Breast Cancer Version 2.2015

Mitigating disparities in breast cancer treatment at an academic safety-net hospital

PURPOSE

Among women with non-metastatic breast cancer, marked disparities in stage at presentation, receipt of guideline-concordant treatment and stage-specific survival have been shown in national cohorts based on race, ethnicity, insurance and language. Little is published on the performance of safety-net hospitals to achieve equitable care. We evaluate differences in treatment and survival by race, ethnicity, language and insurance status among women with non-metastatic invasive breast cancer at a single, urban academic safety-net hospital.

METHODS

We conducted a retrospective study of patients with invasive ductal or lobular breast cancer, diagnosed and treated between 2009 and 2014 at an urban, academic safety-net hospital. Demographic, tumor and treatment characteristics were obtained. Stage at presentation, stage-specific overall survival, and receipt of guideline-concordant surgical and adjuvant therapies were analyzed. Chi-square analysis and ANOVA were used for statistical analysis. Unadjusted survival analysis was conducted by Kaplan-Meier method using log-rank test; adjusted 5 year survival analysis was completed stratified by early and late stage, using flexible parametric survival models incorporating age, race, primary language and insurance status.

RESULTS

520 women with stage 1-3 invasive breast cancer were identified. Median age was 58.5 years, 56.1% were non-white, 31.7% were non-English-speaking, 16.4% were Hispanic, and 50.1% were Medicaid/uninsured patients. There were no statistically significant differences in stage at presentation between age group, race, ethnicity, language or insurance. The rate of breast conserving surgery (BCS) among stage 1-2 patients did not vary by race, insurance or language. Among patients indicated for adjuvant therapies, the rates of recommendation and completion of therapy did not vary by race, ethnicity, insurance or language. Unadjusted survival at 5 years was 93.7% for stage 1-2 and 73.5% for stage 3. Adjusting for age, race, insurance status and primary language, overall survival at 5 years was 93.8% (95% CI 86.3-97.2%) for stage 1-2 and 83.4% (95% CI 35.5-96.9%) for stage 3 disease. Independently, for patients with early- and late-stage disease, age, race, language and insurance were not associated with survival at 5-years.

CONCLUSION

Among patients diagnosed and treated at an academic safety-net hospital, there were no differences in the stage at presentation or receipt of guideline-concordant treatment by race, ethnicity, insurance or language. Overall survival did not vary by race, insurance or language. Additional research is needed to assess how hospitals and healthcare systems mitigate breast cancer disparities.

What Is Known about Breast Cancer in Young Women?

Breast cancer (BC) is the second leading cause of cancer-related death in women under the age of 40 years worldwide. In addition, the incidence of breast cancer in young women (BCYW) has been rising. Young women are not the focus of screening programs and BC in younger women tends to be diagnosed in more advanced stages. Such patients have worse clinical outcomes and treatment complications compared to older patients. BCYW has been associated with distinct tumour biology that confers a worse prognosis, including poor tumour differentiation, increased Ki-67 expression, and more hormone-receptor negative tumours compared to women >50 years of age. Pathogenic variants in cancer predisposition genes such as BRCA1/2 are more common in early-onset BC compared to late-onset BC. Despite all these differences, BCYW remains poorly understood with a gap in research regarding the risk factors, diagnosis, prognosis, and treatment. Age-specific clinical characteristics or outcomes data for young women are lacking, and most of the standard treatments used in this subpopulation currently are derived from older patients. More age-specific clinical data and treatment options are required. In this review, we discuss the epidemiology, clinicopathologic characteristics, outcomes, treatments, and special considerations of breast cancer in young women. We also underline future directions and highlight areas that require more attention in future studies.

Low expression of NR1H3 correlates with macrophage infiltration and indicates worse survival in breast cancer

Background: Nuclear receptor NR1H3 is a key regulator of macrophage function and lipid homeostasis. Here, we aimed to visualize the prognostic value and immunological characterization of NR1H3 in breast cancer. Methods: The expression pattern and prognostic value of NR1H3 were analyzed via multiple databases, including TIMER2, GEPIA2 and Kaplan-Meier Plotter. TISIDB, TIMER2 and immunohistochemical analysis were used to investigate the correlation between NR1H3 expression and immune infiltration. GO enrichment analysis, KEGG analysis, Reactome analysis, ConsensusPathDB and GeneMANIA were used to visualize the functional enrichment of NR1H3 and signaling pathways related to NR1H3. Results: We demonstrated that the expression of NR1H3 was significantly lower in breast cancer compared with adjacent normal tissues. Kaplan-Meier survival curves showed shorter overall survival in basal breast cancer patients with low NR1H3 expression, and poorer prognosis of relapse-free survival in breast cancer patients with low NR1H3 expression. NR1H3 was mainly expressed in immune cells, and its expression was closely related with infiltrating levels of tumor-infiltrating immune cells in breast cancer. Additionally, univariate and multivariate analysis indicated that the expression of NR1H3 and the level of macrophage infiltration were independent prognostic factors for breast cancer. Gene interaction network analysis showed the function of NR1H3 involved in regulating of innate immune response and macrophage activation. Moreover, NR1H3 may function as a predictor of chemoresponsiveness in breast cancer. Conclusion: These findings suggest that NR1H3 serves as a prognostic biomarker and contributes to the regulation of macrophage activation in breast cancer.

Prediction of the histologic upgrade of ductal carcinoma in situ using a combined radiomics and machine learning approach based on breast dynamic contrast-enhanced magnetic resonance imaging

Objective

To investigate whether support vector machine (SVM) trained with radiomics features based on breast magnetic resonance imaging (MRI) could predict the upgrade of ductal carcinoma in situ (DCIS) diagnosed by core needle biopsy (CNB) after surgical excision.

Materials and methods

This retrospective study included a total of 349 lesions from 346 female patients (mean age, 54 years) diagnosed with DCIS by CNB between January 2011 and December 2017. Based on histological confirmation after surgery, the patients were divided into pure (n = 198, 56.7%) and upgraded DCIS (n = 151, 43.3%). The entire dataset was randomly split to training (80%) and test sets (20%). Radiomics features were extracted from the intratumor region-of-interest, which was semi-automatically drawn by two radiologists, based on the first subtraction images from dynamic contrast-enhanced T1-weighted MRI. A least absolute shrinkage and selection operator (LASSO) was used for feature selection. A 4-fold cross validation was applied to the training set to determine the combination of features used to train SVM for classification between pure and upgraded DCIS. Sensitivity, specificity, accuracy, and area under the receiver-operating characteristic curve (AUC) were calculated to evaluate the model performance using the hold-out test set.

Results

The model trained with 9 features (Energy, Skewness, Surface Area to Volume ratio, Gray Level Non Uniformity, Kurtosis, Dependence Variance, Maximum 2D diameter Column, Sphericity, and Large Area Emphasis) demonstrated the highest 4-fold mean validation accuracy and AUC of 0.724 (95% CI, 0.619–0.829) and 0.742 (0.623–0.860), respectively. Sensitivity, specificity, accuracy, and AUC using the test set were 0.733 (0.575–0.892) and 0.7 (0.558–0.842), 0.714 (0.608–0.820) and 0.767 (0.651–0.882), respectively.

Conclusion

Our study suggested that the combined radiomics and machine learning approach based on preoperative breast MRI may provide an assisting tool to predict the histologic upgrade of DCIS.

Treatment Sequencing Patterns and Associated Direct Medical Costs of Metastatic Breast Cancer Care in the United States, 2011 to 2021

IMPORTANCE

Advances in treatment of metastatic breast cancer (MBC) led to changes in clinical practice and treatment costs in the US over the past decade. There is limited information on current MBC treatment sequences and associated costs by MBC subtype in the US.

OBJECTIVES

To identify treatment patterns by MBC subtype and associated anticancer and supportive drug costs from health care sector and Medicare perspectives.

DESIGN, SETTING, AND PARTICIPANTS

This economic evaluation analyzed data of patients with MBC obtained from the nationwide Flatiron Health database, an electronic health record-derived, deidentified database with data from community and academic practices across the US from 2011 to 2021. Participants included women aged at least 18 years diagnosed with MBC, who had at least 6 months of follow-up data, known hormone receptor (HR) and human epidermal growth factor receptor 2 (ERBB2) receptor status, and at least 1 documented line of therapy. Patients with documented receipt of clinical study drugs were excluded. Data were analyzed from June 2021 to May 2022.

MAIN OUTCOMES AND MEASURES

Outcomes of interest were frequency of different drug regimens received as a line of therapy by subtype for the first 5 lines and mean medical costs of documented anticancer treatment and supportive care drugs per patient by MBC subtype and years since metastatic diagnosis, indexed to 2021 US dollars.

RESULTS

Among 15 215 patients (10 171 patients [66.85%] with HR-positive and ERBB2-negative MBC; 2785 patients [18.30%] with HR-positive and ERBB2-positive MBC; 802 patients [5.27%] with HR-negative and ERBB2-positive MBC; 1457 patients [9.58%] with triple-negative breast cancer [TNBC]) who met eligibility criteria, 1777 (11.68%) were African American, 363 (2.39%) were Asian, and 9800 (64.41%) were White; the median (range) age was 64 (21-84) years. The mean total per-patient treatment and supportive care drug cost using publicly available Medicare prices was $334 812 for patients with HR-positive and ERBB2-positive MBC, $284 609 for patients with HR-negative and ERBB2-positive MBC, $104 774 for patients with HR-positive and ERBB2-negative MBC, and $54 355 for patients with TNBC. From 2011 to 2019 (most recent complete year 1 data are for patients diagnosed in 2019), annual costs in year 1 increased from $12 986 to $80 563 for ERBB2-negative and HR-positive MBC, $99 997 to $156 712 for ERBB2-positive and HR-positive MBC, and $31 397 to $53 775 for TNBC.

CONCLUSIONS AND RELEVANCE

This economic evaluation found that drug costs related to MBC treatment increased between 2011 and 2021 and differed by tumor subtype. These findings suggest the growing financial burden of MBC treatment in the US and highlights the importance of performing more accurate cost-effectiveness analysis of novel adjuvant therapies that aim to reduce metastatic recurrence rates for early-stage breast cancer.

Hypofractionated versus conventional intensity-modulated radiation irradiation (HARVEST-adjuvant): study protocol for a randomised non-inferior multicentre phase III trial

INTRODUCTION

Short course regimen has become the major trend in the field of adjuvant radiotherapy for patients with breast cancer. Hypofractionated radiotherapy (HF-RT) regimen of 40-42.5 Gy in 15-16 fractions has been established as a preferred option for whole breast irradiation. However, few evidences of hypofractionated regional nodal irradiation (RNI), especially involving internal mammary nodes (IMNs), could be available during the era of intensity-modulated radiation therapy (IMRT). Against this background, we design this trial to explore the hypothesis that HF-RT regimen involving RNI (including infraclavicular, supraclavicular nodes and IMNs) will be non-inferior to a standard schedule by using IMRT technique.

METHODS AND ANALYSIS

This is an open-label randomised, non-inferior, multicentre phase III trial. Patients with breast cancer with an indication for RNI after breast conserving surgery or mastectomy are randomised at a ratio of 1:1 into the following two groups: hypofractionated regimen of 2.67 Gy for 16 fractions or conventional regimen of 2 Gy for 25 fractions. The dose was prescribed to ipsilateral chest wall or whole breast and RNI (including infraclavicular, supraclavicular nodes and IMNs, lower axilla if indicated). The trial plans to enrol a total of 801 patients and all patients will be treated using IMRT technique. The primary endpoint is 5-year locoregional recurrence. The secondary endpoints include 5-year distant metastasis free survival, invasive recurrence-free survival, overall survival, accumulative acute radiation-induced toxicity and accumulative late radiation-induced toxicity, cosmetic outcomes and quality of life.

ETHICS AND DISSEMINATION

The study has been approved by the Ethical Committee of Ruijin Hospital affiliated to Shanghai Jiao Tong University School of Medicine (version 2018-95-3) and approvals from ethical committee of each participating centre have also been obtained. Research findings will be submitted for publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03829553.

Prognosis comparison between intraoperative radiotherapy and whole-breast external beam radiotherapy for T1–2 stage breast cancer without lymph node metastasis treated with breast-conserving surgery: A case–control study after propensity score matching

Background

External beam radiotherapy (EBRT), an adjuvant to breast-conserving surgery (BCS), requires a long treatment period, is costly, and is associated with numerous complications. Large sample studies with long follow-up periods are lacking regarding whether intraoperative radiotherapy (IORT), an emerging radiotherapy modality, can replace EBRT for patients with T1–2 early stage breast cancer without lymph node metastasis treated with BCS.

Methods

We identified 270,842 patients with T1-2N0M0 breast cancer from 2000 to 2018 in the Surveillance, Epidemiology, and End Results (SEER) database. A total of 10,992 patients were matched by propensity score matching (PSM). According to the radiotherapy method, the patients were divided into the IORT and EBRT groups. Overall survival (OS) and breast cancer-specific survival (BCSS) rates were analyzed and compared between the IORT and EBRT groups by Kaplan–Meier analysis. Bilateral P < 0.05 was considered to indicate significance.

Results

After PSM, the survival analysis showed no significant differences in OS or BCSS rates between the IORT and EBRT groups. In the subgroup analysis, the IORT population diagnosed from 2010 to 2013 (HRs = 0.675, 95% CI 0.467–0.976, P = 0.037) or with T2 stage (HRs = 0.449, 95% CI 0.261–0.772, P = 0.004) had better OS rates, but in the overall population, the OS and BCSS rates were better in patients with T1 stage than in patients with T2 stage (P < 0.0001), and the proportion of chemotherapy was significantly higher in T2 stage than in T1 stage. Patients who had EBRT with unknown estrogen receptor had better OS rates (HRs = 3.392, 95% CI 1.368–8.407, P = 0.008). In addition, the IORT group had better BCSS rates for married (HRs = 0.403, 95% CI 0.184–0.881, P = 0.023), grade III (HRs = 0.405, 95% CI 0.173–0.952, P = 0.038), and chemotherapy-receiving (HRs = 0.327, 95% CI 0.116–0.917, P = 0.034) patients with breast cancer compared to the EBRT group.

Conclusion

Intraoperative radiotherapy results of non-inferior OS and BCSS rates, compared to those of EBRT, in patients with early stage breast cancer without lymph node metastasis treated with BCS, and IORT may provide substantial benefits to patients as an effective alternative to standard treatment. This finding provides new insights into radiotherapy strategies for early stage breast cancer.

Molecular Subtypes As Emerging Predictors of Clinicopathological Response to Neoadjuvant Chemotherapy (NACT) in Locally Advanced Breast Cancer (LABC): A Single-Centre Experience in Western India

Introduction: Locally advanced breast cancer (LABC) is a subset of breast cancer characterized by the most advanced breast tumours in the absence of distant metastasis. Treatment of LABC has evolved from a single modality treatment to multimodality management. Neoadjuvant chemotherapy (NACT) is increasingly being used to treat patients with LABC. This study assessed tumour response after NACT using clinical changes, Response Evaluation Criteria in Solid Tumors (RECIST) criteria and pathological report.

Methodology: This study was a prospective as well as retrospective observational study carried out in the department of general surgery, Dr. Sampurnanand Medical College, Jodhpur. All the patients admitted with stage III (IIIA, IIIB, IIIC) were included in the study after obtaining approval from the institutional ethical committee. Clinical response was assessed by RECIST criteria (clinical complete response (cCR), clinical partial response (cPR), clinical progressive disease (cPD), and clinical stable disease (cSD)) and pathological response by histopathological report (pCR). Response of various molecular subtypes was noted.

Results: Among 31 patients included in the study, cCR observed in 22.58% cases, cPR observed in 61.29% cases while cPD and cSD seen in 3.22% and 12.90% cases, respectively. Pathological complete response (pCR) observed in 19.35% cases. Favourable response seen with human epidermal growth factor receptor 2 (HER2) overexpression (cCR = 50%, pCR = 37.50%) followed by triple negative (cCR = 25%, pCR = 25%) molecular subtypes.

Conclusions: It can be concluded that molecular subtype determination helps in deciding treatment protocol in patients with LABC with HER2 overexpression and triple-negative breast cancers having a better clinicopathological response to NACT than luminal subtypes. NACT results in downstaging of tumours, thus, help in achieving surgically clear margins and elimination of micrometastases which decreases the recurrence rates and morbidity/mortality of patients.

Application of Fluorescence Dye in Combination with Methylene Blue for Axillary Reverse Mapping in Patients with Modified Radical Mastectomy for Breast Cancer

Background. Axillary reverse mapping (ARM) is a novel intraoperative technique developed in recent years. This study was aimed at determining the effect of combined use of fluorescence dye and methylene blue, as well as its feasibility of ARM in patients with breast cancers who undergo modified radical mastectomy. Method. From January 2016 to June 2017, 46 patients with primary breast cancer at stage I-IV (Tis-T3, N0-N3, and M0) who received modified radical mastectomy were enrolled in this study. The exclusion criteria included preoperative radiotherapy/chemotherapy or bilateral disease. Patients were divided into 2 groups: methylene blue group (22 patients, 47.8%) and methylene blue+indocyanine green (ICG) group (24 patients, 52.2%). ARM was performed before surgery. Results. The overall visualization rate of ARM nodes was 80.4% (37/46). The visualization rate was significantly increased in methylene blue+ICG group (91.67%, 22/24) than that in methylene blue group (63.64%, 14/22) ( $P=0.032$ ). There was a statistical difference of visualization rate between clinical groups of N0-N1 and N3-N4 ( $t=2.431$ , $P=0.19<0.05$ ). Although there was no significant difference found in the total drainage volume and arm perimeter of patients between the two groups ( $P>0.05$ ), the harden diameter of the injection site in methylene blue+ICG group was significantly longer than that in methylene blue group ( $P<0.05$ ). Among the 44 patients with different molecular profiling of breast cancer, there was no significant difference of visualization rate of ARM nodes in luminal A group (100%,5/5), luminal B group (75.0%, 18/24, $P=0.21$ ), HER2 group (75.0%, 6/8, $P=0.22$ ), and basal-like group (85.7%, 6/7, $P=0.37$ ). Conclusions. ARM using methylene blue+ICG presented greater identification rate than that with methylene blue alone, especially in patients with more invasive breast cancer. Our finding offers support for the improvement of ARM in future breast cancer management.

Prognostic Factors and a Nomogram Predicting Survival in Patients with Breast Ductal Carcinoma in situ with Microinvasion: A Population-Based Study

Purpose

Ductal carcinoma in situ with microinvasion (DCISM) can be challenging to balance the risks of overtreatment versus undertreatment. We aim to identify prognostic factors in patients with DCISM and construct a nomogram to predict breast cancer-specific survival (BCSS).

Materials and Methods

A retrospective cohort study of women diagnosed with DCISM from 1988 to 2015 who were identified in the Surveillance, Epidemiology and End Results database. Clinical variables and tumor characteristics were evaluated, and Cox proportional-hazards regression was performed. A nomogram was constructed from the multivariate logistic regression to combine all the prognostic factors to predict the prognosis of DCISM patients at 5 years, 10 years, and 15 years.

Results

We identified 5438 total eligible breast cancer patients with a median and max survival time of 78 and 227 months, respectively. Here, patients with poorer survival outcomes were those diagnosed between 1988 and 2001, African-American race, under 40 years of age, higher tumor N stage, progesterone receptor-negative tumor, and received no surgery. The nomogram was constructed by the seven variables and passed the calibration and validation steps. The area under the receiver operating characteristic (ROC) curve (AUC) of both the training set and the validating set (5-year AUC: 0.77 and 0.88, 10-year AUC: 0.75 and 0.73, 15-year AUC: 0.72 and 0.65). Receiving chemotherapy was associated with a better BCSS (hazard ratio, HR=0.45, 95% confidence interval, 95% CI = 0.23–0.89), especially in patients with estrogen receptor (ER) negative, progesterone receptor (PR) negative (HR = 0.35, 95% CI = 0.13–0.97) and ER+PR-/ER-PR+ DCISM (HR = 0.07, 95% CI = 0.01–0.59).

Conclusion

Our current study is the first to construct nomograms of patients with DCISM which could help physicians identify breast cancer patients that more likely to benefit from more intensive treatment and follow-up. Chemotherapy might benefit patients with ER-PR- and ER+PR-/ER-PR+ DCISM.

Does contrast-enhanced mammography have an impact on the detection of cancer in patients with risk of developing breast cancer?

Background

Contrast-enhanced mammography (CEM) has been discovered to be more sensitive and specific than two-dimensional full-field digital mammography (FFDM) in both screening and diagnostic settings. The aim of the study was to assess the additive role of CEM in the detection and characterization of breast lesions in women with increased risk of developing breast cancer. This prospective study included 283 female patients with increased risk of developing breast cancer (i.e., positive family history of breast cancer, personal history of breast cancer, and heterogeneously dense mammary parenchyma) coming for either screening (n = 127/283 (49.1%)) or diagnostic (n = 156/283 (55.1%)) purpose. All patients had FFDM and CEM done, and the findings were evaluated independently; final Breast Imaging Reporting And Data System (BIRADS) classification was given for each modality. Results were then compared with histopathology or ultrasound findings with routine follow-up for normal and typically benign findings.

Results

In this study, 283 women with mean age of 48 were enrolled. Among the studied cases regardless to a specific risk factor, 15/283 (5.3%) were diagnosed as normal, 13/283 (4.6%) as inflammatory lesions, 72/283(25.4%) as benign lesions, 6/283 (2.1%) as benign precancerous lesions, and 177/283 (62.5%) as malignant. The overall sensitivity and specificity of the CEM were 92.7 and 71.43 %, respectively, while FFDM were 80.90 and 59.05%, respectively.

Conclusion

Contrast-enhanced mammography is a valuable screening and diagnostic imaging modality in patients with increased risk of developing breast cancer with diagnostic indices higher than mammography resulting in a significantly higher cancer detection rate.

Assessment of Axillary Lymph Nodes for Metastasis on Ultrasound Using Artificial Intelligence

The purpose of this study was to evaluate an artificial intelligence (AI) system for the classification of axillary lymph nodes on ultrasound compared to radiologists. Ultrasound images of 317 axillary lymph nodes from patients referred for ultrasound guided fine needle aspiration or core needle biopsy and corresponding pathology findings were collected. Lymph nodes were classified into benign and malignant groups with histopathological result serving as the reference. Google Cloud AutoML Vision (Mountain View, CA) was used for AI image classification. Three experienced radiologists also classified the images and gave a level of suspicion score (1-5). To test the accuracy of AI, an external testing dataset of 64 images from 64 independent patients was evaluated by three AI models and the three readers. The diagnostic performance of AI and the humans were then quantified using receiver operating characteristics curves. In the complete set of 317 images, AutoML achieved a sensitivity of 77.1%, positive predictive value (PPV) of 77.1%, and an area under the precision recall curve of 0.78, while the three radiologists showed a sensitivity of 87.8% ± 8.5%, specificity of 50.3% ± 16.4%, PPV of 61.1% ± 5.4%, negative predictive value (NPV) of 84.1% ± 6.6%, and accuracy of 67.7% ± 5.7%. In the three external independent test sets, AI and human readers achieved sensitivity of 74.0% ± 0.14% versus 89.9% ± 0.06% (p = .25), specificity of 64.4% ± 0.11% versus 50.1 ± 0.20% (p = .22), PPV of 68.3% ± 0.04% versus 65.4 ± 0.07% (p = .50), NPV of 72.6% ± 0.11% versus 82.1% ± 0.08% (p = .33), and accuracy of 69.5% ± 0.06% versus 70.1% ± 0.07% (p = .90), respectively. These preliminary results indicate AI has comparable performance to trained radiologists and could be used to predict the presence of metastasis in ultrasound images of axillary lymph nodes.

Clinical trial representativeness and treatment intensity in a real-world sample of women with early stage breast cancer

PURPOSE

The extent to which evidence-based treatments are applied to populations not well represented in early stage breast cancer (EBC) trials remains unknown. This study evaluated treatment intensity for patients traditionally well represented, underrepresented, and unrepresented in clinical trials.

METHODS

This retrospective cohort study used real-world data to evaluate the intensity (high or low) of EBC chemotherapy by patient characteristics (age, race and ethnicity, presence of comorbidity) denoting clinical trial representation status (well represented, underrepresented, unrepresented) for patients diagnosed from 2011 to 2020. Odds ratios (OR) from a logistic regression model was used to evaluate the association between receipt of high-intensity chemotherapy and clinical trial representation status characteristics adjusting for cancer stage and subtype.

RESULTS

Of 970 patients with EBC, 41% were characterized as well represented, 45% as underrepresented, and 13% as unrepresented in clinical trials. In adjusted models, patients aged ≥ 70 versus 45-69 had lower odds of receiving a high-intensity treatment (OR 0.40, 95% CI 0.26-0.60), while those aged < 45 versus 45-69 had higher odds of receiving high-intensity treatment (OR 1.82, 95% CI 1.10-3.01). In predicted estimates, the proportion of patients receiving a high-intensity treatment was 87% for patients aged < 45, 79% for patients aged 45-69, and 60% for patients aged ≥ 70.

CONCLUSION

59% of the EBC population is not well represented in clinical trials. Age was associated with differential treatment intensity. Widening clinical trial eligibility criteria should be considered to better understand survival outcomes, toxicity effects, and ultimately make evidence-based treatment decisions using a more diverse sample.

Transarterial chemoembolization as a part of multi-modality treatment with drug-eluting beads for locally advanced breast cancer: A case report

Locally advanced breast cancer (LABC) is generally treated with combined-modality therapy including systemic chemotherapy, surgery, radiotherapy, and targeted therapy due to its nature of rapid onset of metastatic disease and poor prognosis. In this case report, we present a 61-year-old female who suffered from a huge protruding breast mass (16.2cm) with superficial ulcerative wound noted for three months. LABC was diagnosed via core needle biopsy and PET-CT examination. Initially, she received combined systemic chemotherapy, hormone therapy and radiation therapy; however, severe necrosis caused rupture in part of the breast mass and extensive wound discharge resulting in difficulty in wound care and prolonged disease course. Trans-arterial chemoembolization with drug-eluting beads (DEB-TACE) was applied as a part of combined-modality therapy for shortening the time before surgery. HepaSphere (as one of the DEB) loaded with high dose of epirubicin (total 80mg) was infused intra-arterially due to the nature of slow-releasing effect and longer duration of ischemic effect. Shortly after DEB-TACE following in about 40 days, surgery was smoothly performed. Post-operative adjuvant target therapy and adjuvant chemotherapy with taxane were administered. There was no evidence of local recurrence or distal metastases after 9 months of follow-up. It is suggested that performing DEB-TACE prior to surgery becomes a part of multimodality treatment of LABC to achieve better local control, better wound care and shortened treatment course.

Nipple-Sparing Mastectomy versus Skin-Sparing Mastectomy: Does Saving the Nipple Impact Short- and Long-Term Patient Satisfaction?

BACKGROUND

Nipple-sparing mastectomy (NSM) is an oncologically safe alternative to skin-sparing mastectomy (SSM). This study evaluated whether NSM patients were more satisfied than SSM patients in short- and long-term follow-up.

METHODS

Women who underwent NSM or SSM between 2009 and 2019 completed a postoperative BREAST-Q survey at least 1 year after surgery and patient characteristics were compared. Patient satisfaction at 1-5 years and 6-10 years after NSM and SSM were analyzed.

RESULTS

Overall, 431 patients were included; 247 had NSM and 184 had SSM 1-10 years prior to BREAST-Q survey completion. SSM patients were older, had higher body mass index (BMI), larger breast weight, and more hypertension than NSM patients, but oncologic treatments were similar between groups. BREAST-Q Psychosocial Well-Being and Sexual Well-Being scores were significantly higher in NSM patients compared with SSM patients in the 1-5 years cohort; however, scores attenuated in the 6-10 years cohort. Satisfaction with breasts was nearly significantly higher in NSM patients compared with SSM patients in the 1-5 years cohort (p = 0.056), but no different in the 6-10 years cohort. Receipt of adjuvant chemotherapy, receipt of postmastectomy radiation therapy, and BMI ≥30 were independent risk factors for dissatisfaction with breasts.

CONCLUSIONS

Women who are not candidates for NSM should be reassured that long-term qualify of life is not significantly different between SSM and NSM. Dissatisfaction with reconstructed breasts is linked with other factors (besides the nipple), which patients should be made aware of at the time of surgical decision making.

B-Sure: a randomized pilot trial of an interactive web-based decision support aid versus usual care in average-risk breast cancer patients considering contralateral prophylactic mastectomy

The use of contralateral prophylactic mastectomy (CPM) is increasing among breast cancer patients who are at average or "sporadic" risk for contralateral breast cancer. Because CPM provides no survival benefit for these patients, it is not medically recommended for them. Decision support aids may facilitate more informed, higher quality CPM decision. The purpose of this study was to evaluate the feasibility and acceptability of B-Sure, an online decision support aid to facilitate informed decisions regarding CPM, and to compare the impact of B-Sure in increasing CPM knowledge, reducing decisional conflict, and increasing preparedness to make the CPM decision among breast cancer patients at sporadic risk who are considering CPM. Ninety-three patients with unilateral, nonhereditary breast cancer considering CPM completed a baseline survey, were randomized to receive B-Sure or Usual care, and completed a 4-week follow-up survey assessing decisional conflict, preparedness to make the CPM decision, and CPM knowledge as well as self-efficacy, perceived risk, worry, CPM motivations, and the surgical decision. Study participation was high. B-Sure was viewed by almost 80% of the participants and was evaluated positively. At follow-up, patients assigned to B-Sure reported significantly higher clarity regarding the personal values relevant to the CPM decision and higher knowledge about CPM. B-Sure had smaller effects on other aspects of decisional conflict. B-Sure improved CPM knowledge and reduced decisional conflict. Patients considering CPM may benefit from an online decision support aid, but may be sensitive to approaches that they perceive as biased against CPM.

Single-Cell Transcriptome Analysis Reveals the M2 Macrophages and Exhausted T Cells and Intratumoral Heterogeneity in Triple-Negative Breast Cancer

BACKGROUND

Triple-negative breast cancer (TNBC) is a highly heterogeneous and invasive malignancy that is characterized by high recurrence and mortality rates as well as extremely poor prognosis.

OBJECTIVE

This study aimed to analyze T cells and macrophages in the tumor microenvironment with the aim of identifying targets with therapeutic potential.

METHOD

Single-cell sequencing data of TNBC patients from the GSE118389 dataset were analyzed to examine the immune environment and intratumoral heterogeneity of TNBC patients.

RESULT

Polarized alternatively activated macrophages (M2) and exhausted CD8+ T cells were identified in TNBC patients. Immunosuppressive checkpoint analysis revealed that levels of lymphocyte-activation gene 3 (LAG3) and T cell immunoglobulin and mucin domain-containing protein 3 (TIM-3) of exhausted T cells were significantly higher than levels of programmed cell death protein 1 (PD-1) and cytotoxic T-lymphocyte-associated protein 4 (CTLA-4). This indicates that these markers are potential immunotherapy targets. Furthermore, analysis of significantly altered immune cell markers showed that several markers are associated with the prognosis of TNBC.

CONCLUSION

Overall, these findings demonstrate inter-tissue heterogeneity of TNBC and provide novel therapeutic targets for the treatment of TNBC.

Simultaneous PET/MRI in the Evaluation of Breast and Prostate Cancer Using Combined Na[18F] F and [18F]FDG: a Focus on Skeletal Lesions

PURPOSE

The purpose of this study is to prospectively evaluate the performance of sodium ¹⁸F]fluoride (Na[¹⁸F]F)/2-deoxy-2-[¹⁸F]fluoro-D-glucose ([¹⁸F]FDG) simultaneous time-of-flight enabled positron emission tomography (PET)/magnetic resonance imaging (MRI) for the detection of skeletal metastases in selected patients with advanced breast and prostate cancers.

PROCEDURE

The institutional review board approved this HIPAA-compliant protocol. Written informed consent was obtained from each patient. A total of 74 patients (23 women and 51 men with breast and prostate cancer, respectively) referred for standard-of-care whole-body bone scintigraphy (WBBS) were enrolled in this prospective study. All patients underwent a [^99mTc]methyldiphosphonate ([^99mTc]MDP) WBBS followed by Na[¹⁸F]F/[¹⁸F]FDG PET/MRI. Lesions detected by each imaging modality were tabulated and a lesion-based and patient-based analysis was conducted.

RESULTS

On a patient-based analysis, [^99mTc]MDP WBBS identified skeletal lesions in 37 patients and PET/MRI in 45 patients. On a lesion-based analysis, WBBS identified a total of 81 skeletal lesions, whereas PET/MRI identified 140 lesions. Additionally, PET/MRI showed extra-skeletal lesions in 19 patients, including lymph nodes (16), prostate (4) lung (3), and liver (2) lesions.

CONCLUSIONS

The ability of Na[¹⁸F]F/[¹⁸F]FDG PET/MRI to identify more skeletal lesions than ^99mTc-MDP WBBS and to additionally identify extra-skeletal disease may be beneficial for patient care and represent an alternative to the single modalities performed separately. Na[¹⁸F]F/[¹⁸F]FDG PET/MRI is a promising approach for evaluation of skeletal and extra-skeletal lesions in a selected population of breast and prostate cancer patients.

Impact of ESR1 Polymorphisms on Risk of Breast Cancer in the Chinese Han Population

BACKGROUND

The estrogen receptor-1 (ESR1) gene encodes estrogen receptor-α, which is a major biomarker in the development of breast cancer. This study aimed to investigate the effect of ESR1 polymorphisms on breast cancer in Chinese Han women.

MATERIALS AND METHODS

We genotyped 4 candidate single nucleotide polymorphisms (SNPs) in ESR1 among 503 patients with breast cancer and 503 healthy people using the Agena MassARRAY platform. The association between ESR1 polymorphisms and breast cancer risk was evaluated using odds ratios (ORs) and 95% confidence intervals (95% CIs) under 4 genetic models. The HaploReg v4.1 and GEPIA database were used for SNP functional annotation and ESR1 expression analysis, respectively.

RESULTS

The T allele of rs9383938 in ESR1 was significantly associated with an increased breast cancer risk (OR, 1.26; 95% CI, 1.05-1.50; P = .013). In genetic models, rs9383938 increased breast cancer risk in the codominant model (OR, 1.54; 95% CI, 1.07-2.22; P = .021), the dominant model (OR, 1.31; 95% CI, 1.01-1.68; P = .040), and the additive model (OR, 1.24; 95% CI, 1.04-1.48; P = .017). Stratification analysis showed that rs9383938 and rs2228480 raised the breast cancer susceptibility in individuals aged younger than 52 years old. Rs1801132 of ESR1 was significantly associated with the status of estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2 in the allele model and genetic models (P < .05).

CONCLUSIONS

This study demonstrated that ESR1 polymorphisms might influence breast cancer susceptibility in the Chinese Han population. Further mechanism studies are needed to confirm the contribution of ESR1.

Silencing SALL-4 Gene by Transfecting Small Interfering RNA with Targeted Aminoglycoside-Carboxyalkyl Polyethylenimine Nano-Polyplexes Reduced Migration of MCF-7 Breast Cancer Cells

Background:

The application of non-viral systems for delivering genes to cells is becoming a very interesting issue, especially in the treatment of neoplasms such as Breast Cancer (BC). Polymer-based non-viral systems are safe and feasible gene carriers to be used in targeted cancer therapy. SALL4 gene encodes a transcription factor and is overexpressed in some cancers.

Methods:

In this study, carboxyalkylated-PEI25 (25 kDa) was used to deliver plasmids expressing SALL4-siRNA into MCF-7 cells. DLS and AFM were applied to determine the size of nanoparticles. The MTT method was used to assess cytotoxicity, and the efficiency of transfection was confirmed both qualitatively and quantitatively. Finally, the effect of silencing SALL4 was investigated on the migration of MCF7 cells using the scratch test.

Results:

The results showed that transferring the SALL4-siRNA using PEI25G10C50 reduced the expression of the corresponding transcription factor by 14 folds which attenuated the migration of MCF-7 cells by 58%.

Conclusion:

In conclusion, PEI25G10C50 can serve as an effective gene delivery system for treating BC by targeting SALL-4.

Efficacy and safety analysis of paclitaxel, docetaxel and liposomal paclitaxel after neoadjuvant therapy in breast cancer

BACKGROUND AND PURPOSE

Paclitaxel-based regimens are widely used in the neoadjuvant therapy (NAT) of breast cancer. The purpose is to analysis the efficacy and adverse events (AEs) among common paclitaxel (PTX), docetaxel and liposomal paclitaxel. At the same time, we want to analysis the axillary nodal pathologic complete response (apCR) after NAT among the three groups.

METHODS

From April 2014 to 2020, 647 breast cancer patients underwent operation after NAT were included in this study. Patients received full course of anthracycline- and paclitaxel-based chemotherapy before surgery. The paclitaxel-based regimens included PTX, docetaxel and liposomal paclitaxel. The therapy efficacy and AEs of the three groups were evaluated. At the same time, the apCR was also analyzed.

RESULTS

In general, 30.6% (198/647) of patients achieved breast pathologic complete response (bpCR), which was 28.6%, 28.3% and 39.3% among PTX, docetaxel and liposomal paclitaxel group, respectively (p = 0.067). The total pathologic complete response (tpCR) (achieving both bpCR and apCR) was 21.6% (140/647). The tpCR was 13.3%, 19.4% and 34.4% among PTX, docetaxel and liposomal paclitaxel group, respectively (p = 0.026). The multivariate logistic analysis result showed that clinical tumor stage and molecular subtype were significantly associated with tpCR (all p < 0.05). Among 592 clinical positive patients (cN₊), the apCR was 39.0% (231/592). The multivariate logistic analysis showed that paclitaxel- based regimens and molecular subtype were indicated as independent predictors for apCR of NAT. The apCR was significantly higher in liposomal paclitaxel group (63.5%) than in PTX (24.6%) and docetaxel group (34.8%) (p < 0.001). The subgroup analysis among different molecular subtypes found that in triple negative (TN) and HER-2 positive (HER2+) subgroup, the apCR in liposomal paclitaxel group was significantly higher than those in PTX and docetaxel group (all p < 0.05). But no significant result was found in the subgroup analysis in hormone receptor positive/HER-2 negative subgroup (p = 0.050). Safety analysis indicated that the incidence of neutropenia (grade III-IV) and peripheral neurotoxicity (grade I-II) was significantly lower in the liposomal paclitaxel group than in the PTX and docetaxel group. The incidence of oral mucositis, anaphylaxis and palmar-plantar erythrodysesthesia syndrome was also much lower in liposomal paclitaxel than other two groups (all p < 0.05). And there was no significant difference in other AEs among the three groups (all p > 0.05).

CONCLUSION

Liposome paclitaxel had similar tumor suppressor effect compared with PTX and docetaxel in NAT setting. Moreover, it had a better axillary lymph node (ALN) response after NAT than PTX and docetaxel. These patients who received liposome paclitaxel had more chance to avoid ALN dissection after NAT. At the same time, the application of liposome enables liposome paclitaxel could significantly reduce AEs caused by chemotherapy. Therefore, we suggested the application of liposome paclitaxel in the NAT setting, especially for cN₊ patients with TN and HER2 + disease.

Effect of local surgery on outcomes of stage IV breast cancer

Metastatic breast cancer (MBC), including de novo stage IV, is regarded as being incurable and the mainstay of clinical management is systemic therapy. Traditionally, locoregional surgery is performed only for local control, such as to prevent ulceration and bleeding. In recent years, however, both retrospective and prospective studies have demonstrated the prognostic efficacy of primary surgery for de novo stage IV patients. Therefore, we conducted a meta-analysis to evaluate whether surgical therapy contributes to overall survival (OS) extension. We searched for clinical trials published in electronic databases (PubMed, Embase, and the Cochrane databases) and performed a meta-analysis of the data collected. There were five prospective randomized controlled phase III trials (RCTs). The results of three have been reported. According to our meta-analysis of these RCTs, primary surgery for de novo stage IV breast cancer patients significantly improves OS. However, the Tata trial showed that systemic therapy does not achieve a sufficient effect. Another trial, conducted in Turkey, had statistical shortcomings and patient randomization was not adequately performed The ABCSG (Austrian Breast and Colorectal Cancer Study Group) trial had too few subjects. Meta-analysis of 12 retrospective studies showed that patients with stage IV breast cancer receiving surgery as the initial treatment experienced longer OS (HR: 0.65, P<0.00001). Based on our meta-analysis of three reported RCTs, surgery as the primary treatment does not significantly impact the outcomes of de novo stage IV breast cancer patients. However, these trials had limitations. We await the results of the remaining two ongoing RCTs (ECOG 2108 and JCOG 1017). These trials are anticipated to resolve current controversies and provide many eagerly awaited answers.

Nonliposuction Endoscopic Sentinel Lymph Node Biopsy Through the Periareolar Incision

Background. Sentinel lymph node biopsy (SLNB) has been an alternative to axillary lymph node dissection as a standard procedure for breast cancer patients with clinically negative lymph nodes. Endoscopic technique has been developed for over 20 years but remains to be mastered by a slice of surgeons. Suction and squeezing in the liposuction endoscopic procedures may increase risk of local recurrence and metastasis. In this study, we present our method of SLNB procedure through the periareolar incision which improves the shape of the breast-conserving surgery. Patients and Procedures. Twenty-eight breast cancer patients with clinically negative lymph nodes received this procedure. Methylene blue dye and technetium-99m sulfur colloid were used to be the tracker of sentinel lymph nodes (SLNs). Periareolar incision was the main surgical technique. The STORZ HD endoscopic system and some special instruments were used during the operation. Results. SLNs can be accurately located and biopsied under an endoscope without additional incisions. The SLNs detection rate, sensitivity, and false-negative rate are 88%, 80%, and 11.1%, respectively. And, the complications such as paresthesia and upper limb lymphedema are similar compared with traditional breast-conserving surgery (10.7% vs 9.8% and 7.1% vs 7.8%). Conclusion. Endoscopic technique can be used to accurately assess the status of SLNs in patients with breast cancer. Nonliposuction endoscopic breast-conserving surgery is one of the safe and alternative surgical procedures for early breast cancer.

Oncogene PRR14 promotes breast cancer through activation of PI3K signal pathway and inhibition of CHEK2 pathway

Nuclear envelope component PRR14 has been detected to be upregulated in varieties of cancers, especially in breast cancer. But its role in breast carcinogenesis is poorly understood. In this study, we show PRR14 contributes to breast carcinogenesis mainly through overexpression, which derives from elevated transcription and gene amplification. Increased PRR14 expression promotes breast cancer cell proliferation and tumor formation. Biochemical analysis reveals, in addition to previously reported activation of PI3-kinase/Akt/mTOR pathway, PRR14 overexpression regulates cell cycle in breast cancer by inhibiting CHEK2’s activation, followed with the deregulation of DNA damage pathway. In correspondence, CHEK2 and PRR14 show opposite impact on breast cancer patients receiving chemotherapy. Collectively, our study is the first to document the oncogenetic role of PRR14 in breast cancer, which protects cells from apoptosis and stimulates proliferation by activating the PI3-kinase/Akt/mTOR pathway and inhibiting the CHEK2 pathway. Both of these pathways are of great influence in breast cancer and PRR14 appears to be their novel interacting node, which renders patients more resistance to chemotherapy and provides a potential therapeutic target in breast cancer.

Comparison between AJCC 8th prognostic stage and UICC anatomical stage in patients with primary breast cancer: a single institutional retrospective study

BACKGROUND

The 8th edition American Joint Committee on Cancer (AJCC) proposed a prognostic stage (PS), which included not only anatomical factors, but also biological factors. We aimed to investigate the clinicopathological significance of the PS and to compare PS and anatomical stage (AS) that has been established by the Union for International Cancer Control (UICC).

METHODS

Between 2002 and 2017, 800 patients were included in the study. Patients were classified using pathological UICC AS and pathological AJCC PS. The usefulness of PS in comparison with AS was validated using the Akaike information criterion (AIC) and Harrell concordance index (C-index).

RESULTS

A total of 401 (50.1%) patients had pathological AS I, 324 (40.5%) had AS II, and 75 (9.4%) had AS III. Meanwhile, 535 (66.8%) had pathological PS I, 163 (20.4%) had PS II, and 102 (12.8%) had PS III. The number of AS II cases was 1.99-fold higher than that of PS II cases. For each stage, these survival curves were almost similar between AS and PS classification. Therefore, many patients to be classified into stage I and stage III were included in AS II group, while many patients to be classified into stage II were included in AS I group. To trichotomize the survival groups, PS appeared to be more specific than AS, and AIC and C-index confirmed the speculation.

CONCLUSION

For the prognostication of primary breast cancer patients, AJCC PS appeared to be able to stratify the cases more appropriately than UICC AS.

Prolonged Opioid Use After Surgery for Early-Stage Breast Cancer

INTRODUCTION

This study examined the patterns of prolonged opioid use and the factors associated with higher risk of prolonged opioid use among opioid-naïve working-age patients with early-stage breast cancer.

METHODS

Using MarketScan data, the study identified 23,440 opioid-naïve patients who received surgery for breast cancer between January 2000 and December 2014 and filled at least one opioid prescription attributable to surgery. Prolonged opioid use was defined as one or more prescriptions for opioids within 90 to 180 days after surgery and defined extra-prolonged opioid use as one or more opioid prescriptions between 181 and 365 days after surgery. Multivariable logistic regressions were performed to ascertain factors associated with prolonged and extra-prolonged use of opioids.

FINDINGS

Of the 23,440 patients, 4,233 (18%) had prolonged opioid use, and 2,052 (9%) had extra-prolonged opioid use. Patients who received mastectomy plus reconstruction had the highest rate of prolonged opioid use (38%) followed by mastectomy alone (15%). A multivariable logistic regression confirmed that patients with mastectomy and reconstruction had the highest odds ratio of prolonged opioid use compared to lumpectomy and whole breast irradiation (adjusted odds ratio, 5.6; 95% confidence interval, 5.1-6.1). Mean daily opioid dose was consistently high without any obvious dosage reduction among patients with opioid use.

INTERPRETATION

This large observational study showed a high rate of prolonged opioid use among patients who received surgery for early-stage breast cancer and found significant difference in prolonged opioid use by treatment type.

IMPLICATIONS FOR PRACTICE

This large observational study found a high rate of prolonged opioid use among working-age patients with early-stage breast cancer who received curative surgery, especially among patients who received mastectomy. Among patients with opioid use, the mean daily opioid dose was consistently high without any obvious dosage tapering. This study highlights the need to emphasize appropriate opioid therapy and potential dosage reduction or discontinuation among patients with early-stage breast cancer who received surgical interventions.

Is it ductal carcinoma in situ with microinvasion or "Ductogenesis"? The role of myoepithelial cell markers

Mammary myoepithelial cells have been under-recognized for many years since they were considered less important in breast cancer tumorigenesis compared to luminal epithelial cells. However, in recent years with advances in genomics, cell biology, and research in breast cancer microenvironment, more emphasis has been placed on better understanding of the role that myoepithelial cells play in breast cancer progression. As the result, it has been recognized that the presence or absence of myoepithelial cells play a critical role in the assessment of tumor invasion in diagnostic breast pathology. In addition, advances in screening mammography and breast imaging has resulted in increased detection of ductal carcinoma in situ and consequently more diagnosis of ductal carcinoma in situ with microinvasion. In the present review, we discuss the characteristics of myoepithelial cells, their genomic markers and their role in the accurate diagnosis of ductal carcinoma in situ with microinvasion. We also share our experience with reporting of various morphologic features of ductal carcinoma in situ that may mimic microinvasion and introduce the term of ductogenesis.

A Randomized Parallel Controlled Phase II Trial of Recombinant Human Endostatin Added to Neoadjuvant Chemotherapy for Stage III Breast Cancer

BACKGROUND

To explore the potential advantage of preoperative anti-angiogenosis therapy, we implemented a study to evaluate the efficacy of recombinant human endostatin (EN) in combination with neoadjuvant chemotherapy in the treatment of stage III breast cancer.

PATIENTS AND METHODS

Eighty-seven patients were randomized to neoadjuvant TEC (docetaxel, epirubicin, and cyclophosphamide) or to EN+TEC, followed by surgery. The primary endpoint was the objective response rate (ORR). Secondary endpoints included pathologic complete response (pCR), relapse-free survival (RFS), overall survival (OS), and safety.

RESULTS

Patients receiving EN+TEC achieved significantly higher ORR (81.82%; 36/44) compared with those receiving TEC (58.14%; 25/43; P=0.016). There was a non-significant trend of increased pCR with EN treatment (15.91% vs. 6.98%). The median follow-up was 54 months and revealed a significantly higher RFS with EN+TEC (median, 67.3 months; 95% confidence interval [CI], 61.0-73.7 months), compared with TEC (median, 55.0 months; 95% CI, 48.3-61.7 months; P =0.014). EN+TEC also significantly improved OS (74.2 months; 95% CI, 68.9-79.6 months), compared with TEC (59.1 months; 95% CI, 52.0-66.1 months; P =0 .006). The 3- and 5-year OS rates are estimated to be 88.5% and 82.8% with EN+TEC and 76.7% and 54.4% with TEC, respectively. Cox proportional regression analyses showed that EN+TEC was associated with improved OS (hazard ratio, 0.377; 95% CI, 0.418-0.959; P =0 .041). There was no significant difference in adverse events between EN+TEC and TEC.

CONCLUSION

The combination of EN+TEC neoadjuvant chemotherapy significantly improved the ORR and OS, suggesting a benefit of adding anti-angiogenesis to standard chemotherapy in the treatment of locally advanced breast cancer.

Efficacy analysis of trastuzumab, carboplatin and docetaxel in HER-2-positive breast cancer patients

Efficacy of trastuzumab, carboplatin and docetaxel in human epidermal growth factor receptor-2 (HER-2)-positive breast cancer patients was investigated. A total of 180 HER-2-positive breast cancer patients admitted to The First People's Hospital of Yunnan Province were selected, of which 80 patients were treated with carboplatin and docetaxel and served as the control group (CG), and 100 patients were treated with trastuzumab, carboplatin and docetaxel and served as the research group (RG). Clinical efficacy, pathological efficacy, adverse reactions, inflammatory factors interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α), cellular immune indexes of T-lymphocyte subsets (CD4⁺, CD8⁺, CD4⁺/CD8⁺), and the oxidative stress indexes superoxide dismutase (SOD) and myeloperoxidase (MPO) were observed before and after treatment and were compared between both groups. Patients were followed up for 5 years, and the 5-year disease-free survival (DFS), as well as the overall survival (OS) were compared. Clinical efficacy and pathological efficacy in the RG were significantly higher than those in the CG, and the incidence rate of adverse reactions had no significant difference between the two groups. There was no significant difference in inflammatory factors, cellular immune indexes and oxidative stress indexes between the two groups before treatment. After treatment, the levels of IL-6, TNF-α, CD8⁺ and MPO in both groups were significantly reduced and were significantly lower in RG than those in CG. However, the levels of CD4⁺, CD4⁺/CD8⁺ and SOD in both groups were significantly increased after treatment and were significantly higher in RG than those in CG. The 5-year DFS and OS of the RG were significantly higher than those of the CG. In conclusion, trastuzumab, carboplatin and docetaxel present high efficacy, safety, and 5-year DFS and OS in HER-2-positive breast cancer patients, and have good recovery effect on inflammation, immune response and oxidative stress.

Review of concepts in therapeutic decision-making in HER2-negative luminal metastatic breast cancer

Purpose

Hormone receptor (HR)-positive, Human epidermal growth factor receptor 2 (HER2)-negative metastatic breast cancer (MBC) requires a therapeutic approach that takes into account multiple factors, with treatment being based on anti-estrogen hormone therapy (HT). As consensus documents are valuable tools that assist in the decision-making process for establishing clinical strategies and optimize the delivery of health services, this consensus document has been created with the aim of developing recommendations on cretiera for hormone sensitivity and resistance in HER2-negative luminal MBC and facilitating clinical decision-making.

Methods

This consensus document was generated using a modification of the RAND/UCLA methodology, which included the definition of the project and identification of issues of interest, a non-exhaustive systematic review of the literature, an analysis and synthesis of the scientific evidence, preparation of recommendations, and external evaluation with a panel of 64 medical oncologists specializing in breast cancer.

Results

A Spanish panel of experts reached consensus on 32 of the 32 recommendations/conclusions presented in the first round and were accepted with an approval rate of 100% about definition of metastatic disease not susceptible to local curative treatment, definition of hormone sensitivity and hormone resistance in metastatic luminal disease and therapeutic decision-making.

Conclusion

We have developed a consensus document with recommendations on the treatment of patients with HER2-negative luminal MBC that will help to improve therapeutic benefits.

lncRNA TCL6 correlates with immune cell infiltration and indicates worse survival in breast cancer

BACKGROUND

Long non-coding RNA (lncRNA) T-cell leukemia/lymphoma 6 (TCL6) has been reported as a potential tumor suppressor. However, its expression and function in breast cancer remain unknown. This study was performed to investigate the expression of lncRNA TCL6 in breast cancer and its clinical significance.

METHODS

The survival and clinical molecular roles of TCL6 in breast cancer were analyzed. The underlying mechanism modulated by TCL6 and its correlation with immune-infiltrating cells were investigated. Gene Expression Omnibus (GEO) datasets were further used to confirm the prognostic role of TCL6.

RESULTS

TCL6 low expression was not correlated with age, clinical stage, T stage, lymph node metastasis, distant metastasis, human epidermal growth factor 2 status, but was associated with estrogen receptor and progesterone receptor (PR) status and was an independent factor for worse survival (HR 1.876, P = 0.016). Specifically, low TCL6 expression correlated with worse prognosis in PR-negative patients. TCL6 could predict worse survival in luminal B breast cancer based on intrinsic subtypes. Immune-related pathways such as Janus kinase-signal transducer of activators of transcription were regulated by TCL6. Further finding revealed that TCL6 correlated with immune infiltrating cells such as B cells (r = 0.25, P < 0.001), CD8+ T cells (r = 0.23, P < 0.001), CD4+ T cells (r = 0.25, P < 0.001), neutrophils (r = 0.21, P < 0.001), and dendritic cells (r = 0.27, P < 0.001). TCL6 was also positively correlated with tumor-infiltrating lymphocytes infiltration and PD-1, PD-L1, PD-L2, and CTLA-4 immune checkpoint molecules (P < 0.001).

CONCLUSION

Our findings suggest that lncRNA TCL6 correlates with immune infiltration and may act as a useful prognostic molecular marker in breast cancer.

Impact of Surgical Margins in Breast Cancer After Preoperative Systemic Chemotherapy on Local Recurrence and Survival

Background

While “no tumour on ink” is an accepted margin width for R₀ resection in primary surgery, it’s unclear if it’s oncologically safe after neoadjuvant chemotherapy (NAC). Only limited data demonstrate that surgery within new margins in cases of a pathological complete response (pCR) is safe. We therefore investigated the influence of different margins and pCR on local recurrence and survival rates after NAC.

Methods

We retrospectively analysed data of 406 women with invasive breast cancer, treated with NAC and breast-conserving therapy between 1994 and 2014 in two certified Austrian breast health centres. We compared R ≤ 1 mm, R > 1 mm and RX (pCR) for local recurrence-free survival (LRFS), disease-free survival (DFS) and overall survival (OS).

Results

After a median follow-up of 84.3 months, the 5-year LRFS (R ≤ 1 mm: 94.2%, R > 1 mm: 90.6%, RX: 95.0%; p = 0.940), the 5-year DFS (R ≤ 1 mm: 71.9%, R > 1 mm: 74.1%, RX: 87.2%; p = 0.245) and the 5-year OS (R ≤ 1 mm: 85.1%, R > 1 mm: 88.0%, RX: 96.4%; p = 0.236) did not differ significantly between narrow, wide, nor RX resections. Regarding DFS and OS, a negative nodal status reduced the hazard ratio significantly.

Conclusion

There is no significant difference in LRFS, DFS and OS comparing close, wide or unknown margins after pCR. We suggest that resection in new margins after NAC is safe according to “no tumour on ink”. Resection of the clipped area in cases of pCR is emphasized.

The "Preparation for Shared Decision-Making" Tool for Women With Advanced Breast Cancer: Qualitative Validation Study

Background

The range of decisions and considerations that women with advanced breast cancer (ABC) face can be overwhelming and difficult to manage. Research shows that most patients prefer a shared decision-making (SDM) approach as it provides them with the opportunity to be actively involved in their treatment decisions. The current engagement of these patients in their clinical decisions is suboptimal. Moreover, implementing SDM into routine clinical care can be challenging as patients may not always feel adequately prepared or may not expect to be involved in the decision-making process.

Objective

Avalere Health developed the Preparation for Shared Decision-Making (PFSDM) tool to help patients with ABC feel prepared to communicate with their clinicians and engage in decision making aligned with their preferences. The goal of this study was to validate the tool for its acceptability and usability among this patient population.

Methods

We interviewed a diverse group of women with ABC (N=30). Interviews were audiorecorded, transcribed, and double coded by using NVivo. We assessed 8 themes to understand the acceptability and usability of the tool.

Results

Interviewees expressed that the tool was acceptable for preparing patients for decision making and would be useful for helping patients know what to expect in their care journey. Interviewees also provided useful comments to improve the tool.

Conclusions

This validation study confirms the acceptability and usability of the PFSDM tool for women with ABC. Future research should assess the feasibility of the tool’s implementation in the clinical workflow and its impact on patient outcomes.

Imaging-Based Approach to Axillary Lymph Node Staging and Sentinel Lymph Node Biopsy in Patients With Breast Cancer

OBJECTIVE. This review provides historical and current data to support the role of imaging-based axillary lymph node staging and sentinel lymph node biopsy as the standard of care for axillary management in women with a diagnosis of breast cancer, before and after neoadjuvant systemic therapy. CONCLUSION. The implications of surgical trials (American College of Surgeons Oncology Group [ACOSOG] Z011 and ACOSOG Z1071) on imaging protocols for the axilla are reviewed, in conjunction with the American Joint Committee on Cancer nodal staging guidelines.

Monitoring Breast Cancer Response to Neoadjuvant Chemotherapy Using Ultrasound Strain Elastography

Strain elastography was used to monitor response to neoadjuvant chemotherapy (NAC) in 92 patients with biopsy-proven, locally advanced breast cancer. Strain elastography data were collected before, during, and after NAC. Relative changes in tumor strain ratio (SR) were calculated over time, and responder status was classified according to tumor size changes. Statistical analyses determined the significance of changes in SR over time and between response groups. Machine learning techniques, such as a naïve Bayes classifier, were used to evaluate the performance of the SR as a marker for Miller-Payne pathological endpoints. With pathological complete response (pCR) as an endpoint, a significant difference (P < .01) in the SR was observed between response groups as early as 2 weeks into NAC. Naïve Bayes classifiers predicted pCR with a sensitivity of 84%, specificity of 85%, and area under the curve of 81% at the preoperative scan. This study demonstrates that strain elastography may be predictive of NAC response in locally advanced breast cancer as early as 2 weeks into treatment, with high sensitivity and specificity, granting it the potential to be used for active monitoring of tumor response to chemotherapy.

Breast reconstruction in France, observational study of 140,904 cases of mastectomy for breast cancer

OBJECTIVES

In France, there are few up-to-date epidemiological data on breast reconstruction after mastectomy for breast cancer. The objective of the present study was to measure immediate and delayed breast reconstruction (IBR and DBR, respectively) rates and thus the proportion of patients not benefiting from any reconstruction.

METHODS

We performed an observational study by assessing data from the French nationwide discharge summary database (Programme de Médicalisation des Systèmes d'Information) for the period 2008-2014. All women having undergone a total mastectomy for breast cancer during this period were included. We then searched for reconstructive surgery during the initial or subsequent hospital stays, and recorded the time interval between mastectomy and reconstruction.

RESULTS

Among the 140,904 mastectomies included, the IBR rate was 16.1% on average, and increased over the study period. The time interval between mastectomy and DBR was≤3 years in 92% of cases. For patients included in 2008 and 2009, the DBR rate was 17.8%, and the non-reconstruction rate was 66.4%.

CONCLUSION

The high proportion of women not undergoing breast reconstruction after mastectomy suggests that access to this procedure should be improved.

Treatment patterns, health care resource use and outcomes in metastatic triple-negative breast cancer in Germany: retrospective chart review study (OBTAIN)

Background: There is limited data on the real-life situation and outcomes of patients with metastatic triple-negative breast cancer (mTNBC) in Germany. The aim of this chart review was to describe the current treatment patterns, resource use and outcomes in this patient group. Methods: Retrospective data collection in 30 gyneco-oncological sites (hospitals and office-based) across Germany between January and April 2017. Index date was defined as initiation of treatment with gemcitabine, vinorelbin, capecitabine or eribulin therapy following discontinuation of taxane and/or anthracycline therapy. Results: In the 91 evaluable patients, median time between primary diagnosis and index date was 20.9 months (range 0-187 months). Ten percent of patients had no distant metastases, while 57% had newly diagnosed metastases. Cancer stage at index date was mostly IV (82 patients). A number of 135 different regimens (monotherapy or combination therapy) were used. For first-line chemo treatment, 29 patients received monotherapy and 54 patients combination therapy. Bevacizumab and paclitaxel were also the most frequently used single substances among all therapy lines together and for first-line therapy. While taxanes were at least occasionally administered for second-line therapy, no patient received taxanes for third-line therapy. Chemotherapy modifications in terms of dose reduction or treatment interruption were rare. However, the therapy was terminated in more than two thirds of all cases. Fifty-nine patients were hospitalized at least once. For first-, second- and third-line therapy, median overall survival was 19.1/10.8/14.6 months, and median progression-free survival was 7.7/2.5/5.6 months. Conclusion: In clinical routine, a wide variety of treatment approaches is applied, while outcomes in terms of survival are poor. New treatment options are needed for this challenging tumor type.

Ecotropic virus integration-1 and calreticulin as novel prognostic markers in triple-negative breast cancer: A retrospective cohort study

Triple-negative breast cancer (TNBC) is an aggressive form of breast cancer, for which no specific targete d therapy is currently available. The present study aimed to examine the associations of ecotropic virus integration site 1 (EVI-1) and calreticulin (CRT) with other clinicopathological variables and the prognosis of patients with TNBC. The present retrospective cohort study reviewed the medical records of patients with TNBC treated in the Affiliated Hospitals of Jinzhou Medical University between January 2010 and June 2015. The protein expression levels of EVI-1 and CRT in tumor samples obtained from the patients were examined by immunohistochemical analysis. Univariate and multivariate regression analyses were used to identify associations between clinical characteristics and disease-free survival (DFS) or overall survival (OS). Kaplan-Meier analysis was performed to observe the survival condition (DFS/OS) according to EVI-1 and CRT expression. A total of 88 TNBC patients were included in the present study. Tumor tissues in 52 (59.1%) patients were EVI-1 positive, and tumor tissues in 64 (72.7%) patients were CRT-positive, and these rates were significantly higher compared with those in the corresponding paracancerous tissues (P<0.05). Multivariate analysis revealed that EVI-1 and CRT expression levels were independent variables associated with OS and DFS, and high expression of both CRT and EVI-1 was significantly associated with decreased OS and DFS compared with the other subgroups (low EVI-1/low CRT expression, low EVI-1/high CRT expression and high EVI-1/low CRT expression) of patients with TNBC. EVI-1 and CRT expression in TNBC was significantly correlated with poor outcome. Evaluation of the EVI-1 and CRT status may provide insight into prognosis prediction for patients with TNBC.

Barriers of Access to Breast Reconstruction: A Systematic Review

BACKGROUND

The purpose of this systematic review was to comprehensively summarize barriers of access to breast reconstruction and evaluate access using the Penchansky and Thomas conceptual framework based on the six dimensions of access to care.

METHODS

The authors performed a systematic review that focused on (1) breast reconstruction, (2) barriers, and (3) breast cancer. Eight databases (i.e., EMBASE, MEDLINE, PsycINFO, CINHAL, ePub MEDLINE, ProQuest, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials) were searched. English peer-reviewed articles published between 1996 and 2016 were included.

RESULTS

The authors' search retrieved 4282 unique articles. Two independent reviewers screened texts, selecting 99 articles for inclusion. All studies were observational and qualitative in nature. The availability of breast reconstruction was highest in teaching hospitals, private hospitals, and national cancer institutions. Accessibility affected access, with lower likelihood of breast reconstruction in rural geographic locations. Affordability also impacted access; high costs of the procedure or poor reimbursement by insurance companies negatively influenced access to breast reconstruction. Acceptability of the procedure was not universal, with unfavorable physician attitudes toward breast reconstruction and specific patient and tumor characteristics correlating with lower rates of breast reconstruction. Lastly, lack of patient awareness of breast reconstruction reduced the receipt of breast reconstruction.

CONCLUSIONS

Using the access-to-care framework by Penchansky and Thomas, the authors found that barriers to breast reconstruction existed in all six domains and interplayed at many levels. The authors' systematic review analyzed this complex relationship and suggested multiprong interventions aimed at targeting breast reconstruction barriers, with the goal of promoting equitable access to breast reconstruction for all breast cancer patients.

Risk-reducing medications for primary breast cancer: a network meta-analysis

BACKGROUND

Breast cancer is the most frequently occurring malignancy and the second cause of death for cancer in women. Cancer prevention agents (CPAs) are a promising approach to reduce the burden of breast cancer. Currently, two main types of CPAs are available: selective estrogen receptor modulators (SERMs, such as tamoxifen and raloxifene) and aromatase inhibitors (AIs, such as exemestane and anastrozole).

OBJECTIVES

To assess the efficacy and acceptability of single CPAs for the prevention of primary breast cancer, in unaffected women, at an above-average risk of developing breast cancer.Using a network meta-analysis, to rank single CPAs, based on their efficacy and acceptability (an endpoint that is defined as the inverse of CPA-related toxicity).

SEARCH METHODS

We searched the Cochrane Breast Cancer Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, World Health Organization's International Clinical Trials Registry Platform (WHO ICTRP), and ClinicalTrials.gov on 17 August 2018. We handsearched reference lists to identify additional relevant studies.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that enrolled women without a personal history of breast cancer but with an above-average risk of developing a tumor. Women had to be treated with a CPA and followed up to record the occurrence of breast cancer and adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and conducted risk of bias assessments of the included studies, and assessed the certainty of the evidence using GRADE. Outcome data included incidence of breast carcinoma (both invasive and in situ carcinoma) and adverse events (both overall and severe toxicity). We performed a conventional meta-analysis (for direct comparisons of a single CPA with placebo or a different CPA) and network meta-analysis (for indirect comparisons).

MAIN RESULTS

We included six studies enrolling 50,927 women randomized to receive one CPA (SERMs: tamoxifen or raloxifene, or AIs: exemestane or anastrozole) or placebo. Three studies compared tamoxifen and placebo, two studies compared AIs (exemestane or anastrozole) versus placebo, and one study compared tamoxifen versus raloxifene. The risk of bias was low for all RCTs.For the tamoxifen versus placebo comparison, tamoxifen likely resulted in a lower risk of developing breast cancer compared to placebo (risk ratio (RR) 0.68, 95% confidence interval (CI) 0.62 to 0.76; 3 studies, 22,832 women; moderate-certainty evidence). In terms of adverse events, tamoxifen likely increased the risk of severe toxicity compared to placebo (RR 1.28, 95% CI 1.12 to 1.47; 2 studies, 20,361 women; moderate-certainty evidence). In particular, women randomized to receive tamoxifen experienced a higher incidence of both endometrial carcinoma (RR 2.26, 95% CI 1.52 to 3.38; high-certainty evidence) and thromboembolism (RR 2.10, 95% CI 1.14 to 3.89; high-certainty evidence) compared to women who received placebo.For the AIs versus placebo comparison, AIs (exemestane or anastrozole) reduced the risk of breast cancer by 53% (RR 0.47, 95% CI 0.35 to 0.63; 2 studies, 8424 women; high-certainty evidence). In terms of adverse events, AIs increased the risk of severe toxicity by 18% (RR 1.18, 95% CI 1.09 to 1.28; 2 studies, 8352 women; high-certainty evidence). These differences were sustained especially by endocrine (e.g. hot flashes), gastrointestinal (e.g. diarrhea), and musculoskeletal (e.g. arthralgia) adverse events, while there were no differences in endometrial cancer or thromboembolism rates between AIs and placebo.For the tamoxifen versus raloxifene comparison, raloxifene probably performed worse than tamoxifen in terms of breast cancer incidence reduction (RR 1.25, 95% CI 1.09 to 1.43; 1 study, 19,490 women; moderate-certainty evidence), but its use was associated with lower toxicity rates (RR 0.87, 95% CI 0.80 to 0.95; 1 study, 19,490 women; moderate-certainty evidence), particularly relating to incidence of endometrial cancer and thromboembolism.An indirect comparison of treatment effects allowed us to compare the SERMs and AIs in this review. In terms of efficacy, AIs (exemestane or anastrozole) may have reduced breast cancer incidence slightly compared to tamoxifen (RR 0.67, 95% CI 0.46 to 0.98; 5 RCTs, 31,256 women); however, the certainty of evidence was low. A lack of model convergence did not allow us to analyze toxicity data.

AUTHORS' CONCLUSIONS

For women with an above-average risk of developing breast cancer, CPAs can reduce the incidence of this disease. AIs appear to be more effective than SERMs (tamoxifen) in reducing the risk of developing breast cancer. AIs are not associated with an increased risk of endometrial cancer and thromboembolic events. However, long-term data on toxicities from tamoxifen are available while the follow-up toxicity data on unaffected women taking AIs is relatively short. Additional data from direct comparisons are needed to fully address the issues of breast cancer prevention by risk-reducing medications, with special regards to acceptability (i.e. the benefit/harm ratio).

What Is Important When Making Treatment Decisions in Metastatic Breast Cancer? A Qualitative Analysis of Decision-Making in Patients and Oncologists

BACKGROUND

Metastatic breast cancer (MBC) is an ideal environment for shared decision-making because of the large number of guideline-based treatment options with similar efficacy but different toxicity profiles. This qualitative analysis describes patient and provider factors that influence decision-making in treatment of MBC.

MATERIALS AND METHODS

Patients and community oncologists completed in-person interviews. Academic medical oncologists participated in focus groups. Interviews and focus groups were audio-recorded, transcribed, and analyzed using NVivo. Using an a priori model based on the Ottawa Framework, two independent coders analyzed transcripts using a constant comparative method. Major themes and exemplary quotes were extracted.

RESULTS

Participants included 20 patients with MBC, 6 community oncologists, and 5 academic oncologists. Analysis of patient interviews revealed a decision-making process characterized by the following themes: decision-making style, contextual factors, and preferences. Patient preference subthemes include treatment efficacy, physical side effects of treatment, emotional side effects of treatment, cognitive side effects of treatment, cost and financial toxicity, salience of cutting-edge treatment options (clinical trial or newly approved medication), treatment logistics and convenience, personal and family responsibilities, treatment impact on daily activities, participation in self-defining endeavors, attending important events, and pursuing important goals. Physician decisions emphasized drug-specific characteristics (treatment efficacy, side effects, cost) rather than patient preferences, which might impact treatment choice.

CONCLUSION

Although both patients with MBC and oncologists considered treatment characteristics when making decisions, patients' considerations were broader than oncologists', incorporating contextual factors such as the innovative value of the treatment and life responsibilities. Differences in perspectives between patients and oncologists suggests the value of tools to facilitate systematic communication of preferences in the setting of MBC.

IMPLICATIONS FOR PRACTICE

Both patients with metastatic breast cancer (MBC) and oncologists emphasized importance of efficacy and physical side effects when making treatment decisions. However, other patient considerations for making treatment decisions were broader, incorporating contextual factors such as the logistics of treatments, personal and family responsibilities, and ability to attend important events. Furthermore, individual patients varied substantially in priorities that they want considered in treatment decisions. Differences in perspectives between patients and oncologists suggest the value of tools to facilitate systematic elicitation of preferences and communication of those preferences to oncologists for integration into decision-making in MBC.

Multi-omics Integration Analysis Robustly Predicts High-Grade Patient Survival and Identifies CPT1B Effect on Fatty Acid Metabolism in Bladder Cancer

PURPOSE

The perturbation of metabolic pathways in high-grade bladder cancer has not been investigated. We aimed to identify a metabolic signature in high-grade bladder cancer by integrating unbiased metabolomics, lipidomics, and transcriptomics to predict patient survival and to discover novel therapeutic targets.

EXPERIMENTAL DESIGN

We performed high-resolution liquid chromatography mass spectrometry (LC-MS) and bioinformatic analysis to determine the global metabolome and lipidome in high-grade bladder cancer. We further investigated the effects of impaired metabolic pathways using in vitro and in vivo models.

RESULTS

We identified 519 differential metabolites and 19 lipids that were differentially expressed between low-grade and high-grade bladder cancer using the NIST MS metabolomics compendium and lipidblast MS/MS libraries, respectively. Pathway analysis revealed a unique set of biochemical pathways that are highly deregulated in high-grade bladder cancer. Integromics analysis identified a molecular gene signature associated with poor patient survival in bladder cancer. Low expression of CPT1B in high-grade tumors was associated with low FAO and low acyl carnitine levels in high-grade bladder cancer, which were confirmed using tissue microarrays. Ectopic expression of the CPT1B in high-grade bladder cancer cells led to reduced EMT in in vitro, and reduced cell proliferation, EMT, and metastasis in vivo.

CONCLUSIONS

Our study demonstrates a novel approach for the integration of metabolomics, lipidomics, and transcriptomics data, and identifies a common gene signature associated with poor survival in patients with bladder cancer. Our data also suggest that impairment of FAO due to downregulation of CPT1B plays an important role in the progression toward high-grade bladder cancer and provide potential targets for therapeutic intervention.

Visualization of Sequential Treatments in Metastatic Breast Cancer

PURPOSE

Treatment sequencing of metastatic breast cancer (MBC) is heterogeneous. The primary objective of this study was to develop a visualization technique to understand population-level treatment sequencing for MBC. Secondary outcomes were to describe the heterogeneity of MBC treatment sequencing, as measured by the proportion of patients with a rare sequence, and to generate hypotheses about the impact of sequencing on overall survival.

METHODS

This retrospective review evaluated treatment sequencing for patients with MBC in the SEER-Medicare database. Patients with either de novo MBC or International Classification of Diseases, Ninth Revision, diagnosis codes for secondary metastasis (197.XX-198.XX) on two separate dates, excluding breast (198.81, 198.82, 198.2) and lymph nodes (196.XX), were included. Complete Medicare Parts A, B, and D coverage was required. A treatment sequence that fewer than 11 patients received was considered rare. A graphic was created with each nonrare treatment-sequence grouping on the y-axis and time on the x-axis. Bars representing time on hormonal therapy, chemotherapy, human epidermal growth factor receptor 2-targeted therapy, and other targeted therapies were color coded. Kaplan-Meier-like curves were overlaid on treatment maps, using estimated median survival for each sequence.

RESULTS

Of 6,639 patients with MBC, 56% received a treatment sequence that fewer than 11 other patients received, with 2,985 other unique, rare sequences were identified. Sequence visualization demonstrated differential survival, with longer median survival for those initially receiving hormonal therapy. The median time receiving initial treatment was similar for patients receiving first-line chemotherapy.

CONCLUSION

Treatment-sequence visualization can enhance the capacity to effectively conceptualize treatment patterns and patient outcomes.

21-Gene Recurrence Score Assay and Outcomes of Adjuvant Radiotherapy in Elderly Women With Early-Stage Breast Cancer After Breast-Conserving Surgery

Introduction: To assess the role of the 21-gene recurrence score (RS) assay on decision-making of postoperative radiotherapy (RT) following breast-conserving surgery (BCS) in elderly women with early-stage breast cancer. Methods: The 21-gene RS for elderly (≥65 years) women with stage T1-2N0M0 estrogen receptor-positive breast cancer who underwent BCS from 2004 to 2015 was obtained from the Surveillance, Epidemiology, and End Results program. We estimated the association of 21-gene RS and adjuvant RT related to breast cancer-specific survival (BCSS) using propensity score matching (PSM). Results: We identified 18,456 patients, of which 15,326 (83.0%) received postoperative RT. Of identified patients, 58.9, 34.0, and 7.1% of patients had a low-, intermediate-, and high-risk RS, respectively. Receipt of postoperative RT was not related to the year of diagnosis according to the 21-gene RS groups. Multivariate analysis suggested that receipt of postoperative RT was an independent predictor of better BCSS before (hazard ratio [HR] 0.587, 95% confidence interval [CI] 0.426-0.809, P = 0.001) and after (HR 0.613, 95%CI 0.390-0.963, P = 0.034) PSM. However, subgroups analyses indicated that receipt of postoperative RT was related to better BCSS in women with intermediate-risk RS before (HR 0.467, 95%CI 0.283-0.772, P = 0.003) and after (HR 0.389, 95%CI 0.179-0.846, P = 0.017) PSM, but not in women with low- and high-risk RS groups before and after PSM. Conclusions: Although causation cannot be implied, adjuvant RT in elderly women was associated with a greater effect size in patients with an intermediate-risk RS.