Shared decision-making in medical encounters regarding breast cancer treatment: the contribution of methodological triangulation

The aim of this study on shared decision-making in the doctor-patient encounter about surgical treatment for early-stage breast cancer, conducted in a regional cancer centre in France, was to further the understanding of patient perceptions on shared decision-making. The study used methodological triangulation to collect data (both quantitative and qualitative) about patient preferences in the context of a clinical consultation in which surgeons followed a shared decision-making protocol. Data were analysed from a multi-disciplinary research perspective (social psychology and health economics). The triangulated data collection methods were questionnaires (n = 132), longitudinal interviews (n = 47) and observations of consultations (n = 26). Methodological triangulation revealed levels of divergence and complementarity between qualitative and quantitative results that suggest new perspectives on the three inter-related notions of decision-making, participation and information. Patients' responses revealed important differences between shared decision-making and participation per se. The authors note that subjecting patients to a normative behavioural model of shared decision-making in an era when paradigms of medical authority are shifting may undermine the patient's quest for what he or she believes is a more important right: a guarantee of the best care available.

[Regional recurrence of triple-negative breast cancer: interest of systematic adjuvant lymph node irradiation?]

OBJECTIVE

To evaluate the percentage of regional recurrence (RR) in patients with triple-negative (TN) N0 breast cancer in order to consider the interests of a systematic adjuvant nodal irradiation.

PATIENTS AND METHODS

Between February 1996 and June 2009, 249 patients were treated for TN breast cancer in Léon-Bérard center (Lyon, France). All patients received first surgical treatment followed or not by chemotherapy or radiotherapy. We excluded patients with metastasis at diagnosis, patients who were initially irradiated regional lymph node, patients which ER, PR and/or HER2 status was not known and patients who didn't have standard treatment. Ultimately, 100 patients were included.

RESULTS

Two patients (2%) developed regional recurrence (1 sub and supraclavicular recurrence and 1 supraclavicular recurrence). The median follow-up was 34 months (95% CI: 29,2 to 37,4). The survival rate at 3 years was 98% (95% CI: 90-99). Our study showed no differences in terms of RR between TN cancers and not TN cancers for a median followed up of 34 months.

CONCLUSION

The results of our study do not suggest that patients with TN breast cancer should receive systematic nodal adjuvant radiotherapy.

Cost comparison of axillary sentinel lymph node detection and axillary lymphadenectomy in early breast cancer. A national study based on a prospective multi-institutional series of 985 patients 'on behalf of the Group of Surgeons from the French Unicancer Federation'

BACKGROUND

Our objective was to assess the global cost of the sentinel lymph node detection [axillary sentinel lymph node detection (ASLND)] compared with standard axillary lymphadenectomy [axillary lymph node dissection (ALND)] for early breast cancer patients.

PATIENTS AND METHODS

We conducted a prospective, multi-institutional, observational, cost comparative analysis. Cost calculations were realized with the micro-costing method from the diagnosis until 1 month after the last surgery.

RESULTS

Eight hundred and thirty nine patients were included in the ASLND group and 146 in the ALND group. The cost generated for a patient with an ASLND, with one preoperative scintigraphy, a combined method for sentinel node detection, an intraoperative pathological analysis without lymphadenectomy, was lower than the cost generated for a patient with lymphadenectomy [€ 2947 (σ = 580) versus € 3331 (σ = 902); P = 0.0001].

CONCLUSION

ASLND, involving expensive techniques, was finally less expensive than ALND. The length of hospital stay was the cost driver of these procedures. The current observational study points the heterogeneous practices for this validated and largely diffused technique. Several technical choices have an impact on the cost of ASLND, as intraoperative analysis allowing to reduce rehospitalization rate for secondary lymphadenectomy or preoperative scintigraphy, suggesting possible savings on hospital resources.

Ductal carcinoma in situ of the breast in younger women: a subgroup of patients at high risk

BACKGROUND

After breast conservative treatment (BCT), young age is a predictive factor for recurrence in patients with Ductal Carcinoma In Situ (DCIS) of the breast. The purpose of this study was to evaluate predictive factors for recurrence and outcomes in these younger women (under 40 years) treated for pure DCIS.

METHODS

From 1974 to 2003, 207 cases were collected in 12 French Cancer Centers. Median age was 36.3 years and median follow-up 160 months. Seventy four (35.8%) underwent mastectomy, 67 (32.4%) lumpectomy alone and 66 (31.9%) lumpectomy plus radiotherapy.

RESULTS

37 recurrences occurred (17.8%): 14 (38%) were in situ and 23 (62%) invasive. After BCT, the overall rate of recurrence was 27% (33% in the lumpectomy plus radiotherapy group vs. 21% in the lumpectomy alone group). Comedocarcinoma subtype (p = 0.004), histological size more than 10 mm (p = 0.011), necrosis (p = 0.022) and positive margin status (p = 0.019) were statistically significant predictive factors for recurrence. The actuarial 15-year rates of local recurrence were 29%, 42% and 37% in the lumpectomy alone, lumpectomy and whole breast radiotherapy and lumpectomy + whole breast radiotherapy with additional boost groups respectively. After recurrence, the 10-year overall survival rate was 67.2%.

CONCLUSION

High recurrence rates (mainly invasive) after BCT in young women with DCIS are confirmed. BCT in this subgroup of patients is possible if clear and large margins are obtained, tumor size is under 11 mm and necrosis- and/or comedocarcinoma-free.

Feasibility of Sentinel Lymph Node Biopsy in Multiple Unilateral Synchronous Breast Cancer: Results of a French Prospective Multi-Institutional Study (IGASSU 0502)

Introduction: Controversy remains over whether to perform sentinel lymph node biopsy (SLNB) in multiple (multicentric or multifocal) unilateral synchronous breast cancer. Several small retro- or prospective studies, included pre- or post-operative (or both) multiple synchronous tumours (MST) have suggested that the test performance of SLNB is similar to that seen in unifocal disease. The purpose of this study was to evaluate the feasibility and accuracy of SLNB in preoperatively diagnosed invasive MST.Patients and Methods: The Interest of Axillary SLNB in Multiple Invasive Breast Cancer (IGASSU) study was a prospective multi-institutional study with initial breast surgery, SLNB, and systematic level I to II axillary lymph node dissection (ALND). Patients eligible for the IGASSU study had an operable invasive MST, defined as two or more physically separate invasive tumours in the same or different breast quadrant. The diagnosis of invasive MST was confirmed histologically in all patients by core needle biopsy before surgery. Detection of sentinel node was performed by using either blue patent or radiocolloide injection or both. Injection sites were subareolar.Statistical Analysis: Sensitivity (Se), negative predictive value (NPV), accuracy (A), false negative rate (FNR) and their 95%-confidence intervals (95%CI) were calculated with a classical 2x2 contingency table. A univariate analysis using odds ratio calculation was performed to identify the risk factors for false negative results.Results: Between March 1, 2006, and August 31, 2007, 216 patients were prospectively included from 16 institutions. Of these patients, 211 were evaluable. The SLNB identified rate were 93.4% (197/211). A mean number of 2.2 SLN (range, 1 to 8, ± 1.4) was successfully excised. The mean number of resected nodes in ALND was 12 (range, 1 to 39, ± 5.7). The FNR was 13.6% (14/103) [95%CI: 7- 20%], Se was 86 .4% (89/103) [95%CI: 79- 93%], NPV was 87% (94/108) [95%CI: 80-93%], A was 92.9% (183/197) [95%CI: 89- 96%]. For the 14 false-negative SN, all had ≤ 3 involved nodes in ALND. Table 1 shows patterns of management of the axilla.Table 1 ALND+ALND-Non-identified SLNB113Identified SLNB+4544Identified SLNB-1494 In a univariate analysis, tumour location (only external location vs other location) was the only clinico-pathological factor influencing the FNR (22% [11-33%] vs 7% [4-10%]), even then median aggregate histological tumour size was smaller in external tumours (17mm [range, 12-80] vs 34mm [range, 8- 90], p=0.016).Conclusion: With a FNR of 13.6% (95%CI: 7-20%), we do not recommend SLNB as a routine procedure for multiple unilateral synchronous breast cancer, even for small tumour foci.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 305.

The Influence of Mammaplasty in Axillary Lymphatic Drainage Patterns and Sentinel Lymph Node Detection

Introduction: Controlateral mammaplasty is often necessary during the procedure of breast reconstruction after mastectomy.However the impact of this kind of surgery on axillary lymphatic drainage and sentinel node (SN) detection remains controversial. The American Society of Clinical Oncology (ASCO) as published a guideline in 2005 and recommended that SN biopsy should not be performed in patients with previous mammplasty or axillary surgery.However, because of insufficient evidence and lack of scientific studies, mammaplasty cannot be considered as an absolute contraindication for SN biopsy procedure. Therefore, the same panellists of the ASCO guideline suggested that a preliminary lymphoscintigraphy (LSG) could be done when considering a SN biopsy in patients with previous mammaplasty, with the objective of verifying the integrity of the mammary gland and axillary nodes.The aim of our study was to evaluate the lymphatic patterns and SN detection rates after mammaplasty by using lymphoSPECT-CT (LS).Methods: ten patients who underwent mammaplasty were evaluated by LSG immediately after intradermal periareolar injections of 99mTc -labelled sulphur colloid (NanoCIS*) at two time points: before mammaplasty (Pre-LS) and between 40 to 60 days after mammaplasty (Post- LS).Results: all breasts drained primarily to the axillary SN. The binomial test did not show statistical difference in lymphatic drainage patterns between Pre-LSG and Post-LSG.The average number of hot SN was 1.28 in Pre-LS, 1.14 in Post-LS.The localisation of hot SN was evaluated by:- antero-posterior distance was estimated in centimeter from SN region to dorsal vertebrae spine center-SN's coronal position was compared to grill rib.The preservation of axillary lymphatic drainage after mammaplasty was allowed for SN detection in all studied breasts and the localisation of the sentinel node was the same after surgery than before.Conclusion: after evaluating the impact of the previous mammaplasty surgery on the accuracy of SLN biopsy, we observed that this kind of surgery did not significantly affects the accuracy of lymphatic mapping and that it may be possible to propose sentinel node biopsy after mammaplasty.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1028.

Endocrine adjuvant therapy in male breast cancer (MBC): tamoxifen (TAM), aromatase inhibitors (AI) or both?

Abstract #4133

Background:
 MBC represents less than 1% of male cancers and occurs 10 years later than in women. Hormone receptors (HR) are very often positive, thus TAM is considered the standard endocrine adjuvant treatment (ET); AI has not been evaluated yet in this setting. To our knowledge, this is the first report focused on this option.
 Material and methods:
 From 1990 to 2005, 489 non metastatic patients were collected in 15 cancer centers. Median age was 66 years (34% over 70) and median follow-up was 60 months.
 204 (42%) patients had at least one “chronic disease” (mainly cardiovascular: 20%, metabolic: 10%, respiratory: 6% and neurological: 3%).
 Results:
 There were 39% T1, 41% T2, 9% T3T4, 11% Tx, and 27% N1N2. Lumpectomy and mastectomy were performed in 10% and 90% of the cases. Axillary dissection , sentinel node biopsy or both were performed in 90%, 2% and 5% of the cases, respectively.
 95% of the tumors were ductal carcinomas; 47% were pT1, 20% pT2 and 33% pT3T4. Axillary nodal involvement (ANI) was present in 52.8% of the cases. ER were evaluable in 419 (86%) tumors, including 92% positive. PgR were evaluable in 399 (82%) tumors, including 89% positive. The distribution of HR was: ER+PgR+: 86%; ER+PgR-: 6%; ER-PgR+: 3.3%; ER-PgR-: 4.7%. 417 patients (85%) underwent locoregional radiotherapy. 106 patients (21%) had no adjuvant treatment at all, 30 (6%) had chemotherapy alone, 218 (45.3%) had endocrine therapy alone (ET) and 134 (27.6%) had CT+ET. Adjuvant treatment significantly changes according to pT, pN, SBR grading, presence of vascular emboli and age. Among 344 patients who received ET, 301 (87%) underwent TAM, 34 (10%) AI and 9 (3%) TAM followed by AI. The use of AI was not influenced by pT or pN, but was slightly more frequent in older patients as well as in case on associated comorbidities. For the entire cohort, local recurrence (LR), nodal recurrences (NR) and metastases occurred in 2%, 5% and 22% of the cases; 2% and 10% developed contralateral BC and second cancer. The 5 and 10-year overall survival (OS) rates were 81% and 59%; disease-specific survivals (DSS) were 89% and 72%. Death causes were BC 56%, second cancer 8%, complications 3%, intercurrent disease 15% and unknown 18%. Metastatic risk factors were T stage (T1: 19%, T2: 26%, T3T4: 40%; p= 0.013), pN status (pN0: 12, pN1-3: 26, pN>3: 44%; p<0.0001) and presence of locoregional recurrence (62% versus 18% p<0.0001).Among patients under ET, event rates were very similar in TAM and AI (+/- TAM) groups : LR + NR : 7% vs 5% ; metastases : 21% vs 28% and deaths : 22% vs 24%.
 Conclusion:
 Due to high median age and comorbidity frequency, ET remains the best option in MBC patients. Tamoxifen and AI seem to have a very similar efficiency and tolerance.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 4133.

A nomogram predictive of non-sentinel lymph node involvement in breast cancer patients with a sentinel lymph node micrometastasis

PURPOSE

Predictive factors of non-sentinel lymph node (NSN) involvement at axillary lymph node dissection (ALND) have been studied in the case of sentinel node (SN) involvement, with validation of a nomogram. This nomogram is not accurate for SN micrometastasis. The purpose of our study was to determine a nomogram for predicting the likelihood of NSN involvement in breast cancer patients with a SN micrometastasis.

METHODS

We collated 909 observations of SN micrometastases with additional ALND. Characteristics of the patients, tumours and SN were analysed.

RESULTS

Involvement of SN was diagnosed 490 times (53.9%) with standard staining (HES) and 419 times solely on immunohistochemical analysis (IHC) (46.1%). NSN invasion was observed in 114 patients (12.5%), whereas 62.3% (71) had only one NSN involved and 37.7% (43) two or more NSN involved. In multivariate analysis, significant predictive factors were: tumour size (pT stage < or = 10 mm or >11 and < or = 20 or >20 mm [odds ratio (OR) 2.1 and 3.43], micrometastases detected by HES or IHC [OR 1.64], presence or absence of lymphovascular invasion (LVI) [OR 1.76], tumour histological type mixed or not [OR 2.64]. The rate and probability of NSN involvement with the model are given for 24 groups, with a representation by a nomogram.

CONCLUSION

One group, corresponding to 10.1% of the patients, was associated with a risk of NSN involvement of less than 5%, and five groups, corresponding to 29.8% of the patients, were associated with a risk < or = 10%. Omission of ALND could be proposed with minimal risk for a low probability of NSN involvement.

[Patients' preferences and decision-making: state of the art and applications in cancer]

BACKGROUND

This paper deals with the physician-patient encounter. In France, the current legal framework allows patients to be informed (patients' rights to health information) and to participate to decisions regarding their own health. In such a context, this paper aims to give the reader the broad key components of the so-called 'patient treatment preferences elicitation process' in breast cancer, our research area.

METHODS AND RESULTS

We first present the general context, with a definition of the different physician-patient models. We then present decision aids, tools that aim to provide high-quality information to patients in the decision-making process. Finally, based on our previous studies and on examples drawn from the international literature, we present the empirical process of patients' preferences elicitation, which not only increases patients' knowledge of and satisfaction with the decision made, but also allows patients to be part of their disease management.

CONCLUSION

Far from being a phenomenon in the air supported by a legal system, this method developed in the 90s allows patients and more generally healthcare users to be autonomous without constraining them to a choice.

Prognosis of early-onset breast cancer based on BRCA1/2 mutation status in a French population-based cohort

591

Background: The debate concerning poorer survival for patients with breast cancer (BC) carrying a BRCA1 germline mutation is unresolved, and requires additional data from population-based studies. Methods: We followed 232 women with invasive BC under age 46, ascertained prospectively through a French population-based BC registry, and tested for BRCA1/2 mutations (median follow-up: 82 months). We compared tumour characteristics and survival rates between 21 BRCA1/2 deleterious mutation carriers and 211 non-carriers. Results: As compared to sporadic tumours, BRCA1/2 tumours showed higher grade (p = 0.02), fewer ductal carcinoma in situ (p = 0.02), more frequent medullary histology (p = 0.02), more frequent negative oestrogen and progesterone receptors (p = 0.001 each). At five years, BC-specific survival, metastasis-free survival, ipsilateral recurrence-free survival and contralateral BC-free survival rates for BRCA1/2 mutation carriers were 95.0%, 94.7%, 100% and 90.0% respectively, compared with 89.6%, 78.2%, 88.8% and 94.4% respectively, for non-carriers (not significant). Rates for women carrying only a BRCA1 mutation were 93.3%, 93.3%, 100%, 86.7%, respectively. 76% of BRCA1/2 carriers received chemotherapy. Conclusions: Despite unfavourable tumour features, we found no evidence for poorer short-term survival in BRCA1 mutation carriers compared to non-carriers in this prospective population-based cohort. The high rate of BRCA1 carriers who received chemotherapy for their BC should question the positive impact of this treatment, as suggested by preclinical studies showing increased chemosensitivity of BRCA1-associated tumours.

No significant financial relationships to disclose.

Carcinome canalaire in situ du sein

OBJECTIVE

This study assesses the results of "current clinical practice" among 882 women treated in nine French Cancer Centers from 1985 to 1995 for pure ductal carcinoma in situ (DCIS) of the breast.

METHOD

Median age was 53 years (range 21-87); 177 (20%) patients underwent mastectomy (M), 190 (22%) conservative surgery alone (CS) and 515 (58%) conservative surgery with radiotherapy (CS + RT).

RESULTS

The crude 7-year local relapse (LR) rates were 2%, 31% and 13% among the M, CS and CS+RT subgroups (p<0.0001). All four LR after M were invasive as well as 31 (52%) out of 59 and 40 (61%) out of 66 in the CS and CS+RT groups. Distant metastases occurred in 1%, 3% and 1% of the three treatment groups. No LR factors were found in the M group. Among women treated with CS, the 7-year LR rates were 36%, 31% and 30% among women aged 40 or less, 41 to 60 and 61 or more (NS). For women treated by CS+RT, the LR rates in these age subgroups were 33%, 13% and 8%, respectively (p<0.0001). Patients with negative, positive or uncertain margins had 7-year LR rates of 26%, 56% and 29% respectively if treated with CS (p=0.02) and 11%, 23% and 9% if treated with CS+RT (p=0.0008). RT reduced LR rates by 65% in all histological subgroups, but more particularly in comedocarcinoma and mixed cribriform/papillary subgroups. The 7-year rate of contralateral breast cancer was 7%, identical in all subgroups.

CONCLUSION

Mastectomy remains the safest treatment for women with DCIS, with a 98% 7-year control rate. After conservative surgery, RT reduces very significantly LR rates, according to the NSABP B-17 and EORTC 10853 randomized trial results. The RT benefit is present in all clinical/histological subgroups, but its magnitude varies. Young age (<40 years) and incomplete excision are the most important LR risk factors.

Axillary lymph-node dissection for positive sentinel nodes in breast cancer patients

AIM

The aim was to identify a subset of breast cancer patient with positive sentinel nodes (SNs) for whom secondary axillary clearance would be unnecessary.

METHODS

Between March 1999 and May 2001, 288 patients with T0-T2 breast cancer less than 3cm in diameter had SN detection either by a colorimetric method or using a combined technique. SNs were stained with haematoxylin and eosin (H&E). For all negative SNs, serial sections and immunochemistry (IHC) were performed. All patients with positive SNs underwent a complete axillary lymph node dissection. One hundred and twenty patients were SN positve.

RESULTS

Non-sentinel node positivity (NSNP) was closely associated with the size of the tumour (14.3%, 54.1% and 51.8% for pT1a-b, pT1c and pT2 tumours respectively) and with the size of the SN metastasis: 15.9% IHC detected micrometastasis, 33.3% and 78.8% micro- and macrometastasis detected with H&E staining respectively. NSNP was found in 24.0% and 42.8% of patients with pT1c breast cancer and with micrometastasis detected by IHC and H&E staining. The node positivity rate reached 81.1% for pT1c lesions with macrometastasis in the SN. For the patients with pT2 breast cancer, these rates were 12.5% (IHC), 28.5% (H&E) 91.1% (macrometastasis).

CONCLUSIONS

We are unable to isolate precisely a subset of patients for whom total axillary lymph node dissection would be unnecessary. A subset of 14 small tumours (<1cm diameter) demonstrated micrometastases in the SN without NSNP.

Ductal carcinoma in situ of the breast results of conservative and radical treatments in 716 patients

Until now, less than 5% of the patients with breast ductal carcinoma in situ (DCIS) have been enrolled in clinical trials. Consequently, we have analysed the results of "current practice" among 716 women treated in eight French Cancer Centres from 1985 to 1992: 441 cases (61.6%) corresponded to impalpable lesions, 92 had a clinical size of less than or equal to 2 cm and 70 from 2 to 5 cm; in 113 cases, the size was unspecified. Median age was 53.2 years (range: 21-87 years). 145 patients underwent mastectomy (RS) and 571 conservative surgery (CS) without (136) or with (435) radiotherapy (CS+RT). The mean histological tumour sizes in these three groups were 25.6, 8.2, 14.8 mm, respectively (P<0.0001). After a 91-month median follow-up, local recurrence (LR) rates were 2.1, 30.1 and 13.8% in the RS, CS and CS +RT groups, respectively (P=0.001); LR were invasive in 59 and 60% in the CS and CS+RT groups, respectively. In these groups, the 8-year LR rates were 31.3 and 13.9%, respectively (P=0.0001). Nodal recurrence occurred in 3.7 and 1.8% in the CS and CS+RT groups. Metastases rates were 1.4, 4.4 and 1.4% in the RS, CS and CS+RT groups. Among the 60 cases of invasive LR, in CS and CS+RT groups 19% developed metastases. After multivariate analysis, we did not identify any significant LR risk factor in the CS group, whereas young age (<40 years) and incomplete excision were significant in the CS+RT group (P=0.012 and P=0.02, respectively).

Breast cancer occurred after treatment for Hodgkin's disease: analysis of 133 cases

PURPOSE

To assess the clinical and histological characteristics of breast cancer (BC) occurring after Hodgkin's disease (HD) and give possible therapies and prevention methods.

MATERIALS AND METHODS

In a retrospective multicentric analysis, 117 women and two men treated for HD subsequently developed 133 BCs. The median age at diagnosis of HD was 24 years. The HD stages were stage I in 25 cases (21%), stage II in 70 cases (59%), stage III in 13 cases (11%), stage IV in six cases (5%) and not specified in five cases (4%). Radiotherapy (RT) was used alone in 74 patients (63%) and combined modalities with chemotherapy (CT) was used in 43 patients (37%).

RESULTS

BC occurred after a median interval of 16 years. TNM classification (UICC, 1978) showed 15 T0 (11.3%), 44 T1 (33.1%), 36 T2 (27.1%), nine T3 (6.7%), 15 T4 (11.3%) and 14 Tx (10.5%). Ductal infiltrating carcinoma and ductal carcinoma in situ (DCIS) represented 81.2 and 11.3% of the cases, respectively. Among the infiltrating carcinoma, the axillary involvement rate was 50%. Seventy-four tumours were treated by mastectomy without (67) or with (ten) RT. Forty-four tumours had lumpectomy without (12) or with (32) RT. Another four received RT alone, and one CT alone. Sixteen patients (12%) developed isolated local recurrence. Thirty-nine patients (31.7%) developed metastases and 34 died; 38 are in complete remission whereas five died of intercurrent disease. The 5-year disease-specific survival rate was 65.1%. The 5-year disease-specific survival rates for the pN0, pN1-3 and pN>3 groups were 91, 66 and 15%, respectively (P<0.0001), and 100, 88, and 64% for the TIS, T1 and T2. For the T3 and T4, the survival rates decreased sharply to 32 and 23%, respectively. These secondary BC are of two types: a large number of aggressive tumours with a very unfavourable prognosis (especially in the case of pN>3 and/or T3T4), and many tumours with a 'slow spreading' such as DCIS and microinvasive lesions. These lesions developed especially in patients treated exclusively by RT.

CONCLUSIONS

The young women and girls treated for HD should be carefully monitored in the long-term by clinical examination, mammography and ultrasonography. We suggest that a baseline mammography is performed 5-8 years after supradiaphragmatic irradiation (complete mantle or involved field) in patients who were treated before 30 years of age. Subsequent mammographies should be performed every 2 years or each year, depending on the characteristics of the breast tissue (e.g. density) and especially in the case of an association with other BC risk factors. This screening seems of importance due to excellent prognosis in our T(1S)T(1) groups, and the possibility of offering these young women a conservative treatment.

Shared decision-making in question

Over recent years, communication within the physician-patient relationship has been profoundly changing. New modes of conveying diagnostic and therapeutic information influence the way in which decisions regarding treatment are made. We propose a critical review of the various theoretical models as presented in the literature, from the paternalistic to the shared decision model, in order to reveal conceptual ambiguities and their related methodological problems. This analysis leads to a project for clarifying these problems through a research protocol based on shared decision-making.

Lymphatic mapping and sentinel node biopsy of operable breast cancer

The aim of this study was to evaluate the reliability and accuracy of sentinel node biopsy for invasive breast cancer and the predictability of axillary node status. Between January 1996 and June 1997 a total of 73 patients underwent patent blue dye lymphatic mapping and sentinel node biopsy followed by standard (level I and II) axillary node dissection (one bilateral procedure). The sentinel node was identified in 82.4% (61/74) of the cases and was predictive of axillary status in 96.7% (59/61). The false-negative rate of the procedure was 8.0% (2/25). The sentinel node was involved in 37.7% (23/61) and was the only one invaded in 30.4% (7/23). The sensitivity of the procedure was 92% (CI95% 74-99%) and its specificity 100%. It is currently considered to be an attractive new procedure undergoing evaluation in prospective controlled trials. This study confirmed the reliability and reproducibility of intraoperative lymphatic mapping and sentinel node biopsy. This is the first step toward a new era of minimally invasive axillary surgery for breast cancer.

[Interest of periareolar injection for colorimetric detection of sentinel node in breast cancer]

Most teams working on sentinel node biopsy in the treatment of breast cancer inject either radioactive colloid or vital blue dye around the primary tumour. Many anatomical studies and lymphoscintigraphical studies, some very old, have shown that the lymphatic drainage of the breast is collected first in the periareolar plexus of Sappey, then routed to the axilla in 95% of cases, via one or two primary collectors. In a series of 94 breast cancers measuring less than 3 cm, with any palpable axillary lymph node, 2 ml of patent blue was injected intradermally around the areola, at the two meridians around the tumor. The sentinel node was identified in 89 cases (94,7%), regardless of the location of the primary tumor. All the sentinel nodes were located in the lower axilla. An average of 1.6 nodes were found per patient. In 41 cases, axillary lymph node dissection was performed either immediately (5 technical failures, 9 positive frozen section) or delayed only if the sentinel node was positive, either on standard H&E staining or on immunohistochemistry (27 cases). Thus, axillary lymph node dissection was not performed in 48 patients (55%). In positive node patient, the sentinel node was the only positive lymph node in 20 patients (55%). For 5 positive node patients, axillary lymph node dissection was not performed: poor vital status (2 micro-metastatic nodes) or by decision of patient (3 IHC positive nodes). With this periareolar injection procedure, the rate of detection is highly satisfactory and is comparable to that usually published with peritumoral injection. This procedure seems appropriate in all cases, regardless of the topography, the size or the multifocality of breast cancer.

[The "Action Woman Health" program in three Lyons suburbs]

The cervical cancer screening campaign has been led in three cities in Lyons suburbs from October 1st, 1999 to October 31st, 1999. The objectives of this programme whose title was "Action Femme Santé" (Action Woman Health) were to screen cervical cancer systematically for women who accede with difficulties to smear technique, and to settle in an information, screenings and follow-up system. During the three years, 3,127 smears have been declared and have reached about 2,881 women. The rate of detected disorders is about 2.1%. This campaign has succeeded in its goal about the target public but the participation of health professionals was unsatisfactory because of many obstacles. This implementation of the programme and its results, the weak points and strong points to be kept from such experience, are developed.

Tamoxifen and malignant epithelial-nonepithelial tumours of the endometrium: report of six cases and review of the literature

AIMS

To review the use of tamoxifen in malignant epithelial-nonepithelial tumours of the endometrium. Tamoxifen has been widely used for almost 20 years as adjuvant therapy for breast cancer. Large clinical trials have pointed out that long-term tamoxifen therapy increases the risk of uterine cancers. These tumours include endometrial carcinomas, stromal sarcomas, leiomyosarcomas as well as malignant mixed (epithelial-nonepithelial) tumours.

METHODS

We report here six more cases of malignant epithelial-nonepithelial tumours which, in addition to those reported in the literature, makes a total of 36 presented cases. The pathogenesis of such tumours remains unclear, but it has been claimed that unopposed oestrogenic stimulation due to the agonistic effect of tamoxifen might be involved, as in the case of endometrial carcinomas. Pelvic irradiation has also been incriminated, especiallly in women under 55 years of age.

RESULTS

Among 21 endometrial malignant epithelial-nonepithelial tumours associated with tamoxifen, seven occurred in women less than 55 years old. Five of them had previous pelvic irradiation. The data from the literature and from our series suggest that tamoxifen might favour the occurrence of malignant epithelial-nonepithelial tumours in women with breast cancer aged over 55 years, whereas in younger women both pelvic irradiation and tamoxifen might participate.

[Cervical cancer screening for high risk women: is it possible? Results of a cervical cancer screening program in three suburban districts of Lyon]

Between november 1993 and october 1996, a cervical screening program was proposed for women 25-65-year-old who tend to have little or no medical supervision, in three suburban districts of Lyon. The data and results of the two last Pap-smears have been collected together with details of gynecological follow-up. Both general practitioners and gynaecologists were actively involved. A total of 3,792 women (12.3% of the target) were registered, with a larger proportion of women over 60 (17.7%). According to the "Consensus of Lille", only 403 women (34.4%) had adequate screening (over 50 y: 25.8%, 35-49 y: 39.4%, 25-35 y: 36.5%) and 2,489 women had inappropriate gynaecological follow-up: no smear for 185 women (4.9%) and inadequate schedule of follow-up visits for 476 others (12.5%). Missing data (date or results of Pap smear) were noted for 1,828 patients (48.2%). The screening procedure for women over 50 years was carried out mainly by general practitioner. Of 3,127 registered smears, 62 positive results were found (2.1%). Of these women, 9 were lost to follow-up and 4 did not have appropriate tests. Others results were: 27 negative further investigations, 9 CIN1, 7 CIN2, 3 CIN3, 1 in situ carcinoma and 2 invasive carcinoma. Despite low participation, this pilot study indicates that a procedure can be established to integrate high risk women in cervical cancer screening programme. Active participation of general practitioners is essential.

Nine breast angiosarcomas after conservative treatment for breast carcinoma: a survey from French comprehensive Cancer Centers

OBJECTIVES

To conduct a survey of the angiosarcomas developing after breast conservation for carcinoma in the French Cancer Centers, to study the evolution of these cases in detail, and to review literature in an attempt to propose an optimal treatment scheme.

MATERIAL AND METHODS

Eleven of the 20 French Cancer Centers agreed to research and retrospectively analyze all angiosarcomas discovered in patients previously treated by conservative treatment. The majority of the patients were node negative, T1N0M0. The mean age of the patients at the time of primary breast cancer treatment was 62.5 years, and 69 years at the diagnosis of the angiosarcoma.

RESULTS

During the last two decades, nearly 20,000 patients have been treated conservatively in these 11 centers, and only 9 cases of angiosarcoma were found. The median latency period between the treatment of the breast carcinoma and the diagnosis of the breast angiosarcoma was approximately 74 months, with a range of 57-108 months. Mastectomy was performed as the main treatment of this angiosarcoma. All recurrences after mastectomy for the angiosarcoma appeared within 16 months after the mastectomy. A median time of recurrence was found to be 7.5 months, regardless of the treatment. The angiosarcomas appeared to be very aggressive, and chemotherapy, radiotherapy, and sometimes hyperthermia could only palliate the condition for a short time. After the diagnosis of angiosarcoma, the median survival was 15.5 months, showing a particularly poor prognosis. Only 1 patient of 9 is alive without progressive disease at 32 months after salvage mastectomy for the recurrence of the angiosarcoma. Precise data obtained from 11 centers show that, of 18115 breast carcinomas treated conservatively, only 9 breast angiosarcomas are reported, which represents a prevalence of 5 cases of angiosarcoma per 10,000, which is the same prevalence for primary breast angiosarcomas occurring in healthy breasts.

CONCLUSION

Angiosarcoma developing after breast conserving therapy for carcinoma is a rare event, and induction of it by treatment is controversial. However, early diagnosis is essential and it appears that radical mastectomy gives the highest chance of cure and the best long-term survival.

[The role of the medical corps in a mass screening program for cervical cancer. The program "Female Health Action in 3 urban districts of Lyons]

A pilot study of cervical cancer screening has been initiated in three districts of Lyons suburbs. This campaign aims to increase women participation, specially for high risk groups, helped by an intensive collaboration of general practitioners and gynecologists. Despite several campaign of information, a low rate of participation (13%) was noted. A survey has been performed on the medical population, notably for their participation, eventual changes, encountered problems and perception of such a screening. At time of survey, only half of the general practitioners and 75% of gynecologist still participated. Complexity of administrative procedures, involvement in an epidemiologic survey, lack of time or non-gynecological practice were important obstacles. Volunteer practitioners, enhanced value of public health and university formation of doctors could be necessary in the future for such mass screening.

[Identification of axillary sentinel node by lymphotropic dye in breast cancer. Feasibility study apropos of 128 cases]

AIM OF THE STUDY

The goal of this study was to evaluate the technical feasibility of sentinel node biopsy in breast cancer and its predictivity of axillary node status.

PATIENTS AND METHODS

Between January 1996 and June 1997, 128 patients with invasive breast carcinomas, referred to the Cancer Center of Strasbourg and Lyon (France), underwent lymphatic mapping (Patent Blue dye) and sentinel node biopsy followed by axillary clearance (Berg's level I to II).

RESULTS

Sentinel node was identified in 76.5% of cases and was predictive of axillary status in 94.9% of cases. The false negative rate of the procedure was 5.1%. Sentinel lymph node was involved in 43.9% of cases and it was the only one involved in 30.2% of cases. The sensitivity of the procedure was 94% (CI: 95% = [88%-98%]) and its specificity 100%.

CONCLUSION

Actually considered as new attractive procedure under ongoing evaluation in prospective controlled trials, this study confirms the feasibility and reproductibility of lymphatic mapping and sentinel node biopsy, first stage before entering a new era of minimally invasive axillary surgery in breast cancer.

Iatrogenic risks of endometrial carcinoma after treatment for breast cancer in a large French case-control study. Fédération Nationale des Centres de Lutte Contre le Cancer (FNCLCC)

Since tamoxifen is widely used in breast cancer treatment and has been proposed for the prevention of breast cancer, its endometrial iatrogenic effects must be carefully examined. We have investigated the association between endometrial cancer and tamoxifen use or other treatments in women treated for breast cancer in a case-control study. Cases of endometrial cancer diagnosed after breast cancer (n = 135) and 467 controls matched for age, year of diagnosis of breast cancer and hospital and survival time with an intact uterus were included. Women who had received tamoxifen were significantly more likely to have endometrial cancer diagnosed than those who had not (crude relative risk = 4.9, p = 0.0001). Univariate and adjusted analyses showed that the risk increased with the length of treatment (p = 0.0001) or the cumulative dose of tamoxifen received (p = 0.0001), irrespective of the daily dose. Women who had undergone pelvic radiotherapy also had a higher risk (crude relative risk = 7.8, p = 0.0001). After adjusting for confounding factors, the risk was higher for tamoxifen users (p = 0.0012), treatment for more than 3 years (all p < 0.03) and pelvic radiotherapy (p = 0.012). Women who had endometrial cancer and had received tamoxifen had more advanced disease and poorer prognosis than those with endometrial cancer who had not received this treatment. Our results suggest a causal role of tamoxifen in endometrial cancer, particularly when used as currently proposed for breast cancer prevention. Pelvic radiotherapy may be an additional iatrogenic factor for women with breast cancer. Endometrial cancers diagnosed in women treated with tamoxifen have poorer prognosis. Women who receive tamoxifen for breast cancer should be offered gynaecological surveillance during and after treatment. A long-term evaluation of the risk-benefit ratio of tamoxifen as a preventive treatment for breast cancer is clearly warranted.

Prognostic value of P53 gene mutations in a large series of node-negative breast cancer patients

The most important subgroup of breast cancer patients for which reliable prognostic factors are needed are women without axillary lymph node involvement. Although overall, these patients have a good prognosis, it is known that 20-30% will experience a recurrence of the disease. To determine the prognostic significance of P53 tumor suppressor gene mutation, specimens from 113 primary breast cancers were evaluated for the presence of P53 alterations, as detected by cDNA sequencing of the entire coding sequence of the gene. The median follow-up for patients was 105 months. P53 gene mutation was an independent prognostic marker of early relapse and death. Our results suggest that P53 gene mutations could be an important factor to identify node-negative patients who have a poor prognosis in the absence of adjuvant therapy. Prospective studies should be designed to determine which therapy should be performed in this subgroup of patients.

[Bilateral breast cancer after Hodgkin disease. Clinical and pathological characteristics and therapeutic possibilities: an analysis of 13 cases]

PURPOSE

Though Hodgkin's disease (HD) is one of the malignancies in which considerable progress has been made, long-term side effects have been observed, second primary cancer being the most significant. Several recent reports have indicated an increased risk of breast cancer (BC) in girls and young women among HD patients.

MATERIALS AND METHODS

In a retrospective multicenter analysis, 63 women treated for HD subsequently developed BC. Results that were obtained in 13 women (21%) who developed either synchronous (five cases) or metachronous (eight cases) BC were analyzed. The median age at diagnosis of HD was 19 years. Seven patients underwent exclusive radiotherapy (RT) (including "mantle" supradiaphragmatic irradiation) and six received concomittant radiation therapy and chemotherapy.

RESULTS

The first breast tumor occurred after a median delay of 16 years. According to the TNM classification, we showed nine stage T0 (non palpable lesions), four stage T1, five stage T2, one stage T3, two stage T4 and five stage Tx BC. Seventeen infiltrating carcinomas, two fibrosarcomas and seven ductal carcinomas in situ were observed. Among 15 axillary dissections performed for invasive carcinomas, histological involvement was found in 10 cases. Seventeen tumors were treated by mastectomy and nine patients underwent conservative surgical treatment. With a 70-month median follow-up (range: 15-125), three patients developed locoregional recurrence and four other metastases. At present, eight are alive with no evidence of disease and one died of intercurrent disease.

CONCLUSION

According to previous works, BC represents 6.3 to 9% of all second cancers occurring after HD treatment. The risk is higher in young women treated before 20 years of age, especially before 15 years of age. Factors that favour the development of secondary BC are: supradiaphragmatic irradiation, very young age at treatment, chemotherapy with alkylating agents, and probably genetic factors. We conclude that young women and girls treated for HD should be carefully monitored at least 10 years after the end of the treatment for HD, using clinical examination, mammography and ultrasonography. The optimal rythm of this follow-up is not yet clearly defined. Moreover, after multidisciplinary concertation, we suggest that secondary BC be sometimes treated by conservative radiosurgical approach.

Breast cancer in patients treated for Hodgkin's disease: clinical and pathological analysis of 76 cases in 63 patients

In a retrospective multicentric analysis, 63 women treated between 1941 to 1988 for Hodgkin's disease (HD) subsequently developed 76 breast cancers (BC). The median age at diagnosis of HD was 26 years (range 7-67), and 22 women (35%) were 20 years old or less. Exclusive radiotherapy (RT) was used in 36 women (57%) and combined modalities with chemotherapy (CT) in 25 (39%). Breast cancer occurred after a median interval of 16 years (range 2-40) and the median age at diagnosis of the first BC was 42 years (range 25-73). TNM classification (UICC, 1978) showed 10 T0 (non-palpable lesions) (13%), 20 T1 (26%), 22 T2 (29%), 8 T3 (11%), 7 T4 (9%) and 9 Tx (12%), giving altogether a total of 76 tumours, including, respectively, 5 and 8 bilateral synchronous and metachronous lesions. Among the 68 tumours initially discovered, 53 ductal infiltrating, one lobular infiltrating and two medullary carcinomas were found. Moreover, two fibrosarcomas and 10 ductal carcinoma in situ (DCIS) were also found. Among 50 axillary dissections for invasive carcinomas, histological involvement was found in 31 cases (62%). 45 tumours were treated by mastectomy, without (n = 35) or with (n = 10) RT. 27 tumours had lumpectomy, without (n = 7) or with RT (n = 20). 2 others received RT only, and one only CT. 7 patients (11%) developed isolated local recurrence. 20 patients (32%) developed metastases and all died; 38 are in complete remission, whereas 5 died of intercurrent disease. The 5-year disease-specific survival rate by the Kaplan-Meier method was 61%. The 5-year disease-specific survival rate for pN0, pN1-3 and pN > or = 3 groups were 91%, 66% and 0%, respectively (P < 0.0001) and 100%, 88%, 64% and 23% for the T0, T1, T2 and T3T4 groups, respectively. These secondary BCs seem to be of two types: a large number of aggressive tumours with a very unfavourable prognosis (especially in the case of pN > 3 and/or T3T4); and many tumours with a 'slow development' such as DCIS and microinvasive lesions, especially in patients treated exclusively by RT. Moreover, a very unusual rate of bilateral tumours (21%) was observed. These secondary BC could be 'in field', in 'border of field' or 'out of field'. However, a complete analysis of doses delivered by supradiaphragmatic irradiation was often very difficult, due to large variations in several parameters. We conclude that young women and girls treated for HD should be carefully monitored by clinical examination, mammography and ultrasonography.

Radiation induced sarcomas following treatment for breast cancer: presentation of a series of 14 cases treated with an aggressive surgical approach

According to the criteria established by Cahan et al., we report 14 radiation induced sarcomas occurring in the treated volume after radiation therapy for adenocarcinoma of the breast. All these sarcomas were treated by wide surgical resection. In spite of a macroscopic free margin, only patients who underwent major amputation could hope to be cured. All the centrally located sarcomas recurred.