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Lehrberg A, Sebai M, Finn D, Lee D, Karabon P, Kiran S, Dekhne N. Trends, survival outcomes, and predictors of nonadherence to mastectomy guidelines for nonmetastatic inflammatory breast cancer. Breast J 2021; 27:753-760. [PMID: 34431161 DOI: 10.1111/tbj.14283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 07/21/2021] [Accepted: 08/04/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The Current National Comprehensive Cancer Network guidelines recommend modified radical mastectomy (MRM) as the surgical treatment of choice for nonmetastatic inflammatory breast cancer (IBC). Limited studies have looked into the outcomes of breast conserving surgery (BCS) vs. MRM for IBC. METHODS National Cancer Database (NCDB) data from 2004 to 2014 were retrospectively analyzed. Patients' demographics, tumor characteristics, and overall survival (OS) trends were compared for BCS and MRM cases of nonmetastatic IBC. Univariate and multivariate analyses were performed. RESULTS A total of 413 (3.89%) BCS and 10,197 (96.11%) MRM cases were identified. Median follow-up was 58.45 months. Compared to MRM, BCS patients were more likely to be older, be African American, have Medicare/Medicaid or be uninsured, live in lower education ZIP codes, and live in a metropolitan area (all p < 0.05). BCS rates significantly decreased from 5.84% in 2004 to 3.19% in 2014 (p < 0.001). BCS patients also were more likely to have less than 50% of the breast involved (51.57% vs. 43.88%; p = 0.0081) and were less likely to receive trimodal therapy (50.85% vs. 74.62%; p = <0.0001). The OS was significantly higher in the mastectomy group over 9 years at 62.02% vs. 54.47% in the BCS group. Additionally, in the adjusted multivariate model, BCS cases were associated with 23% higher hazards of overall mortality (p = 0.0091). CONCLUSION BCS was performed in a limited number of cases, which decreased over the study period. The analysis identified both demographic predictors of receiving BCS and significantly lower OS for IBC patients undergoing a BCS.
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Affiliation(s)
- Anna Lehrberg
- Breast Cancer Center, Beaumont Health, Oakland University WB School of Medicine, Royal Oak, Michigan, USA
| | - Mohamad Sebai
- Breast Cancer Center, Beaumont Health, Oakland University WB School of Medicine, Royal Oak, Michigan, USA
| | - Daniel Finn
- Breast Cancer Center, Beaumont Health, Oakland University WB School of Medicine, Royal Oak, Michigan, USA
| | - David Lee
- Breast Cancer Center, Beaumont Health, Oakland University WB School of Medicine, Royal Oak, Michigan, USA
| | - Patrick Karabon
- Breast Cancer Center, Beaumont Health, Oakland University WB School of Medicine, Royal Oak, Michigan, USA
| | - Sayee Kiran
- Breast Cancer Center, Beaumont Health, Oakland University WB School of Medicine, Royal Oak, Michigan, USA
| | - Nayana Dekhne
- Breast Cancer Center, Beaumont Health, Oakland University WB School of Medicine, Royal Oak, Michigan, USA
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Reconstruction in Women with T4 Breast Cancer after Neoadjuvant Chemotherapy: When Is It Safe? J Am Coll Surg 2021; 233:285-293. [PMID: 33957258 DOI: 10.1016/j.jamcollsurg.2021.04.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 04/09/2021] [Accepted: 04/12/2021] [Indexed: 01/20/2023]
Abstract
BACKGROUND Despite limited evidence regarding its safety, immediate reconstruction (IR) is increasingly offered to women with T4 breast cancer. We compared outcomes after IR, delayed reconstruction (DR), and no reconstruction (NR) in patients treated with neoadjuvant chemotherapy (NAC) and postmastectomy radiation therapy (PMRT) for T4 disease. STUDY DESIGN We retrospectively identified consecutive women with T4 tumors treated with trimodality therapy from January 2007 through December 2019. Clinicopathologic characteristics, complications requiring reoperation, time to PMRT, and recurrence patterns were compared. The cumulative incidence of local recurrence (LR) was estimated using Kaplan-Meier methods. RESULTS Of the 269 women identified, the median (IQR) age was 52 (45-62) years; 164 women (61%) had T4d disease. Forty-five women (17%) had IR, 41 (15%) had DR, and 183 (68%) had NR. IR was independently associated with T4a-c disease (odds ratio [OR], 5.75; 95% CI, 2.57-12.87; p < 0.001) and younger age (OR 0.91; 95% CI, 0.86-0.94; p < 0.001). The risk of complications after IR was 22% overall and 46% in T4d patients (6/13), compared with 4.4% overall for NR and 7.3% for DR (p < 0.001). IR was associated with >8-week interval to PMRT (p < 0.001). At a median (range) follow-up of 4.2 (0.2-13) years, the median time to first recurrence was 18 months and was similar between groups (p = 0.13). The cumulative incidence of LR was 16% for T4d disease and 2.2% for T4a-c disease (p < 0.001). CONCLUSIONS After IR, women with T4 tumors, particularly T4d disease, experienced delayed initiation of adjuvant treatment and substantial morbidity, suggesting that an interval of >18 months between mastectomy and reconstruction is advisable.
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Postlewait LM, Teshome M, DeSnyder SM, Lim B, Kuerer HM, Bedrosian I, Woodward WA, Ueno NT, Lucci A. Factors Associated with Pathological Node Negativity in Inflammatory Breast Cancer: Are There Patients Who May be Candidates for a De-Escalation of Axillary Surgery? Ann Surg Oncol 2020; 27:4603-4612. [PMID: 32710271 DOI: 10.1245/s10434-020-08891-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/09/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Modified radical mastectomy (MRM), which includes axillary dissection, is the standard of care for inflammatory breast cancer (IBC). While more limited axillary staging after neoadjuvant chemotherapy (NAC) in clinically node-positive non-IBC has been increasingly adopted, the impact of these techniques in IBC is not clear. To inform patient selection for further study of limited axillary surgery, we aimed to describe the frequency and factors associated with pathological node-negativity (ypN0) in IBC. METHODS Patients with IBC who received NAC and MRM were identified from a prospective institutional database (2004-2019). Binary logistic regression analyses were conducted to identify factors associated with ypN0. RESULTS Of 453 patients, 189 (41.7%) had a post-NAC clinical nodal stage (ycN stage) of N0 (ycN1: 150, 33.1%; ycN2: 4, 0.9%; ycN3: 47, 10.4%; unknown: 63, 13.9%); 156 (34%) were ypN0. On multivariable analysis, higher tumor grade was not associated with ypN0 (odds ratio [OR] 1.59, 95% confidence interval [CI] 0.90-2.81, p =0.11). Compared with hormone receptor (HR)-negative/human epidermal growth factor receptor 2 (HER2)-negative tumors (n =113, 24.9%), HR-positive/HER2-negative tumors (n =169, 37.3%) had a trend toward less ypN0 (OR 0.55, 95% CI 0.29-1.02, p =0.06); HR-positive/HER2-positive tumors (n =79, 17.4%) were similar to HR-negative/HER2-negative tumors (OR 0.72, 95% CI 0.35-1.48, p =0.37); and HR-negative/HER2-positive tumors (n =92, 20.3%) were associated with increased ypN0 (OR 4.82, 95% CI 2.41-9.63, p <0.001). As ycN stage increased, the likelihood of ypN0 decreased compared with ycN0 patients (ycN1/2: OR 0.54, 95% CI 0.32-0.89, p =0.02; ycN3: OR 0.29, 95% CI 0.13-0.67, p =0.004). CONCLUSIONS One-third of patients with IBC who received NAC and MRM had pathologically negative nodes. Factors associated with ypN0 included ycN0 status and HR-negative/HER2-positive subtype. Large, prospective studies are needed to investigate the feasibility of alternative nodal evaluation strategies in IBC, with consideration to these subgroups.
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Affiliation(s)
- Lauren M Postlewait
- Division of Surgery, Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mediget Teshome
- Division of Surgery, Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sarah M DeSnyder
- Division of Surgery, Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bora Lim
- Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Breast Medical Oncology, Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Henry M Kuerer
- Division of Surgery, Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Isabelle Bedrosian
- Division of Surgery, Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Wendy A Woodward
- Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Division of Radiation Oncology, Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naoto T Ueno
- Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Breast Medical Oncology, Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anthony Lucci
- Division of Surgery, Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA. .,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Woodward WA, Ueno NT, Kuerer HM, Lucci A, Shen Y. Reply to 'A standard mastectomy should not be the only recommended breast surgical treatment for non-metastatic inflammatory breast cancer: A large population-based study in the Surveillance, Epidemiology, and End Results database 18'. Breast 2018; 39:148-149. [PMID: 29729725 DOI: 10.1016/j.breast.2018.01.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 01/24/2018] [Indexed: 11/16/2022] Open
Affiliation(s)
- Wendy A Woodward
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Naoto T Ueno
- Department of Breast Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Henry M Kuerer
- Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anthony Lucci
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yu Shen
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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