Tolerance and Outcomes of Neoadjuvant Chemotherapy in Geriatric Breast Cancer Patients.

INTRODUCTION: Neoadjuvant chemotherapy (NAC) is an established treatment option for patients with human epidermal growth factor receptor 2-positive (Her2+) or triple-negative breast cancer (TNBC). However, the toxicities associated with NAC may lead to reduced tolerance in geriatric patients due to medical comorbidities. Our objective is to evaluate the tolerance and outcomes of NAC in geriatric patients with TNBC and Her2+ breast cancer. MATERIALS AND METHODS: An institutional review board approved, retrospective study of 43 geriatric (≥70 y) and 103 non-geriatric (<70 y) patients with TNBC and Her2+ breast cancer was conducted. Demographic, comorbidity, treatment, and toxicity variables were collected. Log-rank tests and Cox regression visualized survival outcomes evaluated associations with clinical and demographic variables. Descriptive statistics were performed. RESULTS: Following NAC, 30% geriatric patients had a pathologic complete response in the primary tumor, 54% had a partial response, and 16% had no response. Of the non-geriatric patients, 24% had a pathologic complete response, 64% had a partial response, and 12% showed no response. NAC-associated toxicities occurred in 81% of geriatric patients and 73% non-geriatric patients, with neutropenia occurring most frequently in both groups. Dose reduction and early discontinuation of NAC each occurred more frequently in the geriatric group (14%; 23%) than the non-geriatric group (7%; 6%). Higher post-treatment Eastern Cooperative Oncology Group scores were associated with worse overall survival and worse recurrence-free survival in both groups. CONCLUSIONS: NAC was associated with reduced tumor and nodal stage in most geriatric patients; however, NAC-associated toxicities were common and led some patients to reduce or stop their NAC regimen prematurely.

Ultrasound-guided radar reflector localization of axillary lymph nodes facilitates targeted axillary dissection.

PURPOSE: This study evaluated feasibility and patient outcomes for targeted axillary lymph node (LN) dissection (TAD) with SAVI SCOUT® ultrasound-guided radar reflector localization (RRL). METHODS: In this IRB-approved retrospective study, 800 consecutive patients who underwent ultrasound-guided RRL between November 2017 and June 2020 were reviewed. Of these patients, those with axillary LN RRL were included in this study. Reports in the electronic medical record were reviewed to determine RRL placement, retrieval, and surgical outcomes. RESULTS: A total of 147 patients met inclusion criteria. Of these, axillary RRL was performed for biopsy-proven metastatic disease in 134 and inconclusive or benign biopsy in 13. RRL was successful in 146/151 lymph nodes (97%). Two patients had placement >10 mm from target and 3 had no post-placement signal. In all 5, the targets were successfully retrieved at surgery. Specimen radiographs were performed in 135 cases and confirmed the intended target in all 135 (100%). In 109 patients who underwent TAD + sentinel lymph node biopsy (SLNB), the RRL LN and the SLN(s) were different in 18 (17%). In 3 of these, the RRL LN was the only malignant LN (3%). In the 105 patients who underwent neoadjuvant chemotherapy, 43% (45/105) achieved nodal pCR and 85% (89/105) had <3 metastatic lymph nodes at surgery. CONCLUSION: Ultrasound-guided RRL of axillary LNs is a feasible approach to facilitate TAD with high placement and retrieval success rates. This enables TAD as an alternative to complete axillary LN dissection (cALND), sparing some patients with low nodal tumor burden from cALND.

Surgical Management of Axilla of Triple-Negative Breast Cancer in the Z1071 Era: A Propensity Score-Matched Analysis of the National Cancer Database.

BACKGROUND: The role of sentinel lymph node biopsy (SLNB) in triple-negative breast cancer (TNBC) patients who present with clinical N1 (cN1) disease and undergo complete clinical response (cCR) to neoadjuvant systemic therapy (NAST) remains unclear. We aimed to study the outcomes of SLNB versus axillary lymph node dissection (ALND) in this setting. PATIENTS AND METHODS: Patients with cN1 TNBC who showed cCR to NAST were selected from the National Cancer Database (NCDB), and propensity score matched 1:1 between SLNB and ALND in all-comers, ypN0, and ypN1 subgroups. Overall survival (OS) was compared using the Kaplan-Meier method. Cox regression was used to identify predictors of OS. RESULTS: Of the 2953 patients selected. 1062 (36.0%) underwent SLNB and 1891 (64.0%) underwent ALND. There was a chronological increase in national SLNB utilization (from 20% in 2012 to 46% in 2017). One thousand three patients were propensity matched between SLNB and ALND, and no OS difference was noted (81.73 ± 1.04 vs. 80.07 ± 0.70 months; p = 0.127). In the ypN0 subgroup, 884 pairs were matched and no significant OS difference was found (85.29 ± 0.84 vs. 82.60 ± 0.68 months; p = 0.638). In ypN+ patients, 129 pairs were matched and demonstrated a trend toward decreased OS with SLNB (64.37 ± 3.12 vs. 72.45 ± 72.45; p = 0.085). Cox regression identified age, inner tumors, advanced T stage, partial/no in-breast response, and nodal status as unfavorable predictors of OS. Definitive axillary surgical procedure was not a predictor in the final model. CONCLUSION: SLNB and ALND appear to yield comparable OS in cN1 TNBC patients who demonstrate cCR to NAST. Caution should be exercised in ypN1 patients as worse OS could be associated with SLNB.

Real-world benefit of combination palbociclib and endocrine therapy for metastatic breast cancer and correlation with neutropenia.

BACKGROUND: Combination CDK4/6 inhibitor and endocrine therapy has been shown to significantly improve progression-free survival (PFS) in patients with hormone receptor (HR)-positive, HER2-negative metastatic breast cancer (mBC). The aim of this retrospective study was to evaluate the real-world benefit of first-line combination therapy in this cohort and to correlate treatment efficacy with neutropenia, a common toxicity of CDK4/6 inhibitors. METHODS: This study included HR-positive, HER2-negative advanced or mBC patients who were treated with palbociclib plus endocrine therapy, mainly letrozole, between 1 January 2015 and 1 March 2018. Progression-free survival (PFS) was determined using Kaplan-Meier analysis. The predictive value of absolute neutrophil count (ANC) and neutrophil-to-lymphocyte ratio (NLR) for PFS were explored using Cox regression models. Both ANC and NLR were used as a time-dependent variable. RESULTS: In total, 165 patients were included with median PFS of 24.19 months (95% CI 18.93-NR). Median PFS for patients with bone-only metastases (n = 54) was not reached (95% CI 18.21-NR). Among patients with all other metastases (n = 111), median PFS was 24.19 months (95% CI 16.33-33.82). Lower ANC was correlated with decreased risk of progression (HR 0.84, 95% CI 0.71-0.97, p = 0.008). There was no significant association between NLR and the risk of disease progression (HR 1.07, 95% CI 0.97-1.18, p = 0.203). CONCLUSION: The effectiveness of palbociclib and endocrine therapy in the treatment of HR-positive, HER2-negative mBC in the real-world setting is similar to the efficacy reported in the PALOMA-2 trial. Patients with lower neutrophil count may have a lower risk of early disease progression.

Effect of surgical complications on outcomes in breast cancer patients treated with mastectomy and immediate reconstruction.

BACKGROUND: Operative complications affect recurrence in non-breast malignancies. Rising rates of mastectomy with immediate reconstruction and their increased post-operative complications fuel concerns for poorer outcome in breast cancer (BC). We sought to determine the effect of complications on recurrence in BC patients. METHODS: A single-institution retrospective review was conducted of incident BC treated with mastectomy and immediate reconstruction. Overall survival and recurrence were compared between patients with complications to those without. RESULTS: Of 201 patients (350 mastectomies, 86 nipple-sparing), 62 (30.8%) had a surgical complication. Patients with complications were older, but groups were similar for type of reconstruction, tobacco use, hormone receptor status, HER2, lymphovascular invasion, and pathologic stage (all p > 0.05). Twenty-two complications (10.9%) were infection, 5 (2.5%) dehiscence, 14 flap necrosis (7%), 21 hematomas (10.4%), and 8 nipple necroses (9%). Recurrence occurred in 18 (8.9%) patients: 4 local, 2 regional, and 12 distant. After 8.9 years of median follow-up, patients with complications trended towards higher recurrence (hazard ratio (HR) 2.23, log-rank p = 0.08, Cox regression p = 0.05), particularly with nipple necrosis (HR 3.28, log-rank p = 0.09, regression p = 0.06). Patients with other complications had similar recurrence-free survival to those without (all p > 0.05). Higher stage (HR 13.66, log-rank p = 0.03) and adjuvant radiation (HR 2.78, log-rank p = 0.04) cases were more likely to recur. Patients with complications had similar overall survival to those without (log-rank p > 0.05). CONCLUSION: BC patients with surgical complications do not have lower overall survival. This finding may be due to the improved prognosis compared to non-breast malignancies.

Impact of Axillary Dissection Among Patients With Sentinel Node-Positive Breast Cancer Undergoing Mastectomy.

BACKGROUND: Results of the American College of Surgeons Oncology Group (ACOSOG) Z0011 trial supports omission of completion axillary lymph node dissection (CLND) after breast-conservation surgery with a positive sentinel lymph node biopsy (SLNB). We hypothesized that CLND also does not impact outcomes in women with clinically node-negative (cN0), pathologically node-positive breast cancer undergoing mastectomy. MATERIALS AND METHODS: A single-institution retrospective review was performed of patients with SLN-positive breast cancer treated from July 1999 through May 2018. Clinicopathologic and outcome data were collected. Patients with SLNBs were compared with those receiving SLNB and CLND. The Kruskal-Wallis, chi-square, and Fisher exact tests were used to assess for differences between continuous and categorical variables. The log-rank test was used for time-to-event analyses, and Cox proportional hazards models were fit for locoregional and distant recurrence and overall survival (OS). RESULTS: Of 329 patients with SLN-positive breast cancer undergoing mastectomy, 60% had CLND (n=201). Median age at diagnosis was 53 years (interquartile range [IQR], 46-62 years). The median number of SLNs sampled was 3 (IQR, 2-4), and the median number of positive SLNs was 1 (IQR, 1-2). Patients receiving CLND had higher tumor grades (P=.02) and a higher proportion of hormone receptor negativity (estrogen receptor, 19%; progesterone receptor, 27%; both P=.007). A total of 44 patients (22%) had increased N stage after CLND. Median follow-up was 51 months (IQR, 29-83 months). No association was found between CLND and change in OS and locoregional or distant recurrence. Completion of postmastectomy radiotherapy was associated with improved OS (P=.04). CONCLUSIONS: CLND is not significantly correlated with reduced recurrence or improved OS among patients who have cN0, SLN-positive breast cancer treated with mastectomy. CLND was significantly correlated with receipt of adjuvant systemic therapy. Completion of postmastectomy radiotherapy was associated with improved OS.

Surgeon Bias in the Management of Positive Sentinel Lymph Nodes.

BACKGROUND: The standard of care for clinically node-negative (cN0) patients following positive sentinel lymph node biopsy (SLNB) was completion axillary lymph node dissection (CALND). Publication of ACOSOG Z0011 in 2010 changed this standard for patients undergoing lumpectomy. Clinicians have since expanded this practice to mastectomy patients, and ongoing prospective studies are seeking to validate this practice. Here, we evaluate patient and tumor characteristics that led surgeons to forego a second surgery for CALND in cN0 mastectomy patients with positive SLNB. PATIENTS AND METHODS: A single institution, retrospective review of cN0 patients with invasive primary breast cancer and positive SLNB from 2010 to 2016 was performed. Patients with T4 disease, positive preoperative axillary biopsy, prior neoadjuvant therapy or axillary surgery were excluded. Patients with positive SLNB undergoing CALND were compared with patients for whom CALND was omitted. Statistical analysis was performed using Kruskal-Wallis tests for continuous variables and χ2 tests or Fischer exact tests for categorical variables. RESULTS: Of 259 patients with positive SLNB, 180 (69.4%) patients underwent mastectomy. CALND was performed at the time of mastectomy in 54 (30%) patients, at time of second operation in 22 (12.2%) patients, and not performed in 104 (57%) patients. Delayed CALND was significantly associated with younger age, larger tumors, increased number of positive sentinel nodes, invasive lobular carcinoma, extranodal extension, and lymphovascular invasion. CONCLUSIONS: The management of cN0 patients with positive SLNB that do not meet ACOSOG Z0011 criteria is evolving and is influenced by tumor and patient characteristics in an attempt to balance the morbidity of CALND with the low rate of local regional recurrence.

Feasibility of Axillary Lymph Node Localization and Excision Using Radar Reflector Localization.

INTRODUCTION: Neoadjuvant chemotherapy (NAC) is commonly used for patients with clinically detected nodal metastases. Sentinel lymph node biopsy (SLNB) after NAC is feasible. Excision of biopsy-proven positive lymph nodes in addition to SLNB, termed targeted axillary dissection (TAD), decreases the false-negative rate of SLNB alone. Positive nodes can be marked with radar reflector-localization (RRL) clips. We report our institutional experience with RRL-guided TAD and demonstrate its safety and feasibility. PATIENTS AND METHODS: We performed an institutional review board-approved retrospective review of consecutive clinically node-positive female patients with breast cancer treated with NAC and RRL-guided TAD between January 2017 and September 2019. Clinicopathologic and treatment data were collected; descriptive statistics are reported. RESULTS: Forty-five patients were analyzed; the median age was 55 years (range, 20-72 years), and the median body mass index was 27.2 kg/m2 (range, 16.5-40.4 kg/m2). All patients received NAC, primary breast surgery, and TAD. All clinically detected nodal metastases were confirmed with percutaneous biopsy and marked with a biopsy clip. RRL clips were implanted a median of 8 days (range, 1-167 days) prior to surgery; all were retrieved without complications. The RRL node was identified as the sentinel lymph node in 36 (80%) patients. Twenty-five patients had positive nodes, of which 24 were identified by RRL node excision, and 1 (4%) patient had a positive node identified by SLNB but not RRL. Over a median follow-up time of 29.6 months, 5 patients recurred (1 local, 4 distant). CONCLUSIONS: RRL-guided TAD after NAC is safe and feasible. This technique allows for adequate assessment of the nodal basin and helps confirm excision of the previously biopsied positive axillary node.

Is it Wise to Omit Sentinel Node Biopsy in Elderly Patients with Breast Cancer?

BACKGROUND: The Society of Surgical Oncology's Choosing Wisely® guidelines recommend against routine sentinel lymph node biopsy (SLNB) in clinically node-negative (cN0), hormone receptor (HR)-positive breast cancer patients aged ≥ 70 years. We examined the effect of SLNB on treatment and outcomes in this population. MATERIALS AND METHODS: A single-institution retrospective review of consecutive cN0 women ≥ 70 years of age who received SLNB was performed. We collected clinicopathologic characteristics and treatment data. Patients were compared according to SLN status with subset analysis of HR-positive patients. Outcomes were analyzed using the Kaplan-Meier method and univariable analysis, and were compared using log-rank tests. RESULTS: Of 500 patients, 345 (69%) were SLN-negative. Median age was 74 years (range 70-96). Most tumors were T1 (72%), N0 (69%), invasive ductal (77%), without lymphovascular invasion (88%), estrogen receptor-positive (88%) and progesterone receptor-positive (75%), and human epidermal growth factor receptor 2 (HER2)-negative (88%) treated with lumpectomy (71%). Median number of SLNs obtained was 2 (range 0-12) and median number of positive SLNs was 0 (range 0-8). Characteristics of the HR-positive subset were similar. In both the overall cohort and the HR-positive subset, SLN status significantly affected the use of adjuvant chemotherapy, although no significant effect on recurrence was observed. SLN-negative patients had better overall survival and less distant recurrence (both p < 0.0001). Adjuvant hormone therapy significantly improved overall survival. CONCLUSIONS: SLNB can be safely omitted in elderly patients with T1, HR-positive, invasive ductal carcinoma tumors, but may still provide important information affecting treatment. Patients who are candidates for adjuvant systemic chemotherapy should still be considered for SLNB.

Characteristics of Microinvasive Ductal Carcinoma In Situ Versus Noninvasive and Invasive Breast Cancer.

BACKGROUND: The present literature is conflicting regarding the management of microinvasive ductal carcinoma in situ (miDCIS) as to following recommendations for DCIS (margin status, surgical axillary staging, and possible observation) versus invasive breast cancer. We hypothesize that miDCIS represents more aggressive disease than pure DCIS. METHODS: We performed a retrospective review of female miDCIS patients compared with age-matched cohorts of DCIS and T1b/c patients with invasive breast cancer. We collected demographic, clinicopathologic, treatment, and outcome information. Analysis of variance or Kruskal-Wallis tests were used to analyze continuous variables and chi-square or Fisher's exact tests for categorical variables. Survival outcomes were analyzed using Kaplan-Meier curves. RESULTS: We included 375 patients (125 in each group) with median age 59 y (range 33-91 y). miDCIS tumors were more likely to be hormone receptor negative and human epidermal growth factor receptor 2 positive compared with DCIS or invasive ductal carcinoma (IDC; all P < 0.001). Subgroup analysis by miDCIS focality demonstrated no significant differences. The number of involved lymph nodes was not significantly different from DCIS patients but was significantly fewer than invasive cancer patients. Of 115 miDCIS patients (88%) staged with sentinel lymph node biopsy, eight (7%) had nodal metastases. Six miDCIS patients (5%) were treated with adjuvant chemotherapy. Over a median follow-up of 23.3 mo, there were no significant differences in local or distant recurrence. CONCLUSIONS: Based on our results, miDCIS has more aggressive pathologic features compared with DCIS and warrants surgical treatment and nodal staging similar to the management of IDC. In addition, similar to IDC, nodal and receptor status may influence medical management.

Development of Malignancy-Risk Gene Signature Assay for Predicting Breast Cancer Risk.

BACKGROUND: Breast cancer (BC) risk assessment models are statistical estimates based on patient characteristics. We developed a gene expression assay to assess BC risk using benign breast biopsy tissue. METHODS: A NanoString-based malignancy risk (MR) gene signature was validated for formalin-fixed paraffin-embedded (FFPE) tissue. It was applied to FFPE benign and BC specimens obtained from women who underwent breast biopsy, some of whom developed BC during follow-up to evaluate diagnostic capability of the MR signature. BC risk was calculated with MR score, Gail risk score, and both tests combined. Logistic regression and receiver operating characteristic curves were used to evaluate these 3 models. RESULTS: NanoString MR demonstrated concordance between fresh frozen and FFPE malignant samples (r = 0.99). Within the validation set, 563 women with benign breast biopsies from 2007 to 2011 were identified and followed for at least 5 y; 50 women developed BC (affected) within 5 y from biopsy. Three groups were compared: benign tissue from unaffected and affected patients and malignant tissue from affected patients. Kruskal-Wallis test suggested difference between the groups (P = 0.09) with trend in higher predicted MR score for benign tissue from affected patients before development of BC. Neither the MR signature nor Gail risk score were statistically different between affected and unaffected patients; combining both tests demonstrated best predictive value (AUC = 0.71). CONCLUSIONS: FFPE gene expression assays can be used to develop a predictive test for BC. Further investigation of the combined MR signature and Gail Model is required. Our assay was limited by scant cellularity of archived breast tissue.

A randomized controlled intervention to promote readiness to genetic counseling for breast cancer survivors.

OBJECTIVE: Breast cancer (BC) survivors with a genetic mutation are at higher risk for subsequent cancer; knowing genetic risk status could help survivors make decisions about follow-up screening. Uptake of genetic counseling and testing (GC/GT) to determine BRCA status is low among high risk BC survivors. This study assessed feasibility, acceptability, and preliminary efficacy of a newly developed psychoeducational intervention (PEI) for GC/GT. METHODS: High risk BC survivors (N = 119) completed a baseline questionnaire and were randomized to the intervention (PEI video/booklet) or control (factsheet) group. Follow-up questionnaires were completed 2 weeks after baseline (T2), and 4 months after T2 (T3). We analyzed recruitment, retention (feasibility), whether the participant viewed study materials (acceptability), intent to get GC/GT (efficacy), and psychosocial outcomes (eg, perceived risk, Impact of Events Scale [IES]). t tests or chi-square tests identified differences between intervention groups at baseline. Mixed models examined main effects of group, time, and group-by-time interactions. RESULTS: Groups were similar on demographic characteristics (P ≥ .05). Of participants who completed the baseline questionnaire, 91% followed through to study completion and 92% viewed study materials. A higher percentage of participants in the intervention group moved toward GC/GT (28% vs 8%; P = .027). Mixed models demonstrated significant group-by-time interactions for perceived risk (P = .029), IES (P = .027), and IES avoidance subscale (P = .012). CONCLUSIONS: The PEI was feasible, acceptable, and efficacious. Women in the intervention group reported greater intentions to pursue GC, greater perceived risk, and decreased avoidance. Future studies should seek to first identify system-level barriers and facilitators before aiming to address individual-level barriers.

Erratum: Author Correction: Surgical Standards for Management of the Axilla in Breast Cancer Clinical Trials with Pathological Complete Response Endpoint.

[This corrects the article DOI: 10.1038/s41523-018-0074-6.].

Health beliefs associated with readiness for genetic counseling among high risk breast cancer survivors.

We used the Health Belief Model (HBM) to explore factors associated with readiness for genetic counseling among breast cancer survivors. Breast cancer survivors meeting NCCN genetic counseling referral criteria completed questionnaires capturing demographic and clinical information and factors guided by the HBM, including health beliefs, psychosocial variables, and cues to action. Using logistic regression, we examined whether the above variables differed based on readiness group (pre-contemplators, who did not plan to make a genetic counseling appointment, and contemplators, who planned to make a genetic counseling appointment in the next 1-6 months). Of 111 participants, 57% were pre-contemplators and 43% were contemplators. Higher cancer worry was associated with increased odds of being a contemplator (OR = 2.99; 95% CI = 1.37-6.54) and higher perceived barriers to genetic counseling were associated with decreased odds of being a contemplator (OR = 0.31; 95% CI = 0.11-0.85). Those who reported a family member encouraged them to get tested were more likely to be contemplators (OR = 3.57; 95% CI = 1.19-10.70). Our results suggest key factors for predicting genetic counseling readiness include cancer worry, perceived barriers, and family influence. There is need for increased genetic counseling awareness. Better understanding of factors related to survivors' decisions about counseling can inform tailored interventions to improve uptake and ultimately reduce cancer recurrence risk.

The Challenges of Providing Feedback to Referring Physicians After Discovering Their Medical Errors.

BACKGROUND: Physicians are encouraged through formalized systems to discuss their own errors with peers for the purposes of quality improvement. However, no clear professional norms exist regarding peer review when physicians discover errors that occurred at other institutions before referral. Our objective was to determine specialist physicians' attitudes and practices regarding providing feedback to referring physicians when prereferral errors are discovered. METHODS: We conducted semistructured interviews of specialists from two National Cancer Institute-designated Cancer Centers. Thematic analysis of transcripts was performed to determine physicians' attitudes toward the delivery of negative feedback regarding prereferral errors, whether and how they communicate these errors to referring physicians, and perceived barriers to doing so. RESULTS: We purposively sampled specialists by discipline, gender, and experience level, who described greater than 50% reliance on external referrals (n = 30). Specialists believed regular, explicit feedback was ideal, but the majority of participants reported practices that did not meet this standard. While there were some structural barriers to providing feedback (lack of time or contact information), the majority of barriers were internal psychological concerns (general discomfort with providing negative feedback, fear of conflict, or defensive reactions) or fears about implications for future referrals or medicolegal risk. CONCLUSIONS: Policies and interventions that structure the approach to this sometimes difficult, yet critically important, opportunity for reducing medical errors warrant investigation as potential mechanisms by which to improve consistency and quality of care while maintaining positive professional relationships.

Surgical Standards for Management of the Axilla in Breast Cancer Clinical Trials with Pathological Complete Response Endpoint.

Advances in the surgical management of the axilla in patients treated with neoadjuvant chemotherapy, especially those with node positive disease at diagnosis, have led to changes in practice and more judicious use of axillary lymph node dissection that may minimize morbidity from surgery. However, there is still significant confusion about how to optimally manage the axilla, resulting in variation among practices. From the viewpoint of drug development, assessment of response to neoadjuvant chemotherapy remains paramount and appropriate assessment of residual disease-the primary endpoint of many drug therapy trials in the neoadjuvant setting-is critical. Therefore decreasing the variability, especially in a multicenter clinical trial setting, and establishing a minimum standard to ensure consistency in clinical trial data, without mandating axillary lymph node dissection, for all patients is necessary. The key elements which include proper staging and identification of nodal involvement at diagnosis, and appropriately targeted management of the axilla at the time of surgical resection are presented. The following protocols have been adopted as standard procedure by the I-SPY2 trial for management of axilla in patients with node positive disease, and present a framework for prospective clinical trials and practice.

Childbearing across borders: Fertility and parenthood attitudes and decisions among breast cancer survivors in USA and Portugal.

OBJECTIVE: To compare fertility and childbearing attitudes and decisions of Portuguese and American female reproductive aged breast cancer survivors. METHODS: This was a cross-sectional study of 102 young breast cancer survivors (59 from Portugal and 43 from USA). Demographic, clinical and reproductive information were collected. Fertility and parenthood attitudes and decisions were assessed through a self-report questionnaire devised specifically for the study. RESULTS: Fertility issues became very important after the diagnosis for most of the women (51%). Few differences existed between USA and Portuguese participants. USA participants were more likely to undergo FP (23% USA vs Portugal 5%, p = 0.01). Portuguese women were more dissatisfied with their physician's explanations about fertility (Portugal: 23% vs USA: 3%; p = 0.01). Overall, women relied on their oncologist for fertility information (70%); only Portuguese women discussed fertility with their family medicine physician (11%). Overall, women showed positive attitudes towards motherhood. Portuguese women were more likely to report their partners placed more value on the family after their illness (Portuguese agree: 55% vs USA agree: 14%; p < 0.001). CONCLUSIONS: Fertility and childbearing after breast cancer are important issues regardless of culture, background or country's heath care system. Overall, few differences across the USA and Portuguese samples were found on fertility and childbearing attitudes and decisions.

Specialist Physicians' Attitudes and Practice Patterns Regarding Disclosure of Pre-referral Medical Errors.

OBJECTIVE: Our objective was to determine specialist physicians' attitudes and practices regarding disclosure of pre-referral errors. SUMMARY BACKGROUND DATA: Physicians are encouraged to disclose their own errors to patients. However, no clear professional norms exist regarding disclosure when physicians discover errors in diagnosis or treatment that occurred at other institutions before referral. METHODS: We conducted semistructured interviews of cancer specialists from 2 National Cancer Institute-designated Cancer Centers. We purposively sampled specialists by discipline, sex, and experience-level who self-described a >50% reliance on external referrals (n = 30). Thematic analysis of verbatim interview transcripts was performed to determine physician attitudes regarding disclosure of pre-referral medical errors; whether and how physicians disclose these errors; and barriers to providing full disclosure. RESULTS: Participants described their experiences identifying different types of pre-referral errors including errors of diagnosis, staging and treatment resulting in adverse events ranging from decreased quality of life to premature death. The majority of specialists expressed the belief that disclosure provided no benefit to patients, and might unnecessarily add to their anxiety about their diagnoses or prognoses. Specialists had varying practices of disclosure including none, non-verbal, partial, event-dependent, and full disclosure. They identified a number of barriers to disclosure, including medicolegal implications and damage to referral relationships, the profession's reputation, and to patient-physician relationships. CONCLUSIONS: Specialist physicians identify pre-referral errors but struggle with whether and how to provide disclosure, even when clinical circumstances force disclosure. Education- or communication-based interventions that overcome barriers to disclosing pre-referral errors warrant development.

Disparities in Use and Access to Postmastectomy Breast Reconstruction Among African American Women: A Targeted Review of the Literature.

Postmastectomy breast reconstruction is a therapy that has been shown to have positive psychological effects on its recipients. There is evidence that racial disparities in its use exist, particularly among African American (AA) women. The purpose of this targeted review of the literature was to examine the use of postmastectomy breast reconstruction among AA women and to explore factors that contribute to such disparities. Published literature that evaluated rates of breast reconstruction in AA women, as well as barriers to reconstruction in this population, was reviewed. All of the reviewed data consisted of retrospective studies. There are conflicting data in the literature regarding disparities in the rates of postmastectomy breast reconstruction among AA women. However, a majority of studies found that AA women were less likely (odds ratios: 0.36-0.71) to receive postmastectomy breast reconstruction compared to white women. System-associated factors, physician-associated factors, and patient-associated factors interact in a complex manner that contributes to the reported disparities. Although there are trends suggesting racial disparities in the rates of postmastectomy breast reconstruction exist, the published data are retrospective and are inherently limited. The pursuit of breast reconstruction is highly individual and involves multiple factors that interact in a complex manner. To this end, prospective studies encompassing sociodemographic factors, clinical factors, and patient preferences are necessary to determine what interventions by physicians can have the greatest impact in ensuring equal access to this therapy when it is desired.