Neoadjuvant chemotherapy in non-metastatic breast cancer: The surgeon's perspective

Breast cancer is the most common non-skin cancer in Australia, affecting 1 in 7 women by the age of 85 years. Current management of early breast cancer is becoming increasingly variable and complex. The typical range of treatments include some combination of surgery, chemotherapy and targeted therapy, immunotherapy, radiotherapy, and endocrine therapy. Neoadjuvant chemotherapy (NACT) in carefully selected patients can facilitate increased rates of breast conservation therapy, and when successful, offers improved cosmesis due to less extensive resection of tissue. A neoadjuvant approach also provides biological insight into a patient's tumour, prognostication based on a patient's response to therapy, as well as enabling their treating oncologist to personalise adjuvant strategies based on the presence or absence of residual cancer at surgery. Neoadjuvant chemotherapy has become an integral element in the provision of breast conserving surgery to selected early-stage breast cancer patients. Appreciating the indications and understanding the likely outcomes from NACT in select situations, can result in significant improvements in patient tailored care.

Breast conservation therapy decreased heart-specific mortality in breast cancer patients compared with mastectomy

AIM

To investigate the impacts of breast conservation therapy (BCT) and mastectomy on heart-specific mortality in breast cancer patients.

METHODS

Patients with primary breast cancer registered in the Surveillance, Epidemiology, and End Results (SEER) database between Jan 1998 and Dec 2015 were included. Patients were divided into either breast conservation therapy or mastectomy group. To compare mortality caused by heart diseases in breast cancer patients with BCT or mastectomy, univariate and multivariate regression after propensity score matching (PSM) were performed. Kaplan-Meier analysis was also used to evaluate heart-specific survival between two groups.

RESULTS

132,616 patients with breast cancer were enrolled in this study. After PSM, four risk factors including age, race, marital status and types of surgery were identified significantly associated with death from heart diseases. Heart-specific survival analysis further showed that overall, BCT poses a lower risk to heart-specific mortality compared with mastectomy.

CONCLUSION

Compared with mastectomy, BCT significantly decreased heart-specific mortality in breast cancer patients.

Routine four-quadrant cavity shaving at the time of wide local excision for breast cancer reduces re-excision rate

INTRODUCTION

Breast conservation therapy (BCT) has been shown to have comparable long-term survival outcomes when compared with mastectomy. Clearance of excision margin is one of the mainstays of the surgical treatment, which if not achieved at the first operation of BCT results in the need for subsequent surgery.

METHODS

This study evaluated the impact of routinely taken cavity shavings on re-excision rates. This retrospective two-centre study describes the use of routine four-quadrant cavity shaving in 449 patients with consecutively treated with wide local excision for invasive cancer or ductal carcinoma in situ.

RESULTS

The overall incomplete excision rate was 10.6%. Routine cavity shaving prevented the need for re-excision in 84 patients (18.7%) and identified the need for further re-excision in 33 patients (7.3%). Median time from surgery to radiotherapy was 50 days (range 13-209) for non-re-excised patients versus 78 days (range 47-260) for re-excised patients (p<0.001). Median time to chemotherapy (n=75) was 44 days (range 14-106) for non-re-excised patients versus 56 days (range 35-116) for re-excised patients (p=0.017).

CONCLUSIONS

This study demonstrates that routine cavity shaving decreases re-excision rate in patients treated with wide local excision and prevents delays to adjuvant treatment due to incomplete excision.

Effect of patient decision aids on decisional conflict and regret associated with breast cancer surgery: a randomized controlled trial

BACKGROUND

Patients with breast cancer encounter difficulties in making surgical treatment decisions. Shared decision-making (SDM) with patient decision aids (PDAs) can minimize patients' decisional conflicts. However, the effect of PDAs in Asia remains inconclusive. This study investigated the effect of SDM assisted by PDAs on the decisional conflict of patients with breast cancer.

METHODS

In this two-group, outcome assessor-blind, randomized controlled trial, 151 patients diagnosed as having breast cancer were assigned to the PDA (SDM with PDA) group or the standard (SDM without PDA) group. Demographic and clinical variables were analyzed to identify variables affecting the treatment choice. The patients' decision-making difficulties were evaluated using the four-item SURE scale during preoperative hospitalization, and decisional conflicts were examined using the five-item Decision Regret scale and Hospital Anxiety and Depression Scale (HADS) 1 month after surgery.

RESULTS

The choice of breast conservation therapy and mastectomy did not significantly differ between the PDA and standard groups. The PDA group had a higher level of depression after making decisions (P = 0.029) than did the standard group. No significant difference in the total scores of the SURE scale and Decision Regret scale were noted between the groups.

CONCLUSION

PDAs did not assist the patients with breast cancer in making breast surgery-related decisions. Clinicians should focus on SDM grounded in evidence-based medicine with care and help patients consider their individual preferences.

TRIAL REGISTRATION

ClinicalTrial.gov, NCT03105076; April 7, 2017 ( http://www.

CLINICALTRIALS

gov ).

Rates of margin positive resection with breast conservation for invasive breast cancer using the NCDB

Background

Previous studies suggest the rate of positive surgical margin (PSM) after lumpectomy for breast cancer is approximately 20 %. The risk of PSM at time of resection is often a source of fear for patients, driving some to elect to undergo mastectomy. This study describes rates and predictors of positive margins for invasive breast cancers in the National Cancer Database (NCDB).

Materials and methods

From 2004 to 2013, patients with non-metastatic invasive breast cancers who underwent breast conservation surgery were identified from the NCDB. Patients’ demographic, clinical, and facility of treatment characteristics were collected and compared. Per SSO-ASTRO-ASCO criteria, margin negative is defined as no gross or microscopic disease (i.e. no tumor on ink). Bivariate tests and multivariate logistic regression were conducted to identify independent predictors of patients with PSM at the time of resection.

Results

A total of 707,798 patients were identified with non-metastatic invasive breast tumors who underwent lumpectomy. Rate of PSM across the entire cohort was 5.02 %. Over time, the rate of PSM decreased significantly from 6.54 % in 2004 to 3.91 % in 2013 (p < 0.001). Pure lobular histology predicted for the highest rate of PSM compared with IDC (8.63 vs 4.55 %; p < 0.001). In adjusted analysis, high grade, non-ductal histology and HER2 amplification were significantly associated with PSM with breast conservation while estrogen and progesterone status were not.

Conclusion

This study demonstrates a 5 % risk of PSM at time of breast conservation surgery using a large, modern national database. Patients with invasive lobular and mixed histology have a nearly two-fold risk of PSM compared to invasive ductal cancers. These results provide important data points to help appropriately counsel patients regarding the risk of PSM.

•

Using the National Cancer Database (NCDB), trends in positive surgical margin (PSM) at time of lumpectomy for early stage invasive breast cancer are decreasing over time.

•

Observed rates of PSM in this analysis are approximately 5 % for the entire cohort.

•

Predictors of PSM are lobular histology, increasing T and N stage, grade, and Her2+ histology.

Assessment of cosmesis and quality of life and their correlation using novel, validated methods in breast cancer patients who had undergone breast conservation therapy

PURPOSE

To assess cosmesis [Breast Cancer Conservation Treatment. Cosmetic Results (BCCT.CORE) software] & QOL [EORTC QLQ (Quality of Life Questionnaire)-C30, BR23 questionnaires] using objective methods &to correlate effect of cosmesis on QOL (Quality of life) in breast cancer patients post BCT (Breast conservation therapy) using a cross-sectional observational study from a tertiary hospital.

MATERIALS & METHODS

Cosmesis & QOL had been assessed in all biopsy-proven adult patients of unilateral breast cancer, who had undergone BCT with minimum three months post-BCT & three months post last adjuvant chemotherapy cycle, whichever is delivered last (with just hormonal therapy or followup remaining based on hormone receptor status). Pearson chi-square & Kendall correlation Tau-b tests had been used for testing association between Cosmesis & QOL. Variation of QOL scores between Cosmetic groups had been assessed using Mann-Whitney U-test.

RESULTS

Cosmesis was Excellent/Good in 60.4 % of patients. 58.4 % of patients had Excellent/Good Quality of Life. Cosmesis & QOL had a positive correlation (intermediate strength) [Kendall correlation factor-0.484]. QOL-Global scale had better median scores in Excellent/ Good cosmetic group when compared to Fair/Poor group, while for functional & symptomatic scales, contrary had been true. Difference of median-scores between the two groups hadn't been statistically significant in five aspects - being upset over hair loss (p-0.09), sexual-enjoyment (p-0.33), nausea-vomiting (p-0.29), constipation (p0.32) & diarrhea (p-0.72).

CONCLUSION

About 2/3rds of patients post-BCT had Excellent/Good Cosmesis & Excellent/Good QOL. Every measure taken before, during & post-BCT to improve Cosmesis might result in better QOL. Future studies must use more accurate three-dimensional methods to assess Cosmesis & its effect on QOL.

Comparing the effect of distance to treatment facility on reconstruction and breast conservation therapy for early-stage invasive ductal carcinoma between the nation and the mountain region

BACKGROUND

Our objective is to evaluate the effect of distance to facility on the use of breast conservation therapy and reconstruction for early stage breast cancer.

METHODS

Utilizing the National Cancer Database, we identified females, age <65, with Stage I invasive ductal carcinoma from 2004 to 2015. Using logistic regression, we compared radiation, mastectomy, and reconstruction treatment patterns. A subgroup analysis was performed within the mountain region (MR).

RESULTS

Nationwide, there are decreasing odds of radiation, increasing odds of mastectomy, and increasing odds of reconstruction. Patients living farther were less likely to receive radiation, more likely to undergo mastectomy, with no effect on reconstruction. Within the MR, patients living farther from their facility were less likely to receive radiation, more likely to undergo mastectomy, however, they were less likely to undergo reconstruction.

CONCLUSIONS

Nationwide and within the MR, patients living farther from their facility are less likely to receive radiation and more likely to undergo mastectomy. There is a disparity between the MR and the nation in use of reconstruction for this population.

The Role of Intraoperative Radiation in Early-stage Breast Cancer

Intraoperative radiation therapy (IORT) is a specialized form of accelerated partial breast irradiation in which a single dose of radiation is delivered to the tumor bed at the time of breast conserving surgery. With completion of radiation to the tumor bed at the time of surgery, IORT promises improved patient convenience, compliance, and quality of life. In addition, with its potentially skin-sparing properties and ability to deliver a high biologically effective dose to the tumor bed while reducing dose to nontarget tissues, IORT results in different but overall less toxicities compared with other modalities of radiation for breast cancer. However, skepticism over the role of IORT in breast cancer exists, and the 2 randomized trials that have analyzed IORT as the definitive radiation component of breast conservation therapy have shown an increase in local recurrence rates with IORT compared with whole breast irradiation, but similar rates of overall survival. In this review, we discuss the practicalities of IORT, the prospective data supporting and negating the role of IORT in lieu of whole breast irradiation, and the toxicity after IORT in early-stage breast cancer. We also review the role of IORT as a radiation boost and specific strategies for successful implementation of IORT in breast cancer.

A prospective cohort study of the safety of breast cancer surgery during COVID-19 pandemic in the West of Scotland

INTRODUCTION

In order to minimise the risk of breast cancer patients for COVID-19 infection related morbidity and mortality prioritisation of care has utmost importance since the onset of the pandemic. However, COVID-19 related risk in patients undergoing breast cancer surgery has not been studied yet. We evaluated the safety of breast cancer surgery during COVID-19 pandemic in the West of Scotland region.

METHODS

A prospective cohort study of patients having breast cancer surgery was carried out in a geographical region during the first eight weeks of the hospital lockdown and outcomes were compared to the regional cancer registry data of pre-COVID-19 patients of the same units (n = 1415).

RESULTS

188 operations were carried out in 179 patients. Tumour size was significantly larger in patients undergoing surgery during hospital lockdown than before (cT3-4: 16.8% vs. 7.4%; p < 0.001; pT2 - pT4: 45.5% vs. 35.6%; p = 0.002). ER negative and HER-2 positive rate was significantly higher during lockdown (ER negative: 41.3% vs. 17%, p < 0.001; HER-2 positive: 23.4% vs. 14.8%; p = 0.004). While breast conservation rate was lower during lockdown (58.6% vs. 65%; p < 0.001), level II oncoplastic conservation was significantly higher in order to reduce mastectomy rate (22.8% vs. 5.6%; p < 0.001). No immediate reconstruction was offered during lockdown. 51.2% had co-morbidity, and 7.8% developed postoperative complications in lockdown. There was no peri-operative COVID-19 infection related morbidity or mortality.

CONCLUSION

breast cancer can be safely provided during COVID-19 pandemic in selected patients.

Breast conservation therapy confers survival and distant recurrence advantage over mastectomy for stage II Triple Negative Breast cancer

INTRODUCTION

Recent studies suggest survival benefit of breast conservation over mastectomy. We evaluated distant recurrence (DR) rates after breast-conservation therapy (BCT) versus mastectomy in our community-based cancer institute.

METHODS

A retrospective review of patients undergoing treatment of Stage 0-3 breast cancer from January, 2002 to December, 2011 was performed. We evaluated outcomes between those having BCT versus mastectomy.

RESULTS

We reviewed 4876 patients. There was no significant difference in DR between patients undergoing BCT versus mastectomy in DCIS (n = 904; BCS 521, mastectomy 383; DR = 1/521 vs 1/383; p = 0.09), Stage I (n = 2202; BCT 1505, mastectomy 697; DR = 6/1505 vs 17/697; p = 0.98) or Stage III cancer (n = 417; BCT 87, mastectomy 330; DR = 17/87 vs 59/330; p = 0.50). There was significantly less DR in Stage II patients (n = 1353) undergoing BCT vs mastectomy (32/645 vs 64/708; p = 0.003). Subgroup analysis of Stage II TNBC (n = 198) subgroup analysis showed 104 mastectomy and 94 BCT patients. Those in the BCT group had significantly lower rates of DR (6/94 vs 16/104; p= 0.03) and significantly higher survival (81/94 vs 69/104; p = 0.007) than those undergoing mastectomy. Of Stage II TNBC patients with DR there was no difference in age, lymph node status or tumor size (p > 0.05 for all) in BCT versus mastectomy groups; there was a significant difference in radiation status (94/94 vs. 28/104; p < 0.0001). Radiation was associated with worse outcomes in the mastectomy group (HR 2.32; p = 0.04).

CONCLUSIONS

We found significantly less DR in Stage II patients undergoing BCT vs mastectomy. This benefit includes a survival advantage in patients with TNBC undergoing BCT. We could not identify an explanatory factor. Until the difference is understood eligible patients with TNBC should be encouraged to undergo BCT.

Breast Reduction and Mastopexy for Repair of Asymmetry After Breast Conservation Therapy: Lessons Learned

BACKGROUND

Breast conservation therapy (BCT) can cause breast distortion and asymmetry. Repair of this asymmetry by means of breast reduction or mastopexy procedures can be challenging and harbor considerably high rates of complications.

METHODS

In this retrospective study, we describe our experience in repairing post-BCT breast asymmetry by performing breast reduction or mastopexy. The surgical protocol we followed consisted of stringent patient selection, thorough surgical planning, basic surgical refinements, and patient education for enhancing the likelihood of achieving a good outcome with minimal surgical complications.

RESULTS

Our search of the departmental database identified 25 patients with breast asymmetry who had undergone breast reduction or mastopexy between 2009 and 2017. Corrective surgery was performed 4 years on average after the completion of radiotherapy, and those patients included eleven who had undergone breast reduction and fourteen who had undergone mastopexy on the radiated side. Two patients (8%) had major complications that required further surgery (major fat necrosis, wound infection, and breast deformation), and five patients (20%) had minor complications (infection, minor fat necrosis, wound dehiscence, and nipple congestion). All complications developed on the radiated breast. There was no correlation between the occurrence of complications and patients' demographics, tumor type, tumor location, and breast tissue resection (p > 0.05).

CONCLUSION

Only two of our 25 patients had major complications following breast reduction and mastopexy for the repair of asymmetry post-BCT. Following our four-step protocol was instrumental in leading to the successful performance of these procedures.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Local Control of Breast Conservation Therapy versus Mastectomy in Multifocal or Multicentric Breast Cancer: A Systematic Review and Meta-Analysis

Objective

Breast conservation therapy (BCT) for female patients with multifocal or multicentric (MF/MC) breast cancer remains controversial. The purpose of the present meta-analysis was to explore whether BCT was feasible for female patients with MF/MC breast cancer and to compare the results of treatment with those of female patients with unifocal breast cancer who underwent BCT and female patients with MF/MC breast cancer who underwent mastectomy.

Methods

Online databases, including PubMed and Embase, were independently searched from inception to January 2018 and reviewed by two authors. The present meta-analysis compared local relapse (LR) of BCT versus mastectomy for patients with MF/MC breast cancer and LR of patients with unifocal breast cancer versus patients with MF/MC breast cancer who underwent BCT. Ten studies comprising 19,272 patients were included.

Results

The cumulative incidence of LR was 5.6% (65/1,163) for MF/MC disease treated with BCT, 4.2% (750/17,656) for unifocal disease treated with BCT, and 2.0% (9/453) for MF/MC disease treated with mastectomy. Thus, the cumulative incidence of LR for MF/MC patients treated with BCT was significantly higher than for mastectomy (p < 0.001). However, the forest plot analysis showed no significant differences in LR between BCT and mastectomy procedures (OR = 1.22, 95% CI = 0.49-3.00, p = 0.67, I² = 0%). Compared with the unifocal group treated with BCT, BCT for MF/MC breast cancer showed a significant difference in LR (OR = 2.25, 95% CI = 1.48-3.42, p = 0.0001, I² = 0%).

Conclusion

The LR of BCT for patients with MF/MC breast cancer was higher than that of BCT for patients with unifocal breast cancer. However, no significant difference was found in the incidence of LR between the BCT group and the mastectomy group in patients with MF/MC breast cancer.

External validation of IBTR! 2.0 nomogram for prediction of ipsilateral breast tumor recurrence

Purpose

IBTR! 2.0 nomogram is web-based nomogram that predicts ipsilateral breast tumor recurrence (IBTR). We aimed to validate the IBTR! 2.0 using an external data set.

Materials and Methods

The cohort consisted of 2,206 patients, who received breast conserving surgery and radiation therapy from 1992 to 2012 at our institution, where wide surgical excision is been routinely performed. Discrimination and calibration were used for assessing model performance. Patients with predicted 10-year IBTR risk based on an IBTR! 2.0 nomogram score of <3%, 3%–5%, 5%–10%, and >10% were assigned to groups 1, 2, 3, and 4, respectively. We also plotted calibration values to observe the actual IBTR rate against the nomogram-derived 10-year IBTR probabilities.

Results

The median follow-up period was 73 months (range, 6 to 277 months). The area under the receiver operating characteristic curve was 0.607, showing poor accordance between the estimated and observed recurrence rate. Calibration plot confirmed that the IBTR! 2.0 nomogram predicted the 10-year IBTR risk higher than the observed IBTR rates in all groups. High discrepancies between nomogram IBTR predictions and observed IBTR rates were observed in overall risk groups. Compared with the original development dataset, our patients had fewer high grade tumors, less margin positivity, and less lymphovascular invasion, and more use of modern systemic therapies.

conclusions

IBTR! 2.0 nomogram seems to have the moderate discriminative ability with a tendency to over-estimating risk rate. Continued efforts are needed to ensure external applicability of published nomograms by validating the program using an external patient population.

[Clinical characteristics and prognosis of patients with ipsilateral breast tumor recurrence after breast conservation therapy]

Objective: To analyze the clinical features and prognosis of the ipsilateral breast tumor recurrence (IBTR) after breast conserving surgery. Methods: From 1999 to 2013, 63 women with IBTR after breast conserving surgery were retrospectively reviewed. All patients had adequate information on tumor location both at first presentation and at recurrence, with or without regional recurrence or distant metastasis. The histologic changes between true local recurrence and elsewhere recurrence groups were compared. The local recurrence, the overall survival after IBTR (IBTR-OS), the disease-free survival after IBTR (IBTR-DFS) were also compared. Results: All patients had undergone lumpectomy, including 38 cases with additional axillary lymph node dissection and 13 cases with sentinel lymph node biopsy. There were 11.3% (7/63) cases received neoadjuvant systemic therapy, 68.3% (43/63) had adjuvant radiotherapy, 60.3% (38/63) underwent adjuvant chemotherapy and 47.6% (30/63) received hormonal therapy. Forty-five cases (71.4%) had recurrence in the same quadrant, and 18 cases (28.6%) had elsewhere recurrence. Compared with histology at presentation, 10.3% of the patients (6/58) had different ones at recurrence and 28.9% of patients (13/45) had different molecular subtypes. The conversion rate of estrogen receptor status (33.3% vs 9.5%, P=0.012) and progesterone receptor status (56.3% vs 19.0%, P=0.005) in patients with elsewhere recurrence was significantly higher than that in patients with same quadrant recurrence. Fifty-nine cases had undergone surgery after IBTR, with 48 cases of secondary breast-conserving surgery and 11 cases of salvage mastectomy. The median time to IBTR of same quadrant recurrence and elsewhere recurrence groups were 26 months and 62 months (P=0.012), respectively. There were 84.4% and 44.4% cases who had local recurrence within 5 years after breast conserving surgery, respectively. Of all cases, the overall 5-year IBTR-OS and 5-year IBTR-DFS rates were 79.4% and 60.4%, respectively. There were no significant differences in 5-year IBTR-OS (77.4% vs. 83.6%, P=0.303) or 5-year IBTR-DFS (60.0% vs. 62.8%, P=0.780) between same quadrant recurrence and elsewhere recurrence groups. Univariate analysis showed that pN0-1 (P<0.001), luminal subtype (P=0.026), adjuvant endocrine therapy (P=0.007) at first presentation, recurrent tumor < 3 cm (P=0.036) and having surgery after IBTR(P=0.002) were favorable factors of IBTR-OS. pN0-1 (P<0.001) at first presentation, recurrent tumor stage Ⅰ-Ⅱ (P<0.001) and having surgery after IBTR(P=0.001) were favorable factors of IBTR-DFS. There was no significant difference between second breast-conserving surgery and salvage mastectomy in IBTR-OS and IBTR-DFS (P>0.05). Conclusions: The IBTR after breast conserving surgery mainly occurred at the original quadrant. Second breast-conserving surgery did not affect patient's prognosis. There were significant differences in biological features between the same quadrant recurrence and elsewhere recurrence, requiring different therapeutic strategies in the future.

Radiation-Associated Angiosarcoma of the Breast: A Case Report and Literature Review

In the last couple of decades, breast conservation therapy, which utilizes a combination of surgery, radiotherapy, and endocrine or chemotherapy, has become the standard of care for treating early-stage breast cancer. This practice has been greatly beneficial in the improvement of the patient's quality of life but has also led to the increased use of radiotherapy and associated soft-tissue sarcomas, with angiosarcoma being the most common malignancy. Radiation-associated angiosarcoma (RAS) of the breast is a rare phenomenon, which has been reported to occur in approximately 0.9 out of 1,000 cases, with a reported onset as late as 23 years following radiotherapy. Here we report 2 cases of RAS that occurred within 6 and 13 years following radiotherapy of their primary breast lesion. We discuss the diagnostic and therapeutic challenges regarding this disease and review the current literature. This case report serves as cautionary lessons on the importance of considering RAS of the breast in the differential diagnosis during evaluation for recurrent breast neoplasms. Ongoing clinical trials using combinations of vascular endothelial growth factor inhibitors and chemotherapy may provide future avenues of treatment for this difficult-to-treat disease.

Breast Conservation Therapy Versus Mastectomy in Patients with T1-2N1 Triple-Negative Breast Cancer: Pooled Analysis of KROG 14-18 and 14-23

Purpose

The aim of this study is to compare the treatment outcomes of breast conserving surgery (BCS) plus radiotherapy (RT) versus mastectomy for patients with pT1-2N1 triple-negative breast cancer (TNBC).

Materials and Methods

Using two multicenter retrospective studies on breast cancer, a pooled analysis was performed among 320 patients with pT1-2N1 TNBC. All patients who underwent BCS (n=212) receivedwhole breast RTwith orwithoutregional nodal RT,while nonewho underwent mastectomy (n=108)received it. All patients received taxane-based adjuvant chemotherapy. The median follow-up periods were 65 months in the BCS+RT group, and 74 months in the mastectomy group.

Results

The median age of all patients was 48 years (range, 24 to 70 years). Mastectomy group had more patients with multiple tumors (p < 0.001), no lymphovascular invasion (p=0.001), higher number of involved lymph node (p=0.028), and higher nodal ratio ≥ 0.2 (p=0.037). Other characteristics were not significantly different between the two groups. The 5-year locoregionalrecurrence-free, disease-free, and overall survivalrates of BCS+RT group versus mastectomy group were 94.6% versus 87.7%, 89.5% versus 80.4%, and 95.0% versus 87.8%, respectively, and the differences were statistically significant after adjusting for covariates (p=0.010, p=0.006, and p=0.005, respectively).

Conclusion

In pT1-2N1 TNBC, breast conservation therapy achieved better locoregional recurrencefree, disease-free, and overall survival rates compared with mastectomy.

Advancements and Personalization of Breast Cancer Treatment Strategies in Radiation Therapy

Significant technologic advances in radiation treatment delivery now allow for more personalized delivery considerations which incorporate individual patient characteristics (such as tumor location and patient anatomy) and more precise delivery in the breast conservation or post-mastectomy setting. The combined advancements with other treatment modalities (i.e., systemic therapy, surgical management) have had direct effects on local-regional management and outcomes such that currently, local-regional relapses after definitive treatment for localized disease are now rarely experienced. Recent advances in the radiation therapy field have come from careful patient selection for a variety of three-dimensional treatment delivery techniques and alternatives to conventional tangential radiation. These advances have been demonstrated to diminished acute/long-term toxicity, minimized dose to surrounding normal tissue structures such as the heart and lung, and ultimately result in an improvement in the therapeutic ratio for radiation treatment. This chapter discusses recent radiation innovations and appropriate patient selection for their application, for a more personalized approach to radiation therapy for breast cancer patients.

Hypofractionated whole breast radiotherapy in breast conservation for early-stage breast cancer: a systematic review and meta-analysis of randomized trials

PURPOSE

Breast conservation therapy (BCT) for early-stage breast cancer involves lumpectomy followed by whole breast radiotherapy, which can involve either standard fractionation (SRT) or accelerated fractionation (ART). This systematic review and meta-analysis was performed to determine whether any benefit exists for ART or SRT.

MATERIALS AND METHODS

We searched MEDLINE (1966-2014), all seven databases of the Cochrane Library (1968-2014), EMBASE (1974-2014), clinicaltrials.gov, ISRCTN, WHO ICTRP, and meeting abstracts in the Web of Science Core Collection (1900-2014). RCTs comparing SRT to ART among women undergoing BCT with stage T1-T2 and/or N1 breast cancer or carcinoma in situ were included. Follow-up was 30 days for acute toxicity, or three years for disease control and late toxicity.

RESULTS

13 trials with 8189 participants were included. No differences were observed in local failure (n = 7 trials; RR 0.97; 95% CI 0.78-1.19, I ² = 0%), locoregional failure, (n = 8 trials; RR 0.86; 95% CI 0.63-1.16, I ² = 0%), or survival (n = 4 trials; RR 1.00; 95% CI 0.85-1.17, I ² = 0%). ART was associated with significantly less acute toxicity (n = 5 trials; RR 0.36; 95% CI 0.21-0.62, I ² = 20%), but no difference in late cosmesis (RR 0.95; 95% CI 0.81-1.12, I ² = 54%).

CONCLUSIONS

ART use does not reduce disease control or worsen long-term cosmetic outcome, and may decrease the risk of acute radiation toxicity as compared to SRT.

Is intraoperative frozen section analysis of reexcision specimens of value in preventing reoperation in breast-conserving therapy?

OBJECTIVES

A prior study at our institution showed a marked reduction in reoperation for margin reexcision following the development of an intraoperative frozen section evaluation of margins (FSM) practice on lumpectomy specimens from patients undergoing breast-conserving therapy (BCT). This study aimed to examine the frequency of FSM utilization, FSM pathology performance, and outcomes for BCT patients undergoing margin reexcision only.

METHODS

Consecutive reexcision-only specimens were reviewed from a 40-month period following the development of the FSM practice. Clinicopathologic features and patient outcomes were assessed.

RESULTS

FSM was performed in 46 (30.7%) of 150 reexcision-only operations. Of the 46 operations with FSM, there were 28 (60.9%) true-negative, 12 (26.1%) true-positive, six (13.0%) false-negative, and no false-positive cases. There was no difference in further reexcision, total operations, or conversion to mastectomy among patients with and without FSM. Need for further reexcision was significantly associated with tumor multifocality (P = .008).

CONCLUSIONS

Despite overall good pathology performance for FSM in reexcision-only specimens, use of FSM did not affect patient outcome. Rather, underlying disease biology appeared most significant in predicting whether adequate surgical margins could be attained.

Evaluating radiotherapy options in breast cancer: does intraoperative radiotherapy represent the most cost-efficacious option?

INTRODUCTION

This study analyzed the cost-efficacy of intraoperative radiation therapy (IORT) compared with whole-breast irradiation (WBI) and accelerated partial-breast irradiation (APBI) for early-stage breast cancer.

MATERIALS AND METHODS

Data for this analysis came from 2 phase III trials: the TARGIT (Targeted Intraoperative Radiotherapy) trial and the ELIOT (Electron Intraoperative Radiotherapy) trial. Cost analyses included a cost-minimization analysis and an incremental cost-effectiveness ratio analysis including a quality-adjusted life-year (QALY) analysis. Cost analyses were performed comparing IORT with WBI delivered using 3-dimensional conformal radiotherapy (3D-CRT), APBI 3D-CRT, APBI delivered with intensity-modulated radiotherapy (IMRT), APBI single-lumen (SL), APBI multilumen (ML), and APBI interstitial (I).

RESULTS

Per 1000 patients treated, the cost savings with IORT were $3.6-$4.3 million, $1.6-$2.4 million, $3.6-$4.4 million, $7.5-$8.2 million, and $2.8-$3.6 million compared with WBI 3D-CRT, APBI IMRT, APBI SL, APBI ML, and APBI I, respectively, with a cost decrement of $1.6-$2.4 million compared with APBI 3D-CRT based on data from the TARGIT trial. The costs per QALY for WBI 3D-CRT, APBI IMRT, APBI SL, APBI ML, and APBI I compared with IORT were $47,990-$60,002; $17,335-$29,347; $49,019-$61,031; $108,162-$120,173; and $36,129-$48,141, respectively, based on data from the ELIOT trial. These results are consistent with APBI and WBI being cost-effective compared with IORT.

CONCLUSION

Based on cost-minimization analyses, IORT represents a potential cost savings in the management of early-stage breast cancer. However, absolute reimbursement is misleading, because when additional medical and nonmedical costs associated with IORT are factored in, WBI and APBI represent cost-effective modalities based on cost-per-QALY analyses. They remain the standard of care.

The impact of local and regional recurrence on distant metastasis and survival in patients treated with breast conservation therapy

Purpose

We evaluated the effect of local recurrence (LR) and regional recurrence (RR) on distant metastasis and survival in patients treated with breast conservation therapy (BCT).

Methods

We analyzed 907 patients who were treated for invasive breast cancer between 1993 and 2006. With 53 months of follow-up, 28 patients (3.1%) developed LR in the breast and 12 patients (1.3%) developed RR before distant metastasis. LR and RR were separated into four patterns to determine the prognostic relevance of recurrence site and time to recurrence: LR within 3 years (early LR), LR after 3 years (late LR), RR within 3 years (early RR), and RR after 3 years (late RR).

Results

Early LR (hazard ratio [HR], 4.76; p=0.003) and early RR (HR, 18.16; p<0.001) were independent predictors of distant metastasis. In terms of overall survival, early LR (HR, 5.24; p=0.002), and early RR (HR, 18.80; p<0.001) were significantly related with poor survival. Patients with late LR/RR had a similar favorable prognosis compared with patients who never experienced LR/RR.

Conclusion

The result suggests that time to LR/RR following BCT is a significant predictor developing a distant metastasis and surviving.