Factors Involved in Delaying Initiation of Adjuvant Chemotherapy After Breast Cancer Surgery.

BACKGROUND: Delays in initiating adjuvant chemotherapy after breast cancer surgery seems to have an impact on patients' risk of relapse and their survival rate. The aim of this retrospective study was to identify factors delaying initiation of adjuvant chemotherapy after breast surgery. MATERIAL AND METHODS: All patients undergoing surgical treatment for mammary cancer between June 2014 and June 2015 and receiving adjuvant chemotherapy were selected retrospectively. RESULTS: In multivariate analysis, 3 factors significantly delay initiation of adjuvant chemotherapy: a secondary procedure (odds ratio [OR], 6.67; P = .00012), inclusion in a therapeutic trial (OR, 8.46; P = .0013), and a positive HER2 status (OR, 3.02; P = .063 [statistically significant]). DISCUSSION: This study provides a brief overview of the population most likely to experience a delay in the initiation of their adjuvant chemotherapy after cancer surgery. Our findings should assist interventions during initial management.

[Techniques and complications of non-genetic risk reducing mastectomies: Guidelines of the National College of French Gynecologists and Obstetricians (CNGOF)]. / Modalités et morbidité des mastectomies de réduction de risque en dehors du risque avéré de prédisposition héréditaire : recommandations du Collège national des gynécologues et obstétriciens français (CNGOF).

OBJECTIVE: Based on an updated review of the international literature covering the different surgical techniques and complications of risk reducing mastectomies (RRM) in non-genetic context, the Commission of Senology (CS) of the College National des Gynécologues Obstétriciens Français (CNGOF) aimed to establish recommendations on the techniques to be chosen and their implementation. DESIGN: The CNGOF CS, composed of 24 experts, developed these recommendations. A policy of declaration and monitoring of links of interest was applied throughout the process of making the recommendations. Similarly, the development of these recommendations did not benefit from any funding from a company marketing a health product. The CS adhered to and followed the AGREE II (Advancing guideline development, reporting and evaluation in healthcare) criteria and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method to assess the quality of the evidence on which the recommendations were based. The potential drawbacks of making recommendations in the presence of poor quality or insufficient evidence were highlighted. METHODS: The CS considered 6 questions in 4 thematic areas, focusing on oncologic safety, risk of complications, aesthetic satisfaction and psychological impact, and preoperative modalities. RESULTS: The application of the GRADE method resulted in 7 recommendations, 6 with a high level of evidence (GRADE 1±) and 1 with a low level of evidence (GRADE 2±). CONCLUSION: There was significant agreement among the CS members on recommendations for preferred surgical techniques and practical implementation.

Delayed care for patients with newly diagnosed cancer due to COVID-19 and estimated impact on cancer mortality in France.

BACKGROUND: The impact of the first coronavirus disease 2019 (COVID-19) wave on cancer patient management was measured within the nationwide network of the Unicancer comprehensive cancer centers in France. PATIENTS AND METHODS: The number of patients diagnosed and treated within 17 of the 18 Unicancer centers was collected in 2020 and compared with that during the same periods between 2016 and 2019. Unicancer centers treat close to 20% of cancer patients in France yearly. The reduction in the number of patients attending the Unicancer centers was analyzed per regions and cancer types. The impact of delayed care on cancer-related deaths was calculated based on different hypotheses. RESULTS: A 6.8% decrease in patients managed within Unicancer in the first 7 months of 2020 versus 2019 was observed. This reduction reached 21% during April and May, and was not compensated in June and July, nor later until November 2020. This reduction was observed only for newly diagnosed patients, while the clinical activity for previously diagnosed patients increased by 4% similar to previous years. The reduction was more pronounced in women, in breast and prostate cancers, and for patients without metastasis. Using an estimated hazard ratio of 1.06 per month of delay in diagnosis and treatment of new patients, we calculated that the delays observed in the 5-month period from March to July 2020 may result in an excess mortality due to cancer of 1000-6000 patients in coming years. CONCLUSIONS: In this study, the delays in cancer patient management were observed only for newly diagnosed patients, more frequently in women, for breast cancer, prostate cancer, and nonmetastatic cancers. These delays may result is an excess risk of cancer-related deaths in the coming years.

[Surgical management of breast cancer in outpatient versus overnight hospitalization: Satisfaction study]. / Prise en charge chirurgicale du cancer du sein ambulatoire versus hospitalisation d'une nuit : enquête de satisfaction.

OBJECTIVES: Breast cancer is the primary female cancer. In cancerology, it is essential to give to the patient some support. The advent of outpatient surgery optimizes the care path. This need for support of patients raises the question of its compatibility with the day surgery. The purpose is to compare the satisfaction of outpatients with those who stay overnight after surgery of breast cancer. MéTHODS: Patients who underwent breast conservative surgery were included. It is a mixed study, a quantitative, observational and prospective one using a satisfaction survey and a qualitative one which consisted on semi - directive individual interviews. We compared the satisfaction rate (highest marks). RESULTS: There were 91 patientes, 38 in the ambulatory group and 53 in the overnight group. There was no significant difference in satisfaction between the two groups (P=0.18). The difficulties frequently highlighted by the patients during their stay were the organizational management, the lack of hospital comfort and the sometimes long wait. The need for human support was unanimous. CONCLUSION: The satisfaction was excellent in the study. The mode of hospitalization does not seem to play a role here on satisfaction. This hospitalization mode can only be envisaged by providing sufficient human and technical resources. Enhanced recovery after surgery appears to be an alternative to outpatient surgery.

Sentinel lymph node biopsy without axillary lymphadenectomy after neoadjuvant chemotherapy is accurate and safe for selected patients: the GANEA 2 study.

PURPOSE: GANEA2 study was designed to assess accuracy and safety of sentinel lymph node (SLN) after neo-adjuvant chemotherapy (NAC) in breast cancer patients. METHODS: Early breast cancer patients treated with NAC were included. Before NAC, patients with cytologically proven node involvement were allocated into the pN1 group, other patient were allocated into the cN0 group. After NAC, pN1 group patients underwent SLN and axillary lymph node dissection (ALND); cN0 group patients underwent SLN and ALND only in case of mapping failure or SLN involvement. The main endpoint was SLN false negative rate (FNR). Secondary endpoints were predictive factors for remaining positive ALND and survival of patients treated with SLN alone. RESULTS: From 2010 to 2014, 957 patients were included. Among the 419 patients from the cN0 group treated with SLN alone, one axillary relapse occurred during the follow-up. Among pN1 group patients, with successful mapping, 103 had a negative SLN. The FNR was 11.9% (95% CI 7.3-17.9%). Multivariate analysis showed that residual breast tumor size after NAC ≥ 5 mm and lympho-vascular invasion remained independent predictors for involved ALND. For patients with initially involved node, with negative SLN after NAC, no lympho-vascular invasion and a remaining breast tumor size 5 mm, the risk of a positive ALND is 3.7% regardless the number of SLN removed. CONCLUSION: In patients with no initial node involvement, negative SLN after NAC allows to safely avoid an ALND. Residual breast tumor and lympho-vascular invasion after NAC allow identifying patients with initially involved node with a low risk of ALND involvement.

Adjuvant chemotherapy in pT1ab node-negative triple-negative breast carcinomas: Results of a national multi-institutional retrospective study.

BACKGROUND: Triple-negative breast cancers (TNBCs) are considered as associated with poor outcome, but prognosis of subcentimetric, node-negative disease remains controversial and evidence that adjuvant chemotherapy (CT) is effective in these small tumours remains limited. PATIENTS AND METHODS: Our objective was to investigate the impact of CT on survival in pT1abN0M0 TNBC. Patients were retrospectively identified from a cohort of 22,475 patients who underwent primary surgery in 15 French centres between 1987 and 2013. As rare pathological types may display very particular prognoses in these tumours, we retained only the invasive ductal carcinomas of no special type according to the last World Health Organisation (WHO) classification which is the most common TNBC histological type. End-points were disease-free survival (DFS) and metastasis-free survival (MFS). A propensity score for receiving CT was estimated using a logistic regression including age, tumour size, Scarff Bloom and Richardson (SBR) grade and lymphovascular invasion. RESULTS: Of a total of 284 patients with pT1abN0M0 ductal TNBC, 144 (51%) received CT and 140 (49%) did not. Patients receiving CT had more adverse prognostic features, such as tumour size, high grade, young age, and lymphovascular invasion. CT was not associated with a significant benefit for DFS (Hazard ratio, HR = 0.77 [0.40-1.46]; p = 0.419, log-rank test) or MFS (HR = 1.00 [0.46-2.19]; p = 0.997), with 5-year DFS and MFS in the group with CT versus without of 90% [81-94%] versus 84% [74-90%], and 90% [81-95%] versus 90% [83%-95%], respectively. Results were consistent in all supportive analyses including multivariate Cox model and the use of the propensity score for adjustment and as a matching factor for case-control analyses. CONCLUSIONS: This study did not identify a significant DFS or MFS advantage for CT in subcentimetric, node-negative ductal TNBC. Although current consensus guidelines recommend consideration of CT in all TNBC larger than 5 mm, clinicians should carefully discuss benefit/risk ratio with patients, given the unproven benefits.

Surgical guidance by freehand SPECT for sentinel lymph node biopsy in early stage breast cancer: A preliminary study.

OBJECTIVE: Sentinel lymph node biopsy (SLNB) is a standard for patients with early breast cancer. Using a gamma-detecting probe connected to an infrared camera, the Declipse freehand SPECT (FhSPECT) system (Surgiceye(®)) is able to detect and locate any radioactive source in 3D. The objective of this study was to evaluate the potential interest of FhSPECT imaging for real-time guidance SLNB in breast cancer. METHODS: A prospective single-center clinical study assessed sensitivity and usability of FhSPECT for SLN detection and surgical guidance in breast cancer patients. SLN detection rate with FhSPECT was compared with lymphoscintigraphy (LS) and colorimetric method. Durations of FhSPECT acquisitions and of the SLNB procedure were measured in order to evaluate the practicability of the device. RESULTS: Between May and September 2014, 20 patients with early stage invasive breast cancer (cT0-2N0) underwent SLNB using FhSPECT and blue dye detection. Preoperative LS revealed 41 radioactive axillary SLNs (median=2 SLN per patient; range 0-4) in 20 patients. Preoperative FhSPECT detected 40 axillary SLNs (median=2; range: 1-4) in 20 patients. The corresponding sensitivity of FhSPECT was 97.5%. For 4 patients (20%), FhSPECT detected more axillary SLNs than LS. The colorimetric method identified only 24 axillary SLNs (2 patients had no blue dye injection on account of a history of allergy), leading to a sensitivity of 67% (24 blue SLNs/36 resected SLNs after blue dye injection). Median duration of FhSPECT acquisitions was 5minutes (range: 1-26min). Median duration of SLNB procedure was 11.5minutes (range: 3-55min). Duration of acquisitions analysis based on the number of use of the device showed decreasing values suggesting the existence of a short learning curve. CONCLUSION: This study demonstrated that FhSPECT is feasible and facilitates SLN identification.

[Assessment of sentinel lymph node biopsy in patients receiving neoadjuvant chemotherapy in breast cancer: before or after?]. / Peut-on proposer un prélèvement du ganglion sentinelle en cas de chimiothérapie néoadjuvante dans les cancers du sein et à quel moment ?

The main goal of preoperative chemotherapy is to reduce the size of the tumor and allow conservative treatment. Neoadjuvant treatment can affect axillary status with a downstaging in one third of the cases. For these patients, the benefit of axillary node dissection is questioned and the sentinel node biopsy (SLNB) seems to be a relevant option. However, the timing of performing SLNB is still debated especially for clinical negative patients with negative axillary ultrasound before preoperative chemotherapy. For axillary positive nodes proved by biopsy/cytology before preoperative chemotherapy, SLNB can be an option if there is a good clinical and radiological response.

[Sentinel node detection using optonuclear probe (gamma and fluorescence) after green indocyanine and radio-isotope injections]. / Détection du ganglion sentinelle dans le cancer du sein par sonde opto-nucléaire après injection de vert indocyanine et de technétium 99m.

OBJECTIVE: Assess the biopsy's feasibility of the sentinel lymph node biopsy (SLNB) using optonuclear probe after of indocyanine green (ICG) and radio-isotope (RI) injections. METHODS: Twenty-one patients with a localized breast cancer and unsuspicious axillary nodes underwent a SLNB after both injections of ICG and radio-isotope. RESULTS: One or more SLN were identified on the 21 patients (identification rate of 100%). The median number SLN was 2 (1-3). Twenty SLN were both radio-actives and fluorescents (54.1%), 11 fluorescent only (29.7%) and 6 were only radio-actives (16.2%). Seven patients had a metastatic SLN (8 SLN overall). Among them, only one had a micrometastasic SLN, 5 others had a macrometastatic SLN and one patient had two macrometastatic SLNs. Among the 8 metastatic SLN, 5 were both fluorescent and radioactive, 2 were only fluorescent and 1 was only radioactive. CONCLUSION: Detection SLN using optonuclear probe after indocyanine green and radio-isotope injections is effective and could be, after validation by randomized trial, a reliable alternative to the blue dye injection for teams who consider that combined detection as the reference.

Laparoscopic hysterectomy after concurrent radiochemotherapy in locally advanced cervical cancer compared to laparotomy: A multi institutional prospective pilot study of cost, surgical outcome and quality of life.

OBJECTIVE: Laparoscopy allows hysterectomies after chemoradiation to be performed without opening the abdominal wall. We measured the costs and quality of life for locally advanced cervical cancer patients operated on via laparoscopy compared to laparotomy. STUDY DESIGN: We conducted an observational prospective multicenter study on locally advanced cervical cancer patients undergoing an extrafascial hysterectomy after concurrent chemoradiotherapy (CRT). We assessed the costs from the medical visit before surgery up to the first month after surgery from the providers' perspective and measured the quality of life using the EORTC QLQ-C30 and QLQ-CX24 up to six months. RESULTS: Sixty two patients (39 laparoscopy and 23 laparotomy) from December 2008 to November 2011 were included. There was no difference in operative time, or intraoperative and post-operative complication rates between the two groups. Intraoperative transfusion and abdominal drain were significantly lower in the laparoscopy group (respectively, p = 0.04 and p < 0.01), as well as the duration of hospital stay (7.3 d vs. 5.7 d, p < 0.001). All patients who underwent laparoscopic hysterectomy were discharged to home, whereas 4 laparotomy patients used convalescence homes (p = 0.01). Mean costs at one month were €10,991 for laparotomy and €11,267 for laparoscopy (p = 0.76). Sexual activity is better for the laparoscopy group at six months (p = 0.01). CONCLUSION: Laparoscopy for an extrafascial hysterectomy after CRT in locally advanced cervical cancer patients brought better quality of life with similar costs compared to laparotomy, and should therefore be the first choice for surgeons.

[Focus on methods for detection of sentinel nodes in breast cancer]. / Mise au point sur les méthodes de détection des ganglions sentinelles dans le cancer du sein.

The sentinel node procedure (GS) is the recommended technique for axillary surgical exploration in localized breast cancer with no clinical or radiological lymph node involvement. This surgical technique is based on a dual isotope and colorimetric detection. Although it allows a significant reduction in morbidity compared to axillary dissection (CA), this procedure induces a number of organizational constraints, in particular for the radioisotope injection. Specially for this reason, other GS methods have emerged in recent years, some of which appear promising (detection by fluorescence and magnetic iron). The objective of this paper was to carry out a synthesis of the reference method of detection (radioisotope) GS and analyze the recent literature on new detection methods.

[Freehand SPECT for navigation and sentinel node detection in breast cancer]. / Intérêt du repérage per-opératoire 3D des ganglions sentinelles dans le cancer du sein.

The sentinel lymph node (SLN) is a standard for the surgical treatment of axillary localized breast cancer N0. It is based on a double isotopic and color detection. With a gamma detecting probe connected to an infrared camera, Déclipse SPECT system (Surgiceye(®)) is able to detect and locate any radioactive source in 3D. Mobile character for use in the operating room is particularly interesting for the intraoperative detection of SLN. We illustrate its usefulness in a clinical case where the preoperative identification of SLN by lymphoscintigraphy was not informative.

[Impact of preoperative breast magnetic resonance imaging on surgical management: experience of two university hospitals]. / Impact de l'IRM mammaire préopératoire sur la prise en charge chirurgicale des cancers du sein: expérience de deux centres hospitaliers universitaires.

OBJECTIVES: Breast magnetic resonance imaging (MRI) has attained a solid position in the diagnosis of breast cancer but its benefit is still to be confirmed in the preoperative staging. The authors assessed the impact of preoperative breast MRI on surgical management of breast cancer in two university hospitals. PATIENTS AND METHODS: This retrospective review was realized in two university hospitals and concerned all patients with breast carcinoma who had a surgical first therapy. We selected 89 patients who underwent preoperative breast MRI in the period between January 2008 and December 2009. RESULTS: The sensitivity of breast MRI for detecting breast tumor was 95%. Fourteen percent of patients had a multifocal disease, 10% a multicentric disease and 2% a synchronous bilateral cancer. The correlation of radiological tumor size with histopathological size was r=0.68 in IRM compared to r=0.45 in conventional imaging (P<0.001). Nineteen additional biopsies were performed and 9.9% of false-positive findings were detected. Retrospectively, planned surgical management was altered in 9% of patients, resulted from use of breast MRI. Six patients had conversion of planned breast conservation to mastectomy and two patients underwent contralateral lumpectomy after discover synchronous bilateral cancer. DISCUSSION AND CONCLUSION: Breast MRI was very sensitive for the detection of breast carcinoma and improved local staging in almost 9% of patients. But, low specificity of this imaging requires a systematically validation of additional lesions by biopsy before surgical planning.