Meeting highlights: a reappraisal of research results for the local treatment of early stage breast cancer

A clinical database of breast cancer patients reveals distinctive clinico-pathological characteristics: a study from central China

BACKGROUND

Breast cancer is the most common malignant tumor in females worldwide. Many differences exist in clinico-pathological characteristics of breast cancer patients between China and Western countries. This study aimed to analyze clinico-pathological characteristics of breast cancer from central China.

METHODS

Clinico- pathological information on breast cancer from three hospitals in central China was collected and analyzed.

RESULTS

From 1994 to 2012, 2,525 patients with a median age 50 years were included in this study. The 45-49-year age group and invasive ductal carcinoma not otherwise specified accounted for the highest proportions (19.1%, 480/2,525 and 81.0%, 1,982/2,446). Stages 0-I, II and III accounted for 28.0% (682/2,441), 48.4% (1,180/2,441), and 23.7% (578/2,441), respectively. Distribution of N stage showed that N0 accounted for 53.2% (1,344/2,525), and proportion of N0 rose from 51.1% (157/307) in 30-39-year age group to 64.3% (110/171) in ≥ 70-year age group, with an average increase of 2.1% in each age group. Modified radical mastectomy, radical mastectomy, breast-conserving surgery and simple mastectomy were performed for 71.8% (1,812/2,525), 18.0% (454/2,525), 5.2% (131/2,525) and 2.6% (66/2,525), respectively. Proportions of breast-conserving surgery in age ≤ 44-year group (68/132, 51.5%) and simple mastectomy in age ≥ 60-year group (57/89, 64.0%) were higher than in the other age groups. Breast cancers positive for estrogen receptor accounted for 53.0% (1,107/ 2,112). The comparisons among this study and other reports showed higher proportion of younger patients, lower proportion of breast- conserving surgery and positive estrogen receptor patients in China than western countries.

CONCLUSIONS

Clinico-pathological characteristics in this study demonstrated clear differences between the center of China than Western countries. Additional classification systems should be developed to guide grading of early breast cancer more accurately, especially for N0 patients. Invasive ductal carcinoma is a focus for intensive research.

Factors predictive of immediate breast reconstruction following mastectomy for invasive breast cancer in Australia

PURPOSE

To investigate person, cancer and treatment determinants of immediate breast reconstruction (IBR) in Australia.

METHODS

Bi-variable and multi-variable analyses of the Quality Audit database.

RESULTS

Of 12,707 invasive cancers treated by mastectomy circa 1998-2010, 8% had IBR. This proportion increased over time and reduced from 29% in women below 30 years to approximately 1% in those aged 70 years or more. Multiple regression indicated that other IBR predictors included: high socio-economic status; private health insurance; being asymptomatic; a metropolitan rather than inner regional treatment centre; higher surgeon case load; small tumour size; negative nodal status, positive progesterone receptor status; more cancer foci; multiple affected breast quadrants; synchronous bilateral cancer; not having neo-adjuvant chemotherapy, adjuvant radiotherapy or adjuvant hormone therapy; and receiving ovarian ablation.

CONCLUSIONS

Variations in access to specialty services and other possible causes of variations in IBR rates need further investigation.

A 10-year (1999 ~ 2008) retrospective multi-center study of breast cancer surgical management in various geographic areas of China

PURPOSE

To study the change of surgical treatments for breast cancer in China over the recent 10 years and the relationship between such a changes and social economical development.

METHODS

The data were extracted from the 10-year database of female primary breast cancer at 7 tertiary hospitals from various geographic areas in China. The Chi-square Cochran-Armitage trend test was used to measure the difference.

RESULTS

Over the 10 year period, mastectomy showed a decline trend while breast conserving surgeries increased. The modified radical mastectomy was the primarily surgical treatment. Among various types of mastectomies, modified radical mastectomy was increasing while Halsted radical mastectomy had shown a decrease trend; no significant changes were observed for the simple mastectomy. Halsted radical mastectomy and breast conserving surgery were used in a higher proportion in high economic areas than low economic areas, while the modified radical mastectomy has been underused in hospitals from high economic areas.

CONCLUSIONS

Modified radical mastectomy was the overall most common choice of operation in China. Breast conserving surgery has been less popular but had been showing an increasing trend. Halsted radical mastectomy has still been in use but showing a decrease these years. Surgeries were not adherent to guidelines completely and needed further effective training.

Practice Guideline for the Breast Conservation Therapy in the Management of Invasive Breast Carcinoma

This is the second of two articles reprinted with permission from: Practice guideline for breast conservation therapy in the management of invasive breast carcinoma. In: Practice Guidelines and Technical Standards. Reston, VA: American College of Radiology;2006:443-468. In this reprinting "G" in Section IV is available in the Online version only. For Section VI please refer to the first publication of ductal carcinoma in-situ (J Am Coll Surg 2007:205:145-161). Parts of this article have been shortened for brevity. The full article is available through the American College of Radiology. The American College of Radiology, with more than 30,000 members, is the principal organization of radiologists, radiation oncologists, and clinical medical physicists in the United States. The College is a nonprofit professional society whose primary purposes are to advance the science of radiology, improve radiologic services to the patient, study the socioeconomic aspects of the practice of radiology, and encourage continuing education for radiologists, radiation oncologists, medical physicists, and persons practicing in allied professional fields. The American College of Radiology will periodically define new practice guidelines and technical standards for radiologic practice to help advance the science of radiology and to improve the quality of service to patients throughout the United States. Existing practice guidelines and technical standards will be reviewed for revision or renewal, as appropriate, on their fifth anniversary or sooner, if indicated. Each practice guideline and technical standard, representing a policy statement by the College, has undergone a thorough consensus process in which it has been subjected to extensive review, requiring the approval of the Commission on Quality and Safety as well as the ACR Board of Chancellors, the ACR Council Steering Committee, and the ACR Council. The practice guidelines and technical standards recognize that the safe and effective use of diagnostic and therapeutic radiology requires specific training, skills, and techniques, as described in each document. Reproduction or modification of the published practice guideline and technical standard by those entities not providing these services is not authorized.

Accelerated Partial Breast Irradiation Using the MammoSite Device: Early Technical Experience and Short-Term Clinical Follow-Up

The MammoSite brachytherapy system is a novel form of intracavitary accelerated partial breast irradiation (APBI) that allows treatment over a 5- to 7-day course after breast conserving surgery (BCS). Fifty-one patients with invasive breast carcinoma underwent BCS and APBI using the MammoSite device, with 30 (59%) patients having drain placement in the lumpectomy cavity. Main outcome measures included time to initiating APBI, cosmesis using the Harvard Scale, and local and distant tumor recurrence with short-term follow-up. Five (9.8%) devices were explanted because of unfavorable final pathological findings or infection. Mean time to the start of APBI in patients without drain placement was 7.2 days (range, 5–12 days) compared with 5.1 days (range, 3–8 days) in patients with drains (P = 0.003). Cosmetic results were excellent in 25 (54.3%) patients, good in 19 (41.3%) patients, and fair in 2 (4.4%) patients. With a mean follow-up of 16 months (range, 6–38 months), no ipsilateral breast recurrences developed in any of the 51 patients. Thirteen patients had at least a 2-year follow-up. Two patients developed brain metastases and died at 19 and 23 months, respectively. The favorable short-term outcomes support further studies comparing APBI with standard whole-breast irradiation in patients undergoing BCS.

Partial irradiation of the breast: Old challenges, new solutions

Breast-conserving treatment, characteristically consisting of surgical removal of the tumor and post-operative whole breast irradiation, is nowadays considered as the standard therapeutic approach for most women with stage I/II, invasive breast cancer. Recently, a number of institutions started investigating the feasibility and safety of novel approaches in radiotherapy, modulating concomitantly treatment time and irradiation volume. Whilst this strategy is still under investigation, recent clinical studies on accelerated partial breast irradiation with intra-operative radiotherapy or high conformality irradiation strongly suggest that the way patients with early breast cancer are irradiated should be revisited.

Diagnosis, Clinical Staging, and Treatment of Breast Cancer

This study compares diagnosis, staging, and treatment of newly diagnosed breast cancer cases over a several-year period. The study design was a retrospective, multiyear comparison between new breast cancer cases diagnosed in 1995 (n = 827) and 1997 (n = 815). Cases were identified through claims data, and medical record abstraction was used to verify each case and to identify clinical staging and type of treatment. All medical records were reviewed by one physician to maximize internal reliability. Both cohorts were predominantly 40 and older, white, married, and postmenopausal. The latter cohort (1997) had a higher proportion of women aged 70 to 79 and a lower proportion of women aged 40 to 49. In both cohorts, women age 40 and older were likely to be diagnosed with breast cancer at the time of mammographic screening, while women younger than 40 were more likely to be diagnosed by clinical breast examination. In logistic regression analyses, controlling for confounding factors such as age, undergoing mammographic screening increased the likelihood of having a low cancer stage at diagnosis by more than three and a half times. Mammographic screening was statistically significantly positively associated with having eligibility for breast-conserving treatment (BCT); however, although an increase in BCT eligibility was observed, actual use of BCT did not change. Mammography leads to a lower clinical stage as well as a greater likelihood of BCT eligibility at time of breast cancer diagnosis, but may not have a substantial effect on treatment choice (lumpectomy vs. mastectomy). Between 1995 and 1997, a trend was observed toward downstaging of disease at diagnosis; further research is warranted to observe whether this trend continues over time.

Workshop on Partial Breast Irradiation: State of the Art and the Science, Bethesda, MD, December 8-10, 2002

Breast conserving surgery followed by radiation therapy has been accepted as an alternative to mastectomy in the management of patients with early-stage breast cancer. Over the past decade there has been increasing interest in a variety of radiation techniques designed to treat only the portion of the breast deemed to be at high risk for local recurrence (partial-breast irradiation [PBI]) and to shorten the duration of treatment (accelerated partial-breast irradiation [APBI]). To consider issues regarding the equivalency of the various radiation therapy approaches and to address future needs for research, quality assurance, and training, the National Cancer Institute, Division of Cancer Treatment and Diagnosis, Radiation Research Program, hosted a Workshop on PBI in December 2002. Although 5- to 7-year outcome data on patients treated with PBI and APBI are now becoming available, many issues remain unresolved, including clinical and pathologic selection criteria, radiation dose and fractionation and how they relate to the standard fractionation for whole breast irradiation, appropriate target volume, local control within the untreated ipsilateral breast tissue, and overall survival. This Workshop report defines the issues in relation to PBI and APBI, recommends parameters for consideration in clinical trials and for reporting of results, serves to enhance dialogue among the advocates of the various radiation techniques, and emphasizes the importance of education and training in regard to results of PBI and APBI as they become emerging clinical treatments.

Omission of radiotherapy after breast-conserving surgery: survival impact and time trends

PURPOSE

To evaluate the survival impact of omission of radiotherapy after breast-conserving surgery and the changes with time.

MATERIAL AND METHODS

Women aged 40-69 with non-metastasized T1-T2 breast cancer, who underwent breast-conserving surgery with axillary node dissection, with or without post-surgery radiotherapy, selected from the SEER (Surveillance, Epidemiology, and End Results) database. The analysis uses proportional hazards models.

RESULTS

Omission of radiotherapy as compared to delivery of radiotherapy was associated with an overall increased mortality hazard ratio of 1.346 (95% confidence interval: 1.204-1.504). Test of constancy showed significant changes with time. The time profile suggested an exponential-like increase from a baseline mortality hazard ratio of 1.17, or 17% excess of relative mortality risk, to a projected hazard ratio of 2.26, or more than doubling of relative mortality risk, for omission of radiotherapy.

CONCLUSION

Omission of radiotherapy in breast-conserving surgery is found to be independently associated with an increase in mortality. The data do not give support to omitting radiation or give rationale to clinical trials that would omit radiation.

Post-surgery radiation in early breast cancer: survival analysis of registry data

BACKGROUND AND PURPOSE

Overviews of randomized trials have shown a small survival advantage with post-surgery radiation in early breast cancer. The present study attempts to extend this observation through a systematic analysis of population data.

MATERIALS AND METHODS

This retrospective cohort study used the Surveillance, Epidemiology, and End Results (SEER) data on 83,776 women with breast cancer diagnosed between 1988 and 1997, stage T1-T2, node negative or node positive. The analysis was performed using the proportional hazard models.

RESULTS

Radiation was associated with a reduced mortality after breast-conserving surgery in node negative patients (hazard ratio 0.757; 95% confidence interval 0.709-0.809; using total mastectomy without radiation as reference) and in node positive patients (hazard ratio 0.777; 0.717-0.842), and after total mastectomy in node positive patients (hazard ratio 0.885; 0.815-0.961). Radiation was associated with an increased hazard ratio of 1.271 (1.080-1.496) after total mastectomy in node negative patients. Without radiation, breast-conserving surgery in node negative patients was associated with an increased hazard ratio (1.167; 1.036-1.314); a similar increase was not observed in node positive patients (hazard ratio 1.011; 0.884-1.155). In all cases, the best survival rates were found with combined breast-conserving surgery and radiation.

CONCLUSION

The available data indicate that post-surgery radiation provides a survival advantage irrespective of the type of surgery in node positive patients. Likewise, survival advantage was observed with post-surgery radiation and breast-conserving procedure in node negative patients.

Differences in treatment patterns for localized breast carcinoma among Asian/Pacific islander women

BACKGROUND

Many studies have examined racial/ethnic differences in treatment for localized breast carcinoma, but to the authors' knowledge few have included Asian/Pacific Islander (API) women.

METHODS

The population-based study included API and non-Hispanic white women diagnosed with localized invasive breast carcinoma in the Greater San Francisco Bay Area during 1994 (n = 1772). Multiple logistic regression was used to assess the association between race/ethnicity and type of surgery, radiation therapy following breast-conserving surgery (BCS), and hormone therapy for estrogen receptor-positive tumors while adjusting for demographic, medical, and census block-group socioeconomic characteristics.

RESULTS

API women were significantly more likely to undergo mastectomies than white women (58% vs. 42%). This difference remained for Chinese and Filipino women after multivariate adjustment (odds ratio vs. whites [OR] = 2.4, 95% confidence interval [95% CI] = 1.4-4.2; OR [95%CI] = 1.8[1.0-3.1], respectively). Chinese women were also more likely than white women to not receive adjuvant therapy, be it radiation after BCS or hormone therapy for estrogen receptor-positive disease. Other API women did not differ from white women in adjuvant therapy use.

CONCLUSIONS

This population-based study identified differences in treatment for localized breast carcinoma by race/ethnicity that were not explained by differences in demographic, medical, or socioeconomic characteristics. These results underscore the importance of looking at treatment patterns separately for API subgroups and support the need for research into cultural differences that may influence breast carcinoma treatment choices.

Delay in adjuvant radiation treatment and outcomes of breast cancer--a review

Recent meta-analyses have shown the importance of locoregional control as a long-term determinant of breast cancer survival. Whether factors related to the delivery of radiotherapy, such as delay, dose, fractionation or irradiated volume, are associated with outcome remains unclear. We performed a critical review of the literature on delay to radiation using a computerized search of papers published between 1985 and 2000. Periods of accrual, details of radiotherapy, surgical and systemic treatment, and information on prognostic factors were noted. Studies on sequencing of adjuvant therapy were compared to studies on delay to radiation, classified according to whether or not patients also received chemotherapy. Comparisons of patients receiving systemic therapy to individuals spared this option were considered uninformative since the impact of delaying radiation is then highly confounded by systemic treatment received. The single published experimental study on sequencing suggests that delay to radiation may compromise local control, and this is consistent with a few retrospective reports on delay to radiotherapy among patients receiving chemotherapy. However, indirect evidence from two randomized clinical trials of chemotherapy, and the majority of observational studies on delay to radiotherapy, suggest that it has no impact on either local, distant control or survival. Factors, methodological, and others, that could explain these inconsistencies are discussed. No study restricted to patients at low risk of recurrence suggested an impact of delaying radiation. Short chemotherapy regimens are likely to represent a safe option with respect to outcome of radiation treatment.

Geographic Differences in Treatment of Early Stage Breast Cancer

The objective of this study was to describe recent time and geographic variations in breast cancer treatment while controlling for patient age, race, and ethnic group. Treatment data for women diagnosed with localized breast cancer from nine defined geographic areas of the United States from 1983 through 1992 were analyzed. Of 80,887 subjects, 33.9% were treated with lumpectomy from 1983 to 1992. The proportion of women treated with lumpectomy varied greatly according to geographic area, ranging from overall percentages of 19.0% in Iowa to 41.4% in Connecticut, but increased in all sites during the time period under study. Women less than 50 years and more than age 80 years and older were most likely to have lumpectomy, while Asian/Pacific islander women were significantly less likely compared to Caucasian women. Rates for African American and Hispanic women were not significantly different than those for Caucasian women. Although consensus conferences and randomized clinical trials have indicated lumpectomy is appropriate therapy for the majority of women diagnosed with early stage breast cancer, large geographic differences in rates have persisted over time. These differences were not explained by underlying differences in age or race distributions in the geographic areas included in this study.

The potential use of intensity modulated radiotherapy (IMRT) in women with pectus excavatum desiring breast-conserving therapy

The purpose of this study was to determine if intensity modulated radiation therapy (IMRT) offers a better treatment plan compared to conventional radiotherapy for patients with pectus excavatum desiring breast-conserving therapy and to assess the feasibility of simultaneous modulated accelerated radiation therapy (SMART) boost. A patient with pectus excavatum desired breast-conserving therapy for her early stage breast cancer. She underwent lumpectomy and axillary lymph node dissection followed by chemotherapy. She was then referred for radiotherapy. A breast board (Med-Tec) with aquaplast body cast was used to limit the movement of the patient, chest wall, and breasts before planning a computed tomography (CT) scan. IMRT including dose-volume histogram (DVH) was compared to that of the conventional plan using parallel opposed tangential beams with a 15-degree wedge pair. Forty-five gray was prescribed to the whole breast to each plan, while 50 Gy was prescribed to the tumor bed using IMRT with SMART boost in 25 fractions over 5 weeks. The coverage of the whole breast was adequate for both plans. IMRT allowed a more homogeneous dose distribution within the breast at the desired dose range. With IMRT there is less volume of ipsilateral lung receiving the radiation dose that is above the tolerance threshold of 15 Gy when compared to that of the conventional plan. However, there is more volume of surrounding normal tissues (the heart, spinal cord, and contralateral breast and lung) receiving low-dose irradiation when IMRT was employed. SMART boost was feasible, allowing a mean dose of 57 Gy to be delivered to the tumor bed simultaneously along with the rest of the breast in 5 weeks. IMRT is feasible in treating early breast cancer patients with pectus excavatum by decreasing the ipsilateral lung volume receiving high-dose radiation when compared to the conventional method. SMART boost shortens the overall treatment time that may have potential radiobiological benefit.

Cost comparison of mastectomy versus breast-conserving therapy for early-stage breast cancer

BACKGROUND

Choice of treatment for early-stage breast cancer depends on many factors, including the size and stage of the cancer, the woman's age, comorbid conditions, and perhaps the costs of treatment. We compared the costs of all medical care for women with early-stage breast cancer cases treated by breast-conserving therapy (BCT) or mastectomy.

METHODS

A total of 1675 women 35 years old or older with incident early-stage breast cancer were identified in a large regional nonprofit health maintenance organization in the period 1990 through 1997. The women were treated with mastectomy only (n = 183), mastectomy with adjuvant hormonal therapy or chemotherapy (n = 417), BCT with radiation therapy (n = 405), or BCT with radiation therapy and adjuvant hormonal therapy or chemotherapy (n = 670). The costs of all medical care for the period 1990 through 1998 were computed for each woman, and monthly costs were analyzed by treatment, adjusting for age and cancer stage. All statistical tests were two-sided.

RESULTS

At 6 months after diagnosis, the mean total medical care costs for the four groups differed statistically significantly (P:<.001), with BCT being more expensive than mastectomy. The adjusted mean costs were $12 987, $14 309, $14 963, and $15 779 for mastectomy alone, mastectomy with adjuvant therapy, BCT plus radiation therapy, and BCT plus radiation therapy with adjuvant therapy, respectively. At 1 year, the difference in costs was still statistically significant (P:<.001), but costs were influenced more by the use of adjuvant therapy than by type of surgery. The 1-year adjusted mean costs were $16 704, $18 856, $17 344, and $19 081, respectively, for the four groups. By 5 years, BCT was less expensive than mastectomy (P:<.001), with 5-year adjusted mean costs of $41 930, $45 670, $35 787, and $39 926, respectively. Costs also varied by age, with women under 65 years having higher treatment costs than older women.

CONCLUSIONS

BCT may have higher short-term costs but lower long-term costs than mastectomy.

Examining the use of breast-conserving treatment for women with breast cancer in a managed care environment

At a National Institutes of Health Consensus Conference in 1991, conservation treatment was considered preferable for patients with early-stage breast cancer. In the early and mid-1990s, however, less than half of the eligible patients received this treatment and the rates varied with patient and provider characteristics. This study explores whether more eligible patients with breast cancer received conservation treatment in recent years in a managed care environment compared to reports in the literature, and if patient and hospital characteristics affected the rate of acceptance. The study population included 753 women with breast cancer in clinical stages 0, I, or II. Patients with Stage III or IV tumors or with tumors larger that 5.0 cm were excluded. A multiple logistic regression incorporated in a mixed-effect model was used to estimate the effect of patient and facility characteristics on the likelihood of using breast-conserving surgery controlling for clinical stages and demographics such as age, race, and marital status. Among the 753 eligible patients, 474 (62.9%) received conservation surgery. Only Hispanic ethnicity and clinical stage significantly affected the likelihood of receiving conservation treatment. Factors such as patient age, hospital size, and teaching status that had been found to be significant predictors in earlier studies were not statistically significant in this study, although conservation treatment was more frequent in younger women and in teaching hospitals. A larger proportion of eligible patients received conservative treatment in this study than in previous reports. This treatment became available in a broader range of institutions, moving from large, academic teaching centers to smaller community hospitals.

Women's experience of breast conserving treatment for breast cancer

The implementation of the National Breast Screening Programme in the UK, and subsequent increase in early detection of small cancers, has facilitated breast conserving treatment for more women with a breast cancer diagnosis than ever before. While a substantial body of literature has evolved regarding psychosocial morbidity and support needs of women at diagnosis and during treatment, there are specific gaps in the current knowledge base. The purpose of this study was to describe the experiences of women who had breast conserving treatment for early breast cancer, focusing on issues related to diagnosis, surgery, and radiotherapy. The study was designed within the context of clinical audit, with a view to informing service development. Seventy-six women who had undergone breast conserving surgery within the last 3-12 months, completed a self-report questionnaire. Findings indicated that although the majority of women expressed satisfaction with their treatment overall, a number of specific areas require attention from healthcare professionals. Further research is required to validate these findings and to explore: potential implications of different referral routes; information and support needs preceding definitive diagnosis; particular needs of those women with ductal carcinoma in situ (DCIS) vs. invasive disease; 'end of treatment' and ongoing information and support needs.

Increasing trends in the use of breast-conserving surgery in California

OBJECTIVES

The purpose of this study was to determine temporal trends in breast-conserving surgery in California from 1988 through 1995.

METHODS

Logistic regression was used to analyze data on 104,466 cases of early-stage breast cancer reported to the California Cancer Registry.

RESULTS

A monotonically increasing trend in breast-conserving surgery was detected after adjustment for age, race/ethnicity, stage at diagnosis, and neighborhood education level. Breast-conserving surgery increased at similar rates among all racial/ethnic groups. Older age, Asian or Hispanic race/ethnicity, late-stage diagnosis, and residence in an undereducated neighborhood were factors associated with lower use of breast-conserving surgery.

CONCLUSIONS

Although disparities are evident, use of breast-conserving surgery increased steadily in all groups examined in this study.

Reducing scatter radiation to the contralateral breast with a mobile, conformal shield during breast cancer radiotherapy

During a standard course of breast radiotherapy, the contralateral breast generally receives approximately 2.5 to 6.0 Gy of scattered radiation. Although most studies have not found an overall increase in metachronous contralateral breast cancers in patients undergoing radiotherapy, a cohort of younger women may be genetically more susceptible to radiation-induced breast cancers and may thus be adversely affected by the scattered radiation. We are attempting to develop a simple, convenient, effective mechanism for minimizing the scattered radiation to the contralateral breast during the process of clinical breast radiotherapy. We therefore designed a conformal, platform-based breast shield consisting of 2.5 cm of molded lead in a mobile counterweighted polystyrene casing. This shield was intended to serve as a physical barrier to prevent both low and high energy scattered photons from the medial and lateral tangential fields. We conducted a prospective trial of 20 women, each woman serving as her own control. Each woman received breast radiotherapy with and without shield, and an array of thermoluminescent dosimeters was positioned across the contralateral breast to evaluate the in vivo dosimetry and the impact of the breast shield on surface absorption of scattered radiation. We found that the use of the breast shield reduced the median dose of scattered radiation by approximately 60% (p < 0.0001). This represented a median dose reduction of approximately 300 cGy at the nipple. The shield was easily positioned and added < 1 min to daily setup time. We conclude that the use of this sort of surface barrier shielding technique was feasible, effective, and practical for clinical use. The degree of scatter reduction accomplished through the use of this breast shield may be biologically significant, especially for those patients with biologic or epidemiologic risk factors that may predispose them to the development of radiogenic breast cancers.

Subtle differences in quality of life after breast cancer surgery

BACKGROUND

Lumpectomy with axillary dissection (LAD) has taken its place alongside mastectomy (M) as the treatment of choice for stage I and II breast cancer. Its appeal is based on lessening disfigurement and thus improving quality of life.

METHODS

We used the SF-36 Health Survey modified with ten questions relevant to breast cancer surgery to evaluate whether quality of life with LAD was better than with mastectomy in women with stage I and II disease. The additional questions addressed satisfaction with intimate relationships and sexuality, and explored impact on the way women dress, use bathing suits, hug people, are comfortable with nudity, and rate their sexual drive and sexual responsiveness.

RESULTS

LAD was not associated with statistically significant better quality-of-life scores on any SF-36 questions, except vitality (P = .02). No differences were noted in the areas of intimacy and sexual satisfaction. LAD patients reported significant differences in matters of dress, use of bathing suits, hugging, comfort with nudity, and sexual drive compared to patients undergoing mastectomy.

CONCLUSIONS

The SF-36 health survey detected few differences in quality of life measures between patients with LAD and those with mastectomy. However, LAD impacts favorably on the way women dress, on comfort with nudity, and on sexual drive.

Eight-year results of a prospective non-randomised study on therapy of small breast cancer. The German Breast Cancer Study Group (GBSG)

In this report, the results of the first controlled clinical trial on breast cancer in Germany, begun in 1983, are presented after a median follow-up of 8 years. Four-year results have been previously published. In pT1 N0 M0 breast cancer, mastectomy as the standard treatment was to be compared with tumorectomy plus radiotherapy to the remaining breast tissue. The study design, originally planned as a comprehensive cohort study including randomised and non-randomised patients, had to be changed into a prospective observation study due to the low randomisation rate. 1036 out of 1119 recruited patients were evaluable. After a median follow-up of 97 months, 237 events (local recurrence, regional recurrence, distant metastases, contralateral breast cancer or death of the patient without previous recurrence) occurred. With the exception of death without recurrence, the events were evenly distributed among the two treatment groups. The 8-year local recurrence rate of the whole patient population is 8.8%. Out of all prognostic factors examined, only tumour size and grade had a significant influence on recurrent disease. Event-free survival decreased in cases with 'uncertain' tumour margins, whereas the width of the margin has no influence on disease recurrence. Based on 151 deaths observed so far, there was no significant difference in overall survival between the two treatment groups. The 8-year results of this study are in accordance with the 4-year results reported previously and with those of other breast-conserving treatment trials. There was no significant difference between the two treatment groups with regard to event-free and overall survival. Incomplete tumorectomy had a negative influence on recurrence.

Predictors of breast-conserving surgery in Connecticut, 1990-1992

BACKGROUND

Breast-conserving surgery (BCS) has been recommended for most early-stage primary breast cancers, but predictors may vary by time and geographic area.

METHODS

Among 5,266 early-stage female breast cancers (diagnosed in 1990-1992) in the population-based Connecticut Tumor Registry, the poverty rate of census tract of residence (an ecologic indicator of socioeconomic status), age at diagnosis, race, marital status, extent of disease, year of diagnosis, and town of residence were analyzed in relation to BCS use.

RESULTS

The poverty rate of census tract was not a statistically significant variable in logistic regression analyses of BCS use; however, age, year of diagnosis, and stage at diagnosis were predictors. Residence in a town with a hospital having radiotherapy facilities or near a university hospital were not predictors of BCS use. High BCS rates (69-94% vs. 49% statewide) were found for residents of a cluster of seven contiguous towns associated with a single (nonuniversity) hospital.

CONCLUSIONS

BCS was not associated with poverty level of area of residence but continued to be lower for larger or node-positive cancers. Attitudes and practices of local physicians were hypothesized as being important in explaining variation in BCS use by town of residence.

Breast preservation in stage I and II carcinoma of the breast. The University of Chicago experience

BACKGROUND

Although breast conservation has received increased acceptance, there are still unresolved issues regarding local treatment techniques, such as the extent of surgery, in relation to the final margins of excision and the use of tumor bed boost radiation. The goal of this study was to determine the local control and breast preservation with particular emphasis on the importance of the final microscopic margins in patients receiving tumor bed boost therapy.

METHODS

The authors analyzed 869 cases of Stage I and II breast carcinoma in 852 women who were treated with breast-conserving surgery and radiation therapy between 1984 and 1994. The median follow-up was 43 months. Final microscopic margins were negative in 762 (88%), microscopically positive in 82 (9%), and unknown in 25 (3%) of the patients. Negative margins were defined as no tumor cells at the surgical margin. The patients were treated with external beam radiation therapy to the entire breast to a median dose of 46 Gray (Gy). A boost to the tumor bed was delivered to 863 (99%) of the patients. The median tumor bed dose was 60 Gy. A multivariate analysis of factors impacting on the local control and overall survival was performed. Variables introduced into the model included size, age, lymph node status, microscopic margins, nuclear grade, histologic grade, and estrogen and progesterone receptor status.

RESULTS

The actuarial 5-year local control rate was 97%. The median time to local failure was 32 months (range, 14-69 months). In multivariate analysis, the only significant factor affecting local control was the status of margins. In patients receiving boost radiation to the excision site, the local control rate at 5 years was 98% and 89%, respectively, if the margins were negative or positive (P < 0.01). This resulted in 5-year actuarial breast preservation rates of 98% and 92% (P = 0.03). In the patients in whom the margins of excision were microscopically positive, the local control rate was 91% if the total dose to the tumor bed was > 60 Gy compared with 76% for a dose < or = 60 Gy (P = 0.05). The 5-year actuarial overall survival rate was 89%. Approximately 94% of the women considered their cosmetic outcome good to excellent.

CONCLUSIONS

By obtaining microscopically negative margins and using tumor bed boost therapy, excellent local control, breast preservation, and cosmesis can be achieved. In patients with microscopically positive margins, an acceptable local control rate can be achieved if a tumor bed boost is given.