Age-specific differences in breast cancer treatment between screen-detected and non-screen-detected breast cancers in women aged 40-74 years at diagnosis in Sweden 2008-2017.

BACKGROUND AND PURPOSE: We have recently demonstrated that screen-detected invasive breast cancers had more favourable tumour characteristics than non-screen-detected. The objective of the study was to analyse differences in breast cancer treatment between screen-detected and non-screen-detected cases by age at diagnosis, with and without adjustment for tumour (T) and nodal (N) status, within a nationwide, population-based mammography screening programme utilising register data. MATERIAL AND METHODS: Data spanning 2008-2017 were collected from the National Quality Register for Breast Cancer. Multivariable logistic regression analysis was used to estimate odds ratios and 95% confidence intervals for treatment disparities between screen-detected and non-screen-detected breast cancer. RESULTS: Among 46,481 women diagnosed with invasive breast cancer aged 40-74 and invited for mammography screening, significant differences in treatment were observed. Screen-detected cases showed higher likelihoods of partial mastectomy compared to mastectomy, endocrine therapy, and radiotherapy, whereas chemotherapy and antibody therapy were less likely compared to non-screen-detected cases. However, when adjusting for surgery type, screen-detected cases showed lower likelihoods of radiotherapy. Age at diagnosis significantly influenced treatment odds ratios, with interactions observed for all treatments except radiotherapy adjusted for surgery. Differences increased with age, except for endocrine therapy. Radiotherapy adjusted for surgery type showed no age-related interaction. Adjusting for T and N did not alter these patterns. INTERPRETATION: In general, screen-detected cases received less aggressive treatment, such as mastectomy, chemotherapy, and antibody therapy, compared to non-screen-detected cases. Disparities increased with age, except for endocrine therapy and radiotherapy adjusted for surgery. Differences persisted after adjusting for T and N, suggesting that these factors cannot solely explain the results.

Ten-year trend analysis of breast cancer, oncoplastic, and reconstructive breast surgery in a single institution (2010-2019), what has not changed?

PURPOSE: There has been a UK national directive to ensure that patients are offered reconstructive surgical options. We aimed to assess any change in oncoplastic practice over a 10-year period. METHODS: The surgical management of 7019 breast cancers was retrospectively assessed at Nightingale Breast Centre, Manchester University UK, from 2010 to 2019. The procedures were categorised into breast conservative surgery (BCS) and mastectomy ± immediate reconstruction. The data were analysed using inclusion and exclusion criteria. RESULTS: The overall rates of BCS and mastectomy were 60.1% and 39.9% respectively. No statistically significant change in the overall rates of BCS or mastectomy was observed over the last decade (p = 0.08). The rate of simple wide local excision (WLE) decreased from 98.7% to 89.3% (p < 0.001), whilst the rate of therapeutic mammoplasty (TM) increased from 1.3% to 8% (p < 0.01). The rate of chest wall perforator flaps (CWPF) changed from zero to account for 2.7% of all BCS by 2019. The overall rate of immediate breast reconstruction (IBR) did not significantly change over the study period, but it consistently remained above the national average of 27%. The rate of implant-based IBR increased from 61.3% to 76.5% (p = 0.012), whilst the rate of Latissimus Dorsi (LD) reconstruction decreased from 26.7% to 5.1% (p < 0.05). Additionally, the rate of nipple-sparing mastectomy significantly increased from 5.2% to 24%. CONCLUSION: No significant changes in the overall rates of BCS was observed, the rates of advanced breast conservation techniques, nipple-sparing mastectomy, and implant-based IBR all have increased, whilst the use of LD reconstruction decreased.

Geographic variation in breast reconstruction surgery after mastectomy for females with breast cancer in Alberta, Canada.

BACKGROUND: Breast cancer is the most common cancer affecting females in Canada, and about half of females with breast cancer are treated with mastectomy. We sought to evaluate geographic variation in breast reconstruction surgery in Alberta, Canada. METHODS: Using linked population-based administrative databases, we extracted data on all Alberta females aged 18 years and older who were diagnosed with breast cancer and treated with mastectomy during 2004-2017. Analyses included regression modelling of odds of reconstruction at 1 year and a spatial scan to identify geographic clusters of lower numbers of reconstruction. RESULTS: A total of 16 198 females diagnosed with breast cancer were treated with a mastectomy, and 1932 (11.9%) had reconstruction within 1 year postmastectomy. Those with reconstruction were more likely to be younger (adjusted odds ratio [OR] 16.7, 95% confidence interval [CI] 13.7-20.3; aged 21-44 yr v. ≥ 65 yr) and were less likely to be from lower-income neighbourhoods. They were more likely to have at least 1 comorbidity and were more likely to have advanced stages of cancer and to require chemotherapy (adjusted OR 0.55, 95% CI 0.47-0.65) or radiotherapy after mastectomy (adjusted OR 0.59, 95% CI 0.39-0.87) than females without reconstruction. We identified rural northern and southeastern clusters with frequencies of reconstruction that were 69.6% and 41.6% of what was expected, respectively. CONCLUSION: We found an overall postmastectomy rate of breast reconstruction of 11.9%, and we identified geographic variation. Predictors of reconstruction in Alberta were similar to those previously described in the literature, specifically with patients in rural communities having lower rates of reconstruction than their urban counterparts. These results suggest that further interventions are required to identify the specific barriers to reconstruction within rural communities and to create strategies to ensure equitable access to all residents.

Disaggregating the Asian-American Breast Cancer Population: Disparities in Reconstruction Rates.

INTRODUCTION: Breast cancer (BC) incidence has been increasing among Asian-Americans (AsAms); recent data suggest these patients are less likely to undergo postmastectomy breast reconstruction (PMBR) compared to non-Asian women. Historically, AsAm BC patients are reported in aggregate, masking heterogeneity within this population. We aim to identify patterns of postmastectomy reconstruction among disaggregated AsAm BC patients at our institution. METHODS: A retrospective chart review was performed for BC patients who underwent mastectomy between 2017 and 2021. Patient demographic and clinical information was collected including self-reported race/ethnicity and reconstruction at time of mastectomy. Self-identified Asian patients were disaggregated into East Asian, Southeast Asian, South Asian, and 'Asian Other.' We examined rates of reconstruction between the different races and the disaggregated Asian subgroups. Univariable and multivariable analysis was performed to examine patient factors associated with PMBR. RESULTS: Six hundred and five patients met inclusion criteria. Forty seven percent of patients identified as Asian, 36% of which as East Asian. Forty four percent of all patients underwent PMBR. Southeast Asian and South Asian women were least likely to undergo reconstruction, while Hispanic and non-Hispanic Black women were most likely to pursue PMBR (P = 0.020). On multivariable analysis, Hispanic, non-Hispanic White, and non-Hispanic Black women were more likely to undergo reconstruction compared to Asian women. Other factors associated with reconstruction were coverage with private insurance and diagnosis of noninvasive disease. CONCLUSIONS: Rates of PMBR are lower among AsAms than non-Asian patients and vary between Asian ethnic subgroups. Further investigation is needed to identify patterns of reconstruction among the disaggregated AsAm population to address disparities.

Assessment of Postmastectomy Radiation Therapy Receipt by Age and Association With Outcomes in Women With Breast Cancer.

PURPOSE: Postmastectomy radiation therapy (PMRT) reduces locoregional recurrence (LRR) and improves overall survival (OS) in patients with breast cancer. Young age has been recognized as a risk factor for LRR. The primary objective of this study was to determine if recommendations for PMRT differed among patients younger than 50 years as compared to women aged 50 years or older. METHODS: We reviewed medical records of patients with breast cancer who underwent mastectomy with or without PMRT from 2010 through 2018. Univariable and multivariable models were used to estimate the association of age with PMRT. RESULTS: Of 2471 patients, 839 (34%) were <50 years; 1632 (66%) were ≥50 years. Patients <50 years had a higher percentage of grade 3 tumors, hormone receptor (HR) negative and/or Her-2/neu positive tumors, clinical stage T2/T3 tumors, and nodal involvement. Compared with patients ≥50 years, patients <50 years were more likely to undergo PMRT (OR 1.57; P = .001) and regional node irradiation (RNI) to the internal mammary nodes. Advanced clinical and pathologic stage, invasive tumor histology, the presence of lymphovascular invasion, and treatment with systemic chemotherapy were predictors of PMRT receipt for patients <50 years (P < .05). PMRT was associated with improved OS and recurrence free survival (RFS) among all patients (P < .01). CONCLUSION: Patients <50 years were more likely to undergo PMRT and to receive RNI to the internal mammary nodes but were also more likely to have other risk factors for recurrence that would warrant a PMRT recommendation. PMRT improved OS and RFS for all patients.

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

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

Trends in bilateral mastectomy rates among different racial backgrounds: A National Cancer Database study.

INTRODUCTION: Studies have shown a decrease in bilateral mastectomy (BM) rates over the past five to ten years, but it is not clear if these decreases are the same across different patient races. METHODS: Using the National Cancer Database (NCDB) we examined BM rates for patients with AJCC Stage 0-II unilateral breast cancer from 2004 to 2020 for White versus nonwhite races (Blacks, Hispanics, and Asians). Multivariable logistic regression was used to identify patient and facility factors associated with BM by patient race from 2004 to 2006 and 2018-2020. RESULTS: Of 1,187,864 patients, 791,594 (66.6%) had breast conserving surgery (BCS), 258,588 (21.8%) had unilateral mastectomy (UM) and 137,682 (11.6%) had BM. Our patient population was 927,530 (78.1%) White patients, 124,636 (10.5%) Black patients, 68,048 (5.7%) Hispanic patients, and 48,341 (4.1%) Asian patients. The BM rate steadily increased from 5.6% to 15.6% from 2004 to 2013, at which point the BM rate decreased to 11.3% in 2020. The decrease in BM was seen across all races, and in 2020, 6,487 (11.7%) Whites underwent BM compared to 506 (10.7%) Hispanics, 331 (9.2%) Asians, and 723 (9.1%) Blacks. Race was a significant independent factor for BM in 2004-2006 and 2018-2020 but all races were more likely to undergo BM in 2004 compared to 2020 after adjusting for patient and facility factors. Compared to Whites, the odds of undergoing BM were OR 0.41 (0.37-0.45) in 2004 compared to OR 0.66 (0.63-0.69) in 2020 for Blacks, OR 0.44 (0.38-0.52) and OR 0.61 (0.57-0.65) for Asians and OR 0.59 (0.52-0.66) and OR 0.71 (0.67-0.75) for Hispanics, respectively. CONCLUSION: BM rates for all races have declined since 2013, and differences in rates of BM amongst races have narrowed.

Oncological Safety of Autologous Fat Grafting in Breast Reconstruction after Mastectomy for cancer: A case-control study.

OBJECTIVE: The use of autologous fat grafting in the context of breast reconstruction is still a matter of controversy. The objective of this study was to compare the local relapse rate in women who had a fat grafting session in the context of breast reconstruction after breast cancer management, to those who had breast reconstruction without fat grafting. METHODS: We performed a retrospective, monocentric, case-control study from January 2007 to December 2017 in our hospital. The cases included women who underwent breast reconstruction with autologous fat grafting and controls, undergoing breast reconstruction without fat grafting. We compared survival and local recurrence between the two groups. RESULTS: 412 women were included: 109 (26.5%) in the lipofilling group and 303 women (73.5%) in the "no lipofilling" group. In the overall study population, lipofilling did not appear to be a predictive factor for recurrence, HR = 1.39 [0.63 - 3.06], p = 0.41; or a predictive factor for overall survival, HR = 0.84 [0.23 - 3.02], p = 0.79, or for distant metastases, HR = 1.10 [0.43 - 2.79], p = 0.84. In contrast, in the subgroup of women treated for invasive cancer, the multivariate analysis showed that lipofilling in this context was an independent predictive factor for local recurrence (HR= 5.06 [1.97 - 10.6], p = 0.04). CONCLUSION: we found an increased risk of local recurrence after lipofilling in women who were managed for invasive breast cancer. This suggests that special consideration should be given to women who have had invasive breast cancer before lipofilling.

Is image-guided core needle biopsy of borderline axillary lymph nodes in breast cancer patients clinically helpful?

BACKGROUND: When borderline axillary lymph nodes (bALN) are identified on ultrasound (US) for breast cancer (BC) patients, preoperative management is unclear. We aimed to evaluate if core needle biopsy (CNB) for bALN is clinically helpful or disruptive. METHODS: Retrospective review of BC patients with bALN from 2014 to 2019 was performed. Clinicopathologic data were compared for those who did and did not have CNB. RESULTS: CNB (n = 34) and no CNB (n = 31) were similar with respect to clinicopathologic factors. Surgical LN-positive rate was the same between cohorts (p = 0.26). CNB was disruptive in 58.8 %; all had CNB for pN0 disease. CNB was helpful in 34.2 %: 14.7 % proceeded directly to axillary dissection; 17.6 % had positive LN localized after neoadjuvant chemotherapy. CONCLUSIONS: CNB for bALN is more likely clinically disruptive and did not impact surgical LN positive rate. BC patients with bALN should undergo CNB only if it will change clinical management.

Metastatic breast cancer: Who benefits from surgery?

BACKGROUND: We sought to identify characteristics of metastatic breast cancer (MBC) patients who may benefit most from primary tumor resection. METHODS: Recursive partitioning analysis (RPA) was used to categorize non-surgical patients with de novo MBC in the NCDB (2010-2015) into 3 groups (I/II/III) based on 3-year overall survival (OS). After bootstrapping (BS), group-level profiles were applied, and the association of surgery with OS was estimated using Cox proportional hazards models. RESULTS: All patients benefitted from surgery (median OS, surgery vs no surgery): 72.7 vs 42.9 months, 47.3 vs 30.4 months, 23.8 vs 14.4 months (all p < 0.001) in BS-groups I, II, and III, respectively. After adjustment, surgery remained associated with improved OS (HR 0.52, 95% CI 0.50-0.55). The effect of surgery on OS differed quantitatively across groups. CONCLUSION: Prognostic groups may inform the degree of benefit from surgery, with the greatest benefit seen in those with the most favorable survival.

Does failed mapping predict sentinel lymph node metastasis in cN0 breast cancer?

Aims: The clinical significance of nonvisualized sentinel lymph nodes (non-vSLNs) is unknown. The authors sought to determine the incidence of non-vSLNs on lymphoscintigraphy, the identification rate during surgery, factors associated with non-vSLNs and related axillary management. Patients & methods: A total of 30,508 consecutive SLN procedures performed at a single institution from 2000 to 2017 were retrospectively studied. Associations between clinicopathological factors and the identification of SLNs during surgery were assessed. Results: Non-vSLN occurred in 525 of the procedures (1.7%). In 73.3%, at least one SLN was identified intraoperatively. Nodal involvement was only significantly associated with SLN nonidentification (p < 0.001). Conclusion: Patients with non-vSLN had an increased risk for SLN metastasis. The detection rate during surgery was consistent, reducing the amount of unnecessary axillary dissection.

Lay abstract To study the clinical significance of nonvisualized sentinel lymph nodes (non-vSLNs) in axillary surgery for breast cancer, 30,508 consecutive SLN procedures performed at a single institution from 2000 to 2017 were retrospectively reviewed with the aim to analyze the incidence of non-vSLNs on lymphoscintigraphy, the identification rate during surgery, factors associated with non-vSLNs and related axillary management. Associations between clinicopathological factors and the identification of SLNs during surgery were assessed. Non-vSLN occurred in 525 of the procedures (1.7%). In 73.3%, at least one SLN was identified intraoperatively. Nodal involvement was only significantly associated with SLN nonidentification (p < 0.001). Patients with non-vSLN had an increased risk for SLN metastasis. The detection rate during surgery was consistent, reducing the amount of unnecessary axillary dissection.

A prospective evaluation of the American College of Surgeons Surgical Risk Calculator as a predictor of complications for breast surgery.

BACKGROUND: The infection rates for operative management of breast cancer are often unpredictable and higher than average for a clean surgical procedure (0.8% and 28%). We aimed to assess the effectiveness of the American College of Surgeons (ACS) Surgical Risk Calculator (SRC), a preoperative scoring system to calculate the risk of surgical site infection (SSI) and serious complications following breast surgery. METHODS: Prospective risk scoring using the SRC on 213 patients in the preoperative clinic and the incidence of SSI and serious complications within 30 days postoperatively was prospectively collected. RESULTS: The overall SSI rate in our sample was 5% (n=11/210 patients). For a one-unit increase in SRC score, the odds of having SSI increased by a factor of 1.88 (95% CI 1.33 to 2.74). Odds of developing SSI were higher in patients with high Body Mass Index (OR 1.25; 95% 1.13 to 1.40) and American Society of Anesthesiologists score 3 (OR 11.54; 95% CI 2.98 to 43.65). The odds of developing an SSI were ∼19 times higher if a patient had an SRC score >3.0 versus those with an SRC score <3.0. Only 3% (n=4) of patients who had an SRC score of <3.0 experienced SSI, compared with 33% (n=7) for those with a risk score of >3.0. Out of 210 patients, 9 had serious complications (4.2%). CONCLUSIONS: ACS SRC Score of more than 3 was associated with a higher likelihood of SSI. SRC was able to predict the risk of SSI and serious complications and can be used preoperatively for identification and risk minimisation.

Delays in operative management of early-stage, estrogen receptor-positive breast cancer during the COVID-19 pandemic: A multi-institutional matched historical cohort study.

BACKGROUND: During the COVID-19 pandemic, guidelines recommended that breast cancer centers delay estrogen receptor-positive breast cancer surgeries with neoadjuvant endocrine therapy. We aimed to evaluate pathologic upstaging of breast cancer patients affected by these guidelines. METHODS: Female patients with stage I/II breast cancer receiving neoadjuvant endocrine therapy were prospectively identified and were matched to a historical cohort of stage I/II estrogen receptor-positive breast cancer patients treated with upfront surgery ≤35 days. Primary outcomes were pathologic T and N upstaging versus clinical staging. RESULTS: After matching, 28 neoadjuvant endocrine therapy and 48 control patients remained. Median age in each group was 65 (P = .68). Most patients (78.6% and 79.2%) had invasive ductal carcinoma with a clinical tumor size of 0.9 cm vs 1.7 cm (P = .056). Time to surgery was 68 days in the neoadjuvant endocrine therapy group and 26.5 days in the control (P < .001). A total of 23 neoadjuvant endocrine therapy patients (82.1%) had the same or lower pT-stage compared with 31 (64.5%) control patients (P = .115). Only 3 (10.7%) neoadjuvant endocrine therapy patients had increased pN-stage vs 14 (29.2%) control patients (P = .063). CONCLUSION: Despite 2.5-times longer delays, patients with early-stage estrogen receptor-positive breast cancer receiving neoadjuvant endocrine therapy did not experience pathologic upstaging during the COVID-19 pandemic. These findings may support the use of neoadjuvant endocrine therapy in similar patients if delays to surgery are projected.

Demographic, tumour, and treatment characteristics of female patients with breast cancer in Sri Lanka; results from a hospital-based cancer registry.

BACKGROUND: Although breast cancer is the most common cancer among Sri Lankan women, there is little published data on patient characteristics and treatment in the local context. We aimed to describe disease characteristics and management in a large contemporary cohort of women with breast cancer at the National Cancer Institute of Sri Lanka (NCISL). METHODS: All women with invasive primary breast cancers diagnosed during 2016-2020 were identified from the NCISL breast cancer registry. The NCISL sees approximately 40% of all cancer patients in Sri Lanka. Cancer stage at diagnosis was defined according to the Tumour, Node, and Metastasis (TNM) staging system and the Estrogen (ER) and progesterone (PR) receptor status was determined based on the results of immunohistochemistry tests. Descriptive statistics were used to describe the study cohort and treatment patterns. RESULTS: Over 5100 patients were diagnosed with breast cancer during the study period at the NCISL. The mean age of the women was 56 (SD 12) years. Common co-morbidities were hypertension (n = 1566, 30%) and diabetes mellitus (n = 1196, 23%). Two thirds (66%) of the cancers were early stage (stage I & II) at diagnosis. ER/PR positivity rate was 72% and HER-2 positivity rate was 22%. Two thirds of the women had undergone mastectomy while 68% had undergone axillary clearance. The rate of chemotherapy delivery was 91% for women with node positive disease while 77% of eligible women (i.e., after wide local excision or with > 3 positive lymph nodes) had received adjuvant radiotherapy. Endocrine therapy was initiated in 88% of eligible women with hormone receptor positive disease while rate of trastuzumab use was 59% among women with HER2 positive breast cancer. CONCLUSIONS: High percentage of advanced breast cancer at diagnosis and high prevalence of comorbidities are some of the major challenges faced in the management of breast cancer in Sri Lanka. Given that stage at diagnosis is the most important prognostic factor determining survival, greater efforts are needed to promote early diagnosis of breast cancer. Considerable lapses in the concordance between guideline recommendations and the delivery of cancer care warrants closer assessment and intervention.

Risk factors and nursing countermeasures of postoperative pulmonary infection in patients with breast cancer: A retrospective analysis.

ABSTRACT: It is necessary to elucidate the potential risk factors of pulmonary infection to provide references for the management of breast cancer.Our study was a retrospective design, patients who underwent modified radical mastectomy for breast cancer in our department of breast surgery from January 2019 to November 2020 were included. The personal and clinical data of included patients with and without pulmonary infection were compared.A total of 234 patients with radical mastectomy were included, the incidence of pulmonary infection was 15.38% with 95%confidence interval (CI) 11.42% to 18.98%. There were significant differences in the age, body mass index, diabetes, duration of surgery, combined radiotherapy and chemotherapy, and duration of drainage between patients with and without pulmonary infections (all P < .05). Logistic regression analysis indicated that age ≥55 years (odds ratio [OR] 2.128, 95%CI 1.105-3.426), body mass index ≥ 24 kg/m2(OR 2.344, 95%CI 1.031-3.299), diabetes (OR 2.835, 95%CI 1.132-4.552), duration of surgery ≥120 minutes (OR 1.394, 95%CI 1.012-1.044), combined radiotherapy and chemotherapy (OR 3.122, 95%CI 1.124-5.273), duration of drainage ≥5 days (OR 1.851, 95%CI 1.112-2.045) might be the independent risk factors of pulmonary infection in patients after radical mastectomy(all P < .05). Pseudomonas aeruginosa and Klebsiella pneumoniae are the most commonly seen bacteria.The incidence of postoperative pulmonary infections in breast cancer patients is high, and there are many associated risk factors. The perioperative management of patients should be strengthened targeted on those risk factors in clinical practice.

Outcomes after mastectomy with immediate breast reconstruction for breast cancer in a multiethnic, middle-income Asian setting.

BACKGROUND: Although immediate breast reconstruction is increasingly becoming popular worldwide, evidence from resource-limited settings is scarce. We investigated factors associated with immediate breast reconstruction in a multiethnic, middle-income Asian setting. Short-term surgical complications, timing of initiation of chemotherapy, and survival outcomes were compared between women undergoing mastectomy alone and their counterparts receiving immediate breast reconstruction. METHODS: This historical cohort study included women who underwent mastectomy after diagnosis with stage 0 to stage IIIa breast cancer from 2011 to 2015 in a tertiary hospital. Multivariable regression analyses were used to assess factors associated with immediate breast reconstruction and to measure clinical outcomes. RESULT: Out of 790 patients with early breast cancer who had undergone mastectomy, only 68 (8.6%) received immediate breast reconstruction. Immediate breast reconstruction was independently associated with younger age at diagnosis, recent calendar years, Chinese ethnicity, higher education level, and invasive ductal carcinomas. Although immediate breast reconstruction was associated with a higher risk of short-term local surgical complications (adjusted odds ratio: 3.58 [95% confidence interval 1.75-7.30]), there were no significant differences in terms of delay in initiation of chemotherapy, 5-year disease-free survival, and 5-year overall survival between both groups in the multivariable analyses. CONCLUSION: Although associated with short-term surgical complications, immediate breast reconstruction after mastectomy does not appear to be associated with delays in initiation of chemotherapy, recurrence, or mortality after breast cancer. These findings are valuable in facilitating shared surgical decision-making, improving access to immediate breast reconstruction, and setting priorities for surgical trainings in middle-income settings.

Primary Surgery with Systemic Therapy in Patients with de Novo Stage IV Breast Cancer: 10-year Follow-up; Protocol MF07-01 Randomized Clinical Trial.

BACKGROUND: The aim of this randomized clinical trial was to evaluate the overall survival (OS) data of patients diagnosed with de novo stage IV breast cancer (BC) who received locoregional treatment (LRT) over a 10-year follow-up. STUDY DESIGN: The MF07-01 is a 1:1 multicenter, randomized clinical trial comparing the LRT with systemic therapy (ST), where ST was given to all patients either immediately after randomization or after surgical resection of the intact primary tumor. RESULTS: A total of 278 patients were randomized and 265 patients were in the final analysis. At 10-year follow-up, survivals were 19% (95% CI 13%-28%) and 5% (95% CI 2%-12%) in the LRT group and ST group, respectively. Median survival was 46 months for the LRT group and 35 months for the ST group, and hazard of death was 29% lower in the LRT group compared with the ST group (hazard ratio [HR] 0.71; 95% CI 0.59-0.86; p = 0.0003). CONCLUSIONS: Patients with a diagnosis of de novo stage IV BC who underwent LRT followed by ST had a 14% higher chance of OS by the end of the 10-year follow-up compared with the patients who received only ST. The longer study follow-up revealed that LRT should be presented to patients when discussing treatment options.

Factors Associated With State-Specific Medicaid Expansion and Receipt of Autologous Breast Reconstruction Among Patients Undergoing Mastectomy.

Importance: Despite demonstrated psychosocial benefits, autologous breast reconstruction remains underutilized. An analysis of the association between Medicaid expansion and autologous breast reconstruction has yet to be performed. Objective: To compare autologous breast reconstruction rates and determine the association between Medicaid expansion and breast reconstruction. Design, Setting, and Participants: A retrospective cross-sectional study was performed using the State Inpatient Database from January 1, 2012, through September 30, 2015, and included 51 340 patients. Patients were identified using the International Classification of Diseases, Ninth Revision, codes for breast cancer, mastectomy, and autologous breast reconstruction. Data from states that expanded Medicaid (New Jersey, New York, and Washington) were compared with states that did not expand Medicaid (Florida, North Carolina, and Wisconsin). Data were analyzed from June 1, 2020, through February 28, 2021. Exposures: The Patient Protection and Affordable Care Act's Medicaid expansion was implemented in 2014; the preexpansion period ranged from 2012 to 2013 (2 years), whereas the postexpansion period ranged from 2014 to 2015 quarter 3 (1.75 years). Main Outcomes and Measures: Primary outcomes included use of autologous breast reconstruction before and after expansion. Independent covariates included patient demographics, comorbidities, and state of residence. Results: Among 45 850 patients who underwent mastectomy and 9215 patients who received autologous breast reconstruction, 36 777 (67%) were White and 32 205 (59%) had private insurance. The use of immediate or delayed autologous reconstruction increased from 18.1% (4951 of 27 290) to 23.0% (4264 of 18 560) throughout the study period. Compared with 2012, the odds of reconstruction were 64% higher in 2015 (odds ratio [OR], 1.64; 95% CI, 1.48-1.80; P < .001). African American (OR, 1.43; 95% CI, 1.33-1.55; P < .001) and Hispanic (OR, 1.44; 95% CI, 1.31-1.60; P < .001) patients had higher odds of reconstruction compared with White patients regardless of state of residence. However, Medicaid expansion was associated with a 28% decrease in the odds of reconstruction (OR, 0.72; 95% CI, 0.61-0.87; P < .001) for African American patients, a 40% decrease (OR, 0.60; 95% CI, 0.50-0.74; P < .001) for Hispanic patients, and 20% decrease (OR, 0.80; 95% CI, 0.67-0.96; P = .01) for patients with Asian, Native American, or other minority race/ethnicity. Medicaid expansion was not associated with changes in the odds of reconstruction for White patients. Conclusions and Relevance: In this cross-sectional study, although the odds of receiving autologous breast reconstruction increased annually, Medicaid expansion was associated with decreased odds of reconstruction for African American patients, Hispanic patients, and other patients of color.

Accurate prediction of breast cancer survival through coherent voting networks with gene expression profiling.

For a patient affected by breast cancer, after tumor removal, it is necessary to decide which adjuvant therapy is able to prevent tumor relapse and formation of metastases. A prediction of the outcome of adjuvant therapy tailored for the patient is hard, due to the heterogeneous nature of the disease. We devised a methodology for predicting 5-years survival based on the new machine learning paradigm of coherent voting networks, with improved accuracy over state-of-the-art prediction methods. The 'coherent voting communities' metaphor provides a certificate justifying the survival prediction for an individual patient, thus facilitating its acceptability in practice, in the vein of explainable Artificial Intelligence. The method we propose is quite flexible and applicable to other types of cancer.

Breast cancer in Brazil: Screening program and surgical approach.

BACKGROUND: Screening mammography for breast cancer (BC) is a current strategy that reduces the mortality of BC by up to 30 %. Although mastectomy has been an important component of treatment for decades, conservative surgery (lumpectomy) has become the gold-standard approach for most cases, yet it depends on early detection of the BC. METHODS: This was an epidemiological study performed through DATASUS (2010-2018). We evaluated the temporal trend of screening mammograms, deaths from BC, and surgical procedures at national, regional and state levels. Statistical analysis was performed on VassarStat®-Website for Statistical Computation (Vassar College, New York, USA) and the R-software (R Foundation, v.4.0.3). RESULTS: During 2010-2018 there were 67,392 oncological mastectomies and 48,567 lumpectomies in Brazil's health system. Mastectomies decreased in the Northeast (-3.67 % ± 0.43 per year) and in Bahia state (-3.58 % ± 0.24 per year). Lumpectomies increased in Brazil (median 2.19 (-9.6 to 20.96)), the Northeast (median -12.07 (-25.8 to 9.43)) and Bahia (median 0.16 (-29.1 to 1.9)). Also, screening mammograms increased in Brazil (3.29 % ± 0.43), the Northeast (6.36 % ± 0.49) and Bahia (5.51 % ± 0.31), with 35,317,728 exams during this period. Deaths from BC increased annually in Brazil (+4.13 % ± 0.86), the Northeast (+4.76 % ± 1.45) and Bahia (+5.65 % ± 0.83). CONCLUSION: The number of mammograms related to the screening program increased in the years 2010-2018 in Brazil. Furthermore, we identified an increase in lumpectomies as opposed to mastectomies, and this approach is associated with a reduction in hospitalization days by almost a half, which in turn might result in a cost decrease and probably an earlier return to work.