The importance of the multidisciplinary team in the decision-making process of patients undergoing neoadjuvant chemotherapy for breast cancer.

BACKGROUND AND OBJECTIVES: Recent literature suggests that rates of breast conservation surgery (BCS) are lower than expected in patients submitted to neoadjuvant chemotherapy (NAC) for breast cancer. The aim of this study was to underscore the role of the multidisciplinary team (MDT) in the decision-making process of patients who underwent breast surgery after NAC. METHODS: We conducted a retrospective study on patients with breast cancer treated according to an algorithm developed at the Breast Unit of Northern Sardinia between January 2019 and May 2023. Data collected included demographics, tumor characteristics, upfront treatment (surgery or NAC), type of primary surgery (BCS or mastectomy [Ma]) and patients' adherence to the treatment proposed by the MDT. RESULTS: Overall, 1061 women were treated during the study period, of whom 164 received NAC (Group A) and 897 upfront surgery (Group B). In group A, conversion from BCS ineligibility to BCS eligibility was observed in 47 patients (40.1%). Final surgery in patients who became BCS-eligible after NAC was BCS in 42 cases (89.3%) and Ma in 5 (10.6%). Rates of patients' adherence to the treatment proposed by the MDT were significantly better in the Group A (p = 0.02). CONCLUSIONS: Our results suggest that the MDT has a pivotal role in increasing the rates of breast conservation in women submitted to NAC.

Rising age-specific rates of immediate breast reconstruction after mastectomy: Report from an Italian Breast Unit.

BACKGROUND AND OBJECTIVES: Immediate breast reconstruction (IBR) represents a fundamental part in the management of patients receiving mastectomy. In recent years, there has been an increasing trend in the use of IBR in all age groups. The study aims were to evaluate the age-specific trend of IBR, and to discuss its effects in work organization at an Italian Breast Unit. METHODS: We searched for women diagnosed with breast cancer between 2010 and 2019, focusing on IBR rates in patients who received mastectomy. Age-specific trends were assessed using the Cochrane-Armitage test. Differences in operative times and hospital stay between women undergoing mastectomy + IBR (Ma + IBR) or mastectomy alone (Ma) were evaluated by Student's t test or χ2 test. RESULTS: Among 1915 patients, 62.4% underwent breast conserving surgery (BCS), and 37.6% mastectomy. Overall, rates of Ma + IBR increased from 32% in 2010 to 58% in 2019 (p < 0.001). Although rates of IBR rose in all age groups, the trend was significantly increased among patients aged 50-59 (p < 0.001), 60-69 (p < 0.0001), and 70-79 (p < 0.05). CONCLUSIONS: Rates of Ma + IBR have increased over years, especially among older women. Ma + IBR resulted in longer operative times and hospital stay than Ma alone. These findings imply that, in the near future, resources should be implemented to improve and strengthen the surgical activity of Breast Units, to support the increasing use of IBR in women of all age groups.

Breast-conserving therapy leads to better survival outcomes compared to mastectomy in patients with early breast cancer: evidences from the recent literature.

Classical studies comparing breast-conserving therapy (BCT) and mastectomy (Mx) focused on the non-inferiority of BCT in terms of survival outcomes. However, recent large retrospective studies have provided evidence that BCT could confer a survival advantage over Mx. The prognostic benefit of BCT was observed in all molecular subgroups, including triple negative breast cancer, and also in young patients affected from the disease, who are often submitted to Mx irrespective of tumor size. This new concept, regarding the prognostic importance related to the type of surgical treatment of breast cancer, is of particular relevance in current times. In fact, in the last two decades there has been a rise in Mx rates in BCT-eligible women, as well as a rise in bilateral mastectomy in patients with unilateral breast cancer. This phenomenon occurs despite lack of scientific evidence supporting the necessity of a more extensive surgery, and is primarily a patient-driven trend. The results of recent studies, demonstrating that BCT achieves better overall survival than Mx, should be incorporated in the multidisciplinary decision-making process. Patients with early breast cancer for whom either BCT or Mx are surgical options, should be properly informed that the prognosis of their disease is largely dependent from the biological behaviour of the tumor, and that Mx should not be considered equal to BCT in terms of survival. The present review underscored that BCT, when feasible, should be considered the option of choice also due to its advantage in survival outcomes.

Comparing Clinicopathologic Features and Surgical Treatment of Premenopausal Breast Cancer across Italy and China: Report from a Medical Exchange Program.

BACKGROUND: This study investigated the differences in clinicopathologic features and surgical treatment between an Italian and a Chinese cohort of premenopausal women with breast cancer, and highlighted the potential advantages of international medical exchange projects. METHODS: Premenopausal women who underwent surgical treatment between 2012 and 2016 at one Italian and one Chinese institution participating in a medical exchange program were compared. Factors associated with the probability to receive mastectomy were determined via logistic analysis. Changes in surgical management at the Chinese institution in the period 2018-2019, after the exchange program, were also evaluated. RESULTS: A total of 505 patients, 318 from Italy and 187 from China, were evaluated. The Chinese patients had more frequently advanced-stage tumours, large tumour size (30.9 vs. 18.1 mm, p < 0.01), invasive carcinoma (92.5 vs. 83.3%, p < 0.01), positive axillary lymph nodes (54.5 vs. 27.4%, p < 0.01), Her-2 positivity (36.4 vs. 22.0%, p < 0.01), and high proliferative index (55.1 vs. 30.2%, p < 0.01). Positive oestrogen receptor status and rates of triple-negative breast cancer did not differ (77.0 vs. 69.5%, p = 0.09 and 14.2 vs. 16%, p = 0.56, respectively). Mastectomy rates were higher among Chinese women (85 vs. 41%, p < 0.001), whereas use of sentinel node biopsy was more frequent among Italian women (77 vs. 33%, p < 0.001). Chinese women had more than 4-fold higher risk of receiving mastectomy. In the last 2 years, the rates of breast-conserving surgery and sentinel node biopsy at the Chinese institution increased from 15 to 23%, and from 33 to 42%, respectively. CONCLUSIONS: Tumour features and surgical strategies for premenopausal breast cancer may differ significantly between Italy and China. Since the international exchange program, patients from the Chinese institution have been offered more frequently less invasive surgery. International exchange programs can help in designing epidemiological studies which may be useful for strategies to improve breast cancer management and control.

The COVID-19 Outbreak May Be Associated to a Reduced Level of Care for Breast Cancer. A Comparative Study with the Pre-COVID Era in an Italian Breast Unit.

The recent COVID-19 pandemic has caused profound changes to healthcare systems as well as had deleterious repercussions on the care of cancer patients. In this comparative study, we sought to evaluate the effects of the COVID-19 pandemic on the surgical management of breast cancer in a breast unit in an Italian region with a low incidence of COVID-19 infection. Eighty-three patients were included, of whom 41 received surgery during the height of the pandemic (Group A, operated on between March and April 2020), and 42 during the same period of the year in 2019 (Group B). Clinicopathological characteristics and surgical outcomes were compared between the two groups. There were no significant differences in the baseline characteristics of the two groups with regard to age (p = 0.62), tumour size (p = 0.25), grade (p = 0.27), histology (p = 0.43), positive lymph node status (p = 0.35), and ER positive status (0.35). Waiting time for surgery was slightly longer in Group A (49.11 vs. 46.39 days, p = 0.38). Patients receiving immediate breast reconstruction were significantly less in Group A (p < 0.001). The use of sentinel node biopsy was similar in the two groups (p = 0.84). Hospital stay was longer in patients of Group B (p = 0.008). The use of regional nerve blocks was lower in Group A (p < 0.001). Patients operated on during the height of the pandemic were less likely to receive immediate reconstruction and regional nerve blocks during surgery. These features configure a situation of reduced level of care for patients with breast cancer. Efforts should be taken by the healthcare systems to maintain standard of care, even in case of a new peak in the coronavirus outbreak.

The emerging role of pectoral nerve block (PECS block) in breast surgery: A case-matched analysis.

To evaluate the benefits of pectoral nerve block (PECS block) in breast cancer surgery, we compared outcomes of 100 patients receiving PECS vs 107 without PECS. Intraoperative use of fentanyl (P < .001) acetaminophen (P = .02), morphine (P < .01), and nonsteroidal anti-inflammatory drugs (NSAIDS) (P < .01) was lower in the PECS group. Occurrence of postoperative nausea and vomiting (PONV) was lower in the PECS group (P = .04). On postoperative day 1, the use of acetaminophen (P = .23), morphine (P = .83), and NSAIDS (P = .4) did not differ. Twenty-one patients received surgery with PECS block plus sedation alone. PECS block can reduce intraoperative use of opioids and analgesic drugs, and is associated with reduced occurrence of PONV. Selected patients can receive breast-conserving surgery with PECS plus sedation, avoiding general anesthesia.

Benefits of Organized Mammographic Screening Programs in Women Aged 50 to 69 years: A Surgical Perspective.

BACKGROUND: The benefits of organized mammographic screening programs (OMSPs) in reducing breast cancer mortality have been addressed by several studies. This study was designed to specifically evaluate the advantages of OMPSs in terms of surgical management of patients with breast cancer. MATERIALS AND METHODS: Surgical treatment of 201 patients with breast cancer aged 50 to 69 years coming from OMSPs was compared with that of 532 non-OMSP patients in same age group. The likelihood of receiving BCS was analyzed through a multivariable regression model. RESULTS: The mean tumor size was smaller in the OMSP patients (14 mm vs. 18 mm; P < .01). The proportion of patients having metastatic lymph nodes was higher in the non-OMSP group (33.3% vs. 17.9%; P < .01). Rates of breast-conserving surgery (BCS) were significantly higher in the OMSP group (89.1% vs. 59.1%; P < .01). Sentinel node biopsy was carried out in 84.1% and 62.5% of patients in the OMSP and non-OMSP groups, respectively (P < .01). Rates of axillary lymph node dissection were significantly different (24.9% in the OMSP group and 35.8% in the non-OMSP group; P = .02). Re-excisions for infiltrated margins after BCS were lower in the OMSP group (4.8% vs. 12.7%; P < .01). Hospital stay was shorter in the OMSP group (2.13 vs. 3.02 days; P < .01). OMPS women had a 3-fold higher probability of receiving BCS. CONCLUSIONS: Patients with breast cancer belonging to OMSPs had a higher probability to receive less invasive surgery and to have shorter hospital stay. Our results support the use of campaigns aimed at increasing adhesion to mammography screening.

Mastectomy patterns, but not rates, are changing in the treatment of early breast cancer. Experience of a single European institution on 2315 consecutive patients.

BACKGROUND: Recent literature reports that rates of mastectomy are increasing in early breast cancer. However, data from European institutions are limited and revealed conflicting results. We report on 15-year trends of mastectomy, mastectomy plus immediate reconstruction and contralateral prophylactic mastectomy (CPM) at an academic institution. METHODS: We identified women diagnosed with unilateral early breast cancer at stage 0-IIa, with tumour size ≤ 4 cm, between 2002 and 2016. Trends were assessed using the Cochrane-Armitage test. Multivariable logistic regression was used to identify factors associated with receipt of mastectomy plus immediate reconstruction. RESULTS: A total of 2315 patients were identified. Of them, 65.7% underwent breast conserving surgery (BCS), while 34.3% underwent mastectomy as upfront surgery. Two point four per cent also received CPM. Immediate reconstruction was performed in 36.0% of patients receiving mastectomy. There was no change in trends of mastectomy over the 15 years studied (p = 0.69), as well as in trends of patients undergoing CPM (p = 0.44). In contrast, rates of immediate reconstruction rose significantly over the study period (from 12.2% in 2002 to 62.7% in 2016, p < 0.0001). Women were more likely to receive mastectomy plus immediate reconstruction if they were aged 50 years or younger, or had tumours larger than 2 cm, or had non-invasive carcinoma. CONCLUSIONS: Our study suggests that rates of both mastectomy and CPM in early breast cancer are not increasing, while use of immediate reconstruction is on the rise.

Usefulness of magnetic resonance in patients with invasive cancer eligible for breast conservation: a comparative study.

BACKGROUND: The role of magnetic resonance imaging (MRI) in newly detected breast cancer remains controversial. We investigated the impact of preoperative MRI on surgical management of infiltrating breast carcinoma (IBC). METHODS: We reviewed data of 237 patients with IBC who were suitable for breast-conserving surgery (BCS) between 2009 and 2011. Of these patients, 109 underwent preoperative MRI (46%; MRI group) and 128 did not (54%; no-MRI group). We analyzed MRI-triggered changes in surgical plan and compared differences in rates of positive margins and mastectomy. RESULTS: Tumor size was larger in the MRI group (16.8 mm vs. 13.9 mm; P < .001). MRI changed the initial surgical planning in 18 of 109 patients (16.5%) because of detection of larger tumor diameter requiring wider resection (8 patients [7.3%]) or additional malignant lesions in the ipsilateral (9 patients [8.2%]) or contralateral breast (1 patient [0.9%]). MRI-triggered treatment changes included mastectomy (n = 12), wider excision (n = 5), and contralateral BCS (n = 1). Reoperation rates for positive margins after BCS appeared higher in the no-MRI group (4.1% vs. 8.6%), but the difference missed statistical significance (P = .9). Overall mastectomy rates were higher in the MRI group (13.7% vs. 7.0%; P < .05). The likelihood of having a change of treatment resulting from MRI was significantly higher for patients with tumors > 15 mm and for those with positive lymph nodes. CONCLUSION: Lymph node positivity and tumor size > 15 mm may predict an MRI-triggered change in surgical plan. Preoperative MRI resulted in higher mastectomy rates justified by biopsy-proven additional foci of carcinoma and did not significantly reduce reoperation rates for positive margins.