RÉSUMÉ
BACKGROUND: Hormonal receptor (HR) positive breast tumors are common. Adjuvant hormonal therapy (AHT) with tamoxifen or Aromatase Inhibitors (AIs) is beneficial depending on the stage of the tumor. Despite the fact that AHT has been shown to improve survival and recurrence, Dutch adherence rates, which were mostly dependent on Tamoxifen prescriptions until 2006, plummeted from 80% after one year to 50% after five years. Nonadherence with AHT reduces its effectiveness. This research presents more recent adherence statistics (from 2006 to 2016), on a larger sample (7,996 vs 1,451), as well as factors that influence AHT adherence. In addition to tamoxifen data, AIs are now included. OBJECTIVE: As low use of adjuvant endocrine therapy is a potentially important and modifiable risk factor for poor outcome, it is important to monitor the rate as an indicator of women's burden of disease and the direction of adherence trends. METHODS: The Netherlands Cancer Registry (NCR) was used to find women with early-stage breast cancer who started AHT within a year of surgery and were linked to the PHARMO Database Network (n = 8,679). The Kaplan-Meier approach was used to measure AHT adherence five years after treatment was started, with a 60-day gap between refills as our primary outcome. Furthermore, the Medication Possession Rate (MPR) was determined using a cutoff of ≥80%. Analysis was performed on influential factors of adherence. RESULTS: The proportion of persistent women declined over time to reach 46.6% at the end of the fifth year and 53.3% of the women had a MPR ≥80% during the fifth year. Older and being diagnosed in 2006-2010 were associated with AHT adherence. CONCLUSION: Dutch 5-year AHT adherence appears to remain poor. Improving AHT adherence in HR+ breast cancer survivors is a critical medical need.
Sujet(s)
Tumeurs du sein , Femelle , Humains , Tumeurs du sein/anatomopathologie , Antinéoplasiques hormonaux/usage thérapeutique , Résultat thérapeutique , Traitement médicamenteux adjuvant , Tamoxifène/usage thérapeutiqueRÉSUMÉ
OBJECTIVES: For patients with ductal carcinoma in situ (DCIS), data about the impact of breast MRI at primary diagnosis on the incidence and characteristics of contralateral breast cancers are scarce. METHODS: We selected all 8486 women diagnosed with primary DCIS in the Netherlands in 2011-2015 from the Netherlands Cancer Registry. The synchronous and metachronous detection of contralateral DCIS (cDCIS) and contralateral invasive breast cancer (cIBC) was assessed for patients who received an MRI upon diagnosis (MRI group) and for an age-matched control group without MRI. RESULTS: Nineteen percent of patients received an MRI, of which 0.8% was diagnosed with synchronous cDCIS and 1.3% with synchronous cIBC not found by mammography. The 5-year cumulative incidence of synchronous plus metachronous cDCIS was higher for the MRI versus age-matched control group (2.0% versus 0.9%, p = 0.02) and similar for cIBC (3.5% versus 2.3%, p = 0.17). The increased incidence of cDCIS was observed in patients aged < 50 years (sHR = 4.22, 95% CI: 1.19-14.99), but not in patients aged 50-74 years (sHR = 0.89, 95% CI: 0.41-1.93). CONCLUSIONS: MRI at primary DCIS diagnosis detected additional synchronous cDCIS and cIBC, and was associated with a higher rate of metachronous cDCIS without decreasing the rate of metachronous cIBC. This finding was most evident in younger patients. KEY POINTS: ⢠Magnetic resonance imaging at primary diagnosis of ductal carcinoma in situ detected an additional synchronous breast lesion in 2.1% of patients. ⢠In patients aged younger than 50 years, the use of pre-operative MRI was associated with a fourfold increase in the incidence of a second contralateral DCIS without decreasing the incidence of metachronous invasive breast cancers up to 5 years after diagnosis. ⢠In patients aged over 50 years, the use of pre-operative MRI did not result in a difference in the incidence of a second contralateral DCIS or metachronous invasive breast cancer.
Sujet(s)
Tumeurs du sein , Carcinome intracanalaire non infiltrant , Humains , Femelle , Adulte d'âge moyen , Tumeurs du sein/imagerie diagnostique , Tumeurs du sein/épidémiologie , Tumeurs du sein/chirurgie , Carcinome intracanalaire non infiltrant/imagerie diagnostique , Carcinome intracanalaire non infiltrant/épidémiologie , Études de cohortes , Région mammaire/anatomopathologie , Imagerie par résonance magnétique/méthodesRÉSUMÉ
Importance: Several less-invasive staging procedures have been proposed to replace axillary lymph node dissection (ALND) after neoadjuvant chemotherapy (NAC) in patients with initially clinically node-positive (cN+) breast cancer, but these procedures may fail to detect residual disease. Owing to the lack of high-level evidence, it is not yet clear which procedure is most optimal to replace ALND. Objective: To determine the diagnostic accuracy of radioactive iodine seed placement in the axilla with sentinel lymph node biopsy (RISAS), a targeted axillary dissection procedure. Design, Setting, and Participants: This was a prospective, multicenter, noninferiority, diagnostic accuracy trial conducted from March 1, 2017, to December 31, 2019. Patients were included within 14 institutions (general, teaching, and academic) throughout the Netherlands. Patients with breast cancer clinical tumor categories 1 through 4 (cT1-4; tumor diameter <2 cm and up to >5 cm or extension to the chest wall or skin) and pathologically proven positive axillary lymph nodes (ie, clinical node categories cN1, metastases to movable ipsilateral level I and/or level II axillary nodes; cN2, metastases to fixed or matted ipsilateral level I and/or level II axillary nodes; cN3b, metastases to ipsilateral level I and/or level II axillary nodes with metastases to internal mammary nodes) who were treated with NAC were eligible for inclusion. Data were analyzed from July 2020 to December 2021. Intervention: Pre-NAC, the marking of a pathologically confirmed positive axillary lymph node with radioactive iodine seed (MARI) procedure, was performed and after NAC, sentinel lymph node biopsy (SLNB) combined with excision of the marked lymph node (ie, RISAS procedure) was performed, followed by ALND. Main Outcomes and Measures: The identification rate, false-negative rate (FNR), and negative predictive value (NPV) were calculated for all 3 procedures: RISAS, SLNB, and MARI. The noninferiority margin of the observed FNR was 6.25% for the RISAS procedure. Results: A total of 212 patients (median [range] age, 52 [22-77] years) who had cN+ breast cancer underwent the RISAS procedure and ALND. The identification rate of the RISAS procedure was 98.2% (223 of 227). The identification rates of SLNB and MARI were 86.4% (197 of 228) and 94.1% (224 of 238), respectively. FNR of the RISAS procedure was 3.5% (5 of 144; 90% CI, 1.38-7.16), and NPV was 92.8% (64 of 69; 90% CI, 85.37-97.10), compared with an FNR of 17.9% (22 of 123; 90% CI, 12.4%-24.5%) and NPV of 72.8% (59 of 81; 90% CI, 63.5%-80.8%) for SLNB and an FNR of 7.0% (10 of 143; 90% CI, 3.8%-11.6%) and NPV of 86.3% (63 of 73; 90% CI, 77.9%-92.4%) for the MARI procedure. In a subgroup of 174 patients in whom SLNB and the MARI procedure were successful and ALND was performed, FNR of the RISAS procedure was 2.5% (3 of 118; 90% CI, 0.7%-6.4%), compared with 18.6% (22 of 118; 90% CI, 13.0%-25.5%) for SLNB (P < .001) and 6.8% (8 of 118; 90% CI, 3.4%-11.9%) for the MARI procedure (P = .03). Conclusions and Relevance: Results of this diagnostic study suggest that the RISAS procedure was the most feasible and accurate less-invasive procedure for axillary staging after NAC in patients with cN+ breast cancer.
Sujet(s)
Tumeurs du sein , Iode , Noeud lymphatique sentinelle , Tumeurs de la thyroïde , Humains , Adulte d'âge moyen , Femelle , Biopsie de noeud lymphatique sentinelle/méthodes , Aisselle , Traitement néoadjuvant , Tumeurs du sein/anatomopathologie , Radio-isotopes de l'iode/usage thérapeutique , Études prospectives , Iode/usage thérapeutique , Métastase lymphatique/anatomopathologie , Tumeurs de la thyroïde/chirurgie , Lymphadénectomie/méthodes , Noeuds lymphatiques/anatomopathologie , Noeud lymphatique sentinelle/anatomopathologieRÉSUMÉ
PURPOSE: To spare DCIS patients from overtreatment, treatment de-escalated over the years. This study evaluates the influence of these developments on the patterns of care in the treatment of DCIS with particular interest in the use of breast conserving surgery (BCS), radiotherapy following BCS and the use and type of axillary staging. METHODS: In this large population-based cohort study all women, aged 50-74 years diagnosed with DCIS from January 1989 until January 2019, were analyzed per two-year cohort. RESULTS: A total of 30,417 women were diagnosed with DCIS. The proportion of patients undergoing BCS increased from 47.7% in 1995-1996 to 72.7% in 2017-2018 (p < 0.001). Adjuvant radiotherapy following BCS increased from 28.9% (1995-1996) to 89.6% (2011-2012) and subsequently decreased to 74.9% (2017-2018; p < 0.001). Since its introduction, the use of sentinel lymph node biopsy (SLNB) increased to 63.1% in 2013-2014 and subsequently decreased to 52.8% in 2017-2018 (p < 0.001). Axillary surgery is already omitted in 55.8% of the patients undergoing BCS nowadays. The five-year invasive relapse-free survival (iRFS) for BCS with adjuvant radiotherapy in the period 1989-2010, was 98.7% [CI 98.4% - 99.0%], compared to 95.0% [CI 94.1% -95.8%] for BCS only (p < 0.001). In 2011-2018, this was 99.3% [CI 99.1% - 99.5%] and 98.8% [CI 98.2% - 99.4%] respectively (p = 0.01). CONCLUSIONS: This study shows a shift toward less extensive treatment. DCIS is increasingly treated with BCS and less often followed by additional radiotherapy. The absence of radiotherapy still results in excellent iRFS. Axillary surgery is increasingly omitted in DCIS patients.
Sujet(s)
Tumeurs du sein , Carcinome canalaire du sein , Carcinome intracanalaire non infiltrant , Tumeurs du sein/épidémiologie , Tumeurs du sein/thérapie , Carcinome intracanalaire non infiltrant/épidémiologie , Carcinome intracanalaire non infiltrant/radiothérapie , Carcinome intracanalaire non infiltrant/chirurgie , Études de cohortes , Femelle , Humains , Mastectomie partielle , Récidive tumorale locale/épidémiologie , Pays-Bas/épidémiologie , Biopsie de noeud lymphatique sentinelle , Résultat thérapeutiqueRÉSUMÉ
PURPOSE: The extended role of breast-conserving surgery (BCS) in the neoadjuvant setting may raise concerns on the oncologic safety of BCS compared to mastectomy. This study compared long-term outcomes after neoadjuvant chemotherapy (NAC) between patients treated with BCS and mastectomy. METHODS: All breast cancer patients treated with NAC from 2008 until 2017 at the Amphia Hospital (the Netherlands) were included. Disease-free and overall survival were compared between BCS and mastectomy with survival functions. Multivariable Cox proportional hazard regression was performed to determine prognostic variables for disease-free survival. RESULTS: 561 of 612 patients treated with NAC were eligible: 362 (64.5%) with BCS and 199 (35.5%) with mastectomy. Median follow-up was 6.8 years (0.9-11.9). Mastectomy patients had larger tumours and more frequently node-positive or lobular cancer. Unadjusted five-year disease-free survival was 90.9% for BCS versus 82.9% for mastectomy (p = .004). Unadjusted five-year overall survival was 95.3% and 85.9% (p < .001), respectively. In multivariable analysis, clinical T4 (cT4) (HR 3.336, 95% CI 1.214-9.165, p = .019) and triple negative disease (HR 5.946, 95% CI 2.703-13.081, p < .001) were negative predictors and pathologic complete response of the breast (HR 0.467, 95% CI 0.238-0.918, p = .027) and axilla (HR 0.332, 95% CI 0.193-0.572, p = .001) were positive predictors for disease-free survival. Mastectomy versus BCS was not a significant predictor for disease-free survival when adjusted for the former variables (unadjusted HR 2.13 (95%CI: 1.4-3.24), adjusted HR 1.31 (95%CI: 0.81-2.13)). In the BCS group, disease-free and overall survival did not differ significantly between cT1, cT2 or cT3 tumours. CONCLUSION: BCS does not impair disease-free and overall survival in patients treated with NAC. Tumour biology and treatment response are significant prognostic indicators.
Sujet(s)
Tumeurs du sein , Mastectomie partielle , Tumeurs du sein/traitement médicamenteux , Tumeurs du sein/chirurgie , Études de cohortes , Survie sans rechute , Femelle , Humains , Mastectomie , Traitement néoadjuvant , Stadification tumorale , Pays-Bas/épidémiologie , Études rétrospectivesRÉSUMÉ
Importance: For women with a 20% or more familial risk of breast cancer without a known BRCA1/2 (BRCA1, OMIM 113705; and BRCA2, OMIM 114480) or TP53 (OMIM 151623) variant, screening guidelines vary substantially, and cost-effectiveness analyses are scarce. Objective: To assess the cost-effectiveness of magnetic resonance imaging (MRI) screening strategies for women with a 20% or more familial risk for breast cancer without a known BRCA1/2 or TP53 variant. Design, Setting, and Participants: In this economic evaluation, conducted from February 1, 2019, to May 25, 2020, microsimulation modeling was used to estimate costs and effectiveness on a lifetime horizon from age 25 years until death of MRI screening among a cohort of 10 million Dutch women with a 20% or more familial risk for breast cancer without a known BRCA1/2 or TP53 variant. A Dutch screening setting was modeled. Most data were obtained from the randomized Familial MRI Screening (FaMRIsc) trial, which included Dutch women aged 30 to 55 years. A health care payer perspective was applied. Interventions: Several screening protocols with varying ages and intervals including those of the randomized FaMRIsc trial, consisting of the mammography (Mx) protocol (annual mammography and clinical breast examination) and the MRI protocol (annual MRI and clinical breast examination plus biennial mammography). Main Outcomes and Measures: Costs, life-years, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) were calculated and discounted by 3%. A threshold of 22â¯000 (US $24â¯795.87) per QALY was applied. Results: This economic evaluation modeling study estimated that, on a lifetime horizon per 1000 women with the Mx protocol of the FaMRIsc trial, 346 breast cancers would be detected, and 49 women were estimated to die from breast cancer, resulting in 22â¯885 QALYs and total costs of 7â¯084â¯767 (US $7â¯985â¯134.61). The MRI protocol resulted in 79 additional QALYs and additional 2â¯657â¯266 (US $2â¯994â¯964.65). Magnetic resonance imaging performed only every 18 months between the ages of 35 and 60 years followed by the national screening program was considered optimal, with an ICER of 21â¯380 (US $24â¯097.08) compared with the previous nondominated strategy in the ranking, when applying the National Institute for Health and Care Excellence threshold. Annual screening alternating MRI and mammography between the ages of 35 and 60 years, followed by the national screening program, gave similar outcomes. Higher thresholds would favor annual MRI screening. The ICER was most sensitive to the unit cost of MRI and the utility value for ductal carcinoma in situ and localized breast cancer. Conclusions and Relevance: This study suggests that MRI screening every 18 months between the ages of 35 and 60 years for women with a family history of breast cancer is cost-effective within the National Institute for Health and Care Excellence threshold for all densities. Higher thresholds would favor annual MRI screening. These outcomes support a change of current screening guidelines for this specific risk group and support MRI screening.
Sujet(s)
Tumeurs du sein/économie , Analyse coût-bénéfice/économie , Dépistage précoce du cancer/économie , Imagerie par résonance magnétique/économie , Adulte , Protéine BRCA1/génétique , Protéine BRCA2/génétique , Tumeurs du sein/diagnostic , Tumeurs du sein/imagerie diagnostique , Tumeurs du sein/épidémiologie , Femelle , Prédisposition génétique à une maladie/génétique , Humains , Adulte d'âge moyen , Facteurs de risque , Protéine p53 suppresseur de tumeur/génétiqueRÉSUMÉ
BACKGROUND: The incidence and clinical significance of multifocality in ipsilateral breast tumor recurrence (IBTR) after breast-conserving therapy (BCT) are unclear. With growing interest in repeat BCT, this information has become of importance. This study aimed to gain insight in the incidence of multifocality in IBTR, to identify patient- and tumor-related predicting factors and to investigate the prognostic significance of multifocality. METHODS: Two hundred and fifteen patients were included in this analysis. All had an IBTR after BCT and were treated by salvage mastectomy and appropriate adjuvant therapy. Predictive tumor- and patient-related factors for multifocality in IBTR were identified using X2 test and univariate logistic regression analyses. Prognostic outcomes were calculated using Kaplan Meier analysis and compared using the log rank test. RESULTS: Multifocality was present in 50 (22.9%) of IBTR mastectomy specimens. Axillary positivity in IBTR was significantly associated with multifocality in IBTR. Chest wall re-recurrences occurred more often after multifocal IBTR (14% versus 7% after unifocal IBTR, p = 0.120). Regional re-recurrences did not differ significantly between unifocal and multifocal IBTR (8% vs. 6%, p = 0.773). Distant metastasis after salvage surgery occurred more frequently after multifocal IBTR (15% vs. 24%, p = 0.122). Overall survival was 132 months after unifocal IBTR and 112 months after multifocal IBTR (p = 0.197). CONCLUSION: The prevalence of multifocality in IBTR is higher than in primary breast cancer. Axillary positivity in IBTR was associated with a multifocal IBTR. Chest wall re-recurrences and distant metastasis were, although not statistically significant, more prevalent after multifocal IBTR.
Sujet(s)
Tumeurs du sein/chirurgie , Mastectomie partielle , Récidive tumorale locale/épidémiologie , Adulte , Sujet âgé , Sujet âgé de 80 ans ou plus , Tumeurs du sein/mortalité , Tumeurs du sein/anatomopathologie , Femelle , Humains , Adulte d'âge moyen , Études rétrospectivesRÉSUMÉ
Axillary reverse mapping (ARM) is a technique by which the lymphatic drainage system of the upper extremities is mapped, so that the lymph channels and glands can be preserved during axillary lymph node dissection (ALND). This can lead to less postoperative morbidity, such as lymphoedema. A randomised multicentre study showed that there are statistically significantly fewer post-operative symptoms if the lymph channels and glands of the upper extremities are spared with this technique. Despite the declining indication for an ALND, ARM can have added value for the patients who do have to undergo ALND.
Sujet(s)
Aisselle/chirurgie , Lymphadénectomie/méthodes , Noeuds lymphatiques/anatomopathologie , Biopsie de noeud lymphatique sentinelle/méthodes , Drainage , Humains , Lymphoedème/étiologie , MorbiditéRÉSUMÉ
PURPOSE: We assessed the uptake of fertility preservation (FP), recovery of ovarian function (OFR) after chemotherapy, live birth after breast cancer, and breast cancer outcomes in women with early-stage breast cancer. METHODS: Women aged below 41 years and referred to our center for FP counseling between 2008 and 2015 were included. Data on patient and tumor characteristics, ovarian function, cryopreservation (embryo/oocyte) and transfer, live birth, and disease-free survival were collected. Kaplan-Meier analyses were performed for time-to-event analyses including competing risk analyses, and patients with versus without FP were compared using the logrank test. RESULTS: Of 118 counseled women with a median age of 31 years (range 19-40), 34 (29%) chose FP. Women who chose FP had less often children, more often a male partner and more often favorable tumor characteristics. The 5-year OFR rate was 92% for the total group of counseled patients. In total, 26 women gave birth. The 5-year live birth rate was 27% for the total group of counseled patients. Only three women applied for transfer of their cryopreserved embryo(s), in two combined with preimplantation genetic diagnosis (PGD) because of BRCA1-mutation carrier ship. The 5-year disease-free survival rate was 91% versus 88%, for patients with versus without FP (P = 0.42). CONCLUSIONS: Remarkably, most women achieved OFR, probably related to the young age at diagnosis. Most pregnancies occurred spontaneously, two of three women applied for embryo transfer because of the opportunity to apply for PGD.
Sujet(s)
Protocoles de polychimiothérapie antinéoplasique/usage thérapeutique , Tumeurs du sein/traitement médicamenteux , Carcinome canalaire du sein/traitement médicamenteux , Carcinome lobulaire/traitement médicamenteux , Préservation de la fertilité/méthodes , Adulte , Tumeurs du sein/métabolisme , Tumeurs du sein/anatomopathologie , Carcinome canalaire du sein/métabolisme , Carcinome canalaire du sein/anatomopathologie , Carcinome lobulaire/métabolisme , Carcinome lobulaire/anatomopathologie , Femelle , Études de suivi , Humains , Naissance vivante , Invasion tumorale , Grossesse , Pronostic , Études prospectives , Récepteur ErbB-2/métabolisme , Récepteurs des oestrogènes/métabolisme , Récepteurs à la progestérone/métabolisme , Taux de survie , Jeune adulteRÉSUMÉ
PURPOSE: Tumor boards, clinical practice guidelines, and cancer registries are intertwined cancer care quality instruments. Standardized structured reporting has been proposed as a solution to improve clinical documentation, while facilitating data reuse for secondary purposes. This study describes the implementation and evaluation of a national standard for tumor board reporting for breast cancer on the basis of the clinical practice guideline and the potential for reusing clinical data for the Netherlands Cancer Registry (NCR). METHODS: Previously, a national information standard for breast cancer was derived from the corresponding Dutch clinical practice guideline. Using data items from the information standard, we developed three different tumor board forms: preoperative, postoperative, and postneoadjuvant-postoperative. The forms were implemented in Amphia Hospital's electronic health record. Quality of clinical documentation and workload before and after implementation were compared. RESULTS: Both draft and final tumor board reports were collected from 27 and 31 patients in baseline and effect measurements, respectively. Completeness of final reports increased from 39.5% to 45.4% (P = .04). The workload for tumor board preparation and discussion did not change significantly. Standardized tumor board reports included 50% (61/122) of the data items carried in the NCR. An automated process was developed to upload information captured in tumor board reports to the NCR database. CONCLUSION: This study shows implementation of a national standard for tumor board reports improves quality of clinical documentation, without increasing clinical workload. Simultaneously, our work enables data reuse for secondary purposes like cancer registration.
Sujet(s)
Tumeurs du sein , Charge de travail , Tumeurs du sein/thérapie , Documentation , Dossiers médicaux électroniques , Femelle , Humains , Rapport de rechercheRÉSUMÉ
The analytical performance of a multi-gene diagnostic signature depends on many parameters, including precision, repeatability, reproducibility and intra-tumor heterogeneity. Here we study the analytical performance of the BluePrint 80-gene breast cancer molecular subtyping test through determination of these performance characteristics. BluePrint measures the expression of 80 genes that assess functional pathways which determine the intrinsic breast cancer molecular subtypes (i.e. Luminal-type, HER2-type, Basal-type). Knowing a tumor's dominant functional pathway can help allocate effective treatment to appropriate patients. Here we show that BluePrint is a highly precise and highly reproducible test with correlations above 98% based on the generated index and subtype concordance above 99%. Therefore, BluePrint can be used as a robust and reliable tool to identify breast cancer molecular subtypes.
RÉSUMÉ
Background Trends in the detection of suspicious microcalcifications at mammography screening and the yield of these lesions after recall are unknown. Purpose To determine trends in recall and outcome of screen-detected microcalcifications during 20 years of mammography screening. Materials and Methods The authors performed a retrospective analysis of a consecutive series of 817 656 screening examinations (January 1997 to January 2017) in a national breast screening program. In 2009-2010 (transition period), screen-film mammography (SFM) was gradually replaced by full-field digital mammography (FFDM). The recalls of suspicious microcalcifications from all radiology reports and pathologic outcome of recalled women with 2-year follow-up were analyzed. Screening outcome in the era of SFM (1997-2008), the transition period (2009-2010), and the era of FFDM (2011-2016) were compared. Trends over time and variations between the SFM and FFDM periods were expressed by using proportions with 95% confidence intervals (CIs). In cases where the analysis based on the CI confirmed clear periods (eg, before and after introduction of FFDM), pre- and postchange outcomes were compared by using χ2 tests. Results A total of 18 592 women (median age, 59 years; interquartile range, 14 years) were recalled at mammography screening, 3556 of whom had suspicious microcalcifications. The recall rate for microcalcifications increased from 0.1% in 1997-1998 to 0.5% in 2015-2016 (P < .001). This was temporally associated with the change from SFM to FFDM. The recalls yielding ductal carcinoma in situ (DCIS) increased from 0.3 per 1000 screening examinations with SFM to 1.1 per 1000 screening examinations with FFDM (P < .001), resulting in a decrease in the positive predictive value for recall for suspicious microcalcifications from 51% to 33% (P < .001). More than half of all DCIS lesions were high grade (52.6%; 393 of 747). The distribution of DCIS grades was stable during the 20-year screening period (P = .36). Conclusion The recall rate for suspicious microcalcifications at mammographic screening increased during the past 2 decades, whereas the ductal carcinoma in situ detection rate increased less rapidly, resulting in a lower positive predictive value for recall. © RSNA, 2020.
Sujet(s)
Tumeurs du sein , Région mammaire , Calcinose , Mammographie , Sujet âgé , Région mammaire/imagerie diagnostique , Région mammaire/anatomopathologie , Tumeurs du sein/complications , Tumeurs du sein/imagerie diagnostique , Tumeurs du sein/anatomopathologie , Calcinose/imagerie diagnostique , Calcinose/étiologie , Calcinose/anatomopathologie , Carcinome intracanalaire non infiltrant , Dépistage précoce du cancer , Femelle , Humains , Mammographie/méthodes , Mammographie/statistiques et données numériques , Adulte d'âge moyen , Pays-Bas , Valeur prédictive des tests , Études rétrospectivesRÉSUMÉ
BACKGROUND: Axillary lymph node dissection (ALND) in breast cancer patients is infamous for its accompanying morbidity. Selective preservation of upper extremity lymphatic drainage and accompanying lymph nodes crossing the axillary basin - currently resected during a standard ALND - has been proposed as a valuable surgical refinement. METHODS: Peroperative Axillary Reversed Mapping (ARM) was used for selective preservation of upper extremity lymphatic drainage. A multicentre patient- and assessor-blinded randomized study was performed in clinical node negative, sentinel node positive early breast cancer patients. Patients were randomized to undergo either standard-ALND or ARM-ALND. Primary outcome was the presence of surgery-related lymphedema at six, 12 and 24 months post-operatively. Secondary outcomes included patient reported and objective signs and symptoms of lymphedema, pain, paraesthesia, numbness, loss of shoulder mobility, quality of life and axillary recurrence risk. RESULTS: No significant differences were found between both groups using the water displacement method with respect to measured lymphedema. ARM-ALND resulted in less reported complaints of lymphedema at six, 12 and 24 months postoperatively (pâ¯<â¯0.05). No axillary recurrence was found in both groups. CONCLUSIONS: In contrast to results of volumetric measurement, patient reported outcomes support selective sparing of the upper extremity lymphatic drainage using ARM as valuable surgical refinement in case of ALND in clinically node negative, sentinel node positive early breast cancer. If completion ALND in clinically node negative, sentinel node positive early breast cancer is considered, selective sparing of upper extremity axillary lymphatics by implementing ARM should be carried out in order to reduce morbidity.
Sujet(s)
Aisselle/chirurgie , Tumeurs du sein/anatomopathologie , Lymphadénectomie , Lymphoedème/étiologie , Complications postopératoires/étiologie , Biopsie de noeud lymphatique sentinelle/méthodes , Adulte , Sujet âgé , Aisselle/anatomopathologie , Agents colorants , Méthode en double aveugle , Femelle , Humains , Métastase lymphatique/anatomopathologie , Adulte d'âge moyen , Grading des tumeurs , Stadification tumorale , Pays-Bas , Mesure de la douleur , Mesures des résultats rapportés par les patients , Qualité de vieRÉSUMÉ
INTRODUCTION: We evaluated the use and value of breast surgical excision biopsies for diagnostic purposes over the last decades in women undergoing mammographic screening, either as a primary procedure or following an inconclusive percutaneous biopsy. METHODS: All women with an excision biopsy among 817,656 screens, obtained from January 1997 to January 2017, were included. RESULTS: Of 18,593 recalled women (recall rate, 2.3%) with screen-detected abnormalities, 908 (4.9%) underwent excision biopsy. Of these, 411 (45.3%) were performed as first diagnostic intervention, decreasing from 4.3 per 1000 screens in 1997-1998 to 0 per 1000 screens in 2015-2016. The remaining 497 (54.7%) excision biopsies were performed secondary to pathologic findings at percutaneous biopsy. During 1997-1998, 1.0 secondary biopsies per 1000 screens were performed, decreasing to 0.3 per 1000 in 2005-2006 and afterwards increased to 0.6 per 1000 in 2015-2016 (pâ¯=â¯0.003). Of all 487 secondary biopsies, 303 (61.0%) had a benign pathology outcome, increasing from 40.4% in 1997-1998 to 70.2% in 2015-2016. Of all 211 biopsies in the three most recent cohorts (2011-2016) the overall upgrade rate was 26.5%, consisting of 39 (18.5%) DCIS (27 low grade) and 17 (8.1%) invasive carcinomas. CONCLUSIONS: Although the use of excision biopsy significantly decreased over the past two decades, we observed a significant increased rate in more recent years. Since the vast majority of currently performed excision biopsies reveals a benign diagnosis or shows low grade DCIS, a secondary excision biopsy should only be considered if radiologic surveillance and repeated percutaneous biopsy continues to yield indeterminate results.
Sujet(s)
Biopsie/tendances , Tumeurs du sein/diagnostic , Dépistage précoce du cancer/tendances , Mammographie/tendances , Adulte , Sujet âgé , Biopsie/méthodes , Région mammaire/anatomopathologie , Région mammaire/chirurgie , Dépistage précoce du cancer/méthodes , Femelle , Humains , Adulte d'âge moyenRÉSUMÉ
BACKGROUND: Approximately 15% of all breast cancers occur in women with a family history of breast cancer, but for whom no causative hereditary gene mutation has been found. Screening guidelines for women with familial risk of breast cancer differ between countries. We did a randomised controlled trial (FaMRIsc) to compare MRI screening with mammography in women with familial risk. METHODS: In this multicentre, randomised, controlled trial done in 12 hospitals in the Netherlands, women were eligible to participate if they were aged 30-55 years and had a cumulative lifetime breast cancer risk of at least 20% because of a familial predisposition, but were BRCA1, BRCA2, and TP53 wild-type. Participants who were breast-feeding, pregnant, had a previous breast cancer screen, or had a previous a diagnosis of ductal carcinoma in situ were eligible, but those with a previously diagnosed invasive carcinoma were excluded. Participants were randomly allocated (1:1) to receive either annual MRI and clinical breast examination plus biennial mammography (MRI group) or annual mammography and clinical breast examination (mammography group). Randomisation was done via a web-based system and stratified by centre. Women who did not provide consent for randomisation could give consent for registration if they followed either the mammography group protocol or the MRI group protocol in a joint decision with their physician. Results from the registration group were only used in the analyses stratified by breast density. Primary outcomes were number, size, and nodal status of detected breast cancers. Analyses were done by intention to treat. This trial is registered with the Netherlands Trial Register, number NL2661. FINDINGS: Between Jan 1, 2011, and Dec 31, 2017, 1355 women provided consent for randomisation and 231 for registration. 675 of 1355 women were randomly allocated to the MRI group and 680 to the mammography group. 218 of 231 women opting to be in a registration group were in the mammography registration group and 13 were in the MRI registration group. The mean number of screening rounds per woman was 4·3 (SD 1·76). More breast cancers were detected in the MRI group than in the mammography group (40 vs 15; p=0·0017). Invasive cancers (24 in the MRI group and eight in the mammography group) were smaller in the MRI group than in the mammography group (median size 9 mm [5-14] vs 17 mm [13-22]; p=0·010) and less frequently node positive (four [17%] of 24 vs five [63%] of eight; p=0·023). Tumour stages of the cancers detected at incident rounds were significantly earlier in the MRI group (12 [48%] of 25 in the MRI group vs one [7%] of 15 in the mammography group were stage T1a and T1b cancers; one (4%) of 25 in the MRI group and two (13%) of 15 in the mammography group were stage T2 or higher; p=0·035) and node-positive tumours were less frequent (two [11%] of 18 in the MRI group vs five [63%] of eight in the mammography group; p=0·014). All seven tumours stage T2 or higher were in the two highest breast density categories (breast imaging reporting and data system categories C and D; p=0·0077) One patient died from breast cancer during follow-up (mammography registration group). INTERPRETATION: MRI screening detected cancers at an earlier stage than mammography. The lower number of late-stage cancers identified in incident rounds might reduce the use of adjuvant chemotherapy and decrease breast cancer-related mortality. However, the advantages of the MRI screening approach might be at the cost of more false-positive results, especially at high breast density. FUNDING: Dutch Government ZonMw, Dutch Cancer Society, A Sister's Hope, Pink Ribbon, Stichting Coolsingel, J&T Rijke Stichting.
Sujet(s)
Tumeurs du sein/imagerie diagnostique , Dépistage précoce du cancer/méthodes , Imagerie par résonance magnétique/méthodes , Mammographie/méthodes , Adulte , Tumeurs du sein/génétique , Femelle , Prédisposition génétique à une maladie , Humains , Adulte d'âge moyenRÉSUMÉ
Between January 1, 2011, and December 31, 2016, we studied the incidence, management and outcome of high-risk breast lesions in a consecutive series of 376,519 screens of women who received biennial screening mammography. During the 6-year period covered by the study, the proportion of women who underwent core needle biopsy (CNB) after recall remained fairly stable, ranging from 39.2% to 48.1% (mean: 44.2%, 5,212/11,783), whereas the proportion of high-risk lesions at CNB (i.e., flat epithelial atypia, atypical ductal hyperplasia, lobular carcinoma in situ and papillary lesions) gradually increased from 3.2% (25/775) in 2011 to 9.5% (86/901) in 2016 (p < 0.001). The mean proportion of high-risk lesions at CNB that were subsequently treated with diagnostic surgical excision was 51.4% (169/329) and varied between 41.0% and 64.3% through the years, but the excision rate for high-risk lesions per 1,000 screens and per 100 recalls increased from 0.25 (2011) to 0.70 (2016; p < 0.001) and from 0.81 (2011) to 2.50 (2016; p < 0.001), respectively. The proportion of all diagnostic surgical excisions showing in situ or invasive breast cancer was 29.0% (49/169) and varied from 22.2% (8/36) in 2014 to 38.5% (5/13) in 2011. In conclusion, the proportion of high-risk lesions at CNB tripled in a 6-year period, with a concomitant increased excision rate for these lesions. As the proportion of surgical excisions showing in situ or invasive breast cancer did not increase, a rising number of screened women underwent invasive surgical excision with benign outcome.
Sujet(s)
Tumeurs du sein/diagnostic , Région mammaire/anatomopathologie , Dépistage précoce du cancer/tendances , Dépistage de masse/tendances , Sujet âgé , Biopsie au trocart/statistiques et données numériques , Biopsie au trocart/tendances , Région mammaire/imagerie diagnostique , Région mammaire/chirurgie , Tumeurs du sein/épidémiologie , Tumeurs du sein/chirurgie , Dépistage précoce du cancer/méthodes , Dépistage précoce du cancer/statistiques et données numériques , Femelle , Études de suivi , Humains , Incidence , Mammographie/statistiques et données numériques , Dépistage de masse/méthodes , Dépistage de masse/statistiques et données numériques , Mastectomie/statistiques et données numériques , Mastectomie/tendances , Adulte d'âge moyen , Pays-Bas/épidémiologieRÉSUMÉ
OBJECTIVE: The aim of this study was to perform a systematic review and meta-analysis to assess the accuracy of different surgical axillary staging procedures compared with ALND. SUMMARY OF BACKGROUND DATA: Optimal axillary staging after neoadjuvant systemic therapy (NST) in node-positive breast cancer is an area of controversy. Several less invasive procedures, such as sentinel lymph node biopsy (SLNB), marking axillary lymph node with radioactive iodine seed (MARI), and targeted axillary dissection (a combination of SLNB and a MARI-like procedure), have been proposed to replace the conventional axillary lymph node dissection (ALND) with its concomitant morbidity. METHODS: PubMed and Embase were searched for studies comparing less invasive surgical axillary staging procedures to ALND to identify axillary burden after NST in patients with pathologically confirmed node-positive breast cancer (cN+). A meta-analysis was performed to compare identification rate (IFR), false-negative rate (FNR), and negative predictive value (NPV). RESULTS: Of 1132 records, 20 unique studies with 2217 patients were included in quantitative analysis: 17 studies on SLNB, 1 study on MARI, and 2 studies on a combination procedure. Overall axillary pathologic complete response rate was 37%. For SLNB, pooled rates of IFR and FNR were 89% and 17%. NPV ranged from 57% to 86%. For MARI, IFR was 97%, FNR 7%, and NPV 83%. For the combination procedure, IFR was 100%, FNR ranged from 2% to 4%, and NPV from 92% to 97%. CONCLUSION: Axillary staging by a combination procedure consisting of SLNB with excision of a pre-NST marked positive lymph node appears to be most accurate for axillary staging after NST. More evidence from prospective multicenter trials is needed to confirm this.
Sujet(s)
Tumeurs du sein/anatomopathologie , Lymphadénectomie/méthodes , Noeuds lymphatiques/chirurgie , Traitement néoadjuvant , Aisselle , Tumeurs du sein/diagnostic , Tumeurs du sein/thérapie , Femelle , Humains , Noeuds lymphatiques/anatomopathologie , Métastase lymphatique , Interventions chirurgicales mini-invasives , Stadification tumoraleRÉSUMÉ
BACKGROUND: Cosmetic result in breast cancer surgery is gaining increased interest. Currently, some 30-40% of the patients treated with breast conserving surgery (BCS) are dissatisfied with their final cosmetic result. In order to prevent disturbing breast deformity oncoplastic surgical techniques have been introduced. The extent of different levels of oncoplastic surgery incorporated in breast conserving surgery and its value with regard to cosmetic outcome, patient satisfaction and quality of life remains to be defined. The aim of this prospective cohort study is to investigate quality of life and satisfaction with cosmetic result in patients with breast cancer, undergoing standard lumpectomy versus level I or II oncoplastic breast conserving surgery. METHODS: Female breast cancer patients scheduled for BCS, from 18 years of age, referred to our outpatient clinic from July 2015 are asked to participate in this study. General, oncologic and treatment information will be collected. Patient satisfaction will be scored preceding surgery, and at 1 month and 1 year follow up. Photographs of the breast will be used to score cosmetic result both by the patient, an independent expert panel and BCCT.Core software. Quality of life will be measured by using the BREAST-Q BCT, EORTC-QLQ and EQ-5D-5 L questionnaires. DISCUSSION: The purpose of this prospective study is to determine the clinical value of different levels of oncoplastic techniques in breast conserving surgery, with regard to quality of life and cosmetic result. Analysis will be carried out by objective measurements of the final cosmetic result in comparison with standard breast conserving surgery. The results of this study will be used to development of a clinical decision model to guide the use oncoplastic surgery in future BCS. TRIAL REGISTRATION: Central Commission of Human Research (CCMO), The Netherlands: NL54888.015.15. Medical Ethical Commission (METC), Maxima Medical Centre, Veldhoven, The Netherlands: 15.107. Dutch Trial Register: NTR5665 , retrospectively registered, 02-25-2016.
Sujet(s)
Tumeurs du sein/psychologie , Tumeurs du sein/chirurgie , Mammoplastie , Mastectomie partielle , Qualité de vie , Tumeurs du sein/diagnostic , Tumeurs du sein/mortalité , Femelle , Humains , Mastectomie partielle/méthodes , Satisfaction des patients , Études prospectives , Enquêtes et questionnaires , Résultat thérapeutiqueRÉSUMÉ
PURPOSE: In a biennial screening mammography programme, we analysed the trends in incidence of screen-detected DCIS and invasive breast cancers in the era of screen-film mammography (SFM) screening, the period of the transition to full-field digital mammography (FFDM) screening and the period of FFDM screening. We also investigated a possible association between the incidence and grading of screen-detected DCIS and invasive breast cancer. METHODS: In the southern part of the Netherlands, FFDM screening gradually replaced SFM screening between May 2009 and April 2010. We included a consecutive series of 484, 422 screens obtained between July 2005 and July 2015 and divided these screens into three groups; SFM-only cohort, transition cohort and FFDM-only cohort. RESULTS: A total of 3059 referred women were diagnosed with DCIS (n = 623) or invasive breast cancer (n = 2436). The majority of DCIS were high-grade (48.2%), whereas the majority of the invasive breast cancers were low-grade (45.4%) or intermediate-grade (41.6%). The cancer detection rate (CDR) per 1000 screened women showed the same distribution by grade in both groups. The transition to FFDM was characterised by an increased overall detection rate of invasive cancers. CONCLUSIONS: Screening mammography detects mostly high-grade DCIS and low- or intermediate-grade invasive cancers. The grade distribution as well as the CDR in the years after the introduction of FFDM remained stable compared to the era of SFM screening. By diagnosing and treating high-grade DCIS, which otherwise may develop into high-grade invasive carcinoma, our findings provide new evidence for the beneficial value of screening mammography programmes.