NCCN Guidelines® Insights: Breast Cancer Screening and Diagnosis, Version 1.2023.

The NCCN Guidelines for Breast Cancer Screening and Diagnosis provide health care providers with a practical, consistent framework for screening and evaluating a spectrum of clinical presentations and breast lesions. The NCCN Breast Cancer Screening and Diagnosis Panel is composed of a multidisciplinary team of experts in the field, including representation from medical oncology, gynecologic oncology, surgical oncology, internal medicine, family practice, preventive medicine, pathology, diagnostic and interventional radiology, as well as patient advocacy. The NCCN Breast Cancer Screening and Diagnosis Panel meets at least annually to review emerging data and comments from reviewers within their institutions to guide updates to existing recommendations. These NCCN Guidelines Insights summarize the panel's decision-making and discussion surrounding the most recent updates to the guideline's screening recommendations.

Estrogen Receptor Positive and Progesterone Receptor Negative Breast Cancer: the Role of Hormone Therapy.

ER+/PR- (estrogen receptor positive and progesterone receptor negative) tumors constitute only a small portion of the breast cancer population. Patients with ER+/PR- tumors, however, are characterized by worse survival compared to patients with ER+/PR+ (estrogen receptor positive and progesterone receptor positive) tumors. Controversy exists regarding the efficacy of hormone blocking therapy for patients with ER+/PR- tumors. The NCDB was queried between 2004 and 2015, and patients with invasive ER+/PR- tumors were identified. We employed univariate Cox proportional hazards to compare outcomes among patients that did or did not receive hormone blocking therapy. We identified 138,398 patients with invasive ER+/PR- tumors, 32,044 (23%) of whom did not receive hormone blocking therapy. The reasons for not receiving hormone blocking therapy included contraindications to treatment, death, patient refusal, and unknown. There were no significant differences in race, income quartile, or education quartile between patients who did and did not receive hormone blocking therapy. Patients who did not receive hormone blocking therapy underwent surgical assessment of the axilla more frequently than those who did receive hormone therapy. Our analysis demonstrated that hormone blocking therapy administration was associated with increased overall survival for up to 10 years of follow up (HR: 0.58; 95% CI: 0.56-0.59, p < 0.001). Hormone blocking therapy may be associated with increased survival for breast cancer patients with ER+/PR- tumors. Although this benefit may last for years after completion of the course, up to 25% of patients do not receive this treatment. Strategies to increase the utilization and adherence to hormone blocking therapy regimens may improve patient survival outcomes.

A Review of Options for Localization of Axillary Lymph Nodes in the Treatment of Invasive Breast Cancer.

Invasive breast cancer is a common disease, and the most common initial site of metastatic disease are the axillary lymph nodes. As the standard of care shifts towards less invasive surgery in the axilla for patients with invasive breast cancer, techniques have been developed for axillary node localization that allow targeted dissection of specific lymph nodes without requiring full axillary lymph node dissection. Many of these techniques have been adapted from technologies developed for localization of lesions within the breast and include marker clip placement with intraoperative ultrasound, carbon-suspension liquids, localization wires, radioactive seeds, magnetic seeds, radar reflectors, and radiofrequency identification devices.The purpose of this article is to summarize these methods and describe benefits and drawbacks of each method for performing localization of lymph nodes in the axilla.

Impact of race, ethnicity, and socioeconomic factors on receipt of radiation after breast conservation surgery: analysis of the national cancer database.

INTRODUCTION: Many eligible women with invasive breast cancer do not receive recommended adjuvant radiation (RT), despite its role in local control and overall survival. We examined trends in RT use over 10 years, and the impact of sociodemographic factors on the receipt of standard-of-care RT, using the National Cancer Database (NCDB). MATERIALS/METHODS: Women under age 70 with invasive breast cancer who underwent BCS from 2004 to 2014 were analyzed. Receipt of RT was evaluated in the whole cohort and by time period to identify temporal trends. Multiple logistic regression models were used to assess associations between factors such as race, insurance status, ethnicity, and receipt of RT. RESULTS: A total of 501,733 patients met eligibility criteria. The percentage of patients undergoing adjuvant RT increased from 86.7% in 2004 to 92.4% in 2012, and then decreased in 2013 and 2014 to 88.9%. On univariate analysis, patients of white race were significantly more likely to receive RT compared with patients of black race (90.4% vs 86.9%, p < 0.0001), as were non-Hispanic women compared to Hispanic patients (90.2% vs. 85.3%, p < 0.0001). On multivariate analysis, race, ethnicity, insurance status, education level, and age remained significantly associated with receipt of RT. On temporal analysis, gaps remained stable, with no significant improvements over time. CONCLUSIONS: This analysis suggests a recent decline in guideline-concordant receipt of RT in women under 70, and persistent disparities in the use of RT after BCS by race, ethnicity, and socioeconomic factors. These findings raise concern for a recent detrimental change in patterns of care delivery.

Breast Cancer Screening and Social Media: a Content Analysis of Evidence Use and Guideline Opinions on Twitter.

There is ongoing debate regarding the best mammography screening practices. Twitter has become a powerful tool for disseminating medical news and fostering healthcare conversations; however, little work has been done examining these conversations in the context of how users are sharing evidence and discussing current guidelines for breast cancer screening. To characterize the Twitter conversation on mammography and assess the quality of evidence used as well as opinions regarding current screening guidelines, individual tweets using mammography-related hashtags were prospectively pulled from Twitter from 5 November 2015 to 11 December 2015. Content analysis was performed on the tweets by abstracting data related to user demographics, content, evidence use, and guideline opinions. Standard descriptive statistics were used to summarize the results. Comparisons were made by demographics, tweet type (testable claim, advice, personal experience, etc.), and user type (non-healthcare, physician, cancer specialist, etc.). The primary outcomes were how users are tweeting about breast cancer screening, the quality of evidence they are using, and their opinions regarding guidelines. The most frequent user type of the 1345 tweets was "non-healthcare" with 323 tweets (32.5%). Physicians had 1.87 times higher odds (95% CI, 0.69-5.07) of providing explicit support with a reference and 11.70 times higher odds (95% CI, 3.41-40.13) of posting a tweet likely to be supported by the scientific community compared to non-healthcare users. Only 2.9% of guideline tweets approved of the guidelines while 14.6% claimed to be confused by them. Non-healthcare users comprise a significant proportion of participants in mammography conversations, with tweets often containing claims that are false, not explicitly backed by scientific evidence, and in favor of alternative "natural" breast cancer prevention and treatment. Furthermore, users appear to have low approval and confusion regarding screening guidelines. These findings suggest that more efforts are needed to educate and disseminate accurate information to the general public regarding breast cancer prevention modalities, emphasizing the safety of mammography and the harms of replacing conventional prevention and treatment modalities with unsubstantiated alternatives.

Burden of preoperative cardiovascular disease risk factors on breast cancer surgery outcomes.

BACKGROUND: Cardiovascular comorbidities have been studied sporadically in breast cancer surgery. No study has provided a comprehensive assessment of the severity and relative influence of preoperative cardiac risk factors on surgical outcomes. METHODS: 78,338 breast cancer surgery patients were identified from the 2006 to 2012 National Surgical Quality Improvement Program (NSQIP) database. We estimated the impact of chronic conditions (diabetes, hypertension, obesity, smoking), acute cardiac events (myocardial infarction, congestive heart disease, angina), and past cardiac procedures (cardiac surgery, percutaneous coronary intervention) on 30-day postoperative complications, reoperation, and readmission. RESULTS: Nearly 65% of patients had chronic conditions, <1% had acute events, and 3% had past procedures. The prevalence of outcomes was low: 5% had complications, 4% underwent reoperation, and 4% were readmitted. Over 65% of complications were wound-related. All risk factor categories were associated with complications (ORs from 1.26 to 4.18). Acute events had the strongest effect on overall (OR 3.54, CI 2.55-4.91) and medical (OR 4.18, CI 2.73-6.41) complications. Chronic conditions and past procedures also predicted reoperation and readmission (ORs from 1.57 to 2.68). The odds of all outcomes increased with the number of chronic conditions (ptrend < 0.001). CONCLUSIONS: Cardiovascular disease has a significant impact on outcomes even in minimal-risk breast cancer surgery. J. Surg. Oncol. 2016;114:144-149. © 2016 Wiley Periodicals, Inc.

The perioperative handoff protocol: evaluating impacts on handoff defects and provider satisfaction in adult perianesthesia care units.

STUDY OBJECTIVE: To evaluate a new perioperative handoff protocol in the adult perianesthesia care units (PACUs). DESIGN: Prospective, unblinded cross-sectional study. SETTING: Perianesthesia care unit in a tertiary care facility serving 55,000 patients annually. PATIENTS: One hundred three surgery patients. INTERVENTIONS: During a 4-week preintervention phase, 53 perioperative handoffs were observed, and data were collected daily by a trained observer. Educational sessions were conducted to train perioperative practitioners on the new protocol. Two weeks after implementation, 50 consecutive handoffs were observed, and practitioners were surveyed with the same methodology as in the preintervention phase. MEASUREMENTS: Type of information shared, type and duration of procedure, total duration of handoff, number and type of providers at the bedside, number of report interruptions, environmental distractions, and any other disruptive events. Observers also tracked technical/equipment problems to include malfunctioning or compromised operation of medical equipment, such as the cardiac monitor, transducer, oxygen tank, and pulse oximeter. MAIN RESULTS: A total of 103 handoffs were observed (53 preintervention and 50 postintervention). The mean number of defects per handoff decreased from 9.92 to 3.68 (P < .01). The mean number of missed information items from the surgery report decreased from 7.57 to 1.2 items per handoff and from 2.02 to 0.94 (P < .01) for the anesthesia report. Technical defects reported by unit nurses decreased from 0.34 to 0.10 (P = .04). Verbal reports delivered by surgeons increased from 21.2% to 83.3%. Although the mean duration of handoffs increased by 2 minutes (P = .01), the average time from patient arrival at PACU to handoff start was reduced by 1.5 minutes (P = .01). Satisfaction with the handoff improved significantly among PACU nurses. CONCLUSIONS: The perioperative handoff protocol implementation was associated with improved information sharing and reduced handoff defects.

Management of positive sub-areolar/nipple duct margins in nipple-sparing mastectomies.

We evaluated management of positive sub-areolar/nipple duct margins in nipple-sparing mastectomies (NSM) at our institution. Retrospective chart review of all NSM from January 2007 to April 2012 was performed and patient, tumor, and treatment information was collected. Sub-areolar/nipple duct margins included ductal tissue from within the nipple. Of 438 NSM, 22 (5%) had positive sub-areolar/nipple duct margins; 21 of 220 cancer-bearing breasts (10%) and 1 of 218 prophylactic mastectomies (0.5%). Positive margins included four with invasive lobular carcinoma and 18 with ductal carcinoma in situ (DCIS). Management included removal of eight nipples and nine nipple areola complexes (NAC). Four of 17 nipple/NAC specimens had evidence of residual DCIS and none had residual invasive cancer. The majority of nipple/NAC specimens excised for a positive margin had no residual malignancy. Future studies are needed to determine the extent of NAC tissue removal required for positive margins.

Intraoperative digital specimen mammography: a significant improvement in operative efficiency.

BACKGROUND: The goal of this study was to determine the length of operative time and its effect on surgeon productivity with the use of intraoperative digital specimen mammography (IDSM) compared to standard specimen mammography (SSM). METHODS: A retrospective chart review was performed on 344 consecutive patients from a single breast surgeon from 2003 to 2010. Operative time was compared between procedures using SSM vs IDSM. Surgeon productivity was evaluated by the number of wire-localized excisions performed prior to and after implementation of IDSM. RESULTS: Two hundred thirty patients underwent SSM and 114 underwent IDSM. Average operative time in the SSM group was 78 minutes vs 68 minutes in the IDSM group (P < .0001). In the first 2 years after implementation of IDSM, the number of wire-localized excisions performed increased by 20%. CONCLUSIONS: Operative times were significantly shorter with the use of IDSM vs SSM, and this was associated with an increase in surgeon productivity.

Application of ACOSOG Z0011 criteria reduces perioperative costs.

BACKGROUND: The ACOSOG Z0011 (Z0011) trial concluded that sentinel lymph node biopsy (SLNB) without completion axillary lymph node dissection (ALND) provides excellent regional control in women with T1-T2 sentinel lymph node (SLN) positive breast cancers receiving breast conservation therapy. We determined whether application of Z0011 guidelines would reduce costs. METHODS: A retrospective chart review of patients with invasive breast cancer treated with lumpectomy and SLNB at our institution during 2009 was performed. We determined the number of overnight hospital admissions following ALND and estimated costs pertaining to the perioperative surgical management of the axilla patients actually received, and compared those to the estimated number of inpatient days and perioperative costs if Z0011 guidelines had been followed for eligible patients. The 2011 Medicare Fee Schedule was used to estimate costs for procedures, and costs for OR time were estimated using procedure length and cost of OR time per minute. RESULTS: A total of 71 patients underwent lumpectomy with SLNB and had at least 1 positive SLN. Estimated costs related to perioperative surgical management of the axilla were $322,775, and there were 36 overnight admissions. Applying Z0011 criteria, 51 patients (72%) would have been eligible to forego completion ALND. Estimated costs would have been $264,513 with 13 overnight admissions, translating into a cost savings of $58,262 and 23 fewer overnight admissions. CONCLUSION: Application of Z0011 guidelines resulted in cost savings, with a 64% reduction in inpatient hospital days and an 18% reduction in early perioperative costs.

Cost comparison of radiation treatment options after lumpectomy for breast cancer.

BACKGROUND: Radiation therapy (RT) after lumpectomy for breast cancer can be delivered with several different regimens. We evaluated a cost-minimization strategy to select among RT options. METHODS: An institutional review board (IRB)-approved retrospective review identified a sample of 100 women who underwent lumpectomy for invasive or in situ breast cancer during 2009. Post lumpectomy RT options included: no radiation in women ≥70 years [T1N0, estrogen receptor (ER)+] per Cancer and Leukemia Group B (CALGB) 9343 (no-RT), accelerated external-beam partial-breast irradiation (APBI), and Canadian fractionation (C-RT), as alternatives to standard whole-breast radiation therapy (WBRT). Eligibility for RT regimens was based on published criteria. RT costs were estimated using the 2011 US Medicare Physician Fee Schedule and average Current Procedural Terminology (CPT) codes billed per regimen at our institution. Costs were modeled in a 1,000-patient theoretical cohort. RESULTS: Median patient age was 56.5 years (range 32-93 years). Tumor histology included invasive ductal cancer (78 %), ductal carcinoma in situ (DCIS) (15 %), invasive lobular cancer (6 %), and mixed histology (1 %). Median tumor size was 1 cm (range 0.2-5 cm). Estimated per-patient cost of radiation was US$5,341.81 for APBI, US$9,121.98 for C-RT, and US$13,358.37 for WBRT. When patients received the least expensive radiation regimen for which they were eligible, 14 % received no-RT, 44 % received APBI, 7 % received C-RT, and 35 % defaulted to WBRT. Using a cost-minimization strategy, estimated RT costs were US$7.67 million, versus US$13.36 million had all patients received WBRT, representing cost savings of US$5.69 million per 1,000 patients treated. CONCLUSIONS: A cost-minimization strategy results in a 43 % reduction in estimated radiation costs among women undergoing breast conservation.

Pilot implementation of a perioperative protocol to guide operating room-to-intensive care unit patient handoffs.

OBJECTIVES: Perioperative handoffs are a particularly high-risk period given patients' postprocedural physiology, their physical transport through the hospital, and the triad transfer of personnel, information, and technology. The authors piloted a new perioperative handoff process to guide patient transfers from the cardiac operating room (OR) to the cardiac surgical intensive care unit (CSICU). The aim of the study was to evaluate the impact of a standardized handoff process on patient care and provider satisfaction. DESIGN: A prospective, unblinded intervention study. SETTING: A CSICU in a teaching hospital. PARTICIPANTS: Two hundred thirty-eight health care practitioners during the transfer of care of 60 patients. INTERVENTIONS: The implementation of a standardized handoff protocol and checklist. MEASUREMENTS AND MAIN RESULTS: After the protocol's implementation, the presence of all handoff core team members at the bedside increased from 0% at baseline to 68% after intervention. The percentage of missed information in the surgery report decreased from 26% to 16% (p = 0.03), but the percentage of missed information in the anesthesia report showed no significant change (19% to 17%, p > 0.05). Handoff satisfaction scores among intensive care unit (ICU) nurses increased from 61% to 81%. On average, the duration of handoff increased by 1 minute. CONCLUSIONS: A standardized handoff protocol that guides the transfer of care from the OR team to the CSICU team can reduce the risk of missed information and improve satisfaction among perioperative providers.

Surgical management of bile duct injuries sustained during laparoscopic cholecystectomy: perioperative results in 200 patients.

OBJECTIVE: A single institution retrospective analysis of 200 patients with major bile duct injuries was completed. Three patients died without surgery due to uncontrolled sepsis. One hundred seventy-five patients underwent surgical repair, with a 1.7% postoperative mortality and a complication rate of 42.9%. SUMMARY BACKGROUND DATA: The widespread application of laparoscopic cholecystectomy (LC) has led to a rise in the incidence of major bile duct injuries (BDI). Despite the frequency of these injuries and their complex management, the published literature contains few substantial reports regarding the perioperative management of BDI. METHODS: From January 1990 to April 2003, a prospective database of all patients with a BDI following LC was maintained. Patients' charts were retrospectively reviewed to analyze perioperative surgical management. RESULTS: Over 13 years, 200 patients were treated for a major BDI following LC. Patient demographics were notable for 150 women (75%) with a mean age of 45.5 years (median 44 years). One hundred eighty-eight sustained their BDI at an outside hospital. The mean interval from the time of BDI to referral was 29.1 weeks (median 3 weeks). One hundred nine patients (58%) were referred within 1 month of their injury for acute complications including bile leak, biloma, or jaundice. Twenty-five patients did not undergo a surgical repair at our institution. Three patients (1.5%) died after delayed referral before an attempt at repair due to uncontrolled sepsis. Twenty-two patients, having intact biliary-enteric continuity, underwent successful balloon dilatation of an anastomotic stricture. A total of 175 patients underwent definitive biliary reconstruction, including 172 hepaticojejunostomies (98%) and 3 end-to-end repairs. There were 3 deaths in the postoperative period (1.7%). Seventy-five patients (42.9%) sustained at least 1 postoperative complication. The most common complications were wound infection (8%), cholangitis (5.7%), and intraabdominal abscess/biloma (2.9%). Minor biliary stent complications occurred in 5.7% of patients. Early postoperative cholangiography revealed an anastomotic leak in 4.6% of patients and extravasation at the liver dome-stent exit site in 10.3% of patients. Postoperative interventions included percutaneous abscess drainage in 9 patients (5.1%) and new percutaneous transhepatic cholangiography and stent placement in 4 patients (2.3%). No patient required reoperation in the postoperative period. The mean postoperative length of stay was 9.5 days (median 9 days). The timing of operation (early, intermediate, delayed), presenting symptoms, and history of prior repair did not affect the incidence of the most common perioperative complications or length of postoperative hospital stay. CONCLUSIONS: This series represents the largest single institution experience reporting the perioperative management of BDI following LC. Although perioperative complications are frequent, nearly all can be managed nonoperatively. Early referral to a tertiary care center with experienced hepatobiliary surgeons and skilled interventional radiologists would appear to be necessary to assure optimal results.