Radiation therapy after sentinel lymph node biopsy for early stage breast cancer using a magnetic tracer: Results of a single institutional prospective study of tolerance.

PURPOSE: . The aim of the study was, through a single institutional analysis of a large population of breast cancer patients, to assess the feasibility of and the tolerance to radiotherapy after the use of magnetic detection method for sentinel lymph node biopsy. MATERIAL AND METHODS: The super paramagnetic iron oxide particles database was collected prospectively and identified 520 cases from October 2013 to December 2016 at our institution. All of them received super paramagnetic iron oxide particles injection 20minutes before the surgical procedure and some of them received also isotope technique. Injection site for super paramagnetic iron oxide particles and isotope was periareolar. Among them, 288 patients received adjuvant radiotherapy. In our study, we evaluated the tolerance of postoperative radiotherapy. RESULTS: The median age of the patients was 64 years. The median follow-up period was 16 months (range: 1-42 months). Double detection of sentinel lymph node was done in the first 30 patients (10.4%). The sentinel lymph node identification rate was 99.7% (287 out of 288). There were 34 axillary lymph node dissections, of which 58.8% were realized straightaway. The total radiation dose was 50Gy EQD2 (range: 28.5-66Gy). Regarding the occurrence of radiodermatitis, 95.8% of patients had grade 0-2 radiodermatitis and 1% had grade 3. During follow-up, 19.4% of patients developed grade 1-2 post-therapeutic fibrosis (of which 92.9% grade 1). CONCLUSION: The results of this large-scale study show that the radiotherapy after sentinel lymph node biopsy using super paramagnetic iron oxide particles is feasible, and that no increase of the toxicity was observed.

Percepção dos internos de uma faculdade de medicina sobre o câncer de mama e reconstrução mamária / Perception of breast cancer and breast reconstruction in medical school students

Introdução: O câncer de mama é o tipo mais comum entre as mulheres no mundo e no Brasil, depois do câncer de pele não melanoma. O objetivo é avaliar a percepção dos estudantes de medicina sobre o câncer de mama e reconstrução mamária. Métodos: Trata-se de estudo transversal piloto composto por alunos do 5º e 6º ano de curso de medicina, realizado de maio de 2016. Resultados: Foi questionado se há possibilidade de reconstrução mamária após a mastectomia, sendo que de forma unânime 100% foi sim. Para melhor caracterização, foi perguntado se a reconstrução pode ser feita no mesmo momento da mastectomia, 69 (57,5%) estudantes marcaram sim e 51 (42,5%) negaram. Em análise aos conhecimentos cirúrgicos, foi perguntado se os mesmos conhecem alguma técnica de reconstrução mamária, sendo que 49 (40,83%) responderam que sim e 71 (59,16%) negaram conhecer. Em relação ao encaminhamento à especialidade médica mais preparada para acompanhar e realizar a reconstrução mamária, 93 (77,5%) discentes elegeram a cirurgia plástica e 26 (21,66%) a mastologia. Quanto à possibilidade de reconstrução de mama em pacientes que farão radioterapia adjuvante, 66 (55%) responderam sim, 51 (42,5%) não e 3 (2,5%) não souberam responder. Quanto a esta possibilidade mesmo em pacientes com implantes de silicone, 59 (49,16%) responderam sim, 3 (2,5%) responderam não e 58 (48,33%) afirmaram não saber sobre o assunto. Conclusão: Observou-se que a Mastologia vem ganhando espaço na reconstrução de mama, inclusive no meio acadêmico, devido ao alto percentual de resposta de que a mesma seria mais preparada do que a Cirurgia Plástica para reconstrução mamária.

Introduction: Breast cancer is the most common type of cancer among women in the world and in Brazil, after non-melanoma skin cancer. Our objective was to evaluate the medical students' perception of breast cancer and breast reconstruction. Methods: This is a cross-sectional pilot study composed of students from the fifth and sixth year of medical school, in May 2016. Results: We questioned whether there is a possibility of breast reconstruction after mastectomy, and the response was unanimous (100%). For a better characterization, we asked if the reconstruction could be done at the same time as the mastectomy, and 69 (57.5%) students said yes and 51 (42.5%) denied. In the analysis of surgical knowledge, we asked whether they knew any breast reconstruction technique, and 49 (40.83%) answered yes and 71 (59.16%) denied knowing. With regard to referral to a medical specialist who was better prepared to follow and perform breast reconstruction, 93 (77.5%) students chose plastic surgery and 26 (21.66%) chose mastology. Regarding the possibility of breast reconstruction in patients who need to undergo adjuvant radiotherapy, 66 (55%) answered yes, 51 (42.5%) did not answer, and three (2.5%) did not know how to respond. Regarding this possibility in patients with silicone implants, 59 (49.16%) answered yes, three (2.5%) answered no, and 58 (48.33%) said they did not know about the subject. Conclusion: We conclude that mastology has been gaining immense interest in the field of breast reconstruction, including in the academic world, based on the high percentage of respondents who stated that they are better prepared for this procedure than for plastic surgery for breast reconstruction.

Patterns of Care for Localized Breast Cancer in Oklahoma, 2003-2006.

Despite well-established clinical guidelines for breast cancer treatment, Standard of Care (SOC) is not universal in the U.S. The purpose of this study was to describe the extent to which patients receive guideline-based, stage-specific treatments for localized female breast cancer in Oklahoma. Data were obtained from the Oklahoma Central Cancer Registry for the period 2003-2006. We included localized, invasive female breast cancers and analyzed both treatment and demographic factors. We used the National Comprehensive Cancer Network (NCCN) treatment guidelines to determine SOC. Among women who received breast conserving surgery (BCS), we used logistic regression to evaluate factors related to SOC. In Oklahoma, 92 percent of the 4,177 localized breast cancer patients were treated with recognized SOC. In women aged ≥65 years with BCS, those ≥75 years had a lower adjusted odds of meeting SOC than did those without insurance, with comorbid conditions, or whose comorbid status was unknown. Among women aged <65 years, those with Medicare/Medicaid, Medicare only, or without insurance, along with comorbid conditions, had a lower adjusted odds of meeting SOC. Overall, 92 percent of women met SOC. Factors such as age, insurance type, and comorbid conditions were associated with meeting SOC.

Patterns of locoregional treatment for nonmetastatic breast cancer by patient and health system factors.

BACKGROUND: The purpose of this study was to examine local definitive therapy for nonmetastatic breast cancer with the Patterns of Care Breast and Prostate Cancer (POCBP) study of the National Program of Cancer Registries (Centers for Disease Control and Prevention). METHODS: POCBP medical record data were re-abstracted in 7 state/regional registry systems (Georgia, North Carolina, Kentucky, Louisiana, Wisconsin, Minnesota, and California) to verify data quality and assess treatment patterns in the population. National Comprehensive Cancer Network clinical practice treatment guidelines were aligned with American Joint Committee on Cancer staging at diagnosis to appraise care. RESULTS: Six thousand five hundred five of 9142 patients with registry-confirmed breast cancer were coded as having primary disease with stage 0 to IIIA tumors and were included in the study. Approximately 88% received guideline-concordant locoregional treatment. However, this outcome varied by age group: 92% of women < age 50 versus 80% of women ≥ age 70 years old received guideline care (P < 0.01). Characteristics that best discriminated receipt (no/yes) of guideline-concordant care in receiver operating curve analyses were the receipt of breast-conserving surgery (BCS) versus mastectomy (C = 0.70), patient age (C = 0.62), a greater tumor stage (C = 0.60), public insurance (C = 0.58), and the presence of at least mild comorbidity (C = 0.55). Radiation therapy (RT) after BCS was the most omitted treatment component causing nonconcordance in the study population. In multivariate regression, the effects of the treatment facility, ductal carcinoma in situ, race, and comorbidity on nonconcordant care differed by age group. CONCLUSIONS: Patterns of underuse of standard therapies for breast cancer vary by age group and BCS use, with which there is a risk of omission of RT.

Understanding process-of-care delays in surgical treatment of breast cancer at a comprehensive cancer center.

Few studies have examined care processes within providers' and institutions' control that expedite or delay care. The authors investigated the timeliness of breast cancer care at a comprehensive cancer center, focusing on factors influencing the time from initial consultation to first definitive surgery (FDS). The care of 1,461 women with breast cancer who underwent surgery at Dana-Farber/Brigham and Women's Cancer Center from 2011 to 2013 was studied. The interval between consultation and FDS was calculated to identify variation in timeliness of care based on procedure, provider, and patients' sociodemographic characteristics. Targets of 14 days for lumpectomy and mastectomy and 28 days from mastectomy with immediate reconstruction were set and used to define delay. Mean days between consultation and FDS was 21.6 (range 1-175, sd 15.8) for lumpectomy, 36.7 (5-230, 29.1) for mastectomy, and 37.5 (7-111, 16) for mastectomy with reconstruction. Patients under 40 were less likely to be delayed (OR = 0.56, 95 % CI = 0.33-0.94, p = 0.03). Patients undergoing mastectomy alone (OR = 2.64, 95 % CI = 1.80-3.89, p < 0.0001) and mastectomy with immediate reconstruction (OR = 1.34 95 % CI = 1.00-1.79, p = 0.05) were more likely to be delayed when compared to lumpectomy. Substantial variation in surgical timeliness was identified. This study provides insight into targets for improvement including better coordination with plastic surgery and streamlining pre-operative testing. Cancer centers may consider investing in efforts to measure and improve the timeliness of cancer care.

Determinants of breast conservation rates: reasons for mastectomy at a comprehensive cancer center.

Bias in referral patterns and variations in multi-disciplinary management may impact breast conservation therapy (BCT) rates between hospitals. Retrospective studies of BCT rates are limited by their inability to differentiate indicated mastectomies versus those chosen by the patient. Our prospective breast cancer data base was queried for patients with invasive breast cancer who underwent surgical therapy at the University of Michigan over a 3-year period. Demographics, stage and histology were recorded along with the reason mastectomy was performed, categorized as "by need" (contraindication to BCT) or "by choice." Multivariate analysis was used to identify factors significantly associated with mastectomy by choice. BCT was associated with tumor size, histology and nodal status, but not older age, either by choice or by need. Of the 34% of patients initially felt to be poor candidates for BCT, it was absolutely contraindicated in 44%, while 56% were thought to have a tumor-to-breast size ratio too large for successful BCT. Of this latter group, 80% underwent neo-adjuvant chemotherapy in an attempt to downstage the primary tumor and perform BCT, which was successful in over half the patients. For the patients initially thought to be good candidates for BCT, only 15% chose to undergo mastectomy, while 5% eventually required mastectomy due to failed attempts to achieve negative margins. Overall, the BCT rate was 63%, however without the use of neo-adjuvant chemotherapy, the BCT rate would have been only 53%. At a tertiary referral center, BCT rates are driven more by contraindications than patient choice, and may be heavily skewed towards mastectomy due to referral patterns. In addition to tumor factors such as stage and histology, BCT rate can be dramatically impacted by neo-adjuvant chemotherapy or genetic counseling. Examining BCT rates alone as a measure of quality, therefore, is not an appropriate standard across institutions serving diverse populations.

[Trends and variation in breast conserving surgery in the southeast and east of the Netherlands over the period 1990-2002]. / Trends en variaties in mammasparende operaties in Zuidoost- en Oost-Nederland in de periode 1990-2002.

OBJECTIVE: To give an overview of the trends and variation in breast-conserving surgery in patients with a breast tumour < or = 2 cm (pT1) or > 2 and < or = 5 cm (pT2), treated in general hospitals in the southeast and east of the Netherlands. DESIGN: Descriptive. METHOD: Data from the regional cancer registries of the Comprehensive Cancer Centre South (CS) and the Comprehensive Cancer Centre Stedendriehoek Twente (CST) were used to study trends and variations in the use of breast-conserving surgery in 12,985 pT1 tumours and 8,893 pT2 tumours in the period 1990-2002. RESULTS: The mean percentage of patients that underwent breast-conserving surgery from 1990-2002 was 54 in the CS region and 43 in the CST region. In patients < 50 years old with a pT1 tumour a decrease in the percentage of breast-conserving surgery from 73 to 64 was seen in the CS region, and in the CST region this percentage decreased from 72 to 51. In pT2 tumours a decrease from 47 to 37 was seen in the CS region and from 34 to 31 in the CST region. In patients of 50 to 69 years of age with a pT1 tumour, the percentage of breast-conserving surgery increased in the CS region from 67 to 74 and in the CST region from 54 to 61. In pT2 tumours it increased from 40 to 44 and from 25 to 37. In patients > or = 70 years the percentage of breast-conserving surgery in pT1 tumours increased from 37 to 59 in the CS region and in the CST region from 42 to 50. In pT2 tumours it increased from 20 to 31 in the CS region whereas it remained 17 in the CST region. The variation in breast-conserving surgery between hospitals in the period 1999-2002 was large. The percentage of breast-conserving surgery in patients with pT1 tumours varied between 47 and 86 in the hospitals in the CS region and between 54 and 71 in the CST region. In patients with a pT2 tumour the percentages varied between 25 and 43 in the CST region and between 16 and 64 in the CS region. CONCLUSION: More than 20 years after the introduction of breast-conserving surgery a large regional variation still exists in the use of this treatment, in the CS region in particular. There is also wide inter-hospital variation.

Breast conservation therapy rates are no different in medically indigent versus insured patients with early stage breast cancer.

PURPOSE: Multiple prospective, randomized studies show that breast conservation therapy (BCT) results in survival rates equal to mastectomy (Mx) for patients with early stage breast cancer (ESBC). Nevertheless, BCT remains underused in certain areas of the nation, without clearly definable reasons. Several studies have implicated socioeconomic status as one potential cause for this disparity in BCT usage. We sought to compare BCT rates in the medically indigent versus insured patients, within the same institution. METHODS: Data from 1993 to 2000, collected from the institutional tumor registry and the hospital's claims records, were analyzed for 928 patients with ESBC (Stages 0, I, and II), treated at a single medical center. The same surgeons treated both insured and indigent patients. Patients treated by BCT or Mx were compared for age, race, stage, insurance status, access to a radiation therapy center, surgeon, and year of diagnosis. RESULTS: Patient age, race, surgeon, or insurance status did not significantly affect the rate of mastectomy. Stage I patients (P < 0.001) and those treated after 1995 had higher BCT rates (54.9% in 1993-95 vs. 70.7% in 1996-2000; P < 0.001). Travel distance to a radiation therapy center had no significant impact on BCT rates, except for patients >40 miles distant. CONCLUSIONS: These data refute the hypothesis that socioeconomic status, as reflected by medical insurance, is a determinant of BCT in women with ESBC. Distance of <40 miles to a radiation therapy facility, Stage I disease, and diagnosis after 1995 were factors associated with higher BCT rates.

Local recurrence and survival among black women with early-stage breast cancer treated with breast-conservation therapy or mastectomy.

BACKGROUND: Black women with breast cancer have significantly worse survival rates and receive diagnoses at relatively younger ages, compared with white patients with breast cancer, in the United States. Young age at diagnosis has been associated with increased risk for local recurrence (LR) after breast-conservation therapy (BCT). The goal of this study was to evaluate the impact of age and BCT on LR and survival rates among black patients with breast cancer. METHODS: The records for 363 black women treated for breast cancer (excluding stage IV disease) at a comprehensive cancer center were reviewed. RESULTS: Fifty-eight percent of patients (n = 211) had tumors < or = 5 cm in diameter. Forty-two of these patients (19.9%) received BCT; the LR rate for this group was 9.8%. A total of 168 patients (79.6%) underwent mastectomy; the LR rate for this group was 8.9%. Data on the primary operation were unavailable for one patient. Five-year disease-free survival rates were similar for patients treated with BCT and those treated with mastectomy (88% and 73%, respectively). LR was associated with significant decreases in 5-year overall survival rates for both the BCT group (67% vs. 95%, P < .01) and the mastectomy group (43% vs. 76%, P < .01). LR and 5-year disease-specific survival rates were similar for patients <50 years of age and patients > or = 50 years of age, regardless of treatment. CONCLUSIONS: LR and survival rates are not compromised by the use of BCT among black American patients. LR is associated with an increased risk of breast cancer death, regardless of treatment type. Younger age at diagnosis was not associated with an increased rate of LR after BCT in this series.