Comparison of Characteristics of Breast Cancer Detected through Different Imaging Modalities in a Large Cohort of Hong Kong Chinese Women: Implication of Imaging Choice on Upcoming Local Screening Program.

Background: We compared the clinico-radio-pathological characteristics of breast cancer detected through mammogram (MMG) and ultrasound (USG) and discuss the implication of the choice of imaging as the future direction of our recently launched local screening program. Methods: Retrospective study of 14613 Hong Kong Chinese female patients with histologically confirmed breast cancer registered in the Hong Kong Breast Cancer Registry between January 2006 and February 2020. Patients were classified into four groups based on the mode of breast cancer detection (detectable by both mammogram and ultrasound (MMG+/USG+), mammogram only (MMG+/USG-), ultrasound only (MMG-/USG+), or not detectable by either (MMG-/USG-). Characteristics of breast cancer detected were compared, including patient demographics, breast density on MMG, mode of presentation, tumour size, histological type, and staging. Types of mammographic abnormalities were also evaluated for MMG+ subgroups. Results: 85% of the cancers were detectable by MMG, while USG detected an additional 9%. MMG+/USG+ cancers were larger, more advanced in stage, often of symptomatic presentation, and commonly manifested as mammographic mass. MMG+/USG- cancers were more likely of asymptomatic presentation, manifested as microcalcifications, and of earlier stage and to be ductal carcinoma in situ. MMG-/USG+ cancers were more likely seen in young patients and those with denser breasts and more likely of symptomatic presentation. MMG-/USG- cancers were often smaller and found in denser breasts. Conclusion: Mammogram has a good detection rate of cancers in our local population. It has superiority in detecting early cancers by detecting microcalcifications. Our current study agrees that ultrasound is one of the key adjunct tools of breast cancer detection.

Biomarkers of Exposure for Dual Use of Electronic Cigarettes and Combustible Cigarettes: Nicotelline, NNAL, and Total Nicotine Equivalents.

INTRODUCTION: Dual use of electronic cigarettes (e-cigarettes) and combustible cigarettes is a major public health issue. It is generally accepted that exclusive e-cigarette use is less harmful than exclusive combustible cigarette use, but most e-cigarette users continue to smoke combustible cigarettes as well. To what extent the use of e-cigarettes reduces harm in people who continue to smoke combustible cigarettes has been debated. The aim of this study was to explore the utility of biomarkers as measures of dual use. METHODS: In two human studies of participants who used e-cigarettes only or both combustible cigarettes and e-cigarettes, we measured urine concentrations of the metabolites of nicotine (total nicotine equivalents) as well as two biomarkers of tobacco exposure: 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), a tobacco-specific carcinogen metabolite, and nicotelline, a tobacco alkaloid not found in significant concentrations in e-cigarette products. RESULTS: The presence of nicotine metabolites indicates either e-cigarette or combustible cigarette use. Nicotelline (half-life of 2-3 hours) indicates recent combustible cigarette use and NNAL (half-life of 10 days or more), indicates combustible cigarette use occurring within several weeks prior to sample collection. CONCLUSIONS: Nicotelline and NNAL are useful biomarkers for combustible tobacco use in users e-cigarettes. The application of these biomarkers provides a tool to help assess whether, or to what extent, dual use of e-cigarettes and combustible cigarettes reduces harm compared to sole use of combustible cigarettes. These biomarkers can also verify exclusive use of e-cigarettes over short (24 hour) or long (several week) time periods. IMPLICATIONS: To what extent dual use of e-cigarettes and combustible cigarettes reduce harm compared to smoking combustible cigarettes only is of considerable public health interest. We show that the levels of the minor tobacco alkaloid nicotelline and the nitrosamine 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) are extremely low in electronic cigarette fluids. The urine biomarkers nicotelline and the NNK metabolite 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) are indicative of cigarette smoking and can be used to assess recent and past smoking in dual users.

The Use of Serratus Anterior Fascial Flap in Integrated Mastectomy and Implant Reconstruction.

BACKGROUND: Tissue reinforcement with acellular dermal matrix (ADM) in implant-based breast reconstruction contributes to the coverage of the implant and avoids its direct exposure to skin incision, yet not without risk of infection. Our integrated technique makes use of the in situ serratus anterior fascia as a support of the implant following mastectomy, which serves the same purpose of ADM in terms of aesthetic outcomes, but minimizes the hazard of infective complications. METHODS: We retrospectively reviewed all the nipple-sparing mastectomies with direct-to-implant immediate reconstruction in Hong Kong Sanatorium and Hospital from 2012 to 2016. The authors made use of the serratus anterior fascial flap as inferolateral coverage for the subpectoral implant. Consequently, the implant would be completely covered by autologous tissues. RESULTS: Among the 51 women included, primary breast cancers account for 91.8% of our indications for these 61 procedures of integrated mastectomy and implant reconstruction. The remaining five (8.2%) were performed as contralateral prophylactic mastectomy. Almost three quarters of the patients had a bra cup size of B or below. After a mean follow-up of 28.9 months, there was no reported post-operative complication of skin flap or nipple-areolar complex necrosis, or infection or extrusion of the implant. CONCLUSIONS: Our series support that the serratus anterior fascial flap could provide autologous coverage in integrated mastectomy and implant breast reconstruction, especially in small- and medium-sized breasts. Appropriate patient selection, as well as meticulous surgical technique, is critical for its success.

Associations between dietary patterns and the risk of breast cancer: a systematic review and meta-analysis of observational studies.

BACKGROUND: Epidemiologic evidence suggests that certain dietary patterns were associated with breast cancer risk, but the results have been inconclusive. We assessed the associations between different dietary patterns and the risk of breast cancer by conducting a meta-analysis of observational studies. METHODS: Relevant articles were searched in PubMed, Embase, and Cochrane library databases through September 2017. Multivariable-adjusted relative risks (RRs) and 95% confidence intervals (CIs) comparing the highest and lowest categories of Western and prudent dietary patterns were combined by using the random-effects meta-analyses. RESULTS: We identified 32 eligible articles including 14 cohort and 18 case-control studies (34 Western and 35 prudent studies). The pooled analyses found that a Western dietary pattern was associated with a 14% increased risk (RR 1.14, 95% CI 1.02, 1.28), whereas a prudent dietary pattern was associated with an 18% reduced risk of breast cancer (RR 0.82, 95% CI 0.75, 0.89). In addition, sub-group analyses showed that the positive association between a Western dietary pattern and breast cancer risk was significant among postmenopausal (RR 1.20, 95% CI 1.06, 1.35), but not premenopausal women (RR 1.18, 95% CI 0.99, 1.40), and significant for hormone receptor-positive tumors (RR 1.18, 95% CI 1.04, 1.33), but not receptor-negative tumors (RR 0.97, 95% CI 0.83, 1.12). In contrast, the inverse association between a prudent dietary pattern and breast cancer was significant in premenopausal (RR 0.77, 95% CI 0.61, 0.98), but not postmenopausal women (RR 0.88, 95% CI 0.74, 1.03), and significant for both hormone receptor-positive and receptor-negative tumors. CONCLUSIONS: The results of the current meta-analysis suggest a possible increased risk of breast cancer associated with a Western dietary pattern and a reduced risk with a prudent dietary pattern. Large-scale cohort studies with a high quality need to be conducted to further confirm the findings of the current meta-analysis. As dietary patterns are modifiable, these findings may provide viable strategies for breast cancer prevention through changes in dietary intake.

Changing pattern of recurrences in patients with early HER2-positive breast cancer receiving neoadjuvant chemotherapy in the era of dual anti-HER2 therapy.

BACKGROUND: Over the last 10 years, there has been a major treatment revolution for early human epidermal growth factor receptor 2 (HER2)-positive breast cancer. We aimed to explore the outcome of different neoadjuvant chemotherapy in a tertiary breast cancer centre with early HER2-positive breast cancer as well as factors associated with pathological complete response (pCR) and recurrence-free survival (RFS). The pattern of recurrence was also studied. METHODS: This retrospective study analysed the outcome of neoadjuvant chemotherapy during the period 2005 to 2016 in a tertiary referral centre in Hong Kong. Patients were divided into three groups according to the neoadjuvant chemotherapy they received: chemotherapy only (Chemo), chemotherapy plus trastuzumab (Chemo-H) and chemotherapy plus double anti-HER2 therapy (Chemo-DH). RESULTS: There were 226 cases analysed during the study period. The rate of pCR was 5%, 26% and 60% in Chemo, Chemo-H and Chemo-DH groups, respectively (Chemo vs pooled Chemo-H/DH: p<0.0001; Chemo-H vs Chemo-DH: p<0.0001). This was accompanied by a trend of increased rate of breast conservation therapy in Chemo-DH cohort (p=0.046). Use of double anti-HER2 therapy, older age (>50 years) and hormone receptor negativity were associated with more pCR. pCR was associated with better RFS. Among those with recurrence, the proportion of patients with brain as the only site of recurrence increased remarkably with more efficacious anti-HER2 treatment (0% in Chemo, 8% in Chemo-H, 67% in Chemo-DH). CONCLUSION: pCR remains an important predictive factor for improved RFS. In the era of dual anti-HER2 neoadjuvant therapy, brain-only recurrence poses a challenge to disease surveillance and treatment.

Oncological Safety and Technical Feasibility of Nipple-Sparing Mastectomy for Breast Cancer: The Hong Kong Experience.

BACKGROUND: Nipple-sparing mastectomy (NSM) has gained widespread popularity in recent years. Nonetheless, patient selection, technical consideration and oncological safety of its extension to breast cancer treatment remain uncertain. Few publications have reviewed the application of NSM in Asian populations. METHODS: We retrospectively reviewed 91 women with malignant breast tumours, who underwent 97 NSM in Hong Kong Sanatorium and Hospital from 2009 to 2015. Breast cancer patients who required mastectomy and opted for immediate reconstruction were considered for NSM if they showed no obvious nipple involvement clinically. All breast specimens were subjected to intraoperative pathological examination of the retroareolar tissue to exclude occult tumour infiltration before the final decision of nipple-areola complex (NAC) preservation. Clinical parameters, tumour characteristics and oncological outcomes were analyzed. RESULTS: Carcinoma of the breast accounts for 99.0% of our indications for therapeutic NSM. Almost all NSM were accompanied with immediate reconstruction. Abnormal pathology was shown in retroareolar tissue of ten patients (10.3%), and seven of these NAC were excised due to tumour involvement detected by intraoperative frozen section. Six (6.2%) NSM were complicated with superficial epidermolysis. Yet, there was no delayed NAC excision because of nipple necrosis. Overall NAC preservation rate reached 92.8%. Local and/or distant recurrences occurred in four patients (4.1%) after a mean follow-up of 20.6 months. One NAC recurrence was documented. CONCLUSION: Our series support the oncological safety of NSM after exclusion of neoplastic NAC involvement preliminarily by intraoperative frozen section and definitively by final pathology. Its technical feasibility is well proven by the low nipple necrosis rate.

Nipple Preservation in Breast Cancer Associated with Nipple Discharge.

BACKGROUND: Breast carcinoma presented with nipple discharge is a rare condition. There is theoretical concern about preserving nipple in these patients since the risk of nipple-areolar complex involvement may be greater, but not many studies in the literature have addressed on this issue. The aim of the current study was to determine the incidence and outcome of nipple preservation in breast cancer associated with nipple discharge. METHODS: Medical records of patients who were diagnosed to have breast carcinoma and presented with nipple discharge from May 2009 to October 2014 were retrospectively reviewed. RESULTS: Sixty patients presented with nipple discharge were diagnosed with breast cancer, which represent 3.8 % of all patients who underwent breast cancer surgery in our unit during the study period. Forty-six patients (76.7 %) had nipple discharge as their only symptom, while the rest also presented with breast mass clinically or radiologically. All patients had mammogram and ultrasound performed, and 53.3 and 63.3 % respectively showed suspicious findings. Forty-one out of 46 (89.1 %) nipple discharge cytology were inadequate or benign. Thirty-two microdochectomy were performed. Routine frozen section was utilized intra-operatively to ensure clear margins. The most common histology was ductal carcinoma in situ (DCIS) (n = 29, 48.3 %), followed by DCIS with invasive ductal carcinoma (n = 23, 38.3 %). Regarding treatment, 26 patients (43.3 %) had nipple preserved, including 21 breast conservative surgery and five nipple-sparing mastectomies. Overall, no local or systemic recurrence was observed at a median follow-up of 27 months. Ten out of 34 (29.4 %) mastectomy specimens showed NAC involvement on pathology. By comparing patients with NAC preserved to patients with NAC removed, no significant preoperative predictors were identified. CONCLUSION: Breast carcinoma patients who present with nipple discharge usually have early-stage cancer. Presence of nipple discharge is not equivalent to NAC involvement. Nipple preservation can be oncologically safe if negative margins are ascertained.

Lobular breast cancers lack the inverse relationship between ER/PR status and cell growth rate characteristic of ductal cancers in two independent patient cohorts: implications for tumor biology and adjuvant therapy.

BACKGROUND: Although invasive lobular carcinoma (ILC) of the breast differs from invasive ductal carcinoma (IDC) in numerous respects - including its genetics, clinical phenotype, metastatic pattern, and chemosensitivity - most experts continue to manage ILC and IDC identically in the adjuvant setting. Here we address this discrepancy by comparing early-stage ILC and IDC in two breast cancer patient cohorts of differing nationality and ethnicity. METHODS: The clinicopathologic features of 2029 consecutive breast cancer patients diagnosed in Hong Kong (HK) and Australia (AUS) were compared. Interrelationships between tumor histology and other clinicopathologic variables, including ER/PR and Ki67, were analysed. RESULTS: Two hundred thirty-nine patients were identified with ILC (11.8%) and 1790 patients with IDC. AUS patients were older (p <0.001) and more often postmenopausal (p <0.03) than HK patients. As expected, ILC tumors were lower in grade and proliferative rate, and more often ER-positive and HER2-negative, than IDC (p <0.002); yet despite this, ILC tumors were as likely as IDC to present with nodal metastases (p >0.7). Moreover, whereas IDC tumors exhibited a strongly negative relationship between ER/PR and Ki67 status (p <0.0005), ILC tumors failed to demonstrate any such inverse relationship (p >0.6). CONCLUSION: These data imply that the primary adhesion defect in ILC underlies a secondary stromal-epithelial disconnect between hormonal signaling and tumor growth, suggesting in turn that this peritumoral feedback defect could reduce both the antimetastatic (adjuvant) and tumorilytic (palliative) efficacy of cytotoxic therapies for such tumors. Hence, we caution against assuming similar adjuvant chemotherapeutic survival benefits for ILC and IDC tumors with similar ER and Ki67, whether based on immunohistochemical or gene expression assays.

Initial experience with the Oncotype DX assay in decision-making for adjuvant therapy of early oestrogen receptor-positive breast cancer in Hong Kong.

OBJECTIVE: To examine the impact of the 21-gene Oncotype DX Breast Cancer Assay on the adjuvant treatment decision-making process for early-stage breast cancer in Hong Kong. DESIGN: Retrospective study. SETTING: Private hospital, Hong Kong. PATIENTS: Study included cases of early-stage breast cancer (T1-2N0-1M0, oestrogen receptor-positive, human epidermal growth factor receptor 2-negative) that were presented at a multidisciplinary breast meeting at a single site. Cases were selected for Oncotype DX testing with the assistance of Adjuvant! Online. The recommendations for adjuvant therapy before and after obtaining the Oncotype DX Recurrence Score results were analysed. RESULTS: A total of 154 cases that met the inclusion criteria were discussed at our multidisciplinary breast meeting. Of these, 64 cases with no clear recommendation by the Meeting Panel were selected for this study and reviewed. The distribution of Recurrence Score results was similar to that reported by others, with a somewhat higher proportion of low Recurrence Scores. Treatment recommendation was changed for 20 (31%) patients after the Oncotype DX result was received. Of the changes in treatment decisions, 16 (80%) were changes to lower-intensity regimens (either equipoise or hormonal therapy). The number of cases receiving an equipoise recommendation decreased by nine (82%), based on the additional information provided by the Oncotype DX test. CONCLUSION: The Oncotype DX Recurrence Score information impacts the decision-making process for adjuvant therapy for early-stage breast cancer in the multidisciplinary care setting in Hong Kong. A larger-scale study is required to gain more experience, evaluate its impact more thoroughly, and assess its cost-effectiveness.

Applying the Unified Theory of Acceptance and Use of Technology to Identify Factors Associated With Intention to Use Teledelivered Supportive Care Among Recently Diagnosed Breast Cancer Survivors During COVID-19 in Hong Kong: Cross-Sectional Survey.

BACKGROUND: Many supportive cancer care (SCC) services were teledelivered during COVID-19, but what facilitates patients' intentions to use teledelivered SCC is unknown. OBJECTIVE: The study aimed to use the unified theory of acceptance and use of technology to investigate the factors associated with the intentions of breast cancer survivors (BCS) in Hong Kong to use various types of teledelivered SCC (including psychosocial care, medical consultation, complementary care, peer support groups). Favorable telehealth-related perceptions (higher performance expectancy, lower effort expectancy, more facilitating conditions, positive social influences), less technological anxiety, and greater fear of COVID-19 were hypothesized to be associated with higher intentions to use teledelivered SCC. Moreover, the associations between telehealth-related perceptions and intentions to use teledelivered SCC were hypothesized to be moderated by education level, such that associations between telehealth-related perceptions and intentions to use teledelivered SCC would be stronger among those with a higher education level. METHODS: A sample of 209 (209/287, 72.8% completion rate) women diagnosed with breast cancer since the start of the COVID-19 outbreak in Hong Kong (ie, January 2020) were recruited from the Hong Kong Breast Cancer Registry to complete a cross-sectional survey between June 2022 and December 2022. Participants' intentions to use various types of teledelivered SCC (dependent variables), telehealth-related perceptions (independent variables), and sociodemographic variables (eg, education, as a moderator variable) were measured using self-reported, validated measures. RESULTS: Hierarchical regression analysis results showed that greater confidence using telehealth, performance expectancy (believing telehealth helps with daily tasks), social influence (important others encouraging telehealth use), and facilitating conditions (having resources for telehealth use) were associated with higher intentions to use teledelivered SCC (range: ß=0.16, P=.03 to ß=0.34, P<.001). Moreover, 2-way interactions emerged between education level and 2 of the telehealth perception variables. Education level moderated the associations between (1) performance expectancy and intention to use teledelivered complementary care (ß=0.34, P=.04) and (2) facilitating conditions and intention to use teledelivered peer support groups (ß=0.36, P=.03). The positive associations between those telehealth perceptions and intentions were only significant among those with a higher education level. CONCLUSIONS: The findings of this study implied that enhancing BCS' skills at using telehealth, BCS' and their important others' perceived benefits of telehealth, and providing assistance for telehealth use could increase BCS' intentions to use teledelivered SCC. For intentions to use specific types of SCC, addressing relevant factors (performance expectancy, facilitating conditions) might be particularly beneficial for those with a higher education level.

Impact of magnetic resonance imaging on preoperative planning for breast cancer surgery.

OBJECTIVES: To review the impact of preoperative breast magnetic resonance imaging on the management of planned surgery, and the appropriateness of any resulting alterations. DESIGN: Retrospective review. SETTING: A private hospital in Hong Kong. PATIENTS; For the 147 consecutive biopsy-proven breast cancer patients who underwent preoperative magnetic resonance imaging to determine tumour extent undergoing operation by a single surgeon between 1 January 2006 and 31 December 2009, the impact of magnetic resonance imaging findings was reviewed in terms of management alterations and their appropriateness. RESULTS: The most common indication for breast magnetic resonance imaging was the presence of multiple indeterminate shadows on ultrasound scans (53%), followed by ill-defined border of the main tumour on ultrasound scans (19%). In 66% (97 out of 147) of the patients, the extent of the operation was upgraded. Upgrading entailed: lumpectomy to wider lumpectomy (23 out of 97), lumpectomy to mastectomy (47 out of 97), lumpectomy to bilateral lumpectomy (15 out of 97), and other (12 out of 97). Mostly, these management changes were because magnetic resonance imaging showed more extensive disease (n=29), additional cancer foci (n=39), or contralateral disease (n=24). In five instances, upgrading was due to patient preference. In 34% (50 out of 147) of the patients, there was no change in the planned operation. Regarding 97 of the patients having altered management, in 12 the changes were considered inappropriately extensive (due to false-positive magnetic resonance imaging findings). In terms of magnetic resonance imaging detection of more extensive, multifocal, multicentric, or contralateral disease, the false-positive rate was 13% and false-negative rate 7%. Corresponding rates for sensitivity and specificity were 95% and 81%, using the final pathology as the gold standard. CONCLUSIONS: Preoperative magnetic resonance imaging had a clinically significant and mostly correct impact on management plans. Magnetic resonance imaging should be included as part of the preoperative investigation in patients planned for breast-conserving surgery, in whom there are doubts about the extent of the tumours based on conventional assessment.

Early data from the first population-wide breast cancer-specific registry in Hong Kong.

BACKGROUND: Current measures for breast cancer prevention and options for treatment adopted in Hong Kong are mainly based on research data and clinical evidence from overseas. It is essential to establish a cancer-specific registry to monitor the status of breast cancer in Hong Kong. OBJECTIVES: We summarized the current status of breast cancer in Hong Kong based on the data collected from Hong Kong Breast Cancer Registry (HKBCR). METHODS: Prevalent and newly diagnosed breast cancers (including in situ and invasive breast cancers) were registered in the HKBCR. Information on patient demographics, risk factors, medical information, and survival were analyzed and reported in this study. RESULTS: Data of 2,330 breast cancer patients were analyzed. We observed an earlier median age at diagnosis in Hong Kong than those reported in other countries. Distribution of cancer stage was: stage 0 (11.4%), stage I (31.4%), stage II (41%), stage III (12.5%), stage IV (0.8%), and unclassified (2.9%). The percentages of patients who received surgery, chemotherapy, radiation therapy, and endocrine therapy were 98.7, 67.9, 64.8, and 64.1%, respectively. At a median follow-up of 1.2 years, locoregional recurrence was recorded at 2%, distant recurrence at 2.8%, and breast-cancer-related mortality at 0.3%. CONCLUSIONS: The HKBCR serves as a surveillance program to monitor disease and treatment patterns. It is pivotal to support research for more effective breast cancer prevention and treatment strategies in Hong Kong.

Minor Tobacco Alkaloids as Biomarkers to Distinguish Combusted Tobacco Use From Electronic Nicotine Delivery Systems Use. Two New Analytical Methods.

Biomarkers for the use of electronic nicotine delivery systems (ENDS) are desirable for studies of the health effects of electronic cigarettes and related devices. However, the aerosols inhaled from these devices do not contain substances that are unique to this class of products, i.e., substances that are not present in cigarette smoke or those that do not have common environmental or dietary sources. Consequently, identifying selective biomarkers for ENDS use remains a challenge. If co-use of conventional tobacco products can be definitively ruled out, then nicotine and its metabolites are suitable for assessing exposure. Self-reports from questionnaires are often used to obtain information on product use. But self-reports may not always be accurate, and are not amenable to obtaining quantitative information on exposure. An alternative approach is to use selective biomarkers for conventional tobacco products to definitively rule out their use. In this article, we describe two new LC-MS/MS methods for the minor tobacco alkaloids anabasine, anatabine, nicotelline, anatalline, and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), a tobacco-specific nitrosamine metabolite, all biomarkers that are selective for the use of conventional tobacco products. Applications of these biomarkers in studies of ENDS use and dual use of ENDS and conventional tobacco products are also discussed.

Poor health literacy associated with stronger perceived barriers to breast cancer screening and overestimated breast cancer risk.

Background: Low health literacy (HL) is negatively associated with mammography screening uptake. However, evidence of the links between poor HL and low mammography screening participation is scarce. Methods: We conducted a cross-sectional questionnaire survey among participants of a cancer screening program. We measured HL using a validated Chinese instrument. We assessed breast cancer screening-related beliefs using the Health Belief Model and the accuracy of risk perception. We used multivariable regression models to estimate the relationship between HL and the outcomes. Results: A total of 821 females were included. 264 (32.2%) had excellent or sufficient, 353 (43.0%) had problematic, and 204 (24.8%) had inadequate health literacy (IHL). Women with IHL were more likely to agree that high price (ß = -0.211, 95% CI -0.354 to -0.069), lack of time (ß = -0.219, 95% CI -0.351 to -0.088), inconvenient service time (ß = -0.291, 95% CI -0.421 to -0.160), long waiting time (ß = -0.305, 95% CI -0.447 to -0.164), fear of positive results (ß = -0.200, 95% CI -0.342 to -0.058), embarrassment (ß = -0.225, 95% CI -0.364 to -0.086), fear of pain (ß = -0.154, 95% CI -0.298 to -0.010), fear of radiation (ß = -0.177, 95% CI -0.298 to -0.056), lack of knowledge on service location (ß = -0.475, 95% CI -0.615 to -0.335), and lack of knowledge on mammography (ß = -0.360, 95% CI -0.492 to -0.228) were barriers. They were also less likely to have an accurate breast cancer risk perception (aOR 0.572, 95% CI 0.341 to 0.956). Conclusion: Women with lower HL could have stronger perceived barriers to BC screening and an over-estimation of their breast cancer risk. Tackling emotional and knowledge barriers, financial and logistical assistance, and guidance on risk perception are needed to increase their breast cancer screening uptake.

Neoadjuvant Therapy with Concurrent Docetaxel, Epirubicin, and Cyclophosphamide (TEC) in High-Risk HER2-Negative Breast Cancers.

INTRODUCTION: Concurrent anthracycline and taxane is an effective and efficient way to deliver neoadjuvant chemotherapy for HER2-negative breast cancers. Data on efficacy and tolerance to 6 cycles of concurrent docetaxel, epirubicin, and cyclophosphamide (TEC) is limited. METHOD: All patients with HER2-negative breast cancers who received neoadjuvant TEC from January 2013 to December 2019 were reviewed. RESULTS: A total of 71 patients [57 luminal B disease; 14 triple negative breast cancer (TNBC)] received neoadjuvant TEC with prophylactic granulocyte colony-stimulating factor (G-CSF). The pathological complete response (pCR) rate was 26.3% and 28.6% for luminal B and TNBC, respectively. With median follow-up of 48.9 months, 3 years disease-free survival was 85.9%, and 3 years overall survival was 89.6%. Non-hematological toxicities were common but the majority was grade 1 or 2. The most common grade 3 or 4 toxicity were hematological, including neutropenia (26.8%) and anemia (15.5%). There was no cardiotoxicity observed. Half of the patients had at least one dose reduction but all patients completed the planned 6 cycles and had breast surgery done. CONCLUSION: Six cycles of TEC with prophylactic G-CSF is an effective and tolerable neoadjuvant regime for HER2-negative breast cancers. Hematological toxicities were the most common toxicities. Although many patients required dose reduction, all patients completed treatment and there was no observed cardiotoxicity.

Ubiquitous atmospheric contamination by tobacco smoke: Nicotine and a new marker for tobacco smoke-derived particulate matter, nicotelline.

Second Hand Smoke (SHS) has always been primarily linked with indoor pollution. To date nicotine was the favoured marker for SHS alongside measurements of particulate matter (PM) levels. As nicotine is mainly found in the gas-phase and reactive in the outdoor environment it is not ideal as a marker for the SHS-driven particulate component in PM. Nicotelline, a minor tobacco alkaloid that is stable, found almost exclusively in the particle phase and easy to quantify even at low concentrations, is being proposed as a better marker. It is the first study using bisulfate-treated quartz fiber filters to show that airborne nicotine (gas+particle phase) is directly proportional to airborne nicotelline in countries that have different climates. The analytical method developed has been validated to show that the use of untreated filters is suitable for the quantification of nicotelline even at low concentrations. Although nicotelline exhibits a seasonal and geographical variation, this is the first comprehensive study which demonstrates the ubiquitous presence of nicotelline in PM from outdoor air samples collected in the USA (0.1-285.6 pgm-3), UK (2.3-9.1 pgm-3), Hong Kong (3.8-109.3 pgm-3) and Malta (4.2-280.8 pgm-3). From the nicotelline apportionment factor of 1589 ng/mg of tobacco smoke PM we estimate the fraction of outdoor airborne PM derived from SHS to be in the range of 0.03-0.08%. While it is unlikely for tobacco smoke-related toxics in outdoor PM to be considered a major health hazard, in heavily polluted microenvironments this marker would be useful in tracing the presence of SHS and emerging Third Hand Smoke components that form or are found in airborne and settled PM that could induce serious health effects.

Effectiveness of One-Stop Screening for Colorectal, Breast, and Prostate Cancers: A Population-Based Feasibility Study.

Colorectal cancer (CRC), prostate cancer (PC) and breast cancer (BC) are among the most common cancers worldwide with well-established screening strategies. We aim to investigate the effectiveness and compliance of a one-stop screening service for CRC, PC and BC. Asymptomatic subjects aged 50-75 years were invited. Eligible subjects were offered fecal immunochemical test (FIT) for CRC screening. Serum prostate specific antigen (PSA) and Prostate Health Index (PHI) were offered for male PC screening and mammogram (MMG) for female BC screening as a one-stop service. Colonoscopy was offered to FIT+ subjects, prostate biopsy to PSA/PHI+ (PSA>10/PHI≥35) males and breast biopsy to MMG+ (Breast Imaging-Reporting and Data System, BI-RADS≥4) females. From August 2018 to April 2020, 3165 subjects were recruited. All participants (1372 men and 1793 women) were willing to accept FIT for CRC screening, and PSA/PHI test or MMG as second cancer screening. 102 subjects diagnosed advanced neoplasms after colonoscopy. Thirty-three males diagnosed PC after prostate biopsy and 15 females diagnosed BC after breast biopsy. No major complication reported in first tier screening tests. Subjects who were willing to undergo CRC screening were highly likely to accept other cancer screening when offered in a one-stop program. In conclusion, the effectiveness and compliance of a one-stop service for CRC, PC, and BC screening among asymptomatic subjects were high. Future studies should be conducted to test various ways of integrating cancer screening programs. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, identifier NCT04034953.

Cosmetic outcome and percentage of breast volume excision in oncoplastic breast conserving surgery.

BACKGROUND: Since breast-conserving surgery demonstrated identical long term survival on seven randomized trials, it has become the preferred treatment option over mastectomy. Oncoplastic surgery applying simple reshaping and displacement techniques allows inclusion of patients with large tumors in the group selected for breast-conserving surgery. However, the cosmetic outcome and the degree of patient satisfaction, especially in relation to the original breast volume and the percentage of breast tissue excised is not well documented. OBJECTIVE: The present study was designed to assess patient satisfaction with cosmetic outcome after oncoplastic breast-conserving surgery, and to establish the correlation between patient satisfaction and percentage of breast volume excision (PBVE). MATERIALS AND METHODS: A total of 169 Asian patients underwent breast-conserving surgery for primary breast cancer at either United Christian Hospital (UCH) or Hong Kong Sanatorium and Hospital (HKSH) from Nov 2007 to Jan 2008 by two breast surgeons. Among this group, 162 patients with breast-conserving surgery incorporating oncoplastic techniques were prospectively recruited for study. Tumor characteristics, patient satisfaction, cosmetic outcome and surgeons' score were prospectively documented. Breast volume (BV) calculation was based on preoperative mammography (BV = 1/3pir(1)r(2)h), which was validated by our previous study to correlate strongly with actual BV (r = 0.98). PBVE was calculated by dividing the fresh specimen weight by the calculated BV. A standardized questionnaire was used to assess patient satisfaction and surgeons' score on cosmetic outcome during the first 1-3 postoperative months. The correlation between PBVE and patient satisfaction was studied. RESULTS: The median age of the group of patients studied was 52 years (range: 20-96 years). The median tumor size was 2.5 cm (range: 0.6-5 cm). The median breast volume was 493 cm(3) (range: 210-1,588 cm(3)). The median PBVE was 7.4% (range: 1-42%), and 94% of patients were very satisfied or satisfied with the cosmetic outcome. In addition, 85% of patients felt that the treated breast was nearly identical with or only slightly different from the untreated breast. In scoring breast shape, surgeons indicated that 89% of the treated breasts were identical to or only minimally different from the untreated breast. Patient satisfaction decreased significantly when the PBVE exceeded 20%. Neither tumor location nor distance of the tumor from the nipple had any effect on patient satisfaction. CONCLUSIONS: This study showed high patient satisfaction and good cosmetic outcome after oncoplastic breast-conserving surgery, even in small breast sized Asian women. The application of oncoplastic technique allows large volume excision, and satisfaction remains high with breast volume excision less than 20% regardless of tumor location or distance of the tumor from the nipple. More complicated oncoplastic techniques, e.g., breast replacement, might be required if breast volume excision exceeds 20%.

Mammographic determination of breast volume by elliptical cone estimation.

BACKGROUND: We propose a new breast volume calculation method, treating the breast as an elliptical cone on craniocaudal and medial-lateral-oblique mammograms. This study aims to compare the accuracy and reproducibility of this proposed calculation method to the old Katariya method, which calculates breast volume as a circular cone on the craniocaudal mammogram only. MATERIALS AND METHODS: From January 2005 to December 2006, 83 mastectomy patients with recorded breast weight and available preoperative mammographic films were included in the present study. Two surgeons independently measured breast height and width on the preoperative craniocaudal and medial-lateral-oblique mammograms. Breast volume was calculated as a circular cone in the craniocaudal view, and as an elliptical cone in both the craniocaudal and the medial-lateral-oblique mammograms. The accuracy of each method was determined and compared by linear regression analyses. Interobserver variability was assessed by bivariate correlation. RESULTS: The most accurate formula for calculating breast volume was the one that assumed the elliptical cone projection. The mean error of estimated breast volume using the elliptical cone (EC) formula is 3.8 cm(3) (standard deviation [SD] = 133 cm(3)). The mean error of traditional circular cone (CC) formula is -51.3 cm(3) (SD = 182 cm(3)). From a linear regression model, the correlation coefficient of estimated breast volume using EC formula measured 0.977, whereas that using the CC formula measured 0.952 (Fig. 1). Measurements were reproducible between the two independent observers; the Pearson correlation for the EC formula is 0.93 (p < 0.001), and that for the CC formula is 0.95 (p < 0.001). CONCLUSIONS: Breast volume can be accurately determined from measurements made on mammograms. The proposed EC formula calculating breast volume on both the craniocaudal and the medial-lateral-oblique mammograms may be more accurate, as the horizontal and vertical dimensions of the breast are not always the same. In addition, height measurement on the medial-lateral-oblique film can eliminate the compression error as the craniocaudal film may miss the base of the breast and underestimate the breast volume. Taking both mammogram views for measurement is comparably reproducible to the traditional method. Reproducibility of measurement can be further enhanced by better defining the point of measurements.

Diffusion-weighted magnetic resonance imaging of breast lesions: first experiences at 3 T.

PURPOSE: Dynamic contrast-enhanced magnetic resonance imaging (MRI) has been established as a valuable tool for the detection of breast cancer. There is evidence suggesting that diffusion-weighted imaging (DWI) may be useful to distinguish between malignant and benign breast lesions. We seek to evaluate the ability of DWI to differentiate between malignant and benign breast lesions at 3 T. METHODS: Dynamic contrast-enhanced MRI and DWI of the breasts were performed in 31 female patients (age: mean, 46 years; range, 34-69 years) with suspected breast lesions on mammography and ultrasound using a 3-T scanner (MAGNETOM Tim Trio; Siemens Medical Solutions, Erlangen, Germany). Each lesion was assigned as either malignant or benign, blinded to the results of mammography and ultrasound, according to their imaging characteristics on contrast-enhanced MRI, DWI, and apparent diffusion coefficient (ADC) measurements. Tissue samples were obtained from all lesions by either needle or excision biopsy. Using histological results as the gold standard, the diagnostic accuracies of the dynamic contrast-enhanced MRI, DWI, and ADC were calculated and compared. RESULTS: All breast lesions (n = 31) were identified on both the dynamic contrast-enhanced MRI and DWI scans. The threshold ADC value was determined to be 0.00121 mm2/s, below which a lesion was considered malignant. The sensitivities/specificities of the dynamic contrast-enhanced MRI, qualitative DWI, and quantitative ADC were 95%/91%, 95%/63.6%, and 90%/91%, respectively. The differences in sensitivities, specificities, positive and negative predictive values, and diagnostic accuracies between the 3 examinations were statistically insignificant. CONCLUSIONS: Diffusion-weighted imaging at 3 T is highly sensitive in the detection of malignant breast lesions even with qualitative assessment alone, whereas ADC measurement offers quantitative assessment and increases the specificity to more than 90%. Further studies involving a larger cohort size and a wider spectrum of breast lesions are indicated.