Final Analysis of a Phase II Trial of Once Weekly Hypofractionated Whole Breast Irradiation for Early Stage Breast Cancer

INTRODUCTION

We hypothesized that five-fraction once weekly hypofractionated whole breast irradiation (WH-WBI) would be safe and effective following breast conserving surgery for medically underserved patients with breast cancer. We report the protocol-specified primary endpoint of in breast tumor recurrence (IBTR) at five years.

METHODS

After signing informed consent, patients were treated with WH-WBI after breast conserving surgery were followed prospectively on an IRB-approved protocol. Women included in this study had stage 0-II breast cancer treated with negative surgical margins and met pre-specified criteria for being underserved. WH-WBI was 28.5 or 30Gy delivered to the whole breast with no elective coverage of lymph nodes. The primary endpoint was IBTR at 5 years. Secondary endpoints were distant disease-free survival (DDFS), recurrence free survival (RFS), overall survival (OS), adverse events, and cosmesis.

RESULTS

158 patients received WH-WBI on protocol from 2010 to 2015. Median follow-up was 5.5 years (range, 0.2-10.0). Stage distribution was ductal carcinoma in situ (DCIS) 22%; invasive pN0 68%; invasive pN1 10%. 28% of patients had grade 3 tumors, 10% were estrogen receptor negative and 24% required adjuvant chemotherapy. There were six IBTR events. The 5-, 7- and 10-year risks of IBRT for all patients were 2.7% (95% CI 0.89-6.34), 4.7% (95% CI 1.4-11.0) and 7.2% (95% CI 2.4-15.8) respectively. The 5, 7 and 10-year rates of DDFS were 96.4, 96.4 and 86.4%, RFS were 95.8%, 93.6 and 80.7%, and OS were 96.7, 88.6 and 76.7%, respectively. Improvement in IBTR-free time was seen in DCIS, lobular histology, low-grade tumors, T1 stage, Her2 negative tumors and receipt of a radiation boost to the lumpectomy bed.

CONCLUSION

Postoperative WH-WBI had favorable disease-specific outcomes that were comparable to those seen with conventional and moderately hypofractionated radiation techniques. WH-WBI may improve access to care for underserved patients with stage 0-II breast cancer.

A Phase II Trial of Once Weekly Hypofractionated Breast Irradiation for Early Stage Breast Cancer

PURPOSE

To report an interim analysis of a phase II trial of once weekly, hypofractionated breast irradiation (WH-WBI) following breast conserving surgery (BCS).

METHODS

Patients had stage 0-II breast cancer treated with breast BCS with negative margins. WH-WBI was 28.5 or 30Gy delivered to the whole breast using tangential beams with no elective coverage of lymph nodes. The primary endpoint was ipsilateral breast tumor recurrence (IBTR). Secondary endpoints were distant disease-free survival (DDFS), recurrence free survival (RFS), overall survival (OS), adverse events and cosmesis.

RESULTS

From 2011 to 2015, 158 patients received WH-WBI. Median follow up was 4.4 years (range 0.2-8.1). Stage distribution was DCIS 22%; invasive pN0 68%; invasive pN1 10%. 80 patients received 30 Gy and 78 received 28.5 Gy with median follow up times of 5.6 and 3.7 years, respectively. There were 5 IBTR events, all in the 30 Gy group. The 5- and 7- year risks of IBRT for all patients were 2.2% (95% CI 0.6-5.8) and 6.0% (95% CI 1.1-17.2), respectively. The 7-year rates of DDFS, RFS, and OS were 96.3%, 91.5% and 89.8%, respectively. Improvement in IBTR-free time was seen in DCIS, lobular histology, low grade tumors, Her2 negative tumors and 28.5 Gy dose (all p < 0.0001).

CONCLUSIONS

Disease-specific outcomes after WH-WBI are favorable and parallel those seen with conventional radiation techniques for stage 0-II breast cancer.

L-Dex, arm volume, and symptom trajectories 24 months after breast cancer surgery

Purpose

Study objectives were to examine: (a) biomarker trajectories (change from presurgical baseline values of Lymphedema index (L‐Dex) units and arm volume difference) and symptom cluster scores 24 months after breast cancer surgery and (b) associations of these objective biomarkers and symptom cluster scores. Patient/treatment characteristics influencing trajectories were also evaluated.

Methods

A secondary analysis of data from the published interim analysis of a randomized parent study was undertaken using trajectory analysis. Five hundred and eight participants included in the prior analysis with 24 months of postsurgical follow‐up were initially measured with bioelectric impedance spectroscopy (BIS) and tape measure (TM) and completed self‐report measures. Patients were reassessed postsurgery for continuing eligibility and then randomized to either BIS or TM groups and measured along with self‐report data at regular and optional* visits 3, 6,12,15*,18, 21*, and 24‐months.

Results

Three subclinical trajectories were identified for each biomarker (decreasing, stable, increasing) and symptom cluster scores (stable, slight increase/decrease, increasing). Subclinical lymphedema was identified throughout the 24‐month period by each biomarker. An L‐Dex increase at 15 months in the BIS group was noted. The self‐report sets demonstrated contingency coefficients of 0.20 (LSIDS‐A soft tissue, P = .031) and 0.19 (FACTB+4, P = .044) with the L‐Dex unit change trajectories.

Conclusions

These data support the need for long‐term (24 months) prospective surveillance with frequent assessments (every 3 months) at least 15 months after surgery. Statistically significant convergence of symptom cluster scores with L‐Dex unit change supports BIS as beneficial in the early identification of subclinical lymphedema.

Patient-Reported Outcomes and Cosmesis After Once-Weekly Hypofractionated Breast Irradiation in Medically Underserved Patients

PURPOSE

To evaluate patient-reported outcomes (PROs) and cosmesis from a phase 2 trial of once-weekly hypofractionated breast irradiation (WH-WBI) after breast-conserving surgery (BCS).

METHODS AND MATERIALS

Patients had stage 0-II breast cancer treated with BCS and negative margins. WH-WBI was 28.5 to 30 Gy in 5 weekly fractions of 5.7 to 6 Gy delivered with or without a boost. PROs were collected for 3 years after treatment using the Breast Cancer Treatment Outcome Scale (BCTOS) and European Organization for Research and Treatment of Cancer Breast Cancer-Specific Quality of Life Questionnaire (QLQ-BR23). Physicians rated cosmetic outcome with the Global Cosmesis Score. Longitudinal growth models were used to assess changes in BCTOS across time, and baseline values and changes between time points were correlated with patient and treatment factors.

RESULTS

From 2011 to 2015, 158 women received WH-WBI, and 148 were eligible for analysis after a median follow-up of 39.3 months. Adverse changes (P < .001) in global BCTOS score and breast pain and arm function subscores were observed 6 months after radiation therapy, followed by improvement to near-baseline values at years 1 and 3. Adverse changes in BCTOS cosmetic subscore were also detected at 6 months (P < .001), with no significant improvement at 1 (P = .385) and 3 (P = .644) years. No effect was detected for longitudinal changes in BCTOS scoring for age, body mass index, diabetes, smoking, breast volume, tumor size, seroma volume, dosimetric factors, dose, boost, or systemic therapy. Physician-rated cosmesis at 3 years was excellent/good in 89% and fair/poor in 11%.

CONCLUSIONS

WH-WBI was associated with transient worsening in arm function and breast pain but persistent adverse changes in cosmetic PROs that were typically mild or moderate in severity. Physician-rated cosmetic outcomes were acceptable.

A Randomized Trial Evaluating Bioimpedance Spectroscopy Versus Tape Measurement for the Prevention of Lymphedema Following Treatment for Breast Cancer: Interim Analysis

Background

Breast cancer-related lymphedema (BCRL) represents a major source of morbidity among breast cancer survivors. Increasing data support early detection of subclinical BCRL followed by early intervention. A randomized controlled trial is being conducted comparing lymphedema progression rates using volume measurements calculated from the circumference using a tape measure (TM) or bioimpedance spectroscopy (BIS).

Methods

Patients were enrolled and randomized to either TM or BIS surveillance. Patients requiring early intervention were prescribed a compression sleeve and gauntlet for 4 weeks and then re-evaluated. The primary endpoint of the trial was the rate of progression to clinical lymphedema requiring complex decongestive physiotherapy (CDP), with progression defined as a TM volume change in the at-risk arm ≥ 10% above the presurgical baseline. This prespecified interim analysis was performed when at least 500 trial participants had ≥ 12 months of follow-up.

Results

A total of 508 patients were included in this analysis, with 109 (21.9%) patients triggering prethreshold interventions. Compared with TM, BIS had a lower rate of trigger (15.8% vs. 28.5%, p < 0.001) and longer times to trigger (9.5 vs. 2.8 months, p = 0.002). Twelve triggering patients progressed to CDP (10 in the TM group [14.7%] and 2 in the BIS group [4.9%]), representing a 67% relative reduction and a 9.8% absolute reduction (p = 0.130).

Conclusions

Interim results demonstrated that post-treatment surveillance with BIS reduced the absolute rates of progression of BCRL requiring CDP by approximately 10%, a clinically meaningful improvement. These results support the concept of post-treatment surveillance with BIS to detect subclinical BCRL and initiate early intervention.

A Prospective Study of L-Dex Values in Breast Cancer Patients Pretreatment and Through 12 Months Postoperatively

BACKGROUND

Data regarding pretreatment, bioimpedance spectroscopy (BIS) L-Dex^® values for patients newly diagnosed with breast cancer, and longitudinal data 12 months postoperatively are lacking. This study describes L-Dex values at the time of breast cancer diagnosis and maximum L-Dex change within 12 months of surgery.

METHODS AND RESULTS

Patients were enrolled in a parent, clinical trial that compares the effectiveness of BIS for early detection of breast cancer-related lymphedema to tape measurement. A total of 280 women with a pretreatment and at least one postoperative L-Dex measurement (within 12 months of surgery) were included. Pretreatment L-Dex readings were compared with population norms and maximum L-Dex changes within 12 months were examined. An L-Dex U400 device was used to obtain BIS measurements. The documented normative mean value using this device is 0.00, which is at the 49th percentile for this sample. Approximately 6% of patients had a pretreatment L-Dex value of ≥7.0; 1.8% had an L-Dex value ≥10.0. For 12 months, 17.1% (n = 48) of patients had a maximum change in L-Dex value from pretreatment of ≥7.0 L-Dex units, suggestive of clinical lymphedema.

CONCLUSIONS

At the time of breast cancer diagnosis, L-Dex values are similar to normative values. Identified maximum changes in L-Dex values 12 months postoperatively suggest that frequent L-Dex measurements during that time frame are of potential clinical benefit. Our findings are consistent with research supporting an L-Dex value of ≥7 as indicative of clinical lymphedema with subclinical lymphedema logically occurring at somewhat lower likely, near ≥6.5.

Cost-effectiveness Analysis of Contralateral Prophylactic Mastectomy Compared to Unilateral Mastectomy with Routine Surveillance for Unilateral, Sporadic Breast Cancer

BACKGROUND

Contralateral prophylactic mastectomy (CPM) rates in younger women with unilateral breast cancer have more than doubled. Studies of cost and quality of life of the procedure remain inconclusive.

METHODS

A cost-effectiveness analysis using a decision-tree model in TreeAge Pro 2015 was used to compare long-term costs and quality of life following unilateral mastectomy (UM) with routine surveillance versus CPM for sporadic breast cancer in women aged 45 years. A 10-year risk period for contralateral breast cancer (CBC), reconstruction, wound complications, cost of routine surveillance, and treatment for CBC were used to estimate accrued costs. In addition, a societal perspective was used to estimate quality-adjusted life years (QALYs) following either treatment for a period of 30 years. Medical costs were obtained from the 2014 Medicare physician fee schedule and event probabilities were taken from recent literature.

RESULTS

The mean cost of UM with surveillance was $14,141 and CPM was $20,319. Treatment with CPM resulted in $6178 more in costs but equivalent QALYs (17.93) compared with UM over 30 years of follow-up. Even with worst-case scenario and varying assumptions, CPM is dominated by UM in terms of cost and quality.

CONCLUSIONS

From this refined model, UM with routine surveillance costs less and provides an equivalent quality of life. Patients undergoing CPM may eliminate the anxiety of routine surveillance, but they face the burden of higher lifetime medical costs.

Ductal carcinoma in situ current trends, controversies, and review of literature

Ductal carcinoma in situ (DCIS) is a non-obligate precursor, non-invasive malignancy confined within the basement membrane of the breast ductal system. There is a wide variation in the natural history of DCIS with an estimated incidence of progression to invasive ductal carcinoma being at least 13%-50% over a range of 10 or more years after initial diagnosis. Regardless of the treatment strategy, long-term survival is excellent. The controversy surrounding DCIS relates to preventing under-treatment, while also avoiding unnecessary treatments. In this article, we review the incidence, presentation, management options and surveillance of DCIS. Furthermore, we address several current controversies related to the management of DCIS, including margin status, sentinel node biopsy, hormonal therapy, the role of radiation in breast conservation surgery, and various risk stratification schemes.

Oncoplastic Reduction Pattern Technique Following Removal of Giant Fibroadenoma

Objective: Oncoplastic surgery was developed to allow for large tumor excision and immediate breast reconstruction with the goal of optimal breast shape and symmetry. Although initially used in women who underwent lumpectomy for breast malignancy, these techniques can be useful for cosmetic issues caused by benign breast disease. We describe a modification of an inferior pedicle with Wise-pattern reduction mammoplasty for oncoplastic reconstruction of a giant fibroadenoma. Methods: A 30-year-old woman with size 32 DD breasts was referred by the surgical oncologist with a biopsy-proven fibroadenoma of the right breast. Surgical oncology excised the mass, and immediate reconstruction was performed with an inferolateral pedicle Wise-pattern reduction technique. Results: Immediately postoperatively, the patient showed excellent symmetry. Follow-up postoperatively showed good wound healing, preserved symmetry, and a viable, sensate nipple. Conclusions: Oncoplastic breast reconstruction in a reduction pattern technique after giant fibroadenoma removal provides an excellent outcome, allowing for improved symmetry.

Longer Time Intervals from Diagnosis to Surgical Treatment in Breast Cancer: Associated Factors and Survival Impact

Time interval (TI) from breast cancer diagnosis to definitive surgery is increasing, but the impact on outcomes is not well understood. TI longer than 30 days is associated with a greater chance of delay of chemotherapy, which may impact survival. We sought to identify factors associated with longer TI and the influence on outcome measures. Methods: We examined TI for stage 0-III breast cancer patients treated between 2006 and 2015 at a university-based cancer center. Univariate and multivariate analyses were used to study factors associated with TI <30, 30 to 60, and >60 days. Kaplan–Meier plots were used to examine the effect of different TI on overall survival, disease-specific survival, and recurrence-free survival. Results: 1589 patients were included with a median follow-up of 47 months. Median TI was 32 days. Median TI increased in patients from 2011 to 2015 compared with those from 2006 to 2010 (35 vs 30 days, P < 0.001). On multivariate analysis, mastectomy (with or without reconstruction), MRI use, and increasing age were independent predictors of TI >30 days. There were no significant differences in overall survival, disease-specific survival, or recurrence-free survival. There was no association between TI >30 days and a subsequent delay >60 days to adjuvant chemotherapy (OR 1.04, 95% CI 0.72–1.52). Conclusions: TI has increased in the last five years. Patient characteristics, tumor biology, and stage do not influence TI, whereas age, mastectomy, and MRI use were all associated with longer TI. Longer TI does not appear to significantly delay adjuvant chemotherapy or influence short-term outcomes.

Longer Time Intervals from Diagnosis to Surgical Treatment in Breast Cancer: Associated Factors and Survival Impact

Time interval (TI) from breast cancer diagnosis to definitive surgery is increasing, but the impact on outcomes is not well understood. TI longer than 30 days is associated with a greater chance of delay of chemotherapy, which may impact survival. We sought to identify factors associated with longer TI and the influence on outcome measures.

METHODS

We examined TI for stage 0-III breast cancer patients treated between 2006 and 2015 at a university-based cancer center. Univariate and multivariate analyses were used to study factors associated with TI <30, 30 to 60, and >60 days. Kaplan-Meier plots were used to examine the effect of different TI on overall survival, disease-specific survival, and recurrence-free survival.

RESULTS

1589 patients were included with a median follow-up of 47 months. Median TI was 32 days. Median TI increased in patients from 2011 to 2015 compared with those from 2006 to 2010 (35 vs 30 days, P < 0.001). On multivariate analysis, mastectomy (with or without reconstruction), MRI use, and increasing age were independent predictors of TI >30 days . There were no significant differences in overall survival, disease-specific survival, or recurrence-free survival. There was no association between TI >30 days and a subsequent delay >60 days to adjuvant chemotherapy (OR 1.04, 95% CI 0.72-1.52).

CONCLUSIONS

TI has increased in the last five years. Patient characteristics, tumor biology, and stage do not influence TI, whereas age, mastectomy, and MRI use were all associated with longer TI. Longer TI does not appear to significantly delay adjuvant chemotherapy or influence short-term outcomes.

Breast abscess after intravenous methamphetamine injection into the breast

Intravenous drug use is a problem plaguing our society. We present a case of a young female who injected methamphetamine into her mammary vein, resulting in the formation of a breast abscess. This case demonstrates a rare but dangerous complication of intravenous drug use and a possible differential diagnosis in a patient presenting with a breast abscess.

Surgical Management of the Axilla in Breast Cancer

This article offers a review of the literature on current surgical management of the axilla in breast cancer. This includes the decision-making process involved in clinically node-negative patients versus clinically node-positive patients, with discussion of the indications for sentinel lymph node biopsy versus axillary dissection. It also examines the surgical axillary management of patients who receive neoadjuvant chemotherapy. This article will help update practicing surgeons on the evolving research and guidelines for the management of breast cancer axillary disease.

Article Commentary: Surgical Management of the Axilla in Breast Cancer

This article offers a review of the literature on current surgical management of the axilla in breast cancer. This includes the decision-making process involved in clinically node-negative patients versus clinically node-positive patients, with discussion of the indications for sentinel lymph node biopsy versus axillary dissection. It also examines the surgical axillary management of patients who receive neoadjuvant chemotherapy. This article will help update practicing surgeons on the evolving research and guidelines for the management of breast cancer axillary disease.

Decline in Frozen Section Diagnosis for Axillary Sentinel Lymph Nodes as a Result of the American College of Surgeons Oncology Group Z0011 Trial

CONTEXT

-Results of the American College of Surgeons Oncology Group Z0011 trial showed that patients with early-stage breast cancer and limited sentinel node metastasis treated with breast conservation and systemic therapy did not benefit from axillary lymph node dissection. Subsequently, most pathology departments have likely seen a decrease in frozen section diagnosis of sentinel lymph nodes.

OBJECTIVE

-To determine the effect of the Z0011 trial on pathology practice and to examine the utility of intraoperative sentinel lymph node evaluation for this subset of patients.

DESIGN

-Pathology reports from cases of primary breast cancer that met Z0011 clinical criteria and were initially treated with lumpectomy and sentinel lymph node biopsy from 2009 to 2015 were collected. Clinicopathologic data were recorded.

RESULTS

-Sentinel lymph node biopsies sent for frozen section diagnosis occurred in 22 of 22 cases (100%) in 2009 and 15 of 22 cases (68%) in 2010 during the pre-Z0011 years, and in 3 of 151 cases (2%) collected in 2011 through 2015, considered to be post-Z0011 years. Of the 151 post-Z0011 cases, 28 (19%) had sentinel lymph nodes with metastasis, and 147 (97%) were spared axillary lymph node dissection.

CONCLUSIONS

-Following Z0011, intraoperative sentinel lymph node evaluation has significantly decreased at our institution. Prior to surgery, all patients had clinically node-negative disease. After sentinel lymph node evaluation, 97% (147 of 151) of the patients were spared axillary lymph node dissection. Therefore, routine frozen section diagnosis for sentinel lymph node biopsies can be avoided in these patients.

A Randomized Prospective Comparison of Patient-Assessed Satisfaction and Clinical Outcomes with Radioactive Seed Localization versus Wire Localization

Radioactive seed localization (RSL) has emerged as an alternative to wire localization (WL) in patients with nonpalpable breast cancer. Few studies have prospectively evaluated patient satisfaction and outcomes with RSL. We report the results of a randomized trial comparing RSL to WL in our community hospital. We prospectively enrolled 135 patients with nonpalpable breast cancer between 2011 and 2014. Patients were randomized to RSL or WL. Patients rated the pain and the convenience of the localization on a 5-point Likert scale. Characteristics and outcomes were compared between groups. Of 135 patients enrolled, 10 were excluded (benign pathology, palpable cancer, mastectomy, and previous ipsilateral cancer) resulting in 125 patients. Seventy patients (56%) were randomized to RSL and 55 (44%) to WL. Fewer patients in the RSL group reported moderate to severe pain during the localization procedure compared to the WL group (12% versus 26%, respectively, p = 0.058). The overall convenience of the procedure was rated as very good to excellent in 85% of RSL patients compared to 44% of WL patients (p < 0.0001). There was no difference between the volume of the main specimen (p = 0.67), volume of the first surgery (p = 0.67), or rate of positive margins (p = 0.53) between groups. RSL resulted in less severe pain and higher convenience compared to WL, with comparable excision volume and positive margin rates. High patient satisfaction with RSL provides another incentive for surgeons to strongly consider RSL as an alternative to WL.

Occult metastases in node-negative breast cancer: A Surveillance, Epidemiology, and End Results-based analysis

INTRODUCTION

The role of immunohistochemistry (IHC) for detecting occult lymph node disease in patients initially found to be node-negative by routine pathology is controversial. In this study, we evaluated trends associated with overall survival in node-negative breast cancer patients staged by IHC.

METHODS

The Surveillance, Epidemiology, and End Results database was queried for all patients with invasive breast adenocarcinoma and negative lymph nodes on routine pathology between 2004 and 2011 who underwent IHC to evaluate for occult nodal disease. Overall survival stratified by N-stage was compared with Kaplan-Meier analysis. Multivariate analysis was performed using a Cox proportional hazards model.

RESULTS

Overall, 93,070 patients were identified, including 4,657 patients with isolated tumor cells (<0.2 mm diameter or <200 cells) and 6,720 patients with micrometastases (0.2-2 mm diameter). Kaplan-Meier curves demonstrated a difference in overall survival across all groups (P < .0001). On multivariate analysis, micrometastases remained an independent predictor for survival compared with IHC-negative patients (hazard ratio 1.40, 95% confidence interval 1.28-1.53), whereas isolated tumor cells were not a significant predictor (hazard ratio 1.05, 95% confidence interval 0.92-1.20).

CONCLUSION

Patients with occult micrometastases in axillary lymph nodes found via IHC demonstrated a significant overall survival difference, but isolated tumor cells have no prognostic significance.

Current practice of thromboprophylaxis in the burn population: A survey study of 84 US burn centers

While there is limited prospective data on the incidence of venous thromboembolism (VTE) in the burn population, there are no prospective studies on the efficacy and safety of VTE prophylaxis in these patients. Despite lack of such data, we hypothesized that most burn centers practice some form of prophylaxis. Eighty-four US burn centers were contacted regarding their modality of VTE prophylaxis, if any. Of the 84 US burn centers, 71 were enrolled in this survey. 76.1% centers reported routine VTE prophylaxis. Modalities included sequential compression device (SCD) (33), subcutaneous heparin (31), enoxaparin (13), dalteparin (3), and intravenous heparin infusion (1). Twenty-one reported combined modalities of SCD and subcutaneous heparin (19), SCD and enoxaparin (1), or SCD and dalteparin (1). Survey results underscore the need to definitively establish risk factors for VTE in the burn population and to prospectively define an evidence-based standard of care in prophylaxis for those patients.

Use of octyl-2-cyanoacrylate in cleft lip repair

Octyl-2-cyanoacrylate (Dermabond; Ethicon, Somerville, NJ) is a synthetic tissue adhesive recently approved for skin closure. This study was designed to assess its effectiveness for use in clefts lip repairs. Sixty-four patients with unilateral, bilateral, or midline cleft lip defects were repaired. The ages at repair ranged from 4 days to 19 months, with an average of 46.5 days. Follow-up ranged from 6 months to 3 years. No complications were found. Several advantages were observed: shorter operative time, formation of a protective barrier, simplified incision care, no need for suture removal, and improved scar outcome. This study supports octyl-2-cyanoacrylate as an alternative to skin sutures in primary cleft lip repair.