Mid- and long-term risk of atrial fibrillation among breast cancer surgery survivors.

BACKGROUND: The risk of incident atrial fibrillation (AF) among breast cancer survivors, especially for younger women, and cancer treatment effects on the association remain unclear. This study aimed to investigate the risk of AF among breast cancer survivors and evaluate the association by age group, length of follow-up, and cancer treatment. METHODS: Using data from the Korean Health Insurance Service database (2010-2017), 113,232 women newly diagnosed with breast cancer (aged ≥ 18 years) without prior AF history who underwent breast cancer surgery were individually matched 1:5 by birth year to a sample female population without cancer (n = 566,160) (mean[SD] follow-up, 5.1[2.1] years). Sub-distribution hazard ratios (sHRs) and 95% confidence intervals (CIs) considering death as a competing risk were estimated, adjusting for sociodemographic factors and cardiovascular/non-cardiovascular comorbidities. RESULTS: BCS had a slightly increased AF risk compared to their cancer-free counterparts (sHR 1.06; 95% CI 1.00-1.13), but the association disappeared over time. Younger BCS (age < 40 years) had more than a 2-fold increase in AF risk (sHR 2.79; 95% CI 1.98-3.94), with the association remaining similar over 5 years of follow-up. The increased risk was not observed among older BCS, especially those aged > 65 years. Use of anthracyclines was associated with increased AF risk among BCS (sHR 1.57; 95% CI 1.28-1.92), which was more robust in younger BCS (sHR 1.94; 95% CI 1.40-2.69 in those aged ≤ 50 years). CONCLUSIONS: Our findings suggest that younger BCS had an elevated risk of incident AF, regardless of the length of follow-up. Use of anthracyclines may be associated with increased mid-to-long-term AF risk among BCS.

Cutting Healthcare Costs with Hematoma-Directed Ultrasound-Guided Breast Lumpectomy.

BACKGROUND: Localization of nonpalpable breast lesions for breast-conserving surgery (BCS) remains highly variable and includes needle/wire localization (NL), radioactive seed localization, radar localization, and hematoma-directed ultrasound-guided (HUG) lumpectomy. The superiority of HUG lumpectomy over NL has been demonstrated repeatedly in terms of safety, accuracy, low positive margin rates, cosmesis, and patient satisfaction. In this study, we evaluate the cost effectiveness of HUG lumpectomy over NL for nonpalpable breast lesions. METHODS: We performed a retrospective review of 569 patients who underwent lumpectomy at the University of Arkansas for Medical Sciences from May 2014 through December 2017. Lumpectomies were stratified by localization technique, i.e. NL versus HUG. A cost-savings estimate was determined for the HUG localization technique, and a total amount of dollars saved over the study period was calculated. RESULTS: Overall, 569 lumpectomies were performed: 501 (88.0%) via HUG and 68 (12.0%) via NL. Intraoperative ultrasound was used in 566 operations (99.5%). Of the lumpectomies performed by HUG, 190 lesions (33.4%) were visible only on mammogram or breast magnetic resonance imaging prior to diagnostic core needle biopsy (CNB). Cost estimates comparing HUG with NL demonstrated a cost savings of $497.00 per procedure, the cost of preoperative needle localization by a radiologist, and a total of $94,430.00 for the study period. CONCLUSION: In utilizing HUG lumpectomy, the initial CNB serves as the diagnostic and localization procedure, thus saving time and a painful second procedure on the day of operation. HUG lumpectomy is safe, accurate, reduces healthcare costs, and results in a better patient experience for the surgical removal of nonpalpable breast lesions.

Evaluating coalition capacity to strengthen community-academic partnerships addressing cancer disparities.

The Arkansas Cancer Connection Program is a community-academic partnership between the University of Arkansas for Medical Sciences and nine community-based coalitions designed to address cancer health disparities through community-based participatory research. In 2005, a survey measuring coalition capacity was administered to 51 Cancer Council members to assess training needs and increase coalition capacity. The highest scoring components were leadership and member engagement while the lowest were development and capacity effectiveness. Effectiveness correlated with aspects of coalition capacity. The evaluation identified training needs, which were met by projects leveraging the coalition's strengths to advance community-based participatory research addressing cancer disparities.

Ronda S. Henry-Tillman, MD, FACS.

Dr Henry-Tillman was recently appointed as a member of the Advisory Committee on Research on Women's Health at the National Institutes of Health (NIH). This committee assists the Office of Research on Women's Health (ORWH) and the NIH in addressing scientific, legal, and ethical issues affecting the health of the nation's women through biomedical and behavioral research and related career opportunities. The ORWH was established in 1990 by the NIH and statutorily mandated by Congress in 1993 as a mechanism for eliciting advice and recommendations on priority issues affecting women's health research. Advisory committee members are expected to provide guidance in such areas as refinement of the NIH's women's health research agenda, exploration of questions regarding gender difference in clinical drug trials, development of methodologies that enhance research on health needs of women, and monitoring the inclusion of women in clinical trials funded by the NIH. The director of the Office of Research on Women's Health is Dr Vivian W. Pinn, former president of the National Medical Association.

The tale of two stories: Challenges and innovations in breast cancer management.

The keynote address The Tale of Two Stories: Challenges and Innovations in Breast Cancer Management presented on March 19-20, 2017 at the celebratory Festschrift Lecture in honor of the great Dr. LaSalle Leffall's on behalf of his impact and contributions to the field of Breast cancer science and treatment as a leader, surgeon, and mentor. This presentation and follow up opinion paper in the field of Breast Disease highlights the challenges that have baffled us and the innovations that have changed and translated into outcomes and those that have not. Where do they parallel and what are the gaps?

Colorectal cancer screening in rural and poor-resourced communities.

To test the efficacy of a community-based intervention, Empowering Communities for Life (EC4L), designed to increase colorectal cancer (CRC) screening through fecal occult blood test (FOBT) in rural underserved communities in a randomized controlled trial. Participants were randomized into 3 groups (2 interventions and 1 control). Interventions were delivered by community lay health workers or by academic health professionals. The main outcome of interest was return rate of FOBT screening kit within 60 days. Participants included 330 screening-eligible adults. The overall return rate of FOBT kits within 60 days was 32%. The professional group (Arm 2) had the highest proportion of returned FOBTs within 60 days at 42% (n = 46/110), a significantly higher return rate than the lay group (Arm 1) [28%(n = 29/103);P = 0.0422] or control group (Arm 3) [25%(n = 29/117);P = 0.0099]. Thus, one arm (Arm 2) of our intervention produced significantly higher CRC screening through FOBT. Community-based participation partnered with academic health professionals enhanced CRC screening among rural and poor-resourced communities.

Insurance coverage mandates: Impact of physician utilization in moderating colorectal cancer screening rates.

Precision public health requires research that supports innovative systems and health delivery approaches, programs, and policies that are part of this vision. This study estimated the effects of health insurance mandate (HiM) variations and the effects of physician utilization on moderating colorectal cancer (CRC) screening rates. A time-series analysis using a difference-in-difference-in-differences (DDD) approach was conducted on CRC screenings (1997-2014) using a multivariate logistic framework. Key variables of interest were HiM, CRC screening status, and physician utilization. The adjusted average marginal effects from the DDD model indicate that physician utilization increased the probability of being "up-to-date" vs. non-compliance by 9.9% points (p = 0.007), suggesting that an estimated 8.85 million additional age-eligible persons would receive a CRC screening with HiM and routine physician visits. Routine physician visits and mandates that lower out-of-pocket expenses constitute an effective approach to increasing CRC screenings for persons ready to take advantage of such policies.

Germline Genetic Variants in TEK, ANGPT1, ANGPT2, MMP9, FGF2 and VEGFA Are Associated with Pathologic Complete Response to Bevacizumab in Breast Cancer Patients.

BACKGROUND: We previously reported improved pathologic complete response (pCR) in a prospective phase II study using neoadjuvant bevacizumab in combination with chemotherapy compared to chemotherapy alone in breast cancer patients (41% vs. 25%, p = 0.0291). In this study, we queried germline single-nucleotide polymorphisms (SNPs) in angiogenesis-related genes for their impact on pCR and overall survival (OS). METHODS: DNA for genotyping was available from 34 subjects who received bevacizumab in addition to chemotherapy and 29 subjects who did not. Using Illumina® technology, we queried 504 SNPs with a minor allele frequency (MAF) of at least 5%, located in 10 angiogenesis-related genes, for their effect on pCR via logistic regression with an additive-inheritance model while adjusting for race and bevacizumab treatment. SNPs that showed significant associations with pCR were selected for additional characterization. RESULTS: After adjusting for race and tumor type, patients who had bevacizumab added to their neoadjuvant therapy were found to experience a significantly improved rate of pCR compared to patients who did not (adjusted OR 8.40, 95% CI 1.90-37.1). When patients were analyzed for SNP effects via logistic regression with race and bevacizumab treatment included as covariates, two SNPs in angiopoietin 1 (ANGPT1), six in ANGPT2, three in fibroblast growth factor 2 (FGF2), four in matrix metalloproteinase 9 (MMP9), three in tyrosine kinase, endothelial (TEK) and two in vascular endothelial growth factor A (VEGFA) were associated with pCR (P<0.05). However, when overall survival was considered, there was no difference between treatment groups or between genotypes. CONCLUSION: Genetic variability in TEK, ANGPT1, ANGPT2, FGF2, MMP9 and VEGFA is associated with pCR in bevacizumab-treated patients. Consistent with other studies, adding bevacizumab to standard chemotherapy did not impact OS, likely due to other factors and thus, while SNPs in TEK, ANGPT1, ANGPT2, FGF2, MMP9 and VEGFA were associated with pCR, they were not predictive of OS in this patient population. TRIAL REGISTRATION: ClinicalTrials.gov NCT00203502.

Prevention of nausea and vomiting following breast surgery.

BACKGROUND: The purpose of this study was to determine the rate of nausea and vomiting in women following breast surgery (PONV) under general anesthesia (GA), before and after the introduction of a standardized prophylactic anti-emetic (AE) regimen. METHODS: We performed a retrospective review of eligible patients, between July 2001 and March 2003. Patients operated on before September 2002 had standard preoperative care (old cohort [OC]); patients operated on after September 2002 were treated prophylactically with oral dronabinol 5 mg and rectal prochlorperazine 25 mg (new cohort [NC]). Data were collected from hospital records regarding age, diagnosis, comorbid conditions, previous anesthesia history, anesthesia and operative details, episodes PONV, and use of AE. The rate and severity of PONV was calculated for both cohorts. RESULTS: Two hundred forty-two patients were studied: 127 patients in the OC and 115 patients in the NC. The median age was 56 years (range 32 to 65). The rate of nausea and vomiting were significantly better in the patients treated prophylactically with dronabinol and prochlorperazine (59% vs. 15%, P < .0001 and 29% vs. 3%, P < .0001). Twenty patients in the OC were given some prophylactic AE treatment and 12 (60%) of them required further treatment; only 12 of 109 patients (11%) in the NC required further AE treatment (P < .0001). CONCLUSION: PONV is a significant problem in breast surgical patients. Preoperative treatment with dronabinol and prochlorperazine significantly reduced the number and severity of episodes of PONV.

The receptor expression pattern in ductal carcinoma in situ predicts recurrence.

BACKGROUND: The treatment of ductal carcinoma in situ (DCIS) is based on size and pathologic morphology. We hypothesized that as with invasive breast cancer, receptor expression in DCIS is important for predicting recurrence. METHODS: Retrospective review from 1990 through 2002 identified 94 DCIS patients who had documented estrogen receptor (ER), progesterone receptor (PR), p53, Her-2/neu (HER), tumor characteristics, type of surgery, use of radiation or tamoxifen, and site of recurrence. RESULTS: Median age and tumor size was 57.5 years and 2.0 cm, respectively. Median follow-up was 4 years. Overall recurrence rate was 6%. The ER-positive/PR-negative/HER-positive receptor pattern represented 50% (3 of 6) of total recurrences (P = .01). The length of disease-free-survival in the ER-positive/PR-negative/HER-positive receptor pattern was significantly shorter than in the rest of the patients (P = .0011). COMMENTS: Receptor expression may be important in DCIS for predicting recurrence. HER positivity, even with ER positivity, is significantly associated with a higher risk of recurrence.

Total skin-sparing mastectomy without preservation of the nipple-areola complex.

BACKGROUND: We hypothesized that total skin-sparing mastectomy (TSM) including where the skin overlying the nipple and areola is preserved would be oncologically safe and facilitate improved cosmetic reconstruction. METHODS: A review (May 2003 through January 2005) was completed on all procedures that were performed through an inframammary incision or a previous scar with reconstruction using Botox, AlloDerm, and a subpectoral tissue implant. RESULTS: Thirty-one patients had 50 TSMs. Twelve percent (6/50) of TSMs had the skin of the nipple and areola resected: 4 (14% of tumors) because of tumor involvement and 2 (4%) because of skin necrosis. Fourteen percent of patients had other complications: 4% (2/50) had infection and/or flap necrosis and 10% (5/50) had superficial epidermolysis requiring no intervention, for a total complication rate of 18%. Average cosmetic score was 8.5 (range 4 to 10). No recurrences are evident after mean follow-up of 7.9 +/- 5.4 months. CONCLUSION: Our short-term experience suggests that TSM has an acceptable complication rate, is theoretically oncologically safe, and facilitates an improved cosmetic result.

Correlation of magnetic resonance imaging and pathologic size of infiltrating lobular carcinoma of the breast.

BACKGROUND: Determining the extent of infiltrating lobular carcinoma (ILCA) in the breast is difficult. This study was designed to determine if the size of ILCA on magnetic resonance imaging (MRI) correlated with final pathology. METHODS: Retrospective study of patients between 1998 and 2004, who were evaluated for extent of ILCA prior to definitive treatment, was conducted. Demographic data and radiology and pathology results were obtained. Spearman correlation coefficient was used. RESULTS: Twenty-nine patients (median age 62 years) had MRI of breast. Fourteen patients (48%) had contralateral MRIs; 13 (45%) normal; 1 (8%) prompted core biopsy; 6 of 13 patients underwent contralateral mastectomies, which were benign. The distribution of tumor size was: T1 = 15 (52%); T2 = 7 (24%); T3 = 5 (17%); T4 = 2 (7%). Spearman correlation coefficient between tumor size on ultrasound and MRI with pathology was .19 (P = .5) and .88 (P < .001), respectively. CONCLUSION: MRI provided superior correlation between tumor size and pathology.

Combined neoadjuvant chemotherapy with bevacizumab improves pathologic complete response in patients with hormone receptor negative operable or locally advanced breast cancer.

OBJECTIVES: To evaluate the pathologic complete response (pCR) and safety of bevacizumab (B) with chemotherapy in the neoadjuvant setting of breast cancer (BC). METHODS: A prospective single-arm, single-institution phase II trial for women with stage IIA-B/IIIA-B-C BC. Patients received neoadjuvant docetaxel, cyclophosphamide, B every 3 weeks for 4 cycles followed by doxorubicin every 3 weeks for 4 cycles followed by surgery. After healing, B was given every 3 weeks for 9 cycles. Radiation therapy, trastuzumab and endocrine therapy were given as indicated. RESULTS: Thirty-nine of 40 patients were evaluable. Median age of participants was 45 years (range, 26 to 72 y). The most serious grade ≥3 adverse events were infection (4), congestive heart failure (2), and pulmonary embolism (1). Thirty-eight of 39 patients underwent surgery. The pCR rate was 41% (16/39), significantly higher than the null-hypothesis rate of 25% (P=0.0204). Rates of pCR were 52% (15/29) in ductal carcinoma compared with 10% (1/10) in nonductal disease (P=0.021), and 59% (10/17) in estrogen receptor-/progesteron receptor- patients compared with 27% (6/22) among patient with at least one positive hormone receptor (P=0.047). African Americans (AA) had 75% pCR (9/12), whereas Whites had only 28% pCR (7/25; P=0.0069), possibly in part because 100% of AA (12/12) had ductal carcinoma compared with only 64% (16/25) of Whites (P=0.017). CONCLUSIONS: Chemotherapy with B improved pCR in BC patients, but was associated with significant toxicity and rare but very serious complications. The improvement was more pronounced in AA patients, those with ductal carcinoma, and those with estrogen receptor-/progesteron receptor - BC.ClinicalTrials.gov Identifier: NCT00203502.

Percutaneous excisional breast biopsy.

BACKGROUND: The utility of the vacuum-assisted breast biopsy device (VABB) under stereotactic guidance is well established. We hypothesized that the complete removal of small benign lesions under ultrasonography guidance in an outpatient setting could be obtained with minimal morbidity with the multidirectional hand held vacuum-assisted biopsy. METHODS: Patients enrolled in this study underwent an ultrasound-guided minimally invasive excisional breast biopsy through a 3-mm incision. Removal of the abnormality was accomplished with a handheld 8- or 11-gauge Mammotome. RESULTS: Eighty-one patients had 101 lesions excised. The average (+/- SD) age of the participants was 46.8 +/- 15.4 years. The average size of the lesions was 1.15 +/- 0.43 cm (range 0.5 cm to 2.0 cm). Ninety-four lesions (93%) had benign pathology, five lesions (5%) were malignant, and two (2%) lesions had atypical hyperplasia. Six-month baseline mammogram performed in 71% of patients more than 40 years old documented resolution of percutaneously removed lesions. CONCLUSIONS: Vacuum-assisted excisional breast biopsy under ultrasound guidance is an effective technique for the therapeutic management of benign lesions.

Touch preparation of breast core needle specimens is a new method for same-day diagnosis.

BACKGROUND: Touch preparation cytology (TPC) has proven to be a quick and accurate intraoperative diagnostic tool for excisional breast biopsy, margins and sentinel nodes. We hypothesized that TPC of core needle biopsy (CNB) specimens can provide a same-day diagnosis in the outpatient setting. METHODS: Outpatients presenting with breast lesions underwent TPC of biopsy cores performed by biopsy gun or vacuum-assisted CNB. The TPC results were compared with the final diagnosis of CNB specimens. RESULTS: In all, 199 CNB and TP were performed between August 1997 and October 2002. Twenty-nine percent of lesions were malignant. Touch preparation was deferred in 21% of cases. In the remaining 157 evaluable cases, TPC had an accuracy of 89% and a false negative rate of 26%. The sensitivity, specificity, positive predictive value and negative predictive value of TPC were 74%, 97%, 93%, and 86% respectively. CONCLUSIONS: Touch preparation cytology on CNB can be performed simply in the outpatient setting. Collaboration between the surgeon and pathologist allows TP to be an accurate means of same-day pathological determination.

A qualitative study of the experiences of one group of African Americans in pursuit of a career in academic medicine.

Recent reports demonstrate that medical school enrollment of minority students has continuously declined over the past several years and underrepresented minorities (URMs) continue to account for a disproportionately low percentage (less than 4%) of full-time academic faculty at medical schools in the United States. This article reports on a qualitative research project to examine the sociocultural experiences that influenced one group of minority physicians pursuing an academic medical career. Nine African American faculty, one resident, and one fellow from a Southern medical school of 574 full-time clinical and basic faculty completed 25 open-ended questions on a structured, qualitative interview plus background demographics. These nine faculty represented 82% (N = 11) of the total number of African American clinical and basic scientist faculty on campus at the end of the 1999 academic year. The narrative interviews describe key decision points, environmental and economic influences, and cultural experiences that affected faculty career choices and illustrate the real-life experiences of current minority faculty and scientists. These narratives contain significant messages for addressing policy on school campuses to improve the opportunities and likelihood of increasing the proportion of minority physicians and scientists.

Reducing cancer disparities through community engagement in policy development: the role of cancer councils.

Cancer is the second leading cause of death in the U.S and a source of large racial and ethnic disparities in population health. Policy development is a powerful but sometimes overlooked public health tool for reducing cancer burden and disparities. Along with other partners in the public health system, community-based organizations such as local cancer councils can play valuable roles in developing policies that are responsive to community needs and in mobilizing resources to support policy adoption and implementation. This paper examines the current and potential roles played by local cancer councils to reduce cancer burden and disparities. Responsive public health systems require vehicles for communities to engage in policy development. Cancer councils provide promising models of engagement. Untapped opportunities exist for enhancing policy development through cancer councils, such as expanding targets of engagement to include private-sector stakeholders and expanding methods of engagement utilizing the Affordable Care Act's Prevention and Public Health Fund.

Oncologic safety of nipple skin-sparing or total skin-sparing mastectomies with immediate reconstruction.

BACKGROUND: Success with skin-sparing mastectomy (SSM) has led to the reconsideration of the necessity to remove the skin overlying the nipple-areola complex. The aim of our study was to compare complications and local recurrence in patients undergoing SSM and total skin-sparing mastectomy (TSSM) with immediate reconstruction. METHODS: This IRB-approved retrospective study involved patients who underwent mastectomy with reconstruction (1998 to 2010). Patient demographics, tumor characteristics, type of surgery, cosmesis, postoperative complications, and recurrence were analyzed. RESULTS: The 293 patients in our study group had a total of 508 procedures: 281 TSSMs and 227 SSMs, distributed among 215 patients with bilateral procedures and 78 with unilateral operations. Mean age was 51.2 ± 10.9 years for TSSM and 53.1 ± 11.5 years for SSM. The average tumor size was 1.9 ± 1.6 cm for TSSM versus 2.1 ± 1.7 cm for the SSM group. The overall complication rate (TSSM 7.1% [20 of 281] and SSM 6.2% [14 of 227], p = 0.67) and local-regional recurrence rate (TSSM 6% [7 of 152] and SSM 5.0% [7 of 141], p = 0.89) were comparable. The TSSM rating was significantly higher (score 9.2 ± 1.1) than the SSM group (score 8.3 ± 1.9, p = 0.04). CONCLUSION: TSSM appears to be oncologically safe with superior cosmesis, affords one-step immediate reconstruction, and can be offered to patients with stages I and II breast cancer and those who have been down-staged with neoadjuvant chemotherapy.

Stage migration with sentinel node biopsy in breast cancer.

BACKGROUND: Axillary staging provides the single most important piece of prognostic information in breast cancer patients. This retrospective study was performed to document the phenomenon of stage migration. METHODS: Of 392 patients, 5 (1%) failed identification of sentinel lymph nodes (SLNs) and therefore underwent axillary lymph node dissection (ALND). Four patients (80%) had metastatic lymph nodes, 302 (77%) patients had negative SLNs, 47 (15%) underwent ALND, 85 (22%) had positive SLNs, 11 (13%) received adjuvant radiation treatment to the axilla, and 74 (87%) underwent completion ALND. RESULTS: The median (quartiles) follow-up period was 29 months (19-46 mo). Twenty of 392 (5%) patients had disease relapse; 2 of which were local (.5%) and the rest were systemic. Earlier relapse was related significantly to lymph node status, tumor grade, and tumor size. SLN-negative patients who did not receive ALND had a relapse rate of 2.3% (6 of 256) compared with 0% in those who were truly negative based on confirmatory ALND. SLN-positive patients who did not receive ALND had a 9% (1 of 11) relapse rate. DISCUSSION: The stage-matched pattern of relapse between SLN biopsy and ALND patients revealed lower relapse rates in SLN biopsy-staged patients, documenting the stage migration phenomenon.