The potential role of three-dimensional surface imaging as a tool to evaluate aesthetic outcome after Breast Conserving Therapy (BCT).

PURPOSE: To establish whether objective measurements of symmetry of volume and shape using three-dimensional surface imaging (3D-SI) can be used as surrogate markers of aesthetic outcome in patients who have undergone breast conserving therapy (BCT). METHODS: Women who had undergone unilateral BCT in the preceding 1-6 years were invited to participate. Participants completed a satisfaction questionnaire (BREAST-Q) and underwent 3D-SI. Volume and surface symmetry were measured on the images. Assessment of aesthetic outcome was undertaken by a panel of clinicians. The Kruskal-Wallis test was used to assess the relationship between volume and shape symmetry measurements with the panel score. Spearman's rho correlations were used to assess the relationship between the measurements and patient satisfaction. RESULTS: 200 women participated. Median volume symmetry was 87% (IQR 78-93) and shape symmetry was 5.9 mm (IQR 4.2-8.0). The participants were grouped according to panel assessment of aesthetic outcome (poor, fair, good, excellent) and the median volume and shape symmetry was calculated for each group. Volume symmetry significantly differed between the groups. Post hoc pairwise comparisons demonstrated that these differences existed between panel scores of fair versus good and good versus excellent. Median shape symmetry also differed according to patient panel groups with four significant pairwise comparisons between poor versus good, poor versus excellent, fair versus good and fair versus excellent. There was a significant but weak correlation of both volume symmetry and surface asymmetry with BREAST-Q scores (correlation coefficients 0.187 and -0.229, respectively). CONCLUSION: Breast volume and shape symmetry are both associated with panel assessment scores and patient satisfaction. The objective volume and shape symmetry measures were strongly associated with panel assessment scores, such that a 3D-SI tool could replace panel assessment as a faster and more objective method of evaluating aesthetic outcomes.

Initial experience of the BREAST-Q breast-conserving therapy module.

PURPOSE: The most recently developed module of the BREAST-Q, a validated patient outcome measure, is for patients who have undergone breast-conserving therapy (BCT) for cancer. This aim of this study was to assess patient satisfaction and quality of life after BCT using BREAST-Q, investigate clinical risk factors for lower satisfaction and explore the relationship between patient satisfaction with the appearance of their breasts and the other domains of the BREAST-Q. METHODS: Women who had undergone unilateral BCT in the preceding 1-6 years were invited to participate at the time of their annual surveillance mammogram. Clinicopathological data were collected from an electronic database. Linear regression was used to evaluate risk factors for lower satisfaction. Spearman's rho correlation coefficients were calculated to evaluate the relationship between domains. RESULTS: 200 women completed the questionnaire. Mean age was 60 years (SD 11.1). Time from surgery was 35.5 months (SD 17.8). Median score for 'Satisfaction with breasts' was 68 (interquartile range 55-80). Lowest scores were for 'sexual wellbeing' (57, IQR 45-66). On multivariate analysis, BMI at the time of surgery (p = 0.002), delayed wound healing (p = 0.001) and axillary surgery (p = 0.003) were independent risk factors for lower satisfaction. There was significant correlation between 'Satisfaction with breasts' and all other BREAST-Q domains. CONCLUSION: High BMI, delayed wound healing and axillary surgery are risk factors for lower patient satisfaction. This first publication reporting the whole dataset for the BREAST-Q BCT will serve as a benchmark for future studies of patient satisfaction following BCT.

Anastrozole for prevention of breast cancer in high-risk postmenopausal women (IBIS-II): an international, double-blind, randomised placebo-controlled trial.

BACKGROUND: Aromatase inhibitors effectively prevent breast cancer recurrence and development of new contralateral tumours in postmenopausal women. We assessed the efficacy and safety of the aromatase inhibitor anastrozole for prevention of breast cancer in postmenopausal women who are at high risk of the disease. METHODS: Between Feb 2, 2003, and Jan 31, 2012, we recruited postmenopausal women aged 40-70 years from 18 countries into an international, double-blind, randomised placebo-controlled trial. To be eligible, women had to be at increased risk of breast cancer (judged on the basis of specific criteria). Eligible women were randomly assigned (1:1) by central computer allocation to receive 1 mg oral anastrozole or matching placebo every day for 5 years. Randomisation was stratified by country and was done with blocks (size six, eight, or ten). All trial personnel, participants, and clinicians were masked to treatment allocation; only the trial statistician was unmasked. The primary endpoint was histologically confirmed breast cancer (invasive cancers or non-invasive ductal carcinoma in situ). Analyses were done by intention to treat. This trial is registered, number ISRCTN31488319. FINDINGS: 1920 women were randomly assigned to receive anastrozole and 1944 to placebo. After a median follow-up of 5·0 years (IQR 3·0-7·1), 40 women in the anastrozole group (2%) and 85 in the placebo group (4%) had developed breast cancer (hazard ratio 0·47, 95% CI 0·32-0·68, p<0·0001). The predicted cumulative incidence of all breast cancers after 7 years was 5·6% in the placebo group and 2·8% in the anastrozole group. 18 deaths were reported in the anastrozole group and 17 in the placebo group, and no specific causes were more common in one group than the other (p=0·836). INTERPRETATION: Anastrozole effectively reduces incidence of breast cancer in high-risk postmenopausal women. This finding, along with the fact that most of the side-effects associated with oestrogen deprivation were not attributable to treatment, provides support for the use of anastrozole in postmenopausal women at high risk of breast cancer. FUNDING: Cancer Research UK, the National Health and Medical Research Council Australia, Sanofi-Aventis, and AstraZeneca.

Omission of breast surgery in selected breast cancer patients with excellent response to neoadjuvant systemic therapy.

Modern neoadjuvant systemic therapy (NST) can result in high pathologic complete response rates (pCR) in triple negative (TN) and human epidermal growth factor receptor 2 positive (HER2+) breast cancer. The role of surgery is, therefore, being reconsidered in this rapidly evolving field. This report presents oncological outcomes of seven patients with TN or HER2+ breast cancer, with exceptional response to NST, and a post-NST image-guided vacuum assisted biopsy showing no residual disease (ypT0), who opted not to have breast surgery. The median age was 49 (IQR 36-61) years and the median tumour size at diagnosis was 50 (IQR 16-65) mm. All patients received breast radiotherapy and continued adjuvant systemic therapies as appropriate. At a median follow-up of 67 (IQR 61-77) months, all patients were alive and free of disease. This small case series supports the need for further research in 'exceptional responders' to provide safe, individualized patient-centred care.

Correlation of age and HRT use with breast density as assessed by Quantra™.

Breast density is a significant predictor in the risk of developing breast cancer. Several methods are available for assessing breast density, but most are subject to intra-observer variability and are unable to assess the breast as a three-dimensional structure. Using Quantra(™) to quantify breast density, we have correlated this with risk factors to determine what impact these variables have on breast density. Women attending for full field digital mammography at the South West London Breast Screening Unit between December 2008 and March 2009 were invited to participate in the study by questionnaire. Consenting women returned the questionnaire allowing further data collection including demographics, menopausal status and hormone replacement therapy (HRT) use. Data were correlated against breast density measurements to determine the degree of association. Mammograms were assessed on a Hologic(™) workstation and breast density calculated using Quantra(™). Quantra(™) is an automated algorithm for volumetric assessment of breast tissue composition from digital mammograms. Six-hundred and eighty-three women were invited to participate. Those with implants or mastectomy were excluded. Three-hundred and twenty questionnaires were fully completed and able to be assessed. The mean age of participants was 59 years (range 49-81). Mean density was 19.7% (range 8.5-48.5%). There was a decrease in density with age (Pearson product-moment correlation coefficient -0.17). Correlation between density and HRT use showed a significant positive result (correlation coefficient 0.07). Quantra(™) has shown to be an accurate, reproducible tool for quantifying breast density, demonstrated by its correlation with lifestyle and demographic data. Given its ease of acquisition this may be the future of breast density quantification in the digital age.

Fertility preservation in women undergoing treatment for breast cancer in the UK: a questionnaire study.

OBJECTIVE: Fertility preservation is an important survivorship issue for women treated for breast cancer. The aim of this work was to examine the referral practices of health care professionals who treat women with breast cancer in the United Kingdom, and to investigate their understanding and knowledge of the fertility preservation options available. METHOD: An invitation to participate in a confidential, online questionnaire was e-mailed to surgeons, oncologists, and clinical nurse specialists who manage patients with breast cancer in the United Kingdom. RESULTS: n = 306 respondents. Factors which influenced whether fertility preservation options were discussed with a patient included the following: patient's age (78%), final tumor/nodes/metastasis status (37.9%); concern that fertility preservation would delay chemotherapy (37.3%); whether the patient had children (33.5%) or a partner (24.7%); estrogen receptor expression (22.6%), lack of knowledge regarding the available options (20.9%); and concern that fertility preservation would compromise the success of cancer treatment (19.8%). Twenty-seven percent did not know whether fertility preservation was available for their patients on the National Health Service. Nearly half (49.4%) of respondents said that gonadotropin-releasing hormone agonists were used for fertility preservation outside the setting of a clinical trial. Knowledge regarding the available options varied according to different members of the multidisciplinary team, with consultant oncologists better informed than consultant surgeons or clinical nurse specialists (p < .05). CONCLUSIONS: Many health care professionals have incomplete knowledge regarding the local arrangements for fertility preservation for patients with breast cancer. This may result in patients receiving inadequate or conflicting information regarding fertility preservation.

A thermodynamic approach for assessing the environmental exposure of chemicals absorbed to microplastic.

The environmental distribution and fate of microplastic in the marine environment represents a potential cause of concern. One aspect is the influence that microplastic may have on enhancing the transport and bioavailability of persistent, bioaccumulative, and toxic substances (PBT). In this study we assess these potential risks using a thermodynamic approach, aiming to prioritize the physicochemical properties of chemicals that are most likely absorbed by microplastic and therefore ingested by biota. Using a multimedia modeling approach, we define a chemical space aimed at improving our understanding of how chemicals partition in the marine environment with varying volume ratios of air/water/organic carbon/polyethylene, where polyethylene represents a main group of microplastic. Results suggest that chemicals with log KOW > 5 have the potential to partition >1% to polyethylene. Food-web model results suggest that reductions in body burden concentrations for nonpolar organic chemicals are likely to occur for chemicals with log KOW between 5.5 and 6.5. Thus the relative importance of microplastic as a vector of PBT substances to biological organisms is likely of limited importance, relative to other exposure pathways. Nevertheless, a number of data-gaps are identified, largely associated with improving our understanding of the physical fate of microplastic in the environment.

Follow-up after treatment for breast cancer in young women.

The majority (80%) of breast cancers are diagnosed in women over the age of 50; only 5% will be in their 20s and 30s. These women have specific needs that include genetic counselling, psychological support, advice with regard to fertility and pregnancy issues and information on coping with treatment-related morbidity. The primary purpose of follow-up is often regarded as the early detection of recurrence as well as the detection of second primary tumours. Rather than concentrating solely on detecting cancer recurrence, clinicians need to be more susceptive to symptoms related to treatment morbidity and to the information needs of their patients. This paper outlines the specific issues listed above that need to be addressed in follow-up clinics and highlights interventions that may help improve the value of follow-up appointments and quality of life for young women with breast cancer.

Improving emissions estimates of home and personal care products ingredients for use in EU risk assessments.

REACh introduces environmental release categories (ERCs) used to describe chemical emissions to the environment. These ERCs contain a number of default values that are combined with product usage data to estimate environmental exposure concentrations for use in risk assessment. The methodology presented in the present work constitutes a novel approach that allows for the coupling of population density and country-specific usage statistics for a range of home and personal care products. Spatially explicit usage estimates are presented for European Union (EU) hypothetical regions (200 × 200-km grid), as described in EU risk assessment frameworks. Recent sales and population density data are combined to assess the relevance of current default assumptions; that 10% of a product will be used in an EU hypothetical region that is inhabited by 20 million people. It is demonstrated that these assumptions are conservative and their relevance geographically limited. The highest usage estimates for hypothetical regions are located in southern England and a transboundary area in Europe consisting of Belgium, the Netherlands, and Germany. The maximum identified usage of 9 home and personal care product types, in an EU hypothetical region, ranges from 4.3% to 11.4%. The 99.5th percentile values, representative of an EU hypothetical region with a population of 20 million, range from 3.6% to 9.0%, which suggests that the current default parameterization of the ERCs may be overly protective for ingredients used in a number of home and personal care product types. Accordingly, it may be justified to use such an analysis to refine the default values in order to provide more realistic exposure estimates for use in REACh assessments.