An International Standard RWD Database Designed - Taiwan Experience

The use of Real-World Data (RWD) in medical data analysis is nowadays required. RWD may come from electronic health records (EHRs), insurance claims, medical products, Internet of Things sensors, health screenings, etc. The goal of RWD is that the data used for analysis should not be affected by environmental variables, experimental control, research context settings, etc. RWD can effectively reduce the cost and improve the accuracy of medical research. The clinical data and patient self-report are integrated, cleaned and pre-processed, and the data format is unified and standardized by international standard formats to provide a structured database for clinical research by this study. An international standard real-world research database was established through the breast cancer database of a medical center in Taipei.

Biosimilar in Breast Cancer: A Narrative Review

Breast cancer (BC) has been identified as a major public health cancer as it topped the list of most prevalent cancers among women in the last three years. Rigorous research has been conducted to improve the prognosis of cancer therapies since the time of inception. Recent advancements in cancer therapy have introduced monoclonal biosimilars as a promising treatment alternative. Monoclonal antibodies (mAbs), produced through cloning, have demonstrated effectiveness in targeting diverse antigens. Biosimilar, considered complex entities compared to small-molecule drugs, pose challenges in replication due to their biological nature. The manufacturing process involves rigorous comparability testing to ensure similarity in quality, safety, and efficacy with the reference product. Trastuzumab biosimilars, such as CT-P6, Ontruzant®, ABP 980, and PF-05280014, have shown efficacy in treating HER2-positive metastatic BCs, presenting a viable alternative to the reference product. The implications of monoclonal biosimilars extend beyond trastuzumab, with bevacizumab emerging as another significant biosimilar for BC treatment. The shift toward biosimilar aims to enhance accessibility to biologics by reducing costs. Health economic analyses indicate potential cost savings, contributing to the overall cost-effectiveness of biosimilar adoption. While concerns about switching between reference products and biosimilars exist, evidence suggests a lower risk of immunogenicity-related side effects with mAbs like trastuzumab. Monoclonal biosimilars present a promising avenue in BC therapy, demonstrating efficacy, safety, and potential cost savings. The integration of biosimilars into cancer treatment strategies offers a means to improve accessibility to effective care while addressing economic considerations in healthcare.

Puzzling Papillomas: A Case of an Intraductal Papilloma Mimicking an Abscess

Intraductal papillomas (IDPs) are benign tumors found within breast ducts. Clinicians should be familiar with IDPs given their association with atypical and neoplastic lesions. In our case, the patient was initially diagnosed with and treated for an abscess given clinical symptoms of breast pain, erythema, and swelling, but upon returning to the clinic a year later due to persistent symptoms, she was found to have an IDP. This case underscores the importance of atypical imaging features and close follow-up when evaluating breast lesions.

Investigation of the Use of Circulating Long Non-coding RNA HOXA Transcript at the Distal Tip (LncRNA HOTTIP) as a Biomarker in Breast Cancer

The critical need for new diagnostic and prognostic methods is highlighted by the fact that breast cancer continues to be the top cause of cancer-related deaths globally. Due to the dysregulation of long non-coding RNAs (lncRNAs) in numerous malignancies, they have become potential biomarkers in cancer. Recent research has focused on the lncRNA HOTTIP (HOXA transcript at the distal tip), which has a function in breast cancer metastasis and carcinogenesis. Until recently, HOTTIP had only been measured in cancer tissues and specimens. The aim of this study is to assess the amounts of the lncRNA HOTTIP in the blood serum of 46 breast cancer patients using real-time PCR analysis and identify the relationships between HOTTIP expression and several known clinical and pathological factors, including tumor grade, stage, lymph node involvement, hormone receptor status, and cell proliferation. The results of the study confirmed a positive relation of HOTTIP expression and breast cancer aggressiveness and metastatic behavior. The analysis results showed elevated HOTTIP values in stage III and T3/T4 tumors with multifocal characteristics and in lymph node involvement. Our findings raise the possibility of HOTTIP serving as a future prognostic biomarker for breast cancer patients.

Demographics, Characteristics, and Outcomes of Male Breast Cancer Patients at the Methodist Health System, Dallas, USA

Breast cancer (BC) is the most common cancer in women and has been extensively studied; however, male BC (MBC) is rare with limited clinical data. Treatment options for MBC are extrapolated from clinical studies in BC in women and have traditionally excluded MBC cases. Over the past decade, an increase in the incidence of MBC has been seen. The purpose of this study is to comprehensively analyze the clinical, pathological, and treatment-related characteristics of MBC cases within our institution's database. MBC cases from 2010 to 2021 at Methodist Dallas Medical Center (MDMC), Dallas, USA, were reviewed retrospectively from the electronic health record and database, and clinical information was obtained. During this time period from 2010 to 2021, there was a total of 1,784 cases of BC with only eight cases (0.45%) consisting of MBC. In our cohort, 75% of MBC cases had a family history of cancer in a first-degree relative. Additionally, 100% of all MBC cases are hormone receptor-positive. No cases of MBC had HER2/neu over-expression. Fifty percent of our MBC patients were diagnosed with locally advanced tumors or metastatic disease. The overall survival (OS) of MBC in our study was 72%.

The Role of Ultrasound Features in Predicting the Breast Cancer Response to Neoadjuvant Chemotherapy

Background Neoadjuvant chemotherapy (NACT) has become the standard of care for locally advanced breast cancer. This study investigates whether baseline ultrasound features can predict complete pathological response (pCR) after NACT. Methods This retrospective study was approved by the Institutional Review Board of King Abdulaziz University Hospital, Jeddah, Saudi Arabia, with a waiver of informed consent. Records of female patients aged over 18 years with locally advanced breast cancer treated with NACT from 2018 to 2020 were reviewed. Baseline ultrasound parameters were assessed, including posterior effect, echo pattern, margin, and maximum lesion diameter. Tumor grade and immunophenotype were documented from the core biopsy. pCR was defined as the absence of invasive residual disease in the breast and axilla. Univariate and multivariate analyses assessed the association between ultrasound features and pathological response. Results A total of 110 breast cancer cases were analyzed: 36 (32.7%) were estrogen receptor (ER)-positive/human epidermal growth factor 2 (HER-2) negative, 49 (44.5%) were HER-2 positive, and 25 (22.7%) were triple-negative (TN). A pCR was achieved in 20 (18%) of cancers. Lesion diameter was significantly different between pCR and non-pCR groups, 28.5 ± 12 mm versus 39 ± 18 mm, respectively, with an area under the curve (AUC) of 0.7, a confidence interval (CI) of 0.55-0.81, and a p-value of 0.01. No significant association was observed between ultrasound features, tumor grade, and immunophenotype with pCR. Conclusion Ultrasound features could not predict pCR. A smaller tumor diameter was the only significant factor associated with pCR. Further prospective studies combining imaging features from different modalities are needed to explore the potential of varying imaging features in predicting post-NACT pathological response more comprehensively.

Prospective Functions of miRNA Variants May Predict Breast Cancer Among Saudi Females

Background Growing knowledge supports the importance of microRNAs (miRNAs) in modulating the initiation and development of breast cancer (BC) and underlying mechanisms. BC is a significant public health in females worldwide, where it remains the leading cause of death among Saudi females. Here, we evaluate the susceptibility of the miRNA genetic variants to the risk of BC in Saudi females. Methods One hundred fifty-four females, including 76 females diagnosed with BC and 78 healthy controls, were analyzed using TaqMan™ (Thermo Fischer Scientific, Waltham, MA) genotyping assays for the miR-196a2 rs11614913 C>T, miR-146a rs2910164 C>G, and miR-499 rs3746444 A>G. We utilized the SNPStats software (https://www.snpstats.net) (Institut Català d'Oncologia, Barcelona, Spain) to choose the best interactive inheritance model for the examined miRNAs. Results The examined miRNA single-nucleotide polymorphisms (SNPs) showed no clear association with the risk of BC (P > 0.05). As for genotypic distributions, significant associations were found for the rs2910164 SNP in most interactive models of inheritance: 2.50 (95% confidence interval {CI}, 1.2-5.17; P = 0.0135) in the codominant model, 2.34 (95% CI, 1.11-4.8; P = 0.0197) in the dominant model, and 2.40 (95% CI, 1.22-4.73; P = 0.0113) in overdominant model. The rs2910164 C/G heterozygosity showed overexpression in cases compared to controls (73.7% versus 53.9%; chi-squared (χ2) = 6.5; P = 0.0109), but the homozygous rs2910164 G/G showed a significant protective effect (21.1% versus 38.5%; χ2 = 17.4; P = 0.019). The heterozygosity did not affect the risk to the BC in the two miRNAs (rs11614913 C>T and rs3746444 A>G). Conclusion Despite lacking associations with the examined miRNAs, the heterozygous genotype rs2910164 C/G can identify at-risk females. More studies should be replicated using a panel of miRNA genes to discover significant associations with the risk of BC.

Histopathological Patterns and Outcomes of Triple-Positive Versus Triple-Negative Breast Cancer: A Retrospective Study at a Tertiary Cancer Center

Background One of the leading causes of cancer-related deaths in females under 45 years old is breast cancer (BC). The definition of triple-negative breast cancer (TNBC) is the lack of expression of estrogen receptors (ERs) as well as progesterone receptors (PRs) and Erb-B2 receptor tyrosine kinase 2 (HER2) gene amplification. Triple-positive breast cancer (TPBC), on the other hand, is defined as tumors expressing a high level of ER, PR, and HER2 receptors. This study aims to assess the phenotypes of TNBC and TPBC by comparing their individual clinical behavior patterns and prognosis throughout the course of the disease in a tertiary cancer center in the Kingdom of Saudi Arabia (KSA). Methods Our study is a retrospective study using electronic medical records (EMRs) to identify all female patients diagnosed with BC using the International Classification of Diseases-10 (ICD-10) codes (between C50 and C50.9). About 1209 cases with primary BC female patients were recognized based on histopathology reports. Further subclassification into TPBC and TNBC was performed. Statistical analysis was performed using Rv3.6.2 (R Studio, version 3.5.2, Boston, MA, USA). The descriptive data were presented as means and standard deviations (SD). Survival curves were approximated using the Kaplan-Meier method. The comparison between survival curves between both groups was achieved using the log-rank test. The multivariate model was constructed based on the identified predictors using univariate analysis. Results Univariate analysis of overall survival (OS) showed that mortality was higher in TNBC compared to TPBC (HR = 2.82, P-value <0.05). However, in a multivariate analysis, molecular subtypes did not show a significant effect on OS with a P-value of 0.94. We found that age at diagnosis has been associated with a 4% increase in mortality risk with a yearly rise in age. Conclusion In this limited retrospective cohort study, we found that TNBC may not be associated with a higher risk of death than TPBC. However, other factors, including age at diagnosis, surgical intervention, and lymphovascular invasion (LVI), have been observed to increase the risk of mortality. On the other hand, patients with TNBC were found to have a worse prognosis in terms of local recurrence. This information cannot be generalized to all patients with BC given the limitations of this study. Further, larger cohorts are needed to explore biological and treatment-related outcomes in patients with TNBC and TPBC.

Trends in Breast Cancer Incidence and Mortality in the United States From 2004-2018: A Surveillance, Epidemiology, and End Results (SEER)-Based Study

The incidence and mortality data for patients with breast cancer in the United States are important to healthcare administrators for planning healthcare measures such as screening mammograms. In this study, we examined breast cancer incidence and incidence-based mortality in the United States from 2004-2018 using the Surveillance, Epidemiology, and End Results (SEER) database. We reviewed 915,417 cases of breast cancer diagnosed between 2004 and 2018. Overall, the data showed an increased incidence rate of breast cancer among all races and a decreased mortality rate among all races. Breast cancer incidence rates increased by 0.3% (95% CI, 0.1, 0.4, p<0.001) per year over the study period. Breast cancer incidence rates increased for all age, race, and stage groups except for stage regional, which showed a statistically significant decrease in the incidence of -0.9% (95% CI, -1.1, -0.7, p<0.001). The highest decrease in mortality was observed among white patients, with an overall statistically significant decrease in rates by -14.3% (95% CI, -18.1, -10.4, p <0.001). The highest decrease in rates was observed between 2016 and 2018: -48.6 (95% CI, -52.6, -44.3, p <0.001). In black/African American patients, the overall incidence-based mortality decreased by -11.6% (95% CI -15.9, -7.1 p <.001), with the highest decrease in rates observed between 2016 and 2018 with a decrease of -51.3% (95% CI -56.6, -45.3, p <0.001). In Hispanic Americans, the overall incidence-based mortality decreased by -12.3% (95% CI -16.9, -7.4, p <.001), which is lower than in white Americans.

Goserelin Ovarian Ablation Failure in Premenopausal Women With Breast Cancer

Breast cancer is the most prevalent cancer known worldwide in women. It is a heterogeneous, phenotypically diverse disease composed of several biologic subtypes that have distinct behavior and response to therapy. Hormone receptor-positive (i.e., estrogen [ER] and/or progesterone [PR] receptor-positive) breast cancers comprise the most common types of breast cancer, accounting for 75% of all cases. This makes endocrine therapy the standardized treatment for patients with ER+/PR+ breast cancer. Drugs that block estrogen receptors or that lower estrogen levels are the mainstay of treatment. High-risk patients benefit from the addition of ovarian function suppression (OFS)/ablation to either an aromatase inhibitor (AI) or tamoxifen. This case report discusses a 36-year-old premenopausal female who presented with an abnormal right breast lump in the upper outer quadrant of the right breast. Due to high suspicion of malignancy, a biopsy was performed which showed features of both lobular and ductal carcinoma with ER and PR positivity, HER 2 was negative. The patient underwent mastectomy with axillary lymph node removal due to concern for multifocal disease. No clinically relevant genetic mutations were present. Oncotype DX breast recurrence score was 16 and no chemotherapy was offered. Due to large tumor size, young age OFS with goserelin 3.6mg/28 days and letrozole 2.5 mg once daily was recommended. After 16 months of treatment, the patient developed a failure of goserelin-induced ovarian suppression. This case report highlights the possibility of the development of hormonal resistance after long-term use of goserelin.

Reverse Axillary Mapping in Breast Cancer Using Blue Dye: A Tertiary Setup Experience

The concept of reverse axillary mapping originated with the main purpose of reducing lymphedema. In this study, we test the advantage of reverse axillary mapping to delineate the arm-draining lymph nodes and their involvement in various stages of breast carcinoma. In this study, we also attempt to redefine the template for axillary dissection in breast cancer.

During the period of September 30, 2020, to August 30, 2021, 46 patients were recruited to undergo a procedure in which isosulfan blue dye was injected into the upper arm and the axilla was explored to isolate the lymph nodes. The lymph nodes were submitted for examination histopathologically.

The results conclusively showed that axillary lymph node metastasis was only influenced by the advanced stage of the disease (p=0.014) and the visualization of the lymphatics was independent of the stage, type of surgery, decubitus, or age.

The study conclusively shows that attempts to preserve the upper limb-draining nodes in advanced stages would be futile and the preservation of such lymph nodes should be limited to the early stages of breast cancer.

Breast Cancer in the Caribbean

Breast cancer (BC) is one of the leading causes of death among women globally. In the Caribbean, there is a higher mortality rate compared with North American and European countries which have higher incidence rates. We conducted a literature review to examine the BC dynamic in the Caribbean and determine the areas where further investigations are needed. The PubMed database was used for identifying relevant studies using a combination of specific keyword searches. All studies focusing on BC within the defined Caribbean population were selected for this review. A total of 117 papers were included. The data were organized and presented under the following headings and reported according to the country where available: BC incidence and mortality, patient demographics, clinicopathology, genetics, behavioral risks, diagnosis and treatment, and BC control. Our review uncovered major variability in the incidence, management, etiology, and mortality of BC among Caribbean countries. Low-resource countries are burdened by more advanced disease with expected poorer BC outcomes (i.e., shorter periods of disease-free survival). Countries with established national cancer registries seem to have a better approach to the management of BC. The introduction of cancer treatment programs in association with international nonprofit groups has shown tremendous improvement in quality, accessible cancer care for patients, particularly in low- and middle-income settings. BC research is relatively limited in the Caribbean, lacking in both scope and consistency. The unique Caribbean BC population of diverse ethnicities, environmental influence, immigrants, socioeconomic status, and sociocultural practices allows an optimal opportunity for epidemiological investigations that can provide deeper insights into the status of BC.

Dosimetric Comparisons of Simulation Techniques for Left-Sided Breast Cancer in the COVID-19 Era: Techniques to Reduce Viral Transmission and Respect the Therapeutic Ratio

Background

The COVID-19 pandemic challenges our ability to safely treat breast cancer patients and requires revisiting current techniques to evaluate optimal strategies. Potential long-term sequelae of breast radiation have been addressed by deep inspiration breath-hold (DIBH), prone positioning, and four-dimensional computed tomography (4DCT) average intensity projection (AveIP)-based planning techniques. Dosimetric comparisons to determine the optimal technique to minimize the normal tissue dose for left-sided breast cancers have not been performed.

Methods

Ten patients with left-sided, early-stage breast cancer undergoing whole breast radiation were simulated in the prone position, supine with DIBH, and with a free-breathing 4DCT scan. The target and organs at risk (OAR) contours were delineated in all scans. Target volume coverage and OAR doses were assessed. One-way analysis of variance (ANOVA) and Kruskal-Wallis one-way ANOVA were used to detect differences in dosimetric parameters among the different treatment plans. Significance was set as p < 0.05.

Results

We demonstrate differences in heart and lung dose by the simulation technique. The mean heart doses in the prone, DIBH, and AveIP plans were 129 cGy, 154 cGy, and 262 cGy, respectively (p=0.02). The lung V20 in the prone, DIBH, and AveIP groups was 0.5%, 10.3% and 9.5%, respectively (p <0.001). Regardless of technique, lumpectomy planning target volume (PTV) coverage did not differ between the three plans with 95% of the lumpectomy PTV volume covered by 100.4% in prone plans, 98.5% in AveIP plans, and 99.3% in DIBH plans (p=0.7).

Conclusions

Prone positioning provides dosimetric advantages as compared to DIBH. When infection risks are considered as in the current coronavirus disease 2019 (COVID-19) pandemic, prone plans have advantages in reducing the risk of disease transmission. In instances where prone positioning is not feasible, obtaining an AveIP simulation may be useful in more accurately assessing heart and lung toxicity and informing a risk/benefit discussion of DIBH vs free breath-hold techniques.

The Perspective of a Breast Cancer Patient: A Survey Study Assessing Needs and Expectations

Background

Patient satisfaction is one of the key indicators of health care quality. We aim to identify patient's needs and expectations in a breast cancer clinic to provide patient-centered care and better overall satisfaction. 

Methods

A 17-item survey was administered to 110 patients at a breast cancer clinic. The survey was designed after a thorough literature review and approved by an oncologist and a palliative care physician. 

Results

Self-reported knowledge about the disease was reported adequate by 90.9% of our patients yet only 55.45% of our patients could identify the stage of their cancer. More education was desired by 32.7% of patients including various treatment options (29%), common complications (24.5%), prognosis (26.3%) and risk factors (11.8%). The majority of our patients were having some form of cancer-related emotional stress and physical symptoms. The majority of our patients (57.27%) wanted their oncologist to address social/emotional issues and 25.45% felt the need for more focus on physical symptoms in their subsequent visits. End-of-life (EoL) care discussions were considered an integral component of overall care by 29% of our patients. Components of EoL care discussions that patients stated they could benefit from included prognosis (27.27%), life expectancy (29%), the treatment effect on the quality of life (22.7%), palliative care (9%), hospice (10.9%), advance directives (11.8%), and family involvement in medical decision-making (13.6%). There was a difference noted regarding their EoL care discussion based on the stage of cancer. Patients with early-stage disease wanted their oncologists to decide on the frequency of this discussion (72.7%). Patients with advanced disease wanted EoL care discussion to be done more frequently as initiated by them or their oncologist or if there’s a change in the treatment plan. 

Conclusions

A discrepancy between self-reported and actual knowledge in breast cancer patients emphasizes the need for patient education. Most patients rely on their oncologists for their diagnosis-related emotional and social issues. Surprisingly, more than a quarter of our patients consider EoL care discussions important even though the majority of our patients were healthy and having stage I and II disease.

eBreCaP: extreme learning-based model for breast cancer survival prediction

Breast cancer is the second leading cause of death in the world. Breast cancer research is focused towards its early prediction, diagnosis, and prognosis. Breast cancer can be predicted on omics profiles, clinical tests, and pathological images. The omics profiles comprise of genomic, proteomic, and transcriptomic profiles that are available as high-dimensional datasets. Survival prediction is carried out on omics data to predict early the onset of disease, relapse, reoccurrence of diseases, and biomarker identification. The early prediction of breast cancer is desired for the effective treatment of patients as delay can aggravate the staging of cancer. In this study, extreme learning machine (ELM) based model for breast cancer survival prediction named eBreCaP is proposed. It integrates the genomic (gene expression, copy number alteration, DNA methylation, protein expression) and pathological image datasets; and trains them using an ensemble of ELM with the six best-chosen models suitable to be applied on integrated data. eBreCaP has been evaluated on nine performance parameters, namely sensitivity, specificity, precision, accuracy, Matthews correlation coefficient, area under curve, area under precision-recall, hazard ratio, and concordance Index. eBreCaP has achieved an accuracy of 85% for early breast cancer survival prediction using the ensemble of ELM with gradient boosting.