Use Of Breast-conserving Surgery Research Articles

Angiosarcoma of the Breast: Overview of Current Data and Multimodal Imaging Findings

Angiosarcoma of the breast is a rare breast cancer, which can arise de novo (primary breast angiosarcoma, PBA) or as a secondary malignancy (secondary breast angiosarcoma, SBA) as a result of a biological insult. In the latter case, it is usually diagnosed in patients with a previous history of radiation therapy following a conserving treatment for breast cancer. Over the years, the advances in early diagnosis and treatment of breast cancer, with increasing use of breast-conserving surgery and radiation therapy (instead of radical mastectomy), brought about an increased incidence of the secondary type. PBA and SBA have different clinical presentations and often represent a diagnostic challenge due to the nonspecific imaging findings. The purpose of this paper is to review and describe the radiological features of breast angiosarcoma, both in conventional and advanced imaging to guide radiologists in the diagnosis and management of this rare tumor.

An Audit of Breast Conservation Surgery for Breast Cancer - a 7-Year Experience from Southern India.

To audit the use of breast conservation surgery for breast cancer treatment in a tertiary care centre over a 7-year period, and also to chart the clinical, demographic and pathological characteristics of breast cancer patients treated in the setting of a referral centre in a middle income (MDI) group country. A retrospective analysis of the case records of all patients of invasive breast cancer treated at our institute between January 2014 and December 2020 was done after obtaining approval from the Institute Ethics Committee (IEC). The number of patients seen, age, parity, menopausal status, family history of cancer, laterality, site of tumour in the breast, the symptomatology, clinical stage and presence or absence of metastases was the clinical parameters examined. The pathological stage and grade of the tumour, receptor status, treatment offered according to stage and the patterns of failure with respect to the surgery performed were recorded. Statistical analysis was a direct head to head comparison of the percentage proportions of the different variables. A total of 685 patients of breast cancer were treated between January 2014 and December 2020. A total of 53% of the cohort was more than 45years old and 56.7% were post menopausal. A total of 58.8% of the patients presented with a cancer in the left breast and in the upper outer quadrant. Nearly 41% of the tumours were more than 4cm in size. The most common receptor profile in our patient population was ER positive, PR positive and HER 2 negative. A total of 27.7% of the patients were offered neo-adjuvant chemotherapy and 63.06% underwent upfront surgery. A total of 19.7% of all surgeries performed (overall) were breast conservation surgeries (BCS). The use of BCS showed an increasing trend over the 7years studied rising from 16.79 to 25% (annually). The local failure rate for BCS was 11.8% but the incidence of distant metastases was not significantly different compared to the patients who underwent a mastectomy. Breast conservation is safe and feasible in a referral setting even in a middle income nation with multi-disciplinary treatment planning and needs to be adopted widely to preserve the body image and self esteem of patients with breast cancer.

Inequalities in breast-conserving surgery for female breast cancer in Świętokrzyskie Province, Poland

Introduction: Breast cancer is the most common cancer among women in the world. Differences in the treatment of breast cancer may be observed by age, disease stage, place of residence and comorbid conditions. Aim: The aim of the study was to analyse the differences in the use of breast-conserving surgery among women in the Świętokrzyskie Province. Material and methods: The study included 483 female residents of Świętokrzyskie Province who were diagnosed with invasive breast cancer in 2013. Following indicators, recommended to evaluate the compliance with the best oncology practice, were calculated: a proportion of patients receiving post-operative breast radiotherapy after the breast-conserving surgery and a proportion of the breast-conservation surgery in pT1 cases. Results and discussion: The difference in the distribution of surgical procedures by age group (breast-conserving surgery vs. mastectomy) in pT1 cases was statistically significant (P = 0.006). The highest values of both indicators were observed in the age group recommended for breast cancer screening in Poland, while the lowest in women 70 years of age and older. Our study revealed a non-significantly higher proportion of patients receiving post-operative breast radiotherapy after breast conserving-surgery in urban than in rural women, amounting to 36.5% and 29.4%, respectively. Conclusions: Existing inequalities in the use of breast-conserving surgery indicate the need to consider the recommended breast cancer treatment to the highest possible proportion of patients residing in rural areas.

Rationale for Mastectomy after Neoadjuvant Chemotherapy

Neoadjuvant chemotherapy (NAC) reduces tumor size, facilitating the use of breast conservation surgery (BCS). However, mastectomy remains the surgical outcome for certain women. The goal of this study was to determine the rationale for mastectomy after NAC, particularly in women eligible for BCS. Retrospective data were reviewed on patients who received NAC between February 2006 and August 2010 at our institution. Demographics and tumor characteristics were compared between patients who received BCS and mastectomy after NAC. Of 149 patients meeting inclusion criteria, 102 (68%) underwent BCS and 47 (32%) underwent mastectomy. Patient preference was the most common rationale for mastectomy (n = 19; 40%), followed by extent of disease (n = 13; 28%), presence of a breast cancer susceptibility gene (BRCA) mutation (n = 9; 19%), persistent positive margins (n = 5; 11%), and wound complications (n = 1; 2%). Of the 47 patients who underwent mastectomy, 37 (79%) were eligible for BCS after NAC. Larger pathologic tumor size (2.05 vs 1.25 cm, P = 0.04) and lobular histology [invasive lobular carcinomas, n = 12/17 (70%) vs invasive ductal carcinomas, n = 36/133 (27%); P < 0.01] were associated with increased rate of mastectomy. After NAC, patient preference, extent of disease, and the presence of a BRCA mutation account for the vast majority of mastectomies. Interestingly, most of these patients were shown to be candidates for breast conservation. This highlights the importance of educating patients about their surgical choice and the lack of evidence, showing a benefit to more extensive surgery.

Factors Affecting Choice of Treatment for Early-Stage Breast Cancer in West Virginia: A 10-Year Experience from a Rural Tertiary Care Center

Recent literature shows changing trends in use of breast conservation surgery (BCS), mastectomy, and contralateral prophylactic mastectomy (CPM) in women with early-stage breast cancer (ESBC). We analyzed factors associated with selection of these treatment modalities in a rural West Virginia tertiary care hospital. We conducted a 10-year analysis of women treated for ESBC at our institution from the institutional cancer registry. Variables were compared between patients choosing BCS versus mastectomy. In women who chose mastectomy, predictors for choice of CPM were also examined. Variables with P < 0.05 on univariate analysis were entered into a multivariate logistic regression model to define independent predictors of treatment choice. The mastectomy rate increased from 18.0 per cent in 2006 to 40.2 per cent in 2013. On multivariate analysis, insurance status (P < 0.001), comorbidities (P = 0.001), and surgeon graduation after 1987-a surrogate for surgeon age-(P = 0.010) predicted receipt of mastectomy. Of those receiving mastectomy, 106 (25.1%) elected CPM. CPM rates increased from 8.0 per cent in 2006 to 45.0 per cent in 2013. Younger age at diagnosis (P < 0.001) and use of preoperative MRI (P = 0.012) independently predicted use of CPM versus unilateral mastectomy. Rates of mastectomy and CPM in ESBC have increased in West Virginia over time. Independent predictors of selecting mastectomy over BCS included insurance status, surgeon age, and associated comorbidities. Younger patients and patients receiving preoperative MRI were more likely to choose CPM. Awareness of these factors will aid in counseling women with ESBC and allow clinicians to address potential biases or disparities that may affect treatment choices. Further prospective study of these findings is warranted.

Abstract A52: Racial Differences in Prevention Decision Making among Women at High Risk of Breast Cancer

Abstract Background &amp; Objectives: Prior research has documented significant racial disparities in adherence to breast cancer screening recommendations, use of breast-conserving surgery by early stage breast cancer patients, and breast cancer mortality. Decision making about breast cancer prevention options among high risk women has been less thoroughly studied, and racial differences remain mostly unexplored in this arena. The current study employs semi-structured interviews and inductive analytic methods to explore prevention decision making among African American and White women. Its core objective is to investigate the degree to which decision-making processes and outcomes differ across racial groups, and the specific content of these differences, in order to support interventions and programs to facilitate empowered, preventive decision making. Methods: In-depth, semi-structured interviews were conducted with 20 African American and 30 non-Hispanic White women at elevated risk of breast cancer. Allowing women to speak in their own words, these interviews explore women's perception of their risk status; the sources and content of risk information they have obtained; their understanding and consideration of prevention options; decision-making processes; decision-making networks, psychosocial well-being; and women's use of financial, time, and energy resources in coping with risk and prevention. Interviews ranged in length from 30 to 140 minutes and were professionally transcribed. Transcribed data are analyzed through grounded theory methods, using the NVivo 10 software package for qualitative data. Results: High risk African American women's experiences are distinct from those of their White counterparts in a range of ways, including the following. (1) African American women are much less frequently aware of the existence of prophylactic surgeries and chemoprevention options are clinically recommended for women at their own level of risk. (2) Among women who do know about these prevention options, African American women are less likely to consider or undertake prophylactic surgeries or chemoprevention to lower their breast cancer risk. (3) A much higher proportion of African American women have experienced several different types of cancer among their loved ones. These women tend to perceive of themselves as at risk for cancer in general, and not to perceive a specific high risk for breast or ovarian cancer. (4) African American women experience considerably more financial limitations on their ability to access health care and engage in specific prevention activities. Most have been uninsured for some period, and have had at least one health care decision affected by financial constraints. (5) African American women are considerably more likely to reference faith, spirituality, and religion in discussing their perceived risk of cancer and their attitudes toward prevention behavior. Conclusions &amp; Implications: High risk women's narratives reveal substantial racial differences in perceptions, feelings, and choices related to breast cancer prevention. African American women who are clinically determined to be at high risk for breast and ovarian cancer are less likely than similar White women to understand this specific risk, to know about prevention options that could lower the risk, or to consider using these options even when they do know about them. The processes through which African American women navigate risk and prevention are also more heavily influenced by religious faith and financial constraint than those of White women. These distinctions merit further investigation, and confirmation with larger samples. Ultimately, knowledge of such inter-group differences may contribute to tailored interventions to support empowered and health-protective decision making among women at elevated risk. Citation Format: Tasleem J. Padamsee, Anna Muraveva, Electra D. Paskett. Racial Differences in Prevention Decision Making among Women at High Risk of Breast Cancer. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr A52.

Racial/Ethnic and Socioeconomic Differences in Colorectal and Breast Cancer Treatment Quality: The Role of Physician-level Variations in Care.

Despite a large body of research showing racial/ethnic and socioeconomic disparities in cancer treatment quality, the relative role of physician-level variations in care is unclear. To examine the effect of physicians on disparities in breast and colorectal cancer care. Linked SEER Medicare data were used to identify Medicare beneficiaries diagnosed with colorectal and breast cancer during 1995-2007 and their treating physicians. We identified treating physicians from Medicare claims data. We measured the use of NIH guideline-recommended therapies from SEER and Medicare claims data, and used logistic models to examine the relationship between race/ethnicity, socioeconomic status, and cancer quality of care. We used physician fixed effects to account for between-physician variations in treatment. Minority and low socioeconomic status beneficiaries with breast and colorectal cancer were less likely to receive any recommended treatments as compared with whites. Overall, between-physician variation explained <20% of the total variation in quality of care. After accounting for between-physician differences, median household income explained 14.3%, 18.4%, and 13.2% of the variation in use of breast-conserving surgery, chemotherapy, and radiation for breast cancer, and 13.7%, 12.9%, and 12.6% of the within-physician variation in use of colorectal surgery, chemotherapy, and radiation for colorectal cancer, whereas race and ethnicity explained <2% of the within-physician variation in cancer care. Between-physician variations partially explain racial disparities in cancer care. Residual within-physician disparities may be due to differences in patient-provider communication, patient preferences and treatment adherence, or unmeasured clinical severity.

Do Socioeconomic Factors and Race Determine the Likelihood of Breast-Conserving Surgery?

BackgroundRacial disparities in the use of breast-conserving surgery (BCS) have been reported and may be due to advanced stage at diagnosis. Our hypothesis was that low-income and ethnic minority patients have an increased tumor size at diagnosis and decreased likelihood of BCS. Patients and MethodsA retrospective review was conducted of early stage breast cancer patients from 10 hospitals in Harris County, Texas, between 2004 and 2011. Clinical stage was calculated on the basis of data from the institutional tumor registries and electronic medical records. Zip code–based socioeconomic factors were downloaded from the US Census Bureau (http://www.census.gov/). Linear regression was used to identify predictors of tumor size, and logistic regression was used to identify predictors of BCS. ResultsThe cohort included 3937 patients, comprising 2546 (65%) whites, 535 (14%) African Americans, 482 (11%) Hispanics, and 374 (10%) Asian/others. Multivariate linear regression demonstrated socioeconomic status (SES), younger age, African American, Hispanic race, and hormone receptor–negative tumors to be associated with increased tumor size at diagnosis (P < .05). Hispanic and Asian/other race, larger tumor size, combined estrogen receptor–negative/progesterone receptor–negative tumors were associated with not receiving BCS. ConclusionRace and SES were both associated with larger tumor size at diagnosis. Larger tumor size, negative hormone receptor status, and Hispanic and Asian race were associated with lack of receipt of BCS. Breast cancer screening programs should target both minority and low SES groups. Rates of BCS should be interpreted cautiously when used as a quality metric because of the multiple factors, including tumor size and biology, contributing to its use.

Modern Trends in the Surgical Management of Paget's Disease.

We examined the incidence and modern national trends in the management of Paget's disease (PD), including the use of breast-conserving surgery (BCS), mastectomy, axillary surgery, and receipt of radiotherapy. Using surveillance, epidemiology and end results (SEER) data, we identified 2631 patients diagnosed with PD during 2000-2011. Of these patients, 185 (7%) had PD of the nipple only, 953 (36.2%) had PD with ductal carcinoma in situ (PD-DCIS), and 1493 (56.7%) had PD with invasive ductal carcinoma (PD-IDC). Trends in age-adjusted incidence, primary surgery, sentinel lymph node biopsy (SLNB), and axillary lymph node dissection were examined. Multivariable logistic regression was used to evaluate factors associated with receipt of BCS and radiotherapy. A decrease in the age-adjusted incidence of PD occurred from 2000 to 2011 (-4.3% per year, p < 0.05). The overall rates of mastectomy in the PD only, PD-DCIS, and PD-IDC groups were 47, 69, and 88.9%, respectively. Only in the PD-IDC group did the proportion of patients undergoing BCS increase significantly, from 8.5% in 2000 to 15.7% in 2011 (p = 0.01). Of those who underwent axillary surgery, the proportion of patients undergoing SLNB increased from 2000 to 2011. In adjusted analyses, Paget's subgroup, older age, central tumor location, low/intermediate grade, tumor size <2.0 cm, SEER region, and year of diagnosis after 2006 were significantly associated with receipt of BCS. The incidence of Paget's disease has decreased over time while modern trends in local therapy suggest that BCS, SLNB, and adjuvant radiotherapy remain underutilized.

A prospective study of the use and effects of screening mammography in women aged 70 and older.

To prospectively examine how age and comorbidity affect screening mammography use, cancer detection, and overall survival. Prospective, with median follow-up of 10.2 years. A population-based cohort of Vermont women with data in the Vermont Breast Cancer Surveillance System. Women aged 70 and older with no history of breast cancer (N = 20,697). Rates of screening, diagnostic procedure use, and breast cancer diagnosis were examined according to age and comorbidity. The effect of breast cancer on overall survival was assessed in relation to detection mode, tumor characteristics, and treatment. Screening declined 9% per year after age 70 and 18% with each unit increase in comorbidity score, with corresponding increases in clinically detected breast cancer. Invasive cancer was associated with greater overall mortality (screen detected: hazard ratio (HR) = 1.22, 95% confidence interval (CI) = 1.07-1.40; clinically detected: HR = 1.68, 95% CI = 1.43-1.96). The latter HR reflects a much greater absolute risk of death for women in a population with high baseline mortality. Use of breast-conserving surgery as the only treatment for Stage I cancer increased markedly with age and was associated with shorter overall survival than radiation or mastectomy (relative risk = 2.23, 95% CI = 1.42-3.47). Lower screening mammography use by older women is associated with more clinically detected breast cancers, which are associated with poorer survival. Treatment received for early-stage cancer influences the effect of screening on survival.

A Novel Approach of INTRABEAM Intraoperative Radiotherapy for Nipple-Sparing Mastectomy With Breast Reconstruction

BackgroundDespite the advancement and increasing use of breast-conserving surgery, mastectomies, including nipple-sparing mastectomy (NSM), are still carried out in a portion of breast cancer patients. However, the role of NSM is still controversial, mainly because of concern about the oncologic safety of the nipple-areola complex (NAC). INTRABEAM (Carl Zeiss, Oberkochen, Germany) is the most widely used mobile intraoperative radiotherapy (IORT) device to date. This pilot study aims to broaden the application of the INTRABEAM system for breast cancer, investigating the feasibility of INTRABEAM IORT in NSM with breast reconstruction. Patients and MethodsFrom December 2012 to June 2013, 7 female patients with breast cancer were enrolled in the study. NSM with or without axillary dissection was performed first. After confirming negative retroareolar frozen section results and no poor local bleeding in the NAC, INTRABEAM IORT was carried out with a single dose of 16 Gy, followed by breast reconstruction. The complications and short-term outcomes were assessed. ResultsThe median radiation time was 13 minutes 14 seconds in the 7 cases. One patient complained of mild pain in the radiation field on the skin in the first 2 weeks. All 7 patients were followed for a median of 7 months. No acute radiation injury with symptoms (heart, lung, or hematologic system), NAC necrosis, local recurrence, or metastasis was observed. Although every patient had reduction in NAC sensitivity, the contours of the breasts (including the NAC) were satisfactory. ConclusionsINTRABEAM IORT may be a feasible and convenient approach for NSM with breast reconstruction in patients with breast cancer.

P0016 A novel approach of intrabeam intraoperative radiotherapy for nipple-sparing mastectomy with breast reconstruction

Background Despite the advancement and increasing use of breast-conserving surgery, mastectomies, including nipple-sparing mastectomy (NSM), are still carried out in a portion of breast cancer patients. However, the role of NSM is still controversial, mainly owing to the oncological safety of the nipple-areola complex (NAC). Intrabeam (Carl Zeiss, Germany) is the most widely used mobile intraoperative radiotherapy (IORT) device to date. This pilot study aims to broaden the application of Intrabeam system for breast cancer, investigating the feasibility of Intrabeam IORT in NSM with breast reconstruction. Methods From December 2012 to June 2013, seven female patients with breast cancer were enrolled in the study. NSM with or without axillary dissection was performed first. After confirming the presence of a negative retroareolar frozen section and that there was no local bleeding of the NAC, Intrabeam IORT was carried out, with a single dose of 16 Gy, followed by breast reconstruction. The complications and short-term outcomes were assessed. Findings The median radiation time was 13 min 14 s. One patient complained of mild pain in the radiation field on the skin in the first 2 weeks. All seven patients were followed up for a median of 7 months. No acute radiation injury with symptoms (heart, lung, or haematological system), NAC necrosis, local recurrence, or metastasis was observed. Although every patient had reduction in NAC sensitivity, the contours of the breasts (including the NAC) were satisfactory. Interpretation Intrabeam IORT may be a feasible and convenient approach for NSM with breast reconstruction in patients with breast cancer.

Biofunctional characteristics of in situ and invasive breast carcinoma

The increasing use of breast-conserving surgery makes it essential to identify biofunctional profiles responsible for the progression of in situ to invasive carcinomas to facilitate the detection of lesions that are most likely to relapse or progress and, thus, to be able to offer patients tailored treatment options. Our objective was to analyse and compare biofunctional profiles in ductal carcinomas in situ (DCIS) and invasive ductal carcinomas (IDC). We also aimed to identify markers in tumor and normal surrounding tissues that may be predictive of locoregional recurrence in patients with DCIS. Biofunctional parameters including mitotic activity, estrogen receptor, progesterone receptor, microvessel density (MVD), c-kit and p27 expression were evaluated in 829 in situ and invasive carcinomas. The impact of the biomarker profiles of DCIS, IDC and normal surrounding tissues on loco-regional recurrence was analyzed. A progressive increase in cell proliferation and a concomitant decrease in steroid hormone receptor-positive lesions was observed during the transition from in situ to invasive carcinomas, as also within each subgroup as grade increased. Conversely, p27 expression and MVD dramatically decreased during the transition from in situ to invasive carcinomas. Finally, we found that a low c-kit expression was indicative of IDC relapse. Cell proliferation, hormonal and differentiation characteristics differed in DCIS with respect to IDC, and the main variation in the transition between the two histologic lesions was the decrease in p27 expression and MVD.

The use of breast-conserving surgery for women treated for breast cancer in the Department of Veterans Affairs

BackgroundPrevious non–stage-adjusted research described a lower use of breast-conserving surgery (BCS) for the treatment of breast cancer in the Veterans Health Administration (VHA) facilities than in the private sector. MethodsWe combined data from the VHA Centralized Cancer Registry with administrative datasets to describe surgical treatment for locoregional breast cancer in VHA facilities from 2000 to 2006. ResultsWhen considering only procedures performed in VHA facilities, BCS rates decreased from 50.5% (53/105) in 2000 to 42.3% (n = 58/137) in 2006; however, after accounting for procedures conducted in the private sector and paid for by the VHA, BCS rates approached those experienced in breast cancer patients cared for outside the VHA. ConclusionsBased solely on procedures performed in the VHA, rates of BCS use are much lower in the VHA than in the private sector. We were able to show similar rates of BCS use when we accounted for procedures paid for by the VHA but performed at an outside facility. Further exploration and prospective analyses to examine these findings are needed.

Abstract P1-14-19: Breast-Conserving Surgery after Neoadjuvant Chemotherapy is Oncologically Safe for Stage III Breast Cancer Patients

Abstract Background The use of breast-conserving surgery (BCS) in patients with large breast tumors downstaged by neoadjuvant chemotherapy (NCT) remains controversial in clinical stage III breast cancer patients because of the possibility of residual tumor and resistance to NCT. The aims of this study were 1) to evaluate the local recurrence (LR) rate depending on the use of NCT and 2) to determine the oncologic safety of BCS after NCT by comparing LR between patients treated with preplanned/downstaged BCS and patients treated with NCT and mastectomy in clinical stage III breast cancer patients. Patients and Methods Between 2000 and 2007, 166 patients with clinical stage III breast cancer received BCS or mastectomy after NCT (NCT group) and 193 patients with clinical stage III breast cancer who underwent surgery first (Surgery group). Among 166 patients of the NCT group, 94 patients (56.6%) received mastectomy after NCT (mastectomy after NCT group), 39 patients (23.5%) received preplanned BCS (preplanned BCS group) and 33 patients (19.9%) received downstaged BCS (downstaged BCS group). The LR rates between the groups were compared. Results At a median follow-up period of 66.9 months (range, 6.5 to 104.1 months), 11 patients in the NCT group and 7 patients in the Surgery group had developed LR. The 5-year LR-free survival rates were 93.6% in the NCT group and 95.9% in the Surgery group and the LR rates were not significantly different between the groups (p = 0.196). In the NCT group, LRs were observed in 6 patients in the mastectomy after NCT group, 3 patients in the preplanned BCS group and 2 patients in the downstaged BCS group. The 5-year LR-free survival rates were 94.4% in the mastectomy after NCT group, 92.0% in the preplanned BCS group and 93.9% in the downstaged BCS group, respectively (p = 0.953). Conclusions Our study demonstrated that the LR was not different depending on the use of NCT in the clinical stage III breast cancer patients. Also, clinical stage III breast cancer patients who received preplanned or downstaged BCS after NCT showed similar LR-free survival rates compared to patients who received mastectomy after NCT. This result supports that BCS after NCT in clinical stage III patients is oncologically safe in terms of LR if primary breast tumor size has became 5cm or less after NCT. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-14-19.

Trends in the use of breast-conserving surgery and adjuvant radiation therapy in patients with DCIS: A U.S. population-based analysis from 1996 to 2007.

1031 Background: The treatment for patients with DCIS remains controversial. Current guidelines based upon best available evidence suggest that breast conserving surgery (BCS) followed by adjuvant radiation therapy (RT) result in acceptable local control and breast cancer specific survival. The purpose of this study was to analyze trends in patterns of care as well as identify factors associated with surgery type and use of adjuvant radiation therapy in a select cohort of patients enrolled into the SEER database. Methods: The study included females 18 years and older with focal DCIS and known tumor size of 5 cm or less diagnosed between 1996 and 2007. The Cochran-Armitage trend test was applied to identify trends in the use of BCS and RT over time. Multivariate logistic regression analyses were used to determine factors associated with receiving BCS vs. mastectomy and BCS plus RT vs. BCS alone. Cox proportional hazard model was used to determine associations with breast cancer-specific mortality. Results: Of the 34,233 women with DCIS, 76.59% were treated with BCS. 66.36% of BCS patients received adjuvant RT over the study period. The proportion of women receiving BCS increased from 71.5% in 1996 to 76.9% in 2007 (p&lt;0.0001). Additionally, the proportion of women who underwent BCS and received adjuvant radiation therapy over the same time period increased from 55.3% to 69.7% (p&lt;0.0001). Multivariate analysis demonstrated that year of diagnosis, race, marital status, geographic region, tumor size, tumor grade and comedo necrosis all were significantly associated with the use of adjuvant radiation therapy, but age was not. Cox proportional hazards models did not associate either surgery type or use of adjuvant radiation in patients undergoing BCS with breast cancer-specific mortality. Conclusions: Based upon reporting within the SEER database, the proportion of DCIS patients undergoing BCS and the BCS patients receiving adjuvant radiation increased over the study time period. Surgery type and use of adjuvant radiation therapy in patients with BCS was not associated with decreased risk of breast-cancer specific death in this cohort.

Utilization of Breast Conserving Therapy in Stages 0, I, and II Breast Cancer Patients in New Jersey

The purpose of the study was to determine the use of breast conservation surgery (BCS) followed by whole breast irradiation [BCS+radiation therapy (RT)] in stages 0, I, and II breast cancer patients treated in New Jersey using the National Cancer Database. A retrospective analysis was conducted using the data from 13 hospitals in New Jersey certified by the American College of Surgeons Commission on Cancer and members of the Cancer Institute of New Jersey's Network affiliates. Subjects with a first primary malignancy of the breast (stages 0, I, and II) treated from 2000 to 2006 were included in the analysis. A total of 11,146 patients with stage 0 (n=2843), stage I (n=4757), and stage II (n=3546) were treated for their breast cancer. Of stage 0, I, and II patients, 72% (n=2053), 73% (n=3482), and 53% (n=1865) received BCS, respectively. Of these patients, 40% (n=826), 67.6% (n=2353), and 63% (n=1177) received adjuvant RT after BCS for their stages 0, I, and II, respectively. Use of BCS+RT was equivalent across racial groups and all ages, except patients above 70 years of age (61% <40 y, 57% 40 to 49 y, 60% 50 to 59 y, 65% 60 to 69 y, and 51% >70 y). These data report an underutilization of RT after BCS in patients with stage 0 breast cancer treated across 13 hospitals in New Jersey. The Commission on Cancer's Rapid Quality Reporting System may be one method of identifying groups of patients not receiving care according to evidence-based guidelines.

P5-13-08: Breast Cancer Index Predicts Likelihood of Breast Conservation Surgery after Neoadjuvant Chemotherapy.

Abstract Introduction: Neoadjuvant chemotherapy increases the likelihood that breast conservation therapy for breast cancer patients will be successful. Breast Cancer Index (BCI), a gene expression assay combining HoxB13/IL17BR ratio and Molecular Grade Index (MGI), is prognostic for the risk of distant recurrence and overall survival in tamoxifen-treated and untreated breast cancer patients. It was previously reported that high risk patients, as determined by BCI, had a 10-fold greater probability of pathologic complete response (pCR) with neoadjuvant chemotherapy than low risk patients. The aim of the current study was to examine the relationship between BCI score and the use of breast conservation surgery (BCS) following treatment with neoadjuvant chemotherapy. Material and Methods: A total of 145 women (tumor size T1, T2 and T3) were treated with neoadjuvant cheomtherapy for stage I-III breast cancer. RNA was extracted from FFPE tumor samples and a real-time RT-PCR assay was completed to generate a BCI score and risk group categorization as previously described (Jerevall et al. Br J Cancer 2011). The relationship between BCS, BCI and clinicopathological factors was examined using univariate and multivariate logistic regression. Results: Of the 145 patients (67% ER+, 54% PR+, 57% &amp;gt;50 y old), 48 (33.1%) underwent BCS. BCI categorized 62 (43%) of patients as low, 50 (34%) as intermediate and 33 (23%) as high risk. The rate of BCS for the three BCI risk categories was 15% (low risk), 48% (intermediate risk) and 45% (high risk). In the low risk group, the rate of BCS was 15% corresponding to a NPV of 85%. This is consistent with previous data from the same cohort, where the NPV of BCI for pCR was 98.4% with only one patient in the low risk group achieving pCR. In univariate analysis, pathological tumor size (pT), ER, PR, grade and BCI were predictors of BCS. A higher BCI score was associated with higher likelihood of BCS (odds ratio of 3.90; CI: 1.45−10.49; p=0.0069). In multivariate analysis, pT and BCI remained significantly associated with BCS, while ER status was not (p=0.23). Results were similar in the subset of patients with T1 and T2 tumors (N=97). In this subset, BCI categorized 42% of patients as low, 37% as intermediate and 21% as high risk and the rate of BCS was 22%, 64% and 60%, respectively. In multivariate analysis of this subset, only BCI was significantly associated with BCS. In all patients, the concordance index based on a model with pT alone was 0.695. When BCI was incorporated into the model with pT, the concordance index increased to 0.801 (p= 0.0002). Conclusion: In this study, we have shown that patients with higher BCI scores were associated with a higher likelihood of receiving BCS after neoadjuvant chemotherapy. Addition of BCI to tumor size increased accuracy in predicting likelihood of BCS. BCI along with standard pathological factors may improve estimation of individual probability of BCS after neoadjuvant chemotherapy. This study gives rise to the hypothesis that patients with low BCI should not be eligible for neoadjuvant chemotherapy since the likelihood of breast conservation is low. Further large confirmatory studies are necessary. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-13-08.

Tratamiento conservador en pacientes con cáncer de mama multicéntrico

Diagnosis of breast cancer is increasingly made in the early stages of the disease, allowing for less aggressive surgery (breast conservation and sentinel node biopsy). Until recently, breast conservation was generally considered to be contraindicated in multicentric breast cancer. However, recent studies have questioned this belief, suggesting that breast-conserving surgery might be an option in these cases if microscopically free margins are obtained. We present a case of multicentric breast cancer, diagnosed and treated conservatively in our department. We also review the data supporting the current use of breast-conserving surgery in multicentric breast cancer.

280 Locoregional and systemic recurrence of breast carcinoma after breast conserving surgery versus modified radical mastectomy

Background and purpose: Early-stage breast cancer is increasing and consequently the use of breast-conserving surgery (BCS). We examined the effect of mastectomy and BCS on overall and breast cancer survival in routine health care in Geneva, Switzerland.Patients and methods: We included all stage I breast cancers treated by surgery (n=1046) recorded at the Geneva Cancer Registry between 1988 and 1999. The effect of treatment type was evaluated by Cox models, which accounted for confounders.Results: Overall, 780 (75%) women had BCS with radiotherapy, 57 (5%) BCS alone and 209 (20%) mastectomy. The overall 10-year survival was 86, 56, and 72%, respectively. The effect of BCS with radiotherapy was similar to that of mastectomy for both breast cancer mortality (adjusted hazard ratio (HR), 0.67; 95%CI, 0.31–1.38) and other causes of mortality (HR, 0.79; 95%CI, 0.49–1.28). Women with BCS alone had higher mortality from breast cancer (HR, 3.95; 95%CI, 1.59–9.84).Conclusions: This retrospective study shows that BCS plus radiotherapy is the predominant treatment in routine practice for stage I breast cancer in Geneva, with the same effect on survival as mastectomy. In this data set the addition of radiotherapy to BCS substantially reduces mortality from breast cancer without increasing other causes of mortality after 10 years of follow-up.