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The article provides information on increase in cases of small breast cancers and screening mammography for diagnosis. Topics discussed include diagnosis of invasive breast cancers from Surveillance, Epidemiology, and End Results (SEER) database; tumor size and change in biologic features; and distant metastasis.

Margin status after definitive breast-conserving surgery (BCS) is a key predictor of local tumor recurrence. This study utilized the National Cancer Database, which captures 70 per cent of all cancer cases nationally, to determine factors associated with persistently positive margins status post-BCS. From 1998 to 2010, there were 1,170,284 patients with stage 0 to 3 breast cancer who underwent BCS. After final definitive surgery, 7.3 per cent of patients had positive margins. On bivariate analysis, persistently positive margin status post-BCS was correlated with patient age, race, ethnicity, comorbidities, facility type and location, tumor size, grade, presence of invasive disease, lymph node positivity, as well as receipt of neoadjuvant chemotherapy and adjuvant radiation therapy (P < 0.001). On multivariate analysis, patients who were black, with multiple comorbidities, living in a Pacific state, who had larger, high-grade, node-positive invasive tumors, who did not receive neoadjuvant chemotherapy, and who did not receive adjuvant radiation therapy were more likely to have persistently positive margins (P < 0.05). Although the goal of BCS is the attainment of negative margins, 7.3 per cent of patients have persistently positive margins after definitive surgery. These patients tend to have more aggressive disease and greater comorbidities, and are less likely to receive adjuvant radiation therapy. [ABSTRACT FROM AUTHOR]

BACKGROUND: Factors influencing the treatment of ductal carcinoma in situ with mastectomy and reconstruction are poorly understood. METHODS: A retrospective cohort study of 196 patients presenting to one institution was performed. RESULTS: Forty-seven patients (24.0%) were treated with mastectomy, while 149 (76.0%) underwent breast-conserving surgery. Of the mastectomy patients, 28 (59.6%) elected for reconstruction. On bivariate analysis, patients who opted for mastectomy were younger than those treated with breast-conserving surgery (median age, 51.8 vs 56.5 years; P 5 .017) and had higher grade tumors (50.0% vs 34.6% grade 3, P 5 .009). Among patients treated with mastectomy, those who opted for reconstruction were younger than those forgoing reconstruction (49.4 vs 56.9 years, P 5.024). Race, ductal carcinoma in situ tumor size, and histologic subtype were not associated with the decision to pursue mastectomy or reconstruction (P . .05 for all). CONCLUSIONS: In patients with ductal carcinoma in situ, the decision to pursue mastectomy and reconstruction appears to be driven by younger patient age and higher tumor grade. [ABSTRACT FROM AUTHOR]

BACKGROUND: We sought to determine factors predicting microinvasion and the prognostic role it plays in patients with ductal carcinoma in situ (DCIS). METHODS: A retrospective cohort study of 205 consecutive patients presenting to the Yale Breast Center, New Haven, CT, was performed. RESULTS: Fifty-one (24.9%) patients had microinvasion on pathology. Patients with microinvasion had larger areas of DCIS and were more likely to have high-grade DCIS of the comedo and solid type associated with necrosis and microcalcifications. On multivariate analysis, none of these factors were independent predictors of microinvasion.With a median follow-up of 8.5 years, there was no difference in the recurrence rate or 5-year actuarial survival between those with microinvasion vs those with pure DCIS. CONCLUSIONS: Microinvasion was associated with more extensive DCIS, higher grade, comedo or solid histology, necrosis, and microcalcifications although none of these were found to be an independent predictor of microinvasion. Furthermore, the presence of microinvasion does not seem to significantly increase the risk of recurrence or decrease survival. [ABSTRACT FROM AUTHOR]

Little is known about factors influencing time between diagnosis and definitive treatment in patients with ductal carcinoma in situ (DCIS). We sought to determine the factors influencing this delay time and implications on outcome. A retrospective review was performed of 127 patients with DCIS who were treated with definitive surgical excision at an academic center from 2000 to 2003. The mean time from diagnosis of DCIS to definitive surgical treatment was 39.5 days (range, 3 to 130 days). Age, race, tumor grade, and histopathologic features were not associated with time to definitive treatment (P > 0.05). However, patients who opted for breast-conserving surgery had a shorter time to definitive treatment compared with patients treated with mastectomy (mean time 32.9 vs 53.9 days, P < 0.001). Of patients undergoing mastectomy, those who opted for reconstruction did not have a prolonged time to treatment (55.0 vs 52.4 days, P = 0.880). Increased time between diagnosis and treatment (greater than 39.5 days) was not associated with worse prognosis in terms of overall survival (five-year actuarial survival: 93.0 vs 97.6%, P = 0.322). No demographic or histopathologic factors were associated with increased time to definitive treatment, although patients treated with mastectomy tended to have a longer diagnosis-to-treatment interval. However, the delay time was not associated with worse outcome. [ABSTRACT FROM AUTHOR]

The ACOSOG Z11 trial is rapidly changing use of axillary dissection, but it is not known how generalizable the Z11 results are. This study compares characteristics of the Z11 patients with the larger group of sentinel node-positive patients and evaluates two previously described Louisville algorithms to determine whether they might still be useful to predict extent of axillary node involvement and guide management of the axilla. The Yale Breast Center database was queried to calculate the Louisville prediction points for patients with a positive sentinel node and to compare the predicted with actual results. Of 1215 sentinel node biopsies performed between 2004 and 2010, 282 (23%) had at least one positive node. Thirty-one per cent of these patients would have been eligible for Z11. This group had much less axillary node involvement than the 69 per cent who were ineligible. The Yale data confirmed the accuracy of the two Louisville models and showed that tumor size, number of positive sentinel nodes, and proportion of positive sentinel nodes were all significant predictors. However, these results were much more robust if at least three sentinel nodes had been removed. The Z11 patients were clearly a good risk group. The data validate the two Louisville models and suggest that the models may be useful to select patients to avoid axillary dissection, both among the currently Z11-eligible and -ineligible populations. A modified algorithm is proposed in which all patients with a positive sentinel node have at least three total nodes removed. [ABSTRACT FROM AUTHOR]

Purpose. The value of nodal ratios (NRs) as a prognostic variable in breast cancer is continually being demonstrated. The purpose of this study was to use NR in patients with ≥4+ nodes to assess a correlation of NR with regional (lymph node) recurrence. Methods. Inclusion criteria was ≥8 nodes dissected with ≥4+ nodes after breast conservation therapy. Of 1060 patients treated from 1975 to 2003 who had a minimum of 8 nodes dissected, 273 were node+; 56 patients had ≥4+ involved nodes and were the focus of this study. Nodal ratios were calculated for each patient and grouped into 3 categories: high (≥70%), intermediate (40%-69%) and low (<40%). Each nodal ratio was correlated with patterns of local, regional, and distant failures and OS. Results. Outcomes for the entire cohort were BRFS-83%, NRFS-93%, DMFS-61%, and OS 63% at 10 yrs. The OS, DMFS, and NRFS correlated with N2 (4-9 nodes+) versus N3 (≥10+) status but did not correlate with BRFS, as expected. When evaluating NR, 18 pts had high NR (>70%). Only 3 patients experienced nodal recurrences, all within previously radiated supraclavicular fields. All 3 in-field regional failures occurred in the N3 group of patients with NR >70%. All were treated with a single AP field prescribed to a dose of 46 Gy at a standard depth of 3 cm. Conclusions. In this group of N2/N3 patients treated with BCT, we were able to identify patients at high risk for regional failures as those with high NR of >70% and ≥10+ nodes. While these findings need to be reproduced in larger datasets, this group of patients with NR of >70% in 4 or more positive axillary lymph nodes may benefit from meticulous targeting of regional nodes, dose escalation, and/or more intensive systemic therapies. [ABSTRACT FROM AUTHOR]

Abstract: Background: Although much data support the National Quality Forum recommendation that breast cancers should be diagnosed by needle biopsy before surgical resection, the exclusion criteria for those that may not be suitable have yet to be defined. Methods: We reviewed all patients treated over the past 3 years at the Yale Breast Center to determine the percentage of patients not diagnosed by needle biopsy, and why. Results: Reasons for the 17% of 630 patients who were not diagnosed by needle biopsy were as follows: inability to cooperate (1%); small or superficial lesion less than 1 cm that technically was easier to excise in the office (4%); bloody discharge without clinical or mammographic mass (1%); lesion adjacent to implant (.5%); a mammographic lesion that was too posterior, too superficial, or too faint to be performed stereotactically (5%); or patient preference (5%). Conclusions: Needle biopsy is the preferred method of diagnosis in most cases, but there are valid reasons why all breast cancers will not be diagnosed in this fashion. [Copyright &y& Elsevier]

Recurring subareolar abscess and lactiferous duct fistula are frequently difficult to manage.Personal experience with 67 cases treated during the past 22 years is reviewed.There were 38 cases of subareolar abscess and 29 of lactiferous duct fistula. Thirty-three patients had resolution with antibiotics and needle aspiration or with incision and drainage,but 34 patients required definitive duct excision. Eight patients had duct excision through circumareolar incisions, and 5 of these had prolonged healing problems or recurrence within 1 year. Twenty-six patients had duct excision by placing a probe into the duct and radially excising an elliptical area of the nipple and areola like a “slice of pie,” and these all healed primarily (P <0.001).Approximately half of the patients with subareolar abscess can be managed medically, but the other half will require definitive duct excision. A radial elliptical incision with primary closure results in excellent cosmesis and low long-term recurrence rates. [Copyright &y& Elsevier]

The article discusses the effect of religious beliefs with other variable with breast cancer screening. Breast cancer carries threats of physical disfigurement and mortality, disruption in marital, family, and other relationships, and financial instability. Although there is evidence that religion and religious beliefs mediate the relationship between life events and outcomes including health, illness and mortality. Research on cultural differences in the use of religion as a coping aid among breast cancer patients is limited. African American women are less likely than white women to undergo breast cancer screening and to be diagnosed, and they are more likely to present late-stage breast disease. Women who are older are more likely than others to believe that religious intervention combines with medical treatment to cure breast cancer. Women with family incomes higher than others and those reporting a consultation with their physicians about preventive breast care and mammography are more likely than other women to report timely clinical breast examinations.

: BackgroundOver the past decade breast cancer mortality has decreased 1% or 2% per year in white women, but not in African-American women. The resulting “mortality gap” is a serious national problem, and it must be a high priority to understand the reasons for it and develop solutions.: MethodsThe literature is reviewed to elucidate reasons for the mortality gap and the current status of possible solutions to the problem. In addition, new results of large population-based surveys in North Carolina are presented that may shed light on the problem.: ResultsThe most important reason for the mortality gap is that African-American women tend to be diagnosed with more advanced stage breast cancer than white women. This is due both to lower utilization of screening mammography and to delayed presentation for women with palpable lumps. This is related both to socioeconomic factors that influence access to medical care and to cultural factors that tend to discourage women from seeking care early for breast problems.: Conclusions:Understanding the cultural beliefs that influence patient behavior will greatly aid physicians in caring for their African-American patients, and ultimately may help reduce the racial gap in breast cancer mortality. [Copyright &y& Elsevier]

Assesses the daily patterns of cell division of all plants and animals, while providing evidence for an ontogenetic basis for circadian coordination of cancer cell proliferation. Indication of murine experiments conducted; Process which the cells of the epithelial lining of the human gut and hematopoietic precursor cells residing within the bone marrow of health individuals undertake; Coordination on cell proliferation in spontaneous human cancer.

Presents a study that evaluates the influence of socioeconomic and cultural factors on the racial difference in breast cancer stage at diagnosis. Greater breast cancer mortality in African American women than in white women; Design of study; Setting; Subjects; Main outcome measures; Results; Conclusions.

Abstract: Background: Although neoadjuvant chemotherapy is increasingly used for breast cancer, if a patient has a complete clinical response, it is often difficult for the surgeon to know exactly where and how much breast tissue to remove. Methods: A method is described where the edges of the tumor are tattooed prior to chemotherapy, allowing all tissue initially involved with tumor to be resected following the chemotherapy. Results: Thirty-four cases have been tattooed prior to neoadjuvant chemotherapy, and the clinical and pathological complete response rates were 56% and 22%, respectively. The tattoos allowed very accurate localization of the residual tumor location and extent. Of the 22 patients who have so far undergone lumpectomy, 77% had residual pathologic evidence of tumor, but the margins were negative in 91% at the first operation. Only 2 patients had to undergo a mastectomy because of persistently positive margins. Conclusions: The technique of breast tattooing is a simple and practical method to guide the extent of breast surgery following neoadjuvant chemotherapy. In contrast to placement of clips, the technique does not require needle localization, and it allows accurate determination of the initial tumor size and margins. [Copyright &y& Elsevier]

A letter to the editor is presented in response to the article "Benefits, harms, and cost-effectiveness of supplemental ultrasonography screening for women with dense breasts" by B. L. Sprague and colleagues, in the previous issues of the journal.

A review of the article "Likelihood that a woman with screen-detected breast cancer has had her 'like saved' by that screening," by H.G. Welch and B.A. Frankel which appeared in the 2011;171 issue is presented.

Presents the author's opinions on educating women about the importance of breast self-examination. Discussion on the role of screening mammography in decreasing breast cancer cases; Views on diagnosis of breast cancer; Discussion on educating women to promote earlier detection of palpable breast masses; Information on the incidence of breast cancer among women.

Background: Positive margins have been reported in 20% to 40% of patients undergoing a partial mastectomy, often resulting in re-excision. How often the re-excision yields additional cancer and whether there are predictors of residual disease remain unknown.Study Design: Patients who had a positive margin (defined as tumor at ink for patients with invasive disease or within 1 mm for patients with ductal carcinoma in situ) in the SHAVE (A Randomized Controlled Trial of Routine Shave Margins Versus Standard Partial Mastectomy in Breast Cancer Patients) trial before randomization were evaluated to determine the rate of additional disease either in cavity shave margins or at re-excision. Details of the SHAVE trial can be found elsewhere.Results: Of the 235 patients in the trial, 82 (34.9%) had a positive margin before randomization; 58 of these patients underwent either cavity shave margins excision or a re-excision of the positive margin(s). Twenty-one (36.2%) patients had residual disease. On bivariate analysis, residual disease was associated with younger patient age (median 51 vs 62 years; p = 0.007), and the presence of high-grade ductal carcinoma in situ (57.1% vs 31.3% for grade 2 and 0% for grade 1; p = 0.025). The following factors were not associated with further disease: patient race; ethnicity; BMI; volume of resection; number of positive margins; extent of ductal carcinoma in situ; and extent, grade, and histologic subtype of invasive cancer. On multivariate analysis, only patient age younger than 60 years remained a significant predictor of residual disease (odds ratio 3.920; 95% CI 1.081 to 14.220; p = 0.038).Conclusions: Positive margins are associated with further disease in more than one-third of patients and, aside from young age, there are no predictors of this. These findings support continued re-excision of positive margins, particularly in patients younger than 60 years of age. [ABSTRACT FROM AUTHOR]

A letter to the editor in response to the article "A systematic assessment of benefits and risks to guide breast cancer screening decisions" by Drs. Lydia Pace and Nancy Keating featured in the April 2, 2014 issue is presented.

Purpose: To compare the clinical-pathologic features and long-term outcomes for women with ductal carcinoma in situ (DCIS) vs. DCIS with microinvasion (DCISM) treated with breast conservation therapy (BCT), to assess the impact of microinvasion. Patients and Methods: A total of 393 patients with DCIS/DCISM from our database were analyzed to assess differences in clinical-pathologic features and outcomes for the two cohorts. Results: The median follow-up was 8.94 years, and the mean age was 55.8 years for the entire group. The DCISM cohort was comprised of 72 of 393 patients (18.3%). Surgical evaluation of the axilla was performed in 58.3% (n = 42) of DCISM vs. 18.1% (n = 58) of DCIS, with only 1 of 42 DCISM (2.3%) vs. 0 of 58 DCIS with axillary metastasis. Surgical axillary evaluation was not an independent predictor of local-regional relapse (LRR), distant relapse-free survival (DRFS), or overall survival (OS) in Cox proportional hazards analysis (p > 0.05). For the DCIS vs. DCISM groups, respectively, the 10-year breast relapse-free survival was 89.0% vs. 90.7% (p = 0.36), DRFS was 98.5% vs. 97.9% (p = 0.78), and OS was 93.2% vs. 95.7% (p = 0.95). The presence of microinvasion did not correlate with LRR, age, presentation, race, family history, margin status, and use of adjuvant hormonal therapy (all p > 0.05). In univariate analysis, pathology (DCIS vs. DCISM) was not an independent predictor of LRR (hazard ratio [HR], 1.58; 95% confidence interval [CI], 0.58–4.30; p = 0.36), DRFS (HR, 0.72; 95% CI, 0.07–6.95; p = 0.77), or OS (HR, 1.03; 95% CI, 0.28–3.82; p = 0.95). Conclusions: Our data imply that the natural history of DCISM closely resembles that of DCIS, with a low incidence of local-regional and distant failures. On the basis of our large dataset, the incidence of axillary metastasis in DCISM appears to be small and not appear to correlate to outcomes, and thus, microinvasion alone should not be the sole criterion for more aggressive treatment. [ABSTRACT FROM AUTHOR]

The article talks about the several cases of women with Granulomatous lobular mastitis (GLM) disease. It discussed GLM is a breast disease that poses therapeutic challenges to healthcare providers and its diagnosis relies on tissue biopsy, mentions the treatment of cystic neutrophilic granulomatous mastitis (CNGM), with antibiotics that target Corynebacterium.

Pseudoangiomatous stromal hyperplasia (PASH) is a benign hyperplastic condition of the breast that can lead to macromastia. The standard treatment for PASH is focal excision or rarely reduction mammoplasty. We present a rare case of postpartum bilateral rapid breast enlargement and axillary growth that was refractory to reduction mammoplasty. Ultimately, the patient required bilateral mastectomy and two‐stage implant‐based breast reconstruction. This more extensive form along with its management represents one of the few reported cases in the literature. The decision to pursue bilateral mastectomy was undertaken after exhausting more conservative options. Excellent aesthetic outcome and pain relief was obtained following definitive extirpative and reconstructive surgery. [ABSTRACT FROM AUTHOR]

Purpose The 21-gene recurrence score (RS) assay is used to help formulate adjuvant chemotherapy recommendations for patients with estrogen receptor-positive, early-stage breast cancer. Most frequently, medical oncologists order RS after surgery. Results take an additional 2 weeks to return, which can delay decision making. We conducted a prospective qualityimprovement project to assess the impact of early guideline-directed RS ordering by surgeons before the first visit with a medical oncologist on adjuvant therapy decision making. Materials and Methods Surgical oncologists ordered RS testing following National Comprehensive Cancer Network guidelines at time of diagnosis or at time of surgery between July 1, 2015 and December 31, 2015. We measured the testing rate of patients eligible for RS, time to chemotherapy decisions, rates of chemotherapy use, accrual to RS-based clinical trials, cost, and physician acceptance of the policy and compared the results to patients who met eligibility criteria for early guideline-directed testing during the 6 months before the project. Results Ninety patients met eligibility criteria during the testing period. RS was ordered for 91% of patients in the early testing group compared with 76% of historical controls (P, .001). Median time to chemotherapy decision was significantly shorter in the early testing group (20 days; 95% CI, 17 to 23 days) compared with historical controls (32 days; 95% CI, 29 to 35 days; P, .001). There were no significant differences in time to chemotherapy initiation, chemotherapy use, RS-based trial enrollment, or calculated costs between the groups. Conclusion Early guideline-directed RS testing in selected patients is an effective way to shorten time to treatment decisions. [ABSTRACT FROM AUTHOR]

The article presents a study on cavity shave margins in breast cancer. Topics include the effect of a routine resection of cavity shave margins on the rate reduction of positive margins of tumors, the decrease in the incidence of reexcision in patients that underwent partial mastectomy, and the use of the Inequality Tests for Two Proportions module of the PASS 2008 software. It also features a table of the factors associated with margin positivity.

BACKGROUND Neoadjuvant chemotherapy (NAC) is the standard of care for patients with locally advanced breast cancer and can yield clinical advantages in individuals with lower stage cancers as well. To the authors' knowledge, the extent and patterns of use of NAC remain unknown. The objective of the current study was to assess temporal trends in NAC use and to examine what clinical, demographic, and treatment site characteristics influence its use. METHODS Data from the National Cancer Data Base regarding 395,486 patients with stage I to stage III breast cancer who received adjuvant or neoadjuvant chemotherapy in the United States from 2003 through 2011 were analyzed. Chi-square tests and logistic regression analyses were used to assess the association between NAC use and patient, tumor, and facility characteristics. RESULTS Overall, 17.4% of patients received NAC, including 4% of patients with stage I disease, 17.8% of patients with stage II disease, and 41.6% of patients with stage III disease. NAC use increased over time from 12.2% to 24.0%, particularly among patients with more advanced cancers. Rates increased from 12.9% to 39.3% in patients with stage IIIA, from 72.3% to 86.4% in patients with stage IIIB, and from 30.1% to 59.3% in patients with stage IIIC cancers. On multivariate analysis, patients aged <60 years, African American individuals, and those treated in academic centers were more likely to receive NAC. NAC use also varied by geographic region and was the highest in the West South Central region (21%) and lowest in the Midwest (15.2%). CONCLUSIONS Although NAC use increased between 2003 and 2011, <50% of all patients with stage III breast cancer were treated with NAC. Substantial regional and practice-related variations exist. Cancer 2015;121:2544-2552. © 2015 American Cancer Society. [ABSTRACT FROM AUTHOR]

Background Neoadjuvant chemotherapy has been shown to increase the rate of breast conservation in clinical trials and small institutional series, but it has never been studied on a national level. Study Design We performed a retrospective review of the National Cancer Database (NCDB). The NCDB is a joint project of the Commission on Cancer of the American College of Surgeons and the American Cancer Society and contains about 80% of the cancer cases in the United States. All women in the NCDB diagnosed with invasive breast cancer from 2006 through 2011, who underwent definitive breast surgery and received either neoadjuvant or adjuvant chemotherapy, excluding patients with distant metastases or T4 tumors, were included and rates of breast preservation were determined. Results Of 354,204 patients who met the inclusion criteria, 59,063 (16.7%) underwent neoadjuvant chemotherapy. This proportion steadily increased from 13.9% in 2006 to 20.5% in 2011 (p < 0.001). Receipt of neoadjuvant chemotherapy was associated with larger tumor size (7% cT1, 25% cT2, and 58% cT3; p < 0.001), more advanced nodal disease (11% cN0, 39% cN1-3; p < 0.001), younger patient age (21% <50 years vs 14% >50 years; p < 0.001), higher tumor grade (18% grade 3, 15% grade 2, vs 12% grade 1; p < 0.001), and estrogen receptor (ER)-negative tumors (21% ER negative vs 15% ER postive; p < 0.001). Multivariate logistic regression showed that when adjusted for the above variables, patients with tumors larger than 3 cm undergoing neoadjuvant chemotherapy were more likely to receive breast preservation than those who opted for primary surgery (odds ratio 1.7, 95% CI 1.6 to 1.8). Conclusions Neoadjuvant chemotherapy increases breast preservation for patients with breast tumor size larger than 3 cm. [ABSTRACT FROM AUTHOR]

Purpose: Little is known about the relationship between the financial burden of cancer and the physical and emotional health of cancer survivors. We examined the association between financial problems caused by cancer and reported quality of life in a population-based sample of patients with cancer. Methods: Data from the 2010 National Health Interview Survey (NHIS) were analyzed. A multivariable regression model was used to examine the relationship between the degree to which cancer caused financial problems and the patients' reported quality of life. Results: Of 2,108 patients who answered the survey question, “To what degree has cancer caused financial problems for you and your family?,” 8.6% reported “a lot,” whereas 69.6% reported “not at all.” Patients who reported “a lot” of financial problems as a result of cancer care costs were more likely to rate their physical health (18.6% v 4.3%, P<.001), mental health (8.3% v 1.8%, P<.001), and satisfaction with social activities and relationships (11.8% v 3.6%, P<.001) as poor compared to those with no financial hardship. On multivariable analysis controlling for all of the significant covariates on bivariate analysis, the degree to which cancer caused financial problems was the strongest independent predictor of quality of life. Patients who reported that cancer caused “a lot” of financial problems were four times less likely to rate their quality of life as “excellent,” “very good,” or “good” (odds ratio=0.24; 95% CI, 0.14 to 0.40; P<.001). Conclusion: Increased financial burden asa result of cancer care costs is the strongest independent predictor of poor quality of life among cancer survivors. [ABSTRACT FROM AUTHOR]

Background: For DCIS patients eligible for breast conservation treatment (BCT), it remains unclear whether presenting with physical signs/symptoms (Phys) confers a worse long-term prognosis compared to mammographically detected DCIS (Mam). Methods: We collected data on 669 DCIS patients treated with BCT from 1974 to 2007 of whom 80 were identified as category 'Phys' and 589 were in category 'Mam.' Results: Treatment parameters (i.e., the RT dose delivered, boost, rates of stereotactic biopsy, re-excision, node dissection) did not differ significantly between the two cohorts ( p = NS). At a 60-month median follow-up, significant associations included younger age at presentation ( p < 0.001), non-white race ( p = 0.041), larger tumor size ( p = 0.002), more 1°/2° papillary histology (1°, p = 0.001; 2°, p = 0.005) for the Phys cohort. As expected, mammograms were more likely to show mass/nodules/asymmetrical densities and less likely to show microcalcifications for the Phys versus Mam group ( p < 0.0001). There were no differences in family history, multifocality, grade, necrosis, or residual disease at re-excision, nodal involvement, status of margins, or ER/PR/HER-2 between the cohorts. The local relapse-free survival was similar at 5 years (100 vs. 96.9 %, p = 0.116) and 10 years (96.2 vs. 96.2 %, p = 0.906), with no significant overall survival difference at 10 years (97.5 vs. 95.9 %, p = 0.364) between the Phys and Mam patients, respectively. On multivariate analysis, presentation was not an independent predictor of local relapse-free survival or overall survival when accounting for age, race, tumor size, mammogram appearance, and adjuvant hormone treatment. Conclusions: Our findings suggest that although some clinicopathological differences exist between DCIS patients presenting with physical signs/symptoms compared with those presenting with mammographically detected disease, long-term outcomes are similar for patients appropriately selected for BCT. [ABSTRACT FROM AUTHOR]

Background. Prior studies have shown earlier recurrence and decreased survival in patients with head and neck cancer who smoked while undergoing radiation therapy. The purpose of the current study was to determine whether smoking status at the time of partial mastectomy and radiation therapy for breast cancer affected recurrence or survival. Method. A single institution retrospective chart review was performed to correlate smoking status with patient demographics, tumor characteristics, and outcomes for patients undergoing partial mastectomy and radiation therapy. Results. There were 624 patients who underwent breast conservation surgery between 2002 and 2010 for whom smoking history and follow-up data were available. Smoking status was associated with race, patient age, and tumor stage, but not with grade, histology, or receptor status. African American women were more likely to be current smokers (22% versus 7%, P < 0.001). With a mean follow-up of 45 months, recurrence was significantly higher in current smokers compared to former or never smokers (P = 0.039). In a multivariate model adjusted for race and tumor stage, recurrence among current smokers was 6.7 times that of never smokers (CI 2.0-22.4). Conclusions. Although the numbers are small, this study suggests that smoking may negatively influence recurrence rates after partial mastectomy and radiation therapy. A larger study is needed to confirm these observations. [ABSTRACT FROM AUTHOR]

Background: Several recent studies have described increasing rates of unilateral and bilateral mastectomy among women with newly diagnosed breast cancer. The use of breast magnetic resonance imaging (MRI) has also risen rapidly, leading to speculation that the high false-positive rate and need for multiple biopsies associated with MRI may contribute to more mastectomies. The objective of this study was to determine whether newly diagnosed patients who underwent preoperative MRI were more likely to undergo mastectomy compared with those who did not have a preoperative MRI. Methods: A retrospective review was performed of all newly diagnosed patients with breast cancer at our academic breast center from 2004 to 2009. Results: The proportion of newly diagnosed patients with breast cancer having MRI prior to surgery increased from 6% in 2004 to 73% in 2009. Of 628 patients who underwent diagnostic MRI, 369 (59%) had abnormal results, 257 (41%) had one or more biopsies, and 73 had additional sites of cancer diagnosed. Patients with a malignant biopsy, or those with an abnormal MRI who did not undergo biopsy, had an increased mastectomy rate (P<0.01). However, patients with a normal MRI or a benign biopsy actually had a decreased mastectomy rate (P<0.05). Although there was a trend toward more bilateral mastectomies, the overall mastectomy rate did not change over this time period. Conclusions: Although there is a strong relationship between the result of an MRI and the choice of surgery, the overall effect is not always to increase the mastectomy rate. Some patients who were initially considering mastectomy chose lumpectomy after an MRI. [ABSTRACT FROM AUTHOR]

Purpose: Quantification of mRNA has historically been done by reverse transcription polymerase chain reaction (RT-PCR). Recently, a robust method of detection of mRNA utilizing in situ hybridization has been described that is linear and shows high specificity with low background. Here we describe the use of the AQUA method of quantitative immunofluorescence (QIF) for measuring mRNA in situ using ESR1 (the estrogen receptor alpha gene) in breast cancer to determine its predictive value compared to Estrogen Receptor a (ER) protein. Methods: Messenger RNA for ER (ESR1) and Ubiquitin C (UbC) were visualized using RNAscope probes and levels were quantified by quantitative in situ hybridization (qISH) on two Yale breast cancer cohorts on tissue microarrays. ESR1 levels were compared to ER protein levels measured by QIF using the SP1 antibody. Results: ESR1 mRNA is reproducibly and specifically measurable by qISH on tissue collected from 1993 or later. ESR1 levels were correlated to ER protein levels in a non-linear manner on two Yale cohorts. High levels of ESR1 were found to be predictive of response to tamoxifin. Conclusion: Quantification of mRNA using qISH may allow assessment of large cohorts with minimal formalin fixed, paraffin embedded tissue. Exploratory data using this method suggests that measurement of ESR1 mRNA levels may be predictive of response to endocrine therapy in a manner that is different from the predictive value of ER. [ABSTRACT FROM AUTHOR]

Purpose: To compare outcomes of salvage mastectomy (SM) and salvage breast-conserving surgery (SBCS) and study the feasibility of SBCS. Methods and Materials: Of 2,038 patients treated with breast-conserving therapy at Yale-New Haven Hospital before 1999, 166 sustained an ipsilateral breast tumor recurrence (IBTR). Outcomes and prognostic factors of patients treated with SM or SBCS were compared. Patients were considered amenable to SBCS if the recurrence was localized on mammogram and physical examination, and had pathologic size <3 cm, confined to the biopsy site, without skin or lymphovascular invasion, and with ≤3 positive nodes. Results: Of the 146 patients definitively managed at IBTR, surgery was SM (n = 116) or SBCS (n = 30). The median length of follow-up after IBTR was 13.8 years. The SM and SBCS cohorts had no significant differences, except at IBTR the SM cohort had a greater tumor size (p = 0.049). Of the SM cohort, 65.5% were considered appropriate for SBCS, and a localized relapse was predicted by estrogen-receptor positive, diploid, and detection of recurrence by mammogram. Multicentric disease correlated with BRCA1/2 mutation, estrogen-receptor negative, lymph node positive at relapse, and detection of recurrence by physical examination. Survival after IBTR was 64.5% at 10 years, with no significant difference between SM (65.7%) and SBCS (58.0%). Only 2 patients in the SBCS cohort subsequently had a second IBTR, and were salvaged with mastectomy. Conclusions: While mastectomy is considered the standard surgical salvage of IBTR, SBCS is feasible and prognostic factors are related to favorable tumor biology and early detection. Patients with BRCA1/2 germline mutations may be less appropriate for SBCS, as multicentric disease was more prevalent. Patients who underwent SBCS had comparable outcomes as those who underwent SM, but remain at continued risk for IBTR. A prospective trial evaluating repeat lumpectomy and partial breast reirradiation is discussed. [Copyright &y& Elsevier]

A letter to the editor is presented in response to the article related to decreasing predominance of breast cancer on left side, in the previous issue.

Abstract: Background: There are an increasing number of fellowship-trained breast surgeons and surgical oncologists who dedicate their clinical practice exclusively to breast disease. However, there are little published data regarding characteristics of a breast surgical practice. Methods: All patient visits at a university-based breast surgery practice were reviewed for calendar years 2006 and 2007. Results: There were 10,381 patient visits, of which 2,334 (22%) represented new patients. Of these, 11% were referred with a diagnosis of cancer. Out of the remainder, 29% had a needle biopsy (8% by the surgeon and 21% by radiology), 29% underwent surgery, and 13% were ultimately diagnosed with cancer. After completion of initial therapy, 6 months or 1 year follow-up was recommended for 59% of the patients. Conclusions: The specialty of breast surgery is unique in its nonoperative volume and extensive duration of follow-up. Strategies need to be designed to make this process more time-efficient for the surgeon. [Copyright &y& Elsevier]

The article discusses the medical examination and diagnosis of a 43-year-old woman experiencing shortness of breath. The medical determination of the disease focusing on the possibility of breast and ovarian cancer is described including the used of transvaginal ultrasound, magnetic resonance imaging, sentinel node biopsy, lumpectomy, among others. A positive for gross cystic disease fluid protein-15 (GCDFP-15) for the breast carcinoma is indicated.

Background: Despite screening mammography, the incidence of Stage IV breast cancer (BC) at diagnosis has not decreased over the past four decades. We previously found that many BCs are small due to favorable biology rather than early detection. This study compared the biology of Stage IV cancers with that of small cancers typically found by screening. Methods: Trends in the incidence of localized, regional, and distant female BC were compared using SEER*Stat. The National Cancer Database (NCDB) was then queried for invasive cancers from 2010 to 2015, and patient/disease variables were compared across stages. Biological variables including estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor 2 (Her2), grade, and lymphovascular invasion were sorted into 48 combinations, from which three biological subtypes emerged: indolent, intermediate, and aggressive. The distributions of the subtypes were compared across disease stages. Multivariable regression assessed the association between Stage IV disease and biology. Results: SEER*Stat confirmed that the incidence of distant BC increased between 1973 and 2015 (annual percent change [APC] = 0.46). NCDB data on roughly 993,000 individuals showed that Stage IV disease at presentation is more common in young, black, uninsured women with low income/education and large, biologically aggressive tumors. The distribution of tumor biology varied by stage, with Stage IV disease including 37.6% aggressive and 6.0% indolent tumors, versus sub-centimeter Stage I disease that included 5.1% aggressive and 40.6% indolent tumors (p < 0.001). The odds of Stage IV disease presentation more than tripled for patients with aggressive tumors (OR3.2, 95% CI 3.0–3.5). Conclusions: Stage I and Stage IV breast cancers represent very different populations of biologic tumor types. This may explain why the incidence of Stage IV cancer has not decreased with screening. [ABSTRACT FROM AUTHOR]