The use of neoadjuvant systemic therapies in breast cancer in Australia and New Zealand: Breast Surgeons of Australia and New Zealand quality audit.

BACKGROUND: Breast surgeons must maintain contemporary knowledge regarding appropriate referral for neoadjuvant chemotherapy (NACT) in breast cancer (BC) patients. To date, the greatest benefit is seen in stage II-III HER2-enriched and triple negative breast cancers (TNBC). This study is the first audit of use of NACT in Australia and New Zealand to stratify data by BC biological subtype. METHODS: Prospective data from 116,745 patients between 2010 and 2019 was provided by the Breast Surgeons of Australia and New Zealand (BreastSurgANZ) Quality Audit (BQA) of Breast Cancer Care. Annual rates of NACT use were determined and change across time analysed with fractional regression. Data from 2018 to 2019 were combined and stratified by biological subtype (LumA, LumB HER2-neg, LumB HER2-pos, HER2 enriched, TNBC, Other basal-like), and age (<50, 51-74, and ≥75 years) and compared using negative binomial regression. RESULTS: The use of NACT increased annually (OR 1.26, P < 0.001), and the use of additional adjuvant chemotherapy (ACT) decreased (OR 0.78, P < 0.001). A significantly greater use of NACT was noted in patients with TNBC and HER2+ BC, and in all patients aged <50 years compared with older ages (P < 0.001), regardless of biological subtype. CONCLUSION: Increased uptake of NACT and decreased use of additional ACT is in keeping with progressive change in practice in response to contemporary evidence. Expansion of BQA data fields related to use of NACT, and detailed audit of NACT rates in Stage II-III TNBC and HER2 enriched BC will allow accurate determination of quality of practice in ANZ.

Breast cancer care and surgery in Australia and New Zealand: compliance of the BreastSurgANZ quality audit with international standards.

BACKGROUND: The Breast Surgeons of Australia and New Zealand (BreastSurgANZ) Quality Audit (BQA) of Breast Cancer Care is a prospective population-based database designed for annual audit of compliance with internally derived Quality Indicators (QI)s. While there is no international consensus for QIs, audit against an external international benchmark is possible through use of QIs defined by the 2017 European Society of Breast Cancer Specialists (EUSOMA) Guidelines. METHODS: BQA data from 29,088 female patients between 1/1/2018 and 31/12/2019 were stratified by the EUSOMA definition of low-volume hospitals (LVH <150 patients p.a.) and high-volume hospitals (HVH ≥150 patients p.a.), and percentage compliance (±95% CI) with 14 mandatory EUSOMA QI sub-parts were determined. RESULTS: ANZ LVH met the quality threshold for 10, and HVH for 8 EUSOMA QI that assessed MDT, surgical approach, adjuvant radiotherapy in the LVH setting, avoidance of overtreatment, and use of endocrine therapy. ANZ did not meet the quality thresholds for QIs assessing use of neoadjuvant chemotherapy, and adjuvant radiotherapy in the HVH setting. CONCLUSION: Breast cancer care in ANZ is comparable with an international standard. ANZ surgeons performed at a high standard in discussion of breast cancer patients by MDT, and appropriate use of adjuvant radiotherapy by LVH. Improvements can be made in completeness of data capture, and inclusion of genetic syndrome and Ki67% in data collection. Due to the rapid evolution of breast cancer treatments, there is need for contemporary update of QI relating to the use of neoadjuvant systemic therapies.

Comparison of volume displacement versus circumferential arm measurements for lymphoedema: implications for the SNAC trial.

BACKGROUND: The Royal Australasian College of Surgeons Sentinel Node versus Axillary Clearance trial is a randomized controlled trial comparing sentinel node biopsy with axillary clearance in breast cancer patients. Primary study end-points include arm volume differences with time, which may indicate the development of lymphoedema. The RACS SNAC trial uses circumferential arm measurements in the estimation of arm volume. This study aimed to assess the accuracy of circumferential volume estimation in comparison with water displacement. METHODS: Eighty-seven women attending the breast clinic at the Women's Health Centre, Royal Adelaide Hospital, were assessed by volumetric and circumferential arm measurements. Correlations between volume estimations and measurements were made, taking into account the width of measuring tape and body mass index. RESULTS: There was a highly significant correlation between circumferential and volumetric arm measurements (Pearson's correlation coefficient = 0.92, P < 0.0001), especially when using the narrow measuring tape. Correlation was best in the overweight BMI group (Pearson's correlation coefficient = 0.94. P < 0.0001) and worst in the obese group (Pearson's correlation coefficient = 0.79, P < 0.0001) but all relationships were statistically significant. CONCLUSION: Using a narrow tape, circumferential arm measurement is an appropriate method for assessing arm volume in the SNAC trial.

Clinical impact of oncoplastic surgery in a specialist breast practice.

BACKGROUND: Oncoplastic breast surgery is an integral and fundamental component of the clinical management of breast cancer. The aim of this study was to determine the proportion of oncoplastic and reconstructive breast cancer procedures undertaken within a specialist breast practice. METHODS: An audit of breast-related cancer procedures was undertaken for patients with early breast cancer between 1 January 2001 and 31 December 2005, treated at the Royal Adelaide Hospital and in private practice. The proportion of oncoplastic and breast reconstructive procedures was calculated to determine the clinical effects on a specialist breast-surgical practice. RESULTS: Breast cancer resection procedures accounted for 1514 of 2113 of operations (72%). Most of these (897 of 1514, 59.2%) were wide local excision or re-excision procedures. Total breast reconstruction operations (i.e. autogenous tissue flaps, tissue expander/implant reconstructions) accounted for 251 procedures. Of these, 67 (26.7%) were carried out at the time of simple mastectomy. Contralateral breast procedures (i.e. reduction mammaplasty, mastopexy and augmentation) accounted for 138 procedures and nipple-areola reconstruction/tattoo accounted for 153 procedures. Oncoplastic procedures, such as skin-sparing mastectomy, latissimus dorsi miniflap and therapeutic mammaplasty accounted for 57 of 599 procedures (9.5%). Breast reconstruction and oncoplastic operations accounted for 599 of 2113 procedures (28%). CONCLUSION: Specialist breast surgeons trained in breast reconstruction and oncoplastic techniques can expect a substantial proportion of their breast practice to include such operative procedures (28% in this series). Subspecialist training in breast surgery should incorporate experience in breast reconstructive and aesthetic surgery for trainees who wish to practise as specialist breast surgeons in the future.

Breast volume replacement using the latissimus dorsi miniflap.

BACKGROUND: Mastectomy is often recommended to women with early breast cancer who have large tumours or where the breast volume requiring resection to achieve adequate tumour clearance is too great to allow for a satisfactory cosmetic result after breast conservation surgery. The use of a latissimus dorsi muscular flap (latissimus dorsi miniflap (LDMF)) to replace the volume loss after major breast sector resection is an option where the tumour to breast volume ratio is large. The present study describes the technique and evaluates the experience of the LDMF at Royal Adelaide Hospital, Adelaide, Australia. METHODS: Between August 1997 and April 2002, 18 women aged 37-64 years underwent wide local excision for primary breast cancer with LDMF reconstruction. Tumour characteristics, breast specimen weight and postoperative sequelae were assessed. Quality of life measurements and objective assessments of aesthetic outcome were evaluated. RESULTS: Tumour diameter ranged from 13 to 80 mm (median 30 mm). Nine patients had multifocal or extensive intraductal component positive tumours. The weight of the resected specimens ranged from 75 to 395 g (median 130 g). There were no major postoperative complications, with a range of inpatient stay of 3-10 days. Seromas were aspirated in 14 patients but did not delay adjuvant treatment. Quality of Life results showed high patient satisfaction in all but one patient. A satisfactory cosmetic result was achieved in all but one patient who subsequently required mastectomy. CONCLUSION: The LDMF procedure allows breast conservation to be achieved in women with large tumour to breast volume ratios, with satisfactory resection margins and good cosmetic and functional results. In the present experience standard oncological adjuvant treatment is not compromised.

Implication of intraoperative sentinel node imprint cytology for consent in the SNAC Trial.

BACKGROUND: Women randomized into the sentinel node biopsy-only arm of the Sentinel Node versus Axillary Clearance Trial require axillary clearance if the sentinel node is unable to be identified, or if the sentinel node contains metastases. The aim of the present study was to determine the likelihood of immediate and delayed axillary clearance in patients in the trial when nodes were subjected to intraoperative imprint cytology. METHODS: A prospective database for 400 patients with operable breast cancer was analysed to determine the likelihood of lymph node involvement according to tumour size. The ability to successfully remove a sentinel node and the accuracy of intraoperative imprint cytology of sentinel nodes was investigated. These data were used to predict the likelihood of patients proceeding to immediate or delayed axillary clearance. RESULTS: The rate of lymph node involvement was 0%, 10%, 30%, and 53% in tumours measuring <5 mm, 6-10 mm, 11-20 mm and 21-30 mm, respectively. A sentinel node was identified in 95% of cases. In a series of 79 consecutive cases using intraoperative imprint cytology, 37% of sentinel nodes containing metastases were identified intraoperatively. The estimated likelihood of undergoing immediate axillary clearance therefore ranges from 5% for tumours <5 mm, up to 24% for tumours 21-30 mm. Similarly the likelihood of delayed clearance ranges from 0% to 32% depending on tumour size. CONCLUSIONS: It is possible to give detailed and accurate information to patients undergoing sentinel node biopsy about both the risk of lymph node involvement and the likelihood of requiring immediate or secondary axillary clearance.

Intraoperative imprint cytologic assessment of the sentinel node for early breast cancer.

An increasing number of patients are undergoing sentinel node biopsy alone for axillary staging of early breast cancer. A reliable method for evaluating the status of the sentinel node intraoperatively would allow patients with sentinel node metastases to undergo immediate rather than delayed axillary clearance. Sentinel nodes in 53 consecutive patients were examined by intraoperative imprint cytology. When compared with subsequent analysis by hematoxylin-eosin staining and immunohistochemistry, the accuracy of imprint cytology for the detecting nodal metastases was 81.1%; the false negative rate was 47.0%, and there were no false positives. Results were made available to the operating surgeon within a mean time of 25 minutes. All but one of the false negatives involved micrometastatic deposits of less than 0.1 mm. Intraoperative imprint cytologic examination of the sentinel node is a useful technique that can be performed efficiently and without loss of nodal tissue for subsequent analysis. With the use of this technique, more than 50% of lymph node-positive patients would potentially be spared a second operation.