Receipt of mastectomy and adjuvant radiotherapy following breast conserving surgery (BCS) in New Zealand women with BCS-eligible breast cancer, 2010-2015: an observational study focusing on ethnic differences.

BACKGROUND: Women with early breast cancer who meet guideline-based criteria should be offered breast conserving surgery (BCS) with adjuvant radiotherapy as an alternative to mastectomy. New Zealand (NZ) has documented ethnic disparities in screening access and in breast cancer treatment pathways. This study aimed to determine whether, among BCS-eligible women, rates of receipt of mastectomy or radiotherapy differed by ethnicity and other factors. METHODS: The study assessed management of women with early breast cancer (ductal carcinoma in situ [DCIS] and invasive stages I-IIIA) registered between 2010 and 2015, extracted from the recently consolidated New Zealand Breast Cancer Registry (now Te Rehita Mate Utaetae NZBCF National Breast Cancer Register). Specific criteria were applied to determine women eligible for BCS. Uni- and multivariable analyses were undertaken to examine differences by demographic and clinicopathological factors with a primary focus on ethnicity (Maori, Pacific, Asian, and Other; the latter is defined as NZ European, Other European, and Middle Eastern Latin American and African). RESULTS: Overall 22.2% of 5520 BCS-eligible women were treated with mastectomy, and 91.1% of 3807 women who undertook BCS received adjuvant radiotherapy (93.5% for invasive cancer, and 78.3% for DCIS). Asian ethnicity was associated with a higher mastectomy rate in the invasive cancer group (OR 2.18; 95%CI 1.72-2.75), compared to Other ethnicity, along with older age, symptomatic diagnosis, advanced stage, larger tumour, HER2-positive, and hormone receptor-negative groups. Pacific ethnicity was associated with a lower adjuvant radiotherapy rate, compared to Other ethnicity, in both invasive and DCIS groups, along with older age, symptomatic diagnosis, and lower grade tumour in the invasive group. Both mastectomy and adjuvant radiotherapy rates decreased over time. For those who did not receive radiotherapy, non-referral by a clinician was the most common documented reason (8%), followed by patient decline after being referred (5%). CONCLUSION: Rates of radiotherapy use are high by international standards. Further research is required to understand differences by ethnicity in both rates of mastectomy and lower rates of radiotherapy after BCS for Pacific women, and the reasons for non-referral by clinicians.

Risk factors at five-year survival in grade 3 breast cancer: a retrospective observational study of the New Zealand population.

BACKGROUND: Breast cancer is the most common cancer in New Zealand, with approximately 3000 new registrations annually, affecting one in nine women and resulting in more than 600 deaths. This study analyzed data of patients with selected prognostic factors of Nottingham grade 3 tumors over a specified five-year period. The study aimed to identify factors that result in differential survival in the female, New Zealand population. METHOD: This is an observational, retrospective cohort study of prospectively collected data from New Zealand Breast Cancer Register. The selected period of 1st January 2011 to 31st, December 2015 allowed a consistent overlap for a national five-year data of grade 3 breast cancer in New Zealand. Mortality was carried out using univariate Fine-Gray competing risk statistical models. RESULTS: This study showed that women in the older age group (> 70 years) had higher five-year mortality risk (HR: 1.7, 95% CI: 0.9-3.0, p = 0.053). Hormonal receptor analysis showed that ER positive, PR negative, and ER negative, PR negative subjects were at increased risk (HR = 3.5, 95% CI 2.3-5.4, p < 0.001) and (HR = 2.6, 95% CI, 1.8-3.9, p < 0.001) respectively. Molecular subtypes Triple Negative Breast Cancer and Luminal B subjects were at increased risk (HR = 3.0, 95% CI, 1.8-4.7, p < 0.001 and (HR = 3.3, 95% CI, 1.7-6.3, p < 0.001) respectively. HER2 enriched subjects were at a higher, but not significant, risk of five-year mortality compared to luminal A (HR = 1.6, 95% CI, 0.8-3.0, p = 0.10). NZ Europeans were at increased risk (HR = 1.7, 95% CI, 0.8-3.2, p = 0.11), with the highest Cumulative Incidence Function CIF, the largest proportion of HER2 enriched and TNBC across ethnicities.; however, Pacific Islanders experienced the highest HER2 CIF. CONCLUSION: The survival rates for grade 3 breast cancer vary across the selected prognostic factors and ethnicity. The results of this study make an initial contribution to the understanding of grade 3 breast cancer in the New Zealand population.

Ethnic disparities in breast cancer survival in New Zealand: which factors contribute?

BACKGROUND: New Zealand has major ethnic disparities in breast cancer survival with Maori (indigenous people) and Pacific women (immigrants or descended from immigrants from Pacific Islands) faring much worse than other ethnic groups. This paper identified underlying factors and assessed their relative contribution to this risk differential. METHODS: This study involved all women who were diagnosed with primary invasive breast cancer in two health regions, covering about 40% of the national population, between January 2000 and June 2014. Maori and Pacific patients were compared with other ethnic groups in terms of demographics, mode of diagnosis, disease factors and treatment factors. Cox regression modelling was performed with stepwise adjustments, and hazards of excess mortality from breast cancer for Maori and Pacific patients were assessed. RESULTS: Of the 13,657 patients who were included in this analysis, 1281 (9.4%) were Maori, and 897 (6.6%) were Pacific women. Compared to other ethnic groups, they were younger, more likely to reside in deprived neighbourhoods and to have co-morbidities, and less likely to be diagnosed through screening and with early stage cancer, to be treated in a private care facility, to receive timely cancer treatment, and to receive breast conserving surgery. They had a higher risk of excess mortality from breast cancer (age and year of diagnosis adjusted hazard ratio: 1.76; 95% CI: 1.51-2.04 for Maori and 1.97; 95% CI: 1.67-2.32 for Pacific women), of which 75% and 99% respectively were explained by baseline differences. The most important contributor was late stage at diagnosis. Other contributors included neighbourhood deprivation, mode of diagnosis, type of health care facility where primary cancer treatment was undertaken and type of loco-regional therapy. CONCLUSIONS: Late diagnosis, deprivation and differential access to and quality of cancer care services were the key contributors to ethnic disparities in breast cancer survival in New Zealand. Our findings underscore the need for a greater equity focus along the breast cancer care pathway, with an emphasis on improving access to early diagnosis for Maori and Pacific women.

Stage of breast cancer at diagnosis in New Zealand: impacts of socio-demographic factors, breast cancer screening and biology.

BACKGROUND: Examination of factors associated with late stage diagnosis of breast cancer is useful to identify areas which are amenable to intervention. This study analyses trends in cancer stage at diagnosis and impact of socio-demographic, cancer biological and screening characteristics on cancer stage in a population-based series of women with invasive breast cancer in New Zealand. METHODS: All women diagnosed with invasive breast cancer between 2000 and 2013 were identified from two regional breast cancer registries. Factors associated with advanced (stages III and IV) and metastatic (stage IV) cancer at diagnosis were analysed in univariate and multivariate models adjusting for covariates. RESULTS: Of the 12390 women included in this study 2448 (19.7%) were advanced and 575 (4.6%) were metastatic at diagnosis. Maori (OR = 1.86, 1.39-2.49) and Pacific (OR = 2.81, 2.03-3.87) compared with NZ European ethnicity, other urban (OR = 2.00, 1.37-2.92) compared with main urban residency and non-screen (OR = 6.03, 4.41-8.24) compared with screen detection were significantly associated with metastatic cancer at diagnosis in multivariate analysis. A steady increase in the rate of metastatic cancer was seen which has increased from 3.8% during 2000-2003 to 5.0% during 2010-2013 period (p = 0.042). CONCLUSIONS: Providing equitable high quality primary care and increasing mammographic screening coverage needs to be looked at as possible avenues to reduce late-stage cancer at diagnosis and to reduce ethnic, socioeconomic and geographical disparities in stage of breast cancer at diagnosis in New Zealand.

Ethnic disparities in Phyllodes Tumour in Aotearoa New Zealand: a retrospective review.

BACKGROUND: Phyllodes tumour (PT) is a rare breast neoplasm and little is known about its epidemiological risk factors. The literature suggests a higher incidence of PT in Asian patients and other minority ethnic groups. The purpose of this study was to identify whether there was a difference in incidence, grade and age at presentation for patients with PT among minority ethnic groups when compared with European patients in Aotearoa New Zealand (AoNZ). METHODS: A retrospective review was conducted across the three District Health Boards (DHBs) in Auckland, Aotearoa New Zealand (AoNZ), from 2008 to 2018 to investigate the relationship between ethnicity and clinical characteristics of PT. Demographic information and histology reports were reviewed to obtain relevant data. The primary outcome measure was ethnicity and the secondary outcome measures were age at presentation, tumour volume and grade. RESULTS: One hundred and fifty-nine patients were included. The total number of non-European patients were 108 (68%). Minority ethnic groups including Pasifika, Maori and MELAA were overrepresented in the patient cohort. Larger tumour volume was significantly correlated with higher tumour grade (p < 0.001). Pasifika patients presented with larger tumours (p 0.05) and at a younger age (p 0.027) when compared with European patients. CONCLUSION: This study found that patients with PT in AoNZ were significantly overrepresented in Asian, Pasifika and MELAA ethnic groups. Pasifika patients may be at an increased risk of presenting at a younger age with larger, higher grade tumours when compared with European patients. Further research is required to investigate the reasons behind these findings in minority ethnic groups.

Neck lump clinic: a new initiative at North Shore Hospital.

BACKGROUND: Neck lumps can cause significant patient anxiety and benefit from a multidisciplinary diagnostic approach, with an ultrasound scan and fine needle aspirate. Internationally, 'one-stop' clinics are used for the evaluation of neck lumps, to date no such clinic has been established in the New Zealand public hospital system. The objective of this study was to demonstrate the feasibility of a one-stop diagnostic neck lump clinic (NLC), aiming for improved patient experience and efficiency. METHODS: A consultant-led pilot NLC was instituted with the involvement of a head and neck surgeon, radiologist and pathologist, allowing ultrasound scan and fine needle aspirate investigations to be performed simultaneously. A retrospective audit of patients in the 12 months prior to commencement of the NLC provided a comparison group. RESULTS: The median number of clinic visits was 2 in the control group and 1 in the NLC (P < 0.001). Time from first specialist appointment to surgery was 192 days compared to 134.5 days for NLC (P = 0.057). Median time from first specialist appointment to treatment decision was 108.5 days compared to 0 days in the NLC (P < 0.001). Eighty-eight percent of patients in the NLC were given a diagnosis at their first appointment. The median number of investigations required was 2 in the control group and 1 in the NLC (P < 0.001). Median cost per patient in the NLC was $794 and $1470 in the control group. CONCLUSION: This pilot trial demonstrates streamlined decision-making and efficient utilization of services with a reduction in clinic visits, investigations and cost. High patient satisfaction was reported with this service.

Recurrent loss of heterozygosity correlates with clinical outcome in pancreatic neuroendocrine cancer.

Pancreatic neuroendocrine tumors (pNETs) are uncommon cancers arising from pancreatic islet cells. Here we report the analysis of gene mutation, copy number, and RNA expression of 57 sporadic well-differentiated pNETs. pNET genomes are dominated by aneuploidy, leading to concordant changes in RNA expression at the level of whole chromosomes and chromosome segments. We observed two distinct patterns of somatic pNET aneuploidy that are associated with tumor pathology and patient prognosis. Approximately 26% of the patients in this series had pNETs with genomes characterized by recurrent loss of heterozygosity (LoH) of 10 specific chromosomes, accompanied by bi-allelic MEN1 inactivation and generally poor clinical outcome. Another ~40% of patients had pNETs that lacked this recurrent LoH pattern but had chromosome 11 LoH, bi-allelic MEN1 inactivation, and universally good clinical outcome. The somatic aneuploidy allowed pathogenic germline variants (e.g., ATM) to be expressed unopposed, with RNA expression patterns showing inactivation of downstream tumor suppressor pathways. No prognostic associations were found with tumor morphology, single gene mutation, or expression of RNAs reflecting the activity of immune, differentiation, proliferative or tumor suppressor pathways. In pNETs, single gene mutations appear to be less important than aneuploidy, with MEN1 the only statistically significant recurrently mutated driver gene. In addition, only one pNET in the series had clearly actionable single nucleotide variants (SNVs) (in PTEN and FLCN) confirmed by corroborating RNA expression changes. The two clinically relevant patterns of LoH described here define a novel oncogenic mechanism and a plausible route to genomic precision oncology for this tumor type.

Accuracy of diagnosis of atypical glandular cells - Conventional and ThinPrep.

The incidence of glandular cervical malignancy is steadily increasing. Glandular abnormalities are more frequently diagnosed on cervical smears. In this study, we attempt to evaluate our experience with glandular cytology and to assess the sensitivity and specificity of the ThinPrep (TP) over conventional Papanicolaou (Pap) smears. Glandular abnormalities during a 3-yr period from October 2000 to October 2003 were retrieved from our cytology database. The study group comprised smears from 369 patients, 272 conventional Pap smears (CPSs) and 97 TP from a total of 400,184 smears. The types of glandular abnormalities were tabulated following a modified Bethesda classification. Correlation with histology and follow-up cytology was achieved in all but six patients. Significant lesions were identified in 116/272 (PPV 42.6%) of CPSs and 58/97 (PPV 58.9%) TPs. Pure glandular abnormalities numbered 125 conventional and 51 TP; significant lesions identified in this group were 36/125 (PPV 28.8%) CPS and 26/51 (PPV 50.9%) TP. Statistical analysis showed significant differences for positive predictive values of TP and CPS and a suggestion of increased sensitivity. The main limiting factor was small numbers of glandular abnormalities and a desirable longer study time.

Patterns of axillary lymph node metastases and recurrent disease in grade 1 breast cancer in a New Zealand cohort: Does ethnicity matter?

BACKGROUND: In New Zealand, Maori and Pacific women are more likely than New Zealand/European women to present at a younger age with larger tumours and metastatic disease. Survival rates are also differential by ethnicity. Many factors are believed to be responsible for this including differences in comorbidities, delays to presentation and delays in treatment. It is unclear whether these differences exist amongst women with grade 1 cancer in New Zealand. Therefore, we examined patterns of axillary nodal involvement, recurrent disease and mortality in grade 1 breast cancer in New Zealand women, and whether ethnicity was an important predictor for any of these outcomes. METHOD: Data was retrieved from the Auckland Breast Cancer Registry (ABCR) and the Waikato Breast Cancer Registry (WBCR) which are prospective, population-based databases. All women newly diagnosed with grade 1 primary invasive breast cancer between 1 June 2000 and 31 May 2013 were identified from the two registries. RESULTS: There were 2857 grade 1 breast cancers diagnosed over this time period. Axillary lymph nodes were involved in 19.0% of women, and 5.1% developed recurrent disease (locoregional or distant). Pacific and Maori women were more likely than NZ European women to have larger tumours and lymphovascular invasion (LVI). Predictors for axillary node involvement were tumour size greater than 10mm, LVI and non-screen detected cancers. Tumour size greater than 10mm, lobular carcinoma and BCS without radiotherapy were predictive of recurrent and or metastatic disease. Ethnicity was not observed to be an independent predictor for axillary nodal involvement, recurrent and/or metastatic disease, or breast cancer specific mortality amongst New Zealand women with grade 1 breast cancer. CONCLUSION: Ethnicity was not a predictor of axillary node involvement, recurrent disease or mortality in grade 1 breast cancer in our population.

Breast implant related anaplastic large cell lymphoma presenting as late onset peri-implant effusion.

In the past 10 years there has been a number of case reports of lymphoma associated with implants. In January 2011 the US FDA (United States Food and Drug Administration) produced a review of the medical literature reporting an association between breast implants and Anaplastic Large Cell Lymphoma (ALCL). A common presenting feature is late onset effusion around the implant.(1) We report the first case in New Zealand and add to the worldwide total of 34 reported cases.

Cervical intraepithelial neoplasia and aneusomy of TERC: assessment of liquid-based cytological preparations.

The implementation of effective screening programs has decreased the incidence and mortality of cervical carcinoma. However, single screening tests are subjective and carry a significant false-negative rate. Therefore, supplementary tests to support the Papanicolaou (PAP) smear are being developed. Human papillomavirus (HPV) testing has increased the specificity of the PAP smear, but has high sensitivity rate. This has proven unhelpful in low-grade lesions and in young women. Cervical carcinogenesis is a multifactorial disorder. In addition to exposure to oncogenic HPV, which is regarded as the initiator, there must be a promoter to eventuate in invasive disease. The promoter factor appears to be the acquisition of extra copies of chromosome 3q and has been shown to be a constant recurrence in cervical carcinoma (squamous and adenocarcinomas). The 3q region contains the RNA sequence of the human telomerase gene TERC. Recent studies have shown a strong correlation between high-grade cervical lesions and abnormalities of TERC. This study supports the previous studies and examines the status of the TERC gene in low and high-grade cervical intraepithelial lesions, diagnosed on cytology. ASC-H smears are also examined in an attempt to categorize lesions that are more likely to progress. Potentially this may help identify women in need of close clinical follow-up and early treatment.

Mucocele-like lesions of the breast: an audit of 2 years at BreastScreen Auckland (New Zealand).

It is recommended that mucocele-like lesions be excised to enable differentiation between benign lesions and carcinoma. In addition, ductal carcinoma in situ may be found in close association. A small series of 12 lesions audited at BreastScreen Auckland has shown six benign, one atypical, and five malignant lesions. Although this is a small series, a high rate of associated malignancy has been reported.

Aggressive fibromatosis of the breast: a case report and literature review.

Aggressive fibromatosis is a rare, locally aggressive disease. It constitutes 0.3% of all solid tumors, but the tumor is rarely seen in the breast, particularly without pectoral muscle and fascial involvement. The etiology is unknown, but an association with Gardner's syndrome has been described. Clinical and imaging findings simulate breast carcinoma. A case in a 53-year-old female patient is reported.