease in the contralateral breast is rare and was not encountered in our series. The pattern of failure is determined by the primary disease and the clinical utility of CPM therefore remains uncertain. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P5-14-15.

Case 25-2009

A 36-year-old woman was seen in the multidisciplinary breast cancer clinic of this hospital for management of hormone-receptor–positive breast cancer. She had a 1.4-cm, grade 2 of 3, infiltrating ductal carcinoma that was positive for estrogen-receptor protein and progesterone-receptor protein and negative for human epidermal growth factor receptor type 2, with micrometastases to 1 of 13 axillary lymph nodes detected by immunohistochemical analysis. A management decision was made.

Association of Routine Pretreatment Magnetic Resonance Imaging with Time to Surgery, Mastectomy Rate, and Margin Status

The benefit of breast MRI for newly diagnosed breast cancer patients is uncertain. This study characterizes those receiving MRI versus those who did not, and reports on their short-term surgical outcomes, including time to operation, margin status, and mastectomy rate. All patients seen in a multidisciplinary breast cancer clinic from July 2004 to December 2006 were retrospectively reviewed. Patients were evaluated by a radiologist, a pathologist, and surgical, radiation, and medical oncologists. Among 577 patients, 130 had pretreatment MRIs. MRI use increased from 2004 (referent, 13%) versus 2005 (24%, p=0.014) and 2006 (27%, p=0.002). Patients having MRIs were younger (52.5 versus 59.0 years, p < 0.001), but its use was not associated with preoperative chemotherapy, family history of breast or ovarian cancer, presentation, or tumor features. MRI was associated with a 22.4-day delay in pretreatment evaluation (p=0.011). Breast conserving therapy (BCT) was attempted in 320 of 419 patients with complete surgical data. The odds ratio for mastectomy, controlling for T size and stage, was 1.80 after MRI versus no MRI (p=0.024). Patients having MRIs did not have fewer positive margins at lumpectomy (21.6% MRI versus 13.8% no MRI, p=0.20), or conversions from BCT to mastectomy (9.8% MRI versus 5.9% no MRI, p=0.35). Breast MRI use was not confined to any particular patient group. MRI use was not associated with improved margin status or BCT attempts, but was associated with a treatment delay and increased mastectomy rate. Without evidence of improved oncologic outcomes as a result, our study does not support the routine use of MRI to select patients or facilitate the performance of BCT.

Changes in surgical management resulting from case review at a breast cancer multidisciplinary tumor board

The treatment of breast cancer requires a multidisciplinary approach, and patients are often referred to a multidisciplinary cancer clinic. The purpose of the current study was to evaluate the impact of this approach on the surgical management of breast cancer. The medical records of 149 consecutive patients referred to a multidisciplinary breast cancer clinic over a 1-year period with a diagnosis of breast cancer were reviewed retrospectively for alterations in radiologic, pathologic, surgical, and medical interpretations and the effect that these alterations had on recommendations for surgical management. A review of the imaging studies resulted in changes in interpretations in 67 of the 149 patients studied (45%). This resulted in a change in surgical management in 11% of patients. Review of the pathology resulted in changes in the interpretation for 43 of the 149 patients (29%). Thirteen patients (9%) had surgical management changes made solely as a result of pathologic reinterpretation. In 51 patients (34%), a change in surgical management was recommended after discussion with the surgeons, medical oncologists, and radiation oncologists that was not based on reinterpretation of the radiologic or pathologic findings. Overall, a second evaluation of patients referred to a multidisciplinary tumor board led to changes in the recommendations for surgical management in 77 of 149 of those patients studied (52%). The changes in management stemmed from differences in mammographic interpretation, pathologic interpretation, and evaluation by medical and radiation oncologists and surgical breast specialists. Multidisciplinary review can provide patients with useful additional information when making difficult treatment decisions.

Microvessels that predict axillary lymph node metastases in patients with breast cancer.

The density of vasoactive endothelial growth factor receptor 3-immunostained microvessels in primary breast cancers correlates with the incidence of axillary lymph node metastasis. Breast cancer microvessel clusters ("hot spots") were sequentially immunostained for factor VIII, type IV collagen, and vasoactive endothelial growth factor receptor 3. Microvessels were counted under light microscopy at a magnification of x 200. Axillary lymph nodes were evaluated for metastases by light microscopy. A multidisciplinary breast cancer clinic and laboratory. Sixty patients with T2 breast cancers treated by lumpectomy (or mastectomy) and axillary lymphadenectomy. Putative lymphatic microvessel density compared with axillary metastases. There were 16% (SE, 1.4%) vs 4% (SE, 0.8%) vasoactive endothelial growth factor receptor 3-immunostained microvessels (P<.001), 38% (SE, 3.9%) vs 65% (SE, 3.1%) type IV collagen-immunostained microvessels (P<.001), and 46% (SE, 4.1%) vs 31% (SE, 3.2%) unstained microvessels (P = .004) in node-positive vs node-negative patients, respectively. A fitted logistic model based on the relative percentage of putative lymphatic microvessels to blood microvessels correctly predicted that 23 (96%) of 24 patients would have a low risk and that 26 (96%) of 27 patients would have a high risk of lymph node metastases. Six (67%) of 9 patients predicted to have an intermediate risk had lymph node metastases. The odds of a patient with breast cancer having axillary lymph node metastasis increased substantially as the proportion of putative lymphatic microvessels increased and the relative proportion of blood microvessels in angiogenic hot spots decreased (log likelihood = 14.6; chi2 = 53.4; P<.001; area under the receiver operation characteristic curve = 0.97).

Lymphatic relapse in women with early breast cancer: a difficult management problem

The aim of this study was to review the ability to control symptoms of regional lymphatic relapse in women with early breast cancer. A retrospective study was made of 759 consecutive women presenting with stage 1 or 2 breast cancer treated by breast conserving surgery and radiotherapy between June 1984 and December 1994, 291 (38.3%) of whom were managed by a policy of observation on the lymphatic pathways. Patterns of lymphatic relapse, relapse management and morbidity caused by recurrent malignancy were reviewed from the case notes. The overall rate of relapse in the ipsilateral axilla and/or supraclavicular fossa was 76/759 (10%) at any time prior to death or last follow-up. 34 of 65 patients who relapsed in the axilla did so despite prior axillary surgery and/or radiotherapy. 41 of 76 patients with regional recurrence presented with symptoms, including lymphoedema, arm pain or sensory motor changes. These symptoms were poorly controlled by palliative surgery, radiotherapy or systemic therapy in 23 cases, including 12 who progressed to arm paralysis. Symptomatic control of patients with regional lymphatic relapse can be very difficult, even in women under regular surveillance in a multidisciplinary breast cancer clinic.

Multidisciplinary breast cancer clinics

In an attempt to improve the care they provide for their patients with breast cancer, the authors' institution developed a multidisciplinary breast cancer clinic (MDBCC) to offer "one-stop shopping" consultation and support for newly diagnosed breast cancer patients. One hundred sixty-two patients, the control group for this study, were evaluated at Henry Ford Hospital during the year prior to the opening of the MDBCC. These patients, who were referred in the traditional sequential consultation manner, were compared with the first 177 patients seen during the first year of the clinic's operation. Retrospective chart reviews were conducted to assess treatment timeliness, and anonymous questionnaires were used to assess patient satisfaction. The authors found that the MDBCC increased patient satisfaction by encouraging involvement of patients' families and friends and by helping patients make treatment decisions (P < 0.001). The time between diagnosis and the initiation of treatment was also significantly decreased (42.2 days vs. 29.6 days; P < 0.0008). Although planning and operating a multidisciplinary clinic is not a new venture, to the best of the authors' knowledge, they have provided the first report demonstrating the benefits described above.