Excising Additional Margins at Initial Breast-Conserving Surgery (BCS) Reduces the Need for Re-excision in a Predominantly African American Population: A Report of a Randomized Prospective Study in a Public Hospital.

BACKGROUND: Margin status is an important prognostic factor for local recurrence after breast conserving surgery (BCS) for breast cancer. We designed a prospective randomized trial to evaluate the effect of shave margins on positive margins and locoregional recurrence (LRR). METHODS: Patients were randomized to BCS or BCS with resection of 5 additional margins (BCS + M). Tumor margins were classified as negative [>2 mm for ductal carcinoma in situ (DCIS); >1 mm for invasive carcinoma] based on guidelines at the time of accrual. RESULTS: A total of 75 patients with stage 0-III breast cancer (76 samples) were randomized, mean age 59.6 years with median follow-up 39.5 months. Overall, 21 patients (27.6 %) had positive margins: 14 had undergone BCS and 7 BCS + M (p = 0.005). Of the 21 patients with positive margins, 19 had DCIS on final pathology (OR 7.56; 95 % CI 1.52-37.51).All patients with positive margins were offered re-excision; 11 had negative final margins after re-excision surgery. Overall, 6 patients (8.3 %) developed LRR with recurrence being more common in the BCS group when compared with the BCS + M group (17.2 vs 2.3 %; p = 0.025). CONCLUSIONS: Taking additional cavity shave margins at the time of initial excision resulted in a reduction in positive margin rate, a decrease in return to operating room for re-excision, and lower LRR.

Implementing the Prospective Surveillance Model (PSM) of Rehabilitation for Breast Cancer Patients with 1-Year Postoperative Follow-up, a Prospective, Observational Study.

BACKGROUND: The Prospective Surveillance Model (PSM) of rehabilitation for patients with breast cancer aims for early identification, treatment, and support of physical impairments postoperatively. The purpose of this study was to describe the incidence of impairments during the first postoperative year and the differences between the patients requiring rehabilitation intervention versus those not requiring intervention. METHODS: A total of 120 patients were enrolled. Impairment measures included: pain, range of motion, and self-reported measures of function using the Upper Extremity Functional Index (UEFI) and Quick Disability of the Arm, Shoulder and Hand (QuickDASH) questionnaires. These measures were performed at designated intervals during the first postoperative year. All patients received exercise and education, and patients with identified impairments underwent individualized rehabilitation intervention. Clinical factors associated with need for intervention were determined using univariate analysis. RESULTS: Thirty-six patients required rehabilitation intervention. There were no statistically significant differences between intervention and no-intervention groups for body mass index, breast surgery type, reconstruction type, or radiotherapy. Statistically significant differences were found between intervention and no-intervention groups in early postoperative UEFI, QuickDASH, pain scores, age, number of lymph nodes removed [9.3 (intervention) vs. 5.6 (no-intervention)], axillary surgery type, chemotherapy, and breast cancer stage. CONCLUSIONS: Survivorship practitioners should have heightened awareness for rehabilitation intervention in patients with greater axillary surgery and burden of disease. Patients with more activity restriction and lower levels of function in the early postoperative period may benefit from rehabilitation intervention. Future studies should focus on implementing a screening tool to identify patients in need of rehabilitation referral.

Psychometric properties of a brief measure of autonomy support in breast cancer patients.

BACKGROUND: The Health Care Climate Questionnaire measures patient perceptions of their clinician's autonomy supportive communication. We sought to evaluate the psychometric properties of a modified brief version of the Health Care Climate Questionnaire (mHCCQ) adapted for breast cancer patients. METHODS: We surveyed 235 women aged 20-79 diagnosed with breast cancer within the previous 18 months at two cancer specialty centers using a print questionnaire. Patients completed the mHCCQ for their surgeon, medical oncologist, and radiation oncologist separately, as well as the overall treatment experience. Exploratory factor analysis (EFA) using principal components was used to explore the factor structure. RESULTS: One hundred sixty out of 235 (68.1%) women completed the survey. Mean age was 57 years and time since diagnosis was 12.6 months. For surgeon, medical oncologist, and radiation oncologist ratings separately, as well as overall treatment, women rated 6 dimensions of perceived physician autonomy support. Exploratory factor analysis indicated a single factor solution for each clinician type and for the overall experience. Further, all six items were retained in each clinician subscore. Internal consistency was 0.93, 0.94, 0.97, and 0.92 for the overall, surgeon, medical oncologist, and radiation oncologist scales, respectively. Hierarchical factor analysis demonstrated that a summary score of the overall treatment experience accounts for only 52% of the total variance observed in ratings of autonomy support for the three provider types. CONCLUSIONS: These results describe the first use of the mHCCQ in cancer patients. Ratings of the overall treatment experience account for only half of the variance in ratings of autonomy support, suggesting that patients perceive and report differences in communication across provider types. Future research is needed to evaluate the relationship between physician communication practices and the quality of decision making, as well as other outcomes among cancer patients.

Implementing a screening tool for identifying patients at risk for hereditary breast and ovarian cancer: a statewide initiative.

BACKGROUND: The Georgia Breast Cancer Genomic Health Consortium is a partnership created with funding from the Centers for Disease Control and Prevention (CDC) to the Georgia Department of Public Health to reduce cancer disparities among high-risk minority women. The project addresses young women at increased risk for hereditary breast and ovarian cancer (HBOC) syndrome through outreach efforts. METHODS: The consortium provides education and collects surveillance data using the breast cancer genetics referral screening tool (B-RST) available at www.BreastCancerGeneScreen.org . The HBOC educational protocol was presented to 73 staff in 6 public health centers. Staff used the tool during the collection of medical history. Further family history assessments and testing for mutations in the BRCA1/2 genes were facilitated if appropriate. RESULTS: Data was collected from November 2012 through December 2013, including 2,159 screened women. The majority of patients identified as black/African American and were 18-49 years old. Also, 6.0 % (n = 130) had positive screens, and 60.9 % (n = 67) of the 110 patients who agreed to be contacted provided a detailed family history. A total of 47 patients (42.7 %) met National Comprehensive Cancer Network guidelines when family history was clarified. Fourteen (12.7 %) underwent genetic testing; 1 patient was positive for a BRCA2 mutation, and 1 patient was found to carry a variant of uncertain significance. CONCLUSIONS: The introduction of genomics practice within public health departments has provided access to comprehensive cancer care for uninsured individuals. The successful implementation of the B-RST into public health centers demonstrates the opportunity for integration of HBOC screening into primary care practices.

Development and psychometric properties of a brief measure of subjective decision quality for breast cancer treatment.

BACKGROUND: Breast cancer patients face several preference-sensitive treatment decisions. Feelings such as regret or having had inadequate information about these decisions can significantly alter patient perceptions of recovery and recurrence. Numerous objective measures of decision quality (e.g., knowledge assessments, values concordance measures) have been developed; there are far fewer measures of subjective decision quality and little consensus regarding how the construct should be assessed. The current study explores the psychometric properties of a new subjective quality decision measure for breast cancer treatment that could be used for other preference sensitive decisions. METHODS: 320 women aged 20-79 diagnosed with AJCC stage 0 - III breast cancer were surveyed at two cancer specialty centers. Decision quality was assessed with single items representing six dimensions: regret, satisfaction, and fit as well as perceived adequacy of information, time, and involvement. Women rated decision quality for their overall treatment experience and surgery, chemotherapy, and radiation decisions separately. Principle components was used to explore factor structure. After scales were formed, internal consistency was computed using Cronbach's alpha. The association of each of the four final scales with patient characteristics scores was examined by Pearson correlation. RESULTS: For overall breast cancer treatment as well as surgery, chemotherapy, and radiation decisions, the six items yielded a single factor solution. Factor loadings of the six decision items were all above .45 across the overall and treatment-specific scales, with the exception of "Right for You" for chemotherapy and radiation. Internal consistency was 0.77, 0.85, 0.82, and 0.78 for the overall, surgery, chemotherapy, and radiation decision quality scales, respectively. CONCLUSIONS: Our measure of subjective appraisal of breast cancer treatment decisions includes 5 related elements; regret and satisfaction as well as perceived adequacy of information, time, and involvement. Future research is needed to establish norms for the measure as is further psychometric testing, particularly to examine how it is associated with outcomes such as quality of life, psychological coping and objective decision quality.

Assessing interventions promoting the uptake of cancer-related genomic services within the Latino community: A scoping review using the RE-AIM framework.

Cancer genomic services (CGS) can support genetic risk-stratified cancer prevention and treatment. Racial/ethnic minority groups are less likely to access and utilize CGS compared with non-Hispanic Whites. Little research has described characteristics of interventions targeted at CGS among Latinos. This scoping review aimed to (1) describe interventions promoting uptake of CGS among Latinos in the United States and Latin America, (2) describe intervention adaptations for Latino participants, and (3) summarize intervention implementation factors suggested by reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework. We conducted a search in English and Spanish of literature published between 2005 and 2022 across PubMed and Latin American and Caribbean Health Sciences Literature databases. Sixteen of 2344 papers met the inclusion criteria of the analysis. Efforts to promote CGS among Latino communities were limited in the US and lower in Latin America. This review highlights the need for in-depth exploration of acculturation-informed interventions and better reporting on implementation factors to enhance their scalability across diverse settings.

The effect of nurse navigation on timeliness of breast cancer care at an academic comprehensive cancer center.

BACKGROUND: A patient navigation process is required for accreditation by the National Accreditation Program for Breast Centers (NAPBC). Patient navigation has previously been shown to improve timely diagnosis in patients with breast cancer. This study sought to assess the effect of nurse navigation on timeliness of care following the diagnosis of breast cancer by comparing patients who were treated in a comprehensive cancer center with and without the assistance of nurse navigation. METHODS: Navigation services were initiated at an NAPBC-accredited comprehensive breast center in July 2010. Two 9-month study intervals were chosen for comparison of timeliness of care: October 2009 through June 2010 and October 2010 through June 2011. All patients with breast cancer diagnosed in the cancer center with stage 0 to III disease during the 2 study periods were identified by retrospective cancer registry review. Time from diagnosis to initial oncology consultation was measured in business days, excluding holidays and weekends. RESULTS: Overall, 176 patients met inclusion criteria: 100 patients prior to and 76 patients following nurse navigation implementation. Nurse navigation was found to significantly shorten time to consultation for patients older than 60 years (B = -4.90, P = .0002). There was no change in timeliness for patients 31 to 60 years of age. CONCLUSIONS: Short-term analysis following navigation implementation showed decreased time to consultation for older patients, but not younger patients. Further studies are indicated to assess the long-term effects and durability of this quality improvement initiative.

Determining the impact of US mammography screening guidelines on patient survival in a predominantly African American population treated in a public hospital during 2008.

BACKGROUND: In November 2009, the US Preventive Service Task Force (USPSTF) published updated breast cancer screening guidelines. This marked a change from the 2002 recommendations and a significant divergence from the American Cancer Society (ACS) guidelines. In the current study, the potential effect of using the revised 2009 USPSTF guidelines on patient disease stage and survival were evaluated and compared with those actually observed and to predicted under ACS recommendations. METHODS: A retrospective chart review was performed for 84 patients who were diagnosed with stage I through III breast cancer at Grady Memorial Hospital during 2008. Previously published tumor volume doubling times were used to model an equation that would estimate tumor sizes. For each patient, a disease stage at diagnosis was predicted, and outcomes were modeled as though the patient had been screened according to the recommended versions of the ACS and USPSTF guidelines. Patient survival rates were then estimated based on prognostic data according to disease stage. RESULTS: The average age of patients in the study was 55 years, and 85% were African American. The USPSTF guidelines predicted later stages at diagnosis (14% stage I, 73% stage II), whereas the ACS guidelines predicted earlier stages (47% stage I, 53% stage II). CONCLUSIONS: A large stage migration was predicted, indicating significantly earlier diagnosis, when the ACS-recommended screening guidelines were followed. The authors concluded that practitioners should understand how race and/or socioeconomic factors increase the risk of breast cancer and should be encouraged to prioritize discussions regarding the benefits and risks of annual mammographic screening, especially among women who have a potentially greater risk of developing breast cancer at a younger age.

Racial disparity in breast cancer survivorship: themes from a series of four national healthcare provider live virtual forums.

PURPOSE: Significant disparity exists in the diagnosis, treatment, and survivorship outcomes among Black breast cancer (BC) survivors. Black BC survivors have more significant survivorship issues and a greater burden of illness than White counterparts. Barriers to rehabilitation exist for all BC survivors but are magnified in Black BC survivors. The purpose of this qualitative research was to document patient, clinician, and researchers' perceptions surrounding contributing factors, lived experiences, and potential solutions to racial disparity in BC survivorship. METHODS: A narrative approach was utilized to identify themes from a series of four virtual healthcare provider forums that explored lived personal and professional experiences, issues, and potential solutions surrounding racial disparity in BC survivorship. Forums included perspectives of patients, healthcare providers, researchers, and stakeholders in the BC field. An independent thematic analysis was performed by the investigators, all of whom have emic perspectives with respect to race and/or BC. RESULTS: Three main themes were identified related to racial disparity in BC survivorship: (1) societal and cultural contributing factors, (2) contribution of healthcare providers and systems, and (3) models of care and research considerations. CONCLUSIONS: The findings provide compelling documentation of lived personal and professional experiences of racial disparity in BC survivorship. Potential solutions exist and must be enacted immediately to ensure equitable survivorship outcomes for Black individuals following a BC diagnosis. IMPLICATIONS FOR CANCER SURVIVORS: Increased awareness related to racial disparity in BC survivorship among survivors, healthcare providers, and researchers will contribute to health equity and improved outcomes for Black individuals.

A prospective model of care for breast cancer rehabilitation: postoperative and postreconstructive issues.

Appropriate and timely rehabilitation is vital in the recovery from breast cancer surgeries, including breast conserving surgery, mastectomy, axillary lymph node dissection (ALND), and breast reconstruction. This article describes the incidence, prevalence, risk factors and time course for early postoperative effects and the role of prospective surveillance as a rehabilitation strategy to prevent and mitigate them. The most common early postoperative effects include wound issues such as cellulitis, flap necrosis, abscess, dehiscence, hematoma, and seroma. Appropriate treatment is necessary to avoid delay in wound healing that may increase the risk of long-term morbidity, unduly postpone systemic and radiation therapy, and delay rehabilitation. The presence of upper quarter dysfunction (UQD), defined as restricted upper quarter mobility, pain, lymphedema, and impaired sensation and strength, has been reported in over half of survivors after treatment for breast cancer. Moreover, evidence suggests that survivors who undergo breast reconstruction may be at higher risk of UQD. Ensuring the survivor's optimum functioning in the early postoperative time period is critical in the overall recovery from breast cancer. The formal collection of objective measures along with patient-reported outcome measures is recommended for the early detection of postoperative morbidity. Prospective surveillance, including preoperative assessment and structured surveillance, allows for early identification and timely rehabilitation. Early evidence supports a prospective approach to address and minimize postoperative effects.

Upper-body morbidity after breast cancer: incidence and evidence for evaluation, prevention, and management within a prospective surveillance model of care.

The purpose of this paper is to review the incidence of upper-body morbidity (arm and breast symptoms, impairments, and lymphedema), methods for diagnosis, and prevention and treatment strategies. It was also the purpose to highlight the evidence base for integration of prospective surveillance for upper-body morbidity within standard clinical care of women with breast cancer. Between 10% and 64% of women report upper-body symptoms between 6 months and 3 years after breast cancer, and approximately 20% develop lymphedema. Symptoms remain common into longer-term survivorship, and although lymphedema may be transient for some, those who present with mild lymphedema are at increased risk of developing moderate to severe lymphedema. The etiology of morbidity seems to be multifactorial, with the most consistent risk factors being those associated with extent of treatment. However, known risk factors cannot reliably distinguish between those who will and will not develop upper-body morbidity. Upper-body morbidity may be treatable with physical therapy. There is also evidence in support of integrating regular surveillance for upper-body morbidity into the routine care provided to women with breast cancer, with early diagnosis potentially contributing to more effective management and prevention of progression of these conditions.

Feasibility of accelerated partial breast irradiation in a large inner-city public hospital.

BACKGROUND: Breast conserving therapy (BCT) that include breast conserving surgery followed by adjuvant radiation therapy has revolutioned medicine by allowing women to avoid mastectomy. Accelerated partial breast irradiation (APBI) has emerged as a valid alternative to whole-breast irradiation that requires a shorter time commitment. We report our novel experience with APBI at a large public hospital that serves low-income and potentially noncompliant patients. METHODS: A retrospective chart review was conducted of women who underwent BCT for stage 0-IIA breast cancer from August 2007 to August 2010 treated with APBI with a brachytherapy catheter. RESULTS: Twenty-four patients (20 African American) were considered for APBI. Average age was 61 years. Four patients could not undergo APBI for technical reasons and completed whole-breast irradiation over a 5 week period. Median follow-up was 19 months. Nine patients (37.5 %) had ductal carcinoma-in-situ, and 15 patients (62.5 %) had invasive ductal carcinoma with an average tumor size of 1.1 cm. All patients had negative margins of >2 mm. Two patients (8 %) treated with the brachytherapy catheter had in-breast tumor recurrence. Thus, all 24 patients initially identified for APBI successfully completed adjuvant radiotherapy. CONCLUSIONS: Patient compliance with postoperative irradiation is key to minimize local recurrence after BCT for breast cancer. This success with a brachytherapy catheter in underserved women in a U.S. public hospital setting indicates that outcomes of compliance and complications are comparable to nationally published results.

Time to treatment for patients receiving BCS in a public and a private university hospital in Atlanta.

Delays in treatment for breast cancer can lead to poorer patient outcome. We analyzed time to treatment among female patients receiving breast-conserving surgery in two different hospital settings, public versus private. Retrospective chart review revealed 270 patients diagnosed during 2004-2008. Three consecutive time intervals were defined (Initial abnormal imaging [I] to core biopsy [II] to surgery /pathology staging [III] to oncology evaluation for adjuvant treatment). Multivariate analyses investigated hospital type and demographic factors. Overall median treatment time was 83 days, Interval II accounting for the longest (43 days). Only 55% of patients received the entire spectrum of care within 90 days; for each consecutive 30-day interval, percentages varied dramatically: 80.7%, 31.1%, and 68.9%.Public hospital patients experienced longer overall time to treatment than private patients (94 versus 77 days, p < 0.001); these differences persisted throughout the intervals. Longer wait times were experienced by African Americans versus Caucasians (89 versus 64 days, p = 0.003), unmarried versus married patients (93 versus 70 days, p < 0.001), and Medicaid-insured patients, p < 0.001. In multivariate analyses, hospital type, race, marital status, and insurance predicted timely treatment within one or more intervals. For patients undergoing breast-conserving therapy, time to treatment differs between private and public settings. However, barriers to timely treatment arise from both system-based issues and patient socio-demographic factors. Studies are needed to evaluate and intervene on this intricate connection.

Treatment adherence and outcome in women with inflammatory breast cancer: does race matter?

BACKGROUND: The authors compared treatment adherence rates and outcome in Caucasian and African American patients with inflammatory breast cancer (IBC). METHODS: The records of 55 (25 Caucasian and 30 African American) IBC patients treated with curative intent from 1995 to 2009 were reviewed. All patients received neoadjuvant doxorubicin (Adriamycin) and/or taxane-based chemotherapy, and mastectomy with or without radiotherapy. The median follow-up period for Caucasian and African American patients was similar (39.5 months and 36.1 months, respectively). RESULTS: There was no difference between races in median age, tumor size, grade, and receptor status at diagnosis. The number of patients who completed neoadjuvant chemotherapy, surgery, and radiotherapy did not differ by race (84% of Caucasians vs 86.7% of African Americans) nor did the median length of time to complete trimodality treatment (263 [range, 207-422] days for Caucasians vs 262 [range, 165-371] days for African Americans). There was a trend toward slightly higher pathological complete response rates in Caucasian than African American women (20% in Caucasians vs 6.7% in African Americans, P = .23). Despite slightly better response rates to neoadjuvant chemotherapy, Caucasian patients did not have higher 3-year local control rates (70% in Caucasians vs 64% in African Americans, P = .73). However, there was a trend toward higher 3-year overall survival in Caucasian versus African American patients (73% in Caucasians vs 55% in African Americans, P = .09) and higher distant metastasis-free survival (60% in Caucasians vs 40% in African Americans, P = .19). CONCLUSIONS: This study is among the largest to examine patients with IBC by race. Being Caucasian or African American did not appear to impact treatment adherence. However, African American patients tended to have poorer response to standard treatment and worse outcome than Caucasian patients.

Improving on national quality indicators of breast cancer care in a large public hospital as a means to decrease disparities for African American women.

BACKGROUND: In April 2007, the National Quality Forum (NQF) endorsed the first nationally recognized hospital-based performance measures for stage I, II, and III breast cancer. The purpose of this study was to document compliance with the 3 NQF breast quality indicators during 2 time intervals in a metropolitan public hospital. MATERIALS AND METHODS: Tumor registry and medical records were used to identify patient demographics and treatments before (2005-2006) and after (2008) implementations in 2007 as a result of the NQF audit. Program changes included: hiring a dedicated medical oncology nurse practitioner, requiring the radiation oncology case manager to attend weekly multidisciplinary conferences, educating Patient Navigators of the importance of multimodal care, and providing support groups for patients addressing importance of completion of all treatment options. RESULTS: A total of 213 female patients were diagnosed with and treated for stage I, II, or III breast cancer in 2005-2006 and 2008. Of these, 189 (89%) were African American (AA) women. Also, 70 patients of 86 (81.3%) received radiation therapy, 60 of 77 (77.9%) received or were considered for adjuvant chemotherapy, and 124 of 144 (86.1%) for hormonal therapy according to NQF indicators. After 2007, patients receiving radiation therapy increased from 75.8 to 95.8%. Patients receiving or considered for adjuvant chemotherapy or hormonal therapy increased from 73.7 to 93.7% and from 84.1 to 90.0%, respectively. CONCLUSIONS: NQF breast cancer indicators provided a mechanism to improve compliance of multimodal treatment in our center. Raising awareness of these indicators in the multidisciplinary conference, hiring dedicated personnel, and educating patients has led to major improvements in breast cancer care.

The effects of additional tumor cavity sampling at the time of breast-conserving surgery on final margin status, volume of resection, and pathologist workload.

INTRODUCTION: Margin status is an important prognostic factor for local recurrence after breast-conserving surgery (BCS) in patients with breast malignancy. It is unclear whether the removal of additional tumor cavity margins reduces the reoperation rate and is cosmetically acceptable. This study compares the reoperation rates, volume of breast excised in cm(3), and number of pathology slides examined in two groups of patients who underwent BCS with or without four or five additional margins (BCS + M). METHODS: We retrospectively analyzed 320 patients who underwent BCS or BCS + M for stage 0-I-II breast cancer from 2004 to 2007. We classified the margins as negative (>or=1 mm), close (<1 mm), or positive based on the distance from the tumor to the margin of resection. RESULTS: Of 320 cases analyzed, 199 (62.2%) underwent BCS and 121 (37.8%) had BCS + M. Overall, patients with BCS + M had a higher negative margins rate (85.1% vs. 57.2%, P < 0.05) and a lower reoperation rate. However, when ductal carcinoma in situ (DCIS) and infiltrating ductal carcinoma (IDC) were analyzed separately, only patients with IDC showed a higher negative margin rate (91% vs. 62.1%, P < 0.001) and a lower volume of breast tissue excised (205.63 vs. 392.27, P = 0.03). There was no significant increase in pathology workload in both groups. CONCLUSIONS: Resection of four to five additional margins during BCS for early-stage invasive breast cancer results in a higher rate of negative microscopic margins, lower volume of breast excised, and subsequently, a lower reoperation rate. The advantages of this approach include improved patient satisfaction and decreased cost.

Management of breast abscesses in nonlactating women.

Breast abscess in nonlactating women is a rare clinic-pathological entity. A retrospective analysis of all cases of breast abscesses in nonlactating women in a community teaching hospital from 2000 to 2006 was performed. We analyzed their clinical characteristics, prevalence of diabetes mellitus (DM), surgical and medical management, and clinical outcome. We identified 116 breast abscesses in 98 nonlactating women; 89 per cent of patients were black. At presentation, 63 patients (64%) had a known history of DM and eight patients (8%) had newly diagnosed DM. Patients with DM had an increased length of hospital stay than nondiabetic women (P < 0.01). Most patients (70%) were treated with incision and drainage and antibiotics with a mean time of abscess resolution of 47 +/- 54 days. There was no correlation with breast abscess and smoking history. Glycemic control was suboptimal with 46 per cent of subjects receiving insulin therapy during the hospital stay. We found a high prevalence of DM (72%) in nonlactating women presenting with breast abscess. Diabetic women had a longer hospital stay and longer duration of the abscess compared with the patients without diabetes. Diabetes screening in nonlactating women with breast abscess and intensified glycemic control might improve clinical outcome.

The utility of breast MRI in the management of breast cancer.

Breast magnetic resonance imaging (MRI) is increasingly used in the evaluation of breast cancer. The impact of this modality on patient management at a single institution is evaluated in this paper. A retrospective review was performed for 114 breast cancer patients who had breast MRI as part of their diagnostic evaluation. Clinical information, mammograms, breast ultrasounds and MRI scans were reviewed to determine whether the MRI findings led to a change in patient management. Outcomes as the result of breast MRI were stratified as favorable and unfavorable. Ninety-five patients who had complete clinical, radiologic, and pathologic data were identified. The indications for breast MRI included: high risk screening (n = 3), diagnostic evaluation of disease after neo-adjuvant chemotherapy (n = 24) or prior to re-excision (n = 8), extent of in situ ductal, infiltrating ductal or infiltrating lobular disease histology (DCIS n = 3, IDC n = 24, ILC n = 17), identification of unknown primary (n = 2), assessment of contralateral breast (n = 4), recurrence surveillance (n = 5), and other (n = 5). MRI was concordant with clinical findings and other modalities in 70.5% of cases. MRI altered planned clinical management in 28 of 95 patients (29.5%). Management changes were favorable in 21 patients (75%). Diagnostic evaluation of the breast by MRI alters patient management in 30% of cases depending upon the indications. Alteration in patient management is favorable in 75% of cases. Evaluation of the breast by MRI alters the clinical management of nearly one-third of patients. Changes are favorable for the majority of these cases. Patients undergoing evaluation for contralateral disease, invasive lobular carcinoma and assessment of chemotherapeutic response may derive a more meaningful benefit from MRI.

Using National Quality Forum breast cancer indicators to measure quality of care for patients in an AVON comprehensive breast center.

In April 2007, the National Quality Forum (NQF) endorsed the first nationally recognized hospital-based performance measures for quality of care for breast cancer. The aim of this study was to measure quality of care at our AVON Center for Breast Care (AVONCBC) using these indicators. We retrospectively reviewed tumor registry and medical records of females under age 70 diagnosed with breast cancer in years 2005-2006. For patients diagnosed with hormone receptor negative breast cancer, 22 of 29 (75.9%) and 28 of 32 (87.5%) were considered for or received chemotherapy in 2005 and 2006, respectively. Of those patients, 21 of 29 (72.4%) and 24 of 32 (75.0%) were considered for or received chemotherapy within the NQF 4-month period. For patients undergoing breast conserving surgery (BCS), 20 of 23 (86.9%) in 2005 and 37 of 39 (94.9%) in 2006 were referred for adjuvant radiation therapy. The proportion of patients who received radiation therapy within 1 year of diagnosis was 18 of 23 (78.2%) and 29 of 39 (74.4%) for diagnosis years 2005 and 2006, respectively. The vast majority of patients in our AVONCBC are referred to medical and/or radiation oncology for adjunctive therapy and about three-fourths receive treatment compliant with the NQF QI. To increase our compliance rate, we are developing methods to improve access to the multiple disciplines in our AVONCBC. Using the NQF indicators serves to assess hospital performance at a systems-level and as a useful method for tracking cancer quality of care.

Race and triple negative threats to breast cancer survival: a population-based study in Atlanta, GA.

BACKGROUND: Breast cancers with a triple negative tumor (TNT) subtype (as defined by lacking protein expression of estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2)) preclude the use of available targeted therapies and may contribute to poor outcome and to the historically poorest survival observed among African-American (AA) women. This study examines association of the ER/PR/HER2 subtypes with race and breast cancer survival. METHODS: Breast tumors from a population-based cohort of 116 AA and 360 white Atlanta women aged 20-54, diagnosed from 1990 to 1992 were centrally reviewed and tested by immunohistochemistry. Multivariate survival analyses within subtypes (TNT, ER-PR-HER2+, ER+/PR+HER2+, ER+/PR+HER2-) were conducted using weighted Cox regression and included socio-demographic, prognostic, and treatment factors. RESULTS: TNTs were more prevalent among young women and particularly among AA women (Odds Ratio [OR] = 1.9, 95% Confidence Interval [CI] 1.2-2.9), adjusting for age, stage, grade, and poverty index. Overall mortality was higher for AA women (Hazard Ratio [HR] = 1.9, 95% CI, 1.5-2.5) and differed by subtypes (P < 0.001). Within the TNT subtype, racial differences in survival persisted, after additional adjustment for treatment and comorbidities (HR = 2.0, 95% CI 1.0-3.7). TNTs were uniquely associated with high expression of p16, p53, and Cyclin E; and low Bcl-2 and Cyclin D1 expression. CONCLUSIONS: The high prevalence of TNTs among younger women and particularly younger AA women, along with unique protein expression patterns and poorer survival, suggests varying gene-environment etiologies with respect to age and race/ethnicity and a need for effective therapies.