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There is a paucity of data on the use of intraoperative radiotherapy (IORT) with low-energy X-rays in Malaysian women with early breast cancer. The aim of this study is to evaluate the clinical, cosmetic, and patient-reported outcomes in low- and high-risk early breast cancer patients treated with breast conserving surgery (BCS) and IORT.Patients suitable for BCS who were treated with IORT between January 2016 and June 2019 from three centres were analysed. They were divided into low-risk and high-risk groups based on the risk of recurrence according to the TARGeted Intraoperative radioTherapy (TARGIT) A and B study criteria. Outcomes of interest included local recurrence, wound complications, and radiation toxicity, with a subset analysed for cosmetic and patient-reported outcomes.Within a median follow-up of 31 months, there were 104 and 211 patients in the low- and high-risk groups, respectively. No significant difference was observed in local recurrence rates (low-risk, 1.0% vs. high-risk, 1.4%; p = 1.000). Both cohorts exhibited low frequencies of severe wound complications ranging between 1.4 and 1.9%. No major radiation toxicities were reported in either group. In the subgroup analysis, low-risk patients had significantly better mean scores in the subscales of inframammary fold and scar. Based on the BREAST-Q patient-reported outcomes questionnaire, seven out of nine parameters were scored similarly between both groups with no significant difference.This study showed that the use of IORT in both low- and high-risk early breast cancers is efficacious and safe with low recurrence rates and an acceptable toxicity profile.

Background: Primary breast angiosarcoma is a rare malignancy with non-specific clinical and radiological findings. Case Report: A 30-year-old lady presented with left breast pain and lumpiness for over one year. She has had several breast ultrasounds (US) and was treated for acute mastitis and abscess. Subsequently, in view of the rapid growth of the lump and worsening pain, she was re-investigated with US, elastography, digital breast tomosynthesis (DBT) and MRI. MRI raised the suspicion of angiosarcoma. The diagnosis was confirmed after biopsy and she underwent mastectomy. Discussion: Literature review on imaging findings of breast angiosarcoma, especially on MRI, is discussed. MRI features showed heterogeneous low signal intensity on T1 and high signal intensity on T2. Dynamic contrast enhancement (DCE) features included either early enhancement with or without washout in the delayed phase, and some reported central areas of non-enhancement. Conclusion: This case report emphasises on the importance of MRI in clinching the diagnosis of breast angiosarcoma, and hence, should be offered sooner to prevent diagnostic delay.

Background: OBJECTIVE: This study aims to determine the 5-year overall survival of young breast cancer according to tumour biology in Malaysia. METHODOLOGY: Multicenter retrospective study with convenience sampling method used to recruit the patients. All young women aged 50years and below with breast cancer who underwent surgery/under follow up from 1st January 2014 to 31st December 2017 in Hospital Tengku Ampuan Rahimah (HTAR), Klang, Hospital Selayang and Hospital Putrajaya were in included. Categorical data were analyzed using Chi-Square analysis and Fisher’s Exact Test. 5-year overall survival was calculated using Kaplan Meier. Cox Regression to estimate hazard ratio for mortality in patients with different tumour biology. Recurrence were analysed using Chi-Square analysis. RESULTS: A total of 360 patients were recruited predominantly within 41years to 50years of age (63.9%). The majority of the patients were Malays (66.4%). Most of the patients were in Stage II (39.4%) with a significant number of patients in Stage III and IV (25.0% & 26.4% respectively). 56.1% had tumour biology of Luminal A followed by Triple negative (21.7%), HER2 Enriched (12.2%) and Luminal B (10%). Kaplan Meier analysis showed that the 5-year overall survival was 58.3%. There were no statistical significance across the tumour biology subtypes. Among the tumour biology groups, Triple Negative had the highest probability of survival with 54.5%. CONCLUSION: We observed that Triple Negative had the highest probability of survival at 5years while Luminal B (HER 2 Positive) had the lowest probability. The 5-years overall survival was not statistically significant with accordance to locoregional recurrence rate and in different tumour biology. Keywords: Breast cancer, young women, tumour biology, overall survival, locoregional recurrence Citation Format: Mee Hoong See, Phrabakaran Rajehgopal, Mei Sze Teh, Lee Lee Lai, Abqariyah Yahya. A COMPARISON OF BREAST CANCER SURVIVAL ACROSS DIFFERENT TUMOUR BIOLOGY IN YOUNG WOMEN: A MULTICENTRIC DATABASE STUDY IN KLANG VALLEY, MALAYSIA [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P5-03-21.

PurposeThis study aims to describe the adverse events following immunization (AEFIs) of SARS-CoV-2 vaccination in cancer patients/survivors associated with their psychological distress.MethodsA cross-sectional study was conducted to assess AEFIs after the receipt of SARS-CoV-2 vaccines in cancer patients/survivors attending a university hospital in Malaysia. Psychological distress was measured using the Hospital Anxiety and Depression Scale (HADS) before and after the first and second doses of COVID-19 vaccine.ResultsA total of 217 complete responses were received. Compared with before vaccination, both HADS Anxiety (HADS-A) and HADS Depression (HADS-D) scores were significantly reduced after the first and second dose of the SARS-CoV-2 vaccine. Most of the participants had mild-or-moderate systemic and local AEFIs, with the most common being pain at the injection site, tiredness, and headache for both the first and second doses of the vaccine. Positive correlations between the total AEFI score and HADS-A (r = 0.309, p r = 0.214, p = 0.001) scores were observed after the first dose of the SARS-CoV-2 vaccine. Similarly, positive associations were observed between the total AEFI score and HADS-A (r = 0.305, p r = 0.235, p ConclusionMild-to-moderate AEFIs found in this study help address vaccine hesitancy in cancer patients/survivors. Receiving the SARS-CoV-2 vaccine had a positive effect on decreasing psychological distress in cancer patients/survivors. High severity of an AEFI was associated with higher anxiety and depressive symptoms.

PURPOSE Addressing unwarranted clinical variation in oncology practices is expected to lead to improved cancer outcomes. Particularly, the application and impact of treatment guidelines on breast cancer outcomes are poorly studied in resource-limited settings. We measured adherence to a set of locally developed adjuvant treatment guidelines in a middle-income setting. Importantly, the impact of guidelines adherence on survival following breast cancer was determined. METHODS Data of 3,100 Malaysian women with nonmetastatic breast cancer diagnosed between 2010 and 2017 were analyzed. Adherence to the Malaysian Clinical Practice Guidelines for Management of Breast Cancer second Edition was measured. Outcomes comprised overall survival and event-free survival. RESULTS Guideline adherence for chemotherapy, radiotherapy, hormonal therapy, and targeted therapy were 61.7%, 79.2%, 85.1%, and 26.2%, respectively. Older age was generally associated with lower adherence to guidelines. Compared with patients who were treated according to treatment guidelines, overall survival and event-free survival were substantially lower in patients who were not treated accordingly; hazard ratios for all-cause mortality were 1.69 (95% CI, 1.29 to 2.22), 2.59 (95% CI, 1.76 to 3.81), 3.08 (95% CI, 1.94 to 4.88), and 4.48 (95% CI, 1.98 to 10.13) for chemotherapy, radiotherapy, hormone therapy, and targeted therapy, respectively. Study inferences remain unchanged following sensitivity analyses. CONCLUSION Our study findings appear to suggest that adherence to treatment guidelines that have been adapted for resource-limited settings may still provide effective guidance in improving breast cancer outcomes.

Desmoid type fibromatosis of the breast is a rare stromal tumor that accounts for

We looked at the usefulness of magnetic resonance imaging (MRI) in decision-making and surgical management of patients selected for intraoperative radiotherapy (IORT). We also compared lesion size measurements in different modalities (ultrasound (US), mammogram (MMG), MRI) against pathological size as the gold standard. 63 patients eligible for IORT based on clinical and imaging criteria over a 34-month period were enrolled. All had MMG and US, while 42 had additional preoperative MRI for locoregional preoperative staging. Imaging findings and pathological size concordances were analysed across the three modalities. MRI changed the surgical management of 5 patients (11.9%) whereby breast-conserving surgery (BCS) and IORT was cancelled due to detection of satellite lesion, tumor size exceeding 30mm and detection of axillary nodal metastases. Ten of 42 patients (23.8%) who underwent preoperative MRI were subjected to additional external beam radiotherapy (EBRT); 7 due to lymphovascular invasion (LVI), 2 due to involved margins, and 1 due to axillary lymph node metastatic carcinoma detected in the surgical specimen. Five of 21 (23.8%) patients without prior MRI were subjected to additional EBRT post-surgery; 3 had LVI and 2 had involved margins. The rest underwent BCS and IORT as planned. MRI and MMG show better imaging-pathological size correlation. Significant increase in the mean ‘waiting time’ were seen in the MRI group (34.1 days) compared to the conventional imaging group (24.4 days). MRI is a useful adjunct to conventional imaging and impacts decision making in IORT. It is also the best imaging modality to determine the actual tumour size.

Background Many institutions withheld elective lists and triaged surgeries during the peak of coronavirus disease 2019 (COVID-19) pandemic. As a result, older surgical patients have had to wait for rescheduled dates in a long waitlist. This study aimed to identify the psychological impact in these patients when they returned for surgery. Methods This was a cross-sectional study which included 153 patients aged ≥ 65 years undergoing elective surgery. Trained interviewers recruited and assessed psychological status pre-operatively with two validated questionnaires - Hospital Anxiety and Depression Scale (HADS) and 36-item Short Form Health Survey (SF-36). Specific questions were asked about their postponed surgeries, appetite and fear. Results A total of 36 out of 153 (23.5%) patients had their procedures deferred during the first wave of COVID-19 pandemic. Postponed cases were significantly based on the nature of surgery (p = 0.002), cancer diagnosis (p = 0.006) and surgical specialty (p = 0.023). Median HADS scores were higher for patients who were postponed (2.00 versus 4.00 for anxiety, p = 0.180 and 0.00 versus 1.00 for depression, p = 0.424) although no statistical significance was shown. In the whole study population, anxiety was a significant predictor for depression and vice versa (p p = 0.018), female (OR 2.41, p = 0.024), cancer (OR 2.19, p = 0.039) and major surgery (OR 2.39, p = 0.023). Similarly, older patients ≥ 85 years old (OR 10.44, p = 0.003) and female (OR 6.07, p = 0.006) had higher risk for depression. Both anxiety and depression were significant risks for loss of appetite (p = 0.005 and 0.001). Lastly, the fear of disease progression due to rescheduling was more frequent in cancer patients (p = 0.035). Conclusion The mental health and disease burden of older surgical patients should be taken into careful consideration when cases need to be postponed in our healthcare system.

Purpose This study aims to evaluate in vivo skin dose delivered by intraoperative radiotherapy (IORT) and determine the factors associated with an increased risk of radiation‐induced skin toxicity. Methodology A total of 21 breast cancer patients who underwent breast‐conserving surgery and IORT, either as IORT alone or IORT boost plus external beam radiotherapy (EBRT), were recruited in this prospective study. EBT3 film was calibrated in water and used to measure skin dose during IORT at concentric circles of 5 mm and 40 mm away from the applicator. For patients who also had EBRT, the maximum skin dose was estimated using the radiotherapy treatment planning system. Mid‐term skin toxicities were evaluated at 3 and 6 months post‐IORT. Results The average skin dose at 5 mm and 40 mm away from the applicator was 3.07 ± 0.82 Gy and 0.99 ± 0.28 Gy, respectively. Patients treated with IORT boost plus EBRT received an additional skin dose of 41.07 ± 1.57 Gy from the EBRT component. At 3 months post‐IORT, 86% of patients showed no evidence of skin toxicity. However, the number of patients suffering from skin toxicity increased from 15% to 38% at 6 months post‐IORT. We found no association between the IORT alone or with the IORT boost plus EBRT and skin toxicity. Older age was associated with increased risk of skin toxicities. A mathematical model was derived to predict skin dose. Conclusion EBT3 film is a suitable dosimeter for in vivo skin dosimetry in IORT, providing patient‐specific skin doses. Both IORT alone and IORT boost techniques resulted in similar skin toxicity rates.

Thermal imbalances are very common during surgery. Hypothermia exposes the patient to post-operative shivering, cardiac dysfunction, coagulopathy, bleeding, wound infection, delayed anesthesia recovery, prolonged hospital stay and increased hospitalization cost. There are many factors contributing to intraoperative hypothermia. This is a prospective cohort study conducted through observation and measurement of pediatric surgical patients' temperature. Convenience sampling methods were used in this study. Initial skin temperature and core temperature at 10 min, 30 min,1 h, 2 h, 3 h, 4 h, 5 h, 6 h and at the end of surgery were recorded. Body temperature was monitored from time of transfer to the operating table until recovery and discharge to the respective pediatric ward. The overall incidence of intraoperative hypothermia was still very high at about 46.6% even though active and passive temperature management were carried out during surgery. Patient's age, body weight, duration of surgery, type of surgery, intraoperative blood loss, type of anesthesia and operating room temperature were factors that contributed to intraoperative hypothermia. Hypothermia is common in surgery, especially in major and long duration surgery. Intraoperative hypothermia can be life threatening if it is not handled carefully. Various methods are used before, during and after surgery to maintain a patient's body temperature within the normothermia range. The use of an active warming device like the Bair Hugger® air-forced warming system seems to be a good method for reducing the risk of intraoperative hypothermia and effectively maintaining body temperature for all major and minor surgeries.

Highlights • Gastrointestinal (GI) tract metastasis in breast cancer is rare and occurs more commonly in invasive lobular carcinoma. • The interval between the index breast cancer and GI tract spread may be as long as 30 years. • 20% of patients with GI tract metastasis are asymptomatic, and detection may rely on physical examination and imaging. • Management follows the principles of treatment in systemic disease in breast cancer, with consideration for surgery in obstruction, perforation or bleeding., Introduction Breast cancer metastasis to the gastrointestinal (GI) tract is rare and occurs more frequently in invasive lobular carcinoma. Patients may be asymptomatic or present with variable vague symptoms that may be mistakenly attributed to side effects of chemotherapy or other benign GI diseases. Treatment follows the principles of systemic disease and includes hormonal therapy, chemotherapy and signal transduction inhibitors, with surgical intervention indicated for complications such as obstruction, perforation and hemorrhage. Presentation of case We present the case of a female patient with a history of invasive lobular breast carcinoma who had undergone mastectomy and axillary dissection, followed by chemoradiotherapy. Over the next nine years, she developed ovarian and bone metastases for which appropriate treatment was provided. A right iliac fossa mass was discovered during routine clinic review, though she remained asymptomatic. Computed tomography scan showed ileocecal intussusception. Histopathological examination of the right hemicolectomy specimen following emergency surgery confirmed metastatic invasive lobular carcinoma to the GI tract. Discussion GI tract metastasis may present 30 years after the primary breast cancer. Up to 20% of patients may be asymptomatic as shown by Montagna et al. When present, symptoms are commonly non-specific and vague. Histological diagnosis is challenging. GI metastasis typically appears as intramural infiltration of the bowel wall by small cells arranged in cords. Conclusion It is important to maintain a suspicion for GI tract metastasis in breast cancer patients who present with abdominal mass or GI symptoms, as this aids in prompt institution of accurate and appropriate management.

Breast cancer is the most commonly occurring cancer in women worldwide. While mammography remains the gold standard in breast cancer screening, ultrasound is an important imaging modality for both screening and cancer diagnosis. This paper presents a novel method for the detection of breast lesions in ultrasound images using texton filter banks, local configuration pattern features, and classification, without employing any segmentation technique. The developed method was able to accurately detect and classify breast lesions and achieved an accuracy, sensitivity, specificity, and positive predictive value of 96.1%, 96.5%, 95.3%, and 97.9%, respectively. The paradigm that we describe may, therefore, be useful as an effective tool to detect breast nodules during screening and in whole breast imaging, enabling clinicians to focus on images where a lesion is already known to be present. The developed method may also serve as a component for automatic breast nodule detection, and, when found, for the subsequent classification between lesion type benign versus malignant.

Introduction Breast conserving surgeries were previously contraindicated for central breast cancers because of poor cosmetic outcomes of central mastectomy without oncoplastic surgery. Grisotti flap is a breast-conserving surgery incorporating oncoplastic surgery technique for centrally located breast cancers. We present our experience and outcome from Breast Surgery Unit, University Malaya Medical Center. Materials and methods A prospective analysis of 15 patients with central retroareolar breast cancer operated from 2012 to 2018 in University Malaya Medical Center. We assessed postoperative complications, margins, locoregional recurrence, and survival outcome. All patients received postoperative radiotherapy. Patients were followed-up 1 week, 1 month, 3 monthly for 1 year and 6 monthly for 5 years. Results Mean age of patients is 62 years. Mean follow-up is 51 months (15-84 months). All tumors were less than 5 cm (1-2.5 cm). Majority of the patients are stage 1 (6 patients/40%) and stage 2 (8 patients/ 53.3%). 2 patients had surgical site infection resolved with antibiotics. One patient had hematoma. None require reoperation. Tumor margins were clear in all patients. No locoregional recurrence. Overall survival is 100%. All are satisfied with their cosmetic outcomes. Conclusions Grisotti flap is a volume displacement technique, which provides satisfactory cosmetic outcome for centrally located breast cancer. This evolutionary thinking leads us to changes in existing techniques with the purpose of achieving oncological safety while reaching for better esthetic results. Our 5 years' experience in Asian population showed that this technique is oncologically safe with good cosmetic outcomes and could be used selectively. It provides a good alternative in patients who are otherwise subjected for mastectomy. This relatively simple technique is a worthwhile endeavor and should be offered when feasible.

Purpose To measure the baseline prevalence of cardiovascular disease (CVD), its modifiable and non-modifiable risk factors in breast cancer patients, and determine their association with adjuvant treatment decision-making. Method From 2016 to 2017, 2,127 women newly-diagnosed with breast cancer were prospectively recruited. Participants' cardiovascular biomarkers were measured prior to adjuvant treatment decision-making. Clinical data and medical histories were obtained from hospital records. Adjuvant treatment decisions were collated 6-8 months after recruitment. A priori risk of cardiotoxicity was predicted using the Cardiotoxicity Risk Score. Results Mean age was 54 years. Eighty-five patients had pre-existing cardiac diseases and 30 had prior stroke. Baseline prevalence of hypertension was 47.8%. Close to 20% had diabetes mellitus, or were obese. Dyslipidaemia was present in 65.3%. The proportion of women presenting with ≥2 modifiable CVD risk factors at initial cancer diagnosis was substantial, irrespective of age. Significant ethnic variations were observed. Multivariable analyses showed that pre-existing CVD was consistently associated with lower administration of adjuvant breast cancer therapies (odds ratio for chemotherapy: 0.32, 95% confidence interval: 0.17-0.58). However, presence of multiple risk factors of CVD did not appear to influence adjuvant treatment decision-making. In this study, 63.6% of patients were predicted to have high risks of developing cardiotoxicities attributed to a high baseline burden of CVD risk factors and anthracycline administration. Conclusion While recent guidelines recommend routine assessment of cardiovascular comorbidities in cancer patients prior to initiation of anticancer therapies, this study highlights the prevailing gap in knowledge on how such data may be used to optimise cancer treatment decision-making.

Rare protein-truncating variants (PTVs) in partner and localiser of BRCA2 (Mutation testing was performed on germline DNA (n=15 768) using targeted sequencing panels. The functional impact of missense variants was tested in mouse embryonic stem cell based functional assays.PTVs inDespite genetic and lifestyle differences between Asian and other populations, the population prevalence of

Background Although immediate breast reconstruction is increasingly becoming popular worldwide, evidence from resource-limited settings is scarce. We investigated factors associated with immediate breast reconstruction in a multiethnic, middle-income Asian setting. Short-term surgical complications, timing of initiation of chemotherapy, and survival outcomes were compared between women undergoing mastectomy alone and their counterparts receiving immediate breast reconstruction. Methods This historical cohort study included women who underwent mastectomy after diagnosis with stage 0 to stage IIIa breast cancer from 2011 to 2015 in a tertiary hospital. Multivariable regression analyses were used to assess factors associated with immediate breast reconstruction and to measure clinical outcomes. Result Out of 790 patients with early breast cancer who had undergone mastectomy, only 68 (8.6%) received immediate breast reconstruction. Immediate breast reconstruction was independently associated with younger age at diagnosis, recent calendar years, Chinese ethnicity, higher education level, and invasive ductal carcinomas. Although immediate breast reconstruction was associated with a higher risk of short-term local surgical complications (adjusted odds ratio: 3.58 [95% confidence interval 1.75–7.30]), there were no significant differences in terms of delay in initiation of chemotherapy, 5-year disease-free survival, and 5-year overall survival between both groups in the multivariable analyses. Conclusion Although associated with short-term surgical complications, immediate breast reconstruction after mastectomy does not appear to be associated with delays in initiation of chemotherapy, recurrence, or mortality after breast cancer. These findings are valuable in facilitating shared surgical decision-making, improving access to immediate breast reconstruction, and setting priorities for surgical trainings in middle-income settings.

Purpose: This study aimed to investigate the psychological distress and its associated factors among cancer survivors in Malaysia during the COVID-19 pandemic.Methods: An anonymous Internet-based study was conducted between 23 April and 26 June 2020. During the study period, the country underwent Phase 3 and Phase 4 of the Movement Control Order (MCO), Conditional Movement Control Order (CMCO), and Recovery Movement Control Order (RMCO). Psychological distress was measured using the Hospital Anxiety and Depression Scale (HADS), which is a 14-item self-assessment scale for measuring distress (total HADS score (HADS-T)) with two subscales, namely anxiety (HADS-A) and depression (HADS-D). Results: From a total of 631 responses received, the proportion of participants with abnormal anxiety and depression was 29.0% and 20.9%, respectively. Distress was reported in 23.0% of the respondents. A total of 16.45% had combined abnormal anxiety and depression. The highest HADS-A (6.10; 95% CI 5.64‒6.56), HADS-D (5.61; 95% CI 5.14‒6.08), and HADS-T (11.71; 95% CI 10.84‒12.58) scores were reported among respondents during Phase 4 of the MCO. Partial least squares-based structural equation modelling (PLS-SEM) revealed that self-perceived health status, perceived susceptibility, and severity of COVID-19 have the greatest effect, leading to higher HADS-A, HADS-D, and HADS-T scores. Conclusion: Heightened psychological distress was evident in cancer survivors particularly during the enforcement of the MCO over COVID-19. Providing support to address cancer survivors’ psychological and emotional needs during the COVID-19 pandemic is essential.Implication for cancer survivors: Cancer survivors or their carers should be made aware of the high psychological risk during infectious disease outbreaks and seek timely support.

Oncoplastic breast surgery (OBS) improves margin clearance and produces good esthetic outcome in breast cancer treatment. This study evaluates the complications and outcome of OBS in a multiracial patient cohort. Data of 421 patients between 2011 and 2018 were analyzed. The majority were Malays (41.8%), followed by Chinese (39.7%) and Indians (16.8%). Low local complications were noted, with no significant differences in disease-free survival (P = .927) and overall survival (P = .719) between low and high OBS levels. Shared decision-making in offering OBS for Asian women has potential to become a practical option in breast cancer treatment.

Background Mastectomy rates among women with early breast cancer in Asia have traditionally been high. This study assessed trends in the surgical management of young women with early-stage breast cancer in Asian settings. Survival in women treated with breast-conserving surgery (BCS; lumpectomy with adjuvant radiotherapy) and those undergoing mastectomy was compared. Methods Young women (aged less than 50 years) newly diagnosed with stage I or II (T1-2 N0-1 M0) breast cancer in four hospitals in Malaysia, Singapore and Hong Kong in 1990-2012 were included. Overall survival (OS) was compared for patients treated by BCS and those who had a mastectomy. Propensity score analysis was used to account for differences in demographic, tumour and treatment characteristics between the groups. Results Some 63·5 per cent of 3536 women underwent mastectomy. Over a 15-year period, only a modest increase in rates of BCS was observed. Although BCS was significantly associated with favourable prognostic features, OS was not significantly different for BCS and mastectomy; the 5-year OS rate was 94·9 (95 per cent c.i. 93·5 to 96·3) and 92·9 (91·7 to 94·1) per cent respectively. Inferences remained unchanged following propensity score analysis (hazard ratio for BCS versus mastectomy: 0·81, 95 per cent c.i. 0·64 to 1·03). Conclusion The prevalence of young women with breast cancer treated by mastectomy remains high in Asian countries. Patients treated with BCS appear to survive as well as those undergoing mastectomy.

Background: Significant re-excision rates in breast-conserving surgery (BCS) after neoadjuvant systemic chemotherapy may result from difficulties in defining the surgical target particularly in cases with excellent treatment response. Devices allowing an exact topographic localisation of the lesion in the resected tissue could reduce re-excision rates by optimising the intraoperative detection of involved margins. Methods: 80 patients with invasive breast cancer receiving BCS after neoadjuvant chemotherapy were included in this non-randomized case-control study. 40 patients with specimen radiography performed in a standard approach (control group) were compared to 40 patients with use of a radiopaque tissue transfer system (study group). Results: 19/80 (23.75%) patients required re-excision because of involved margins; among those, 14/40 (35%) were in the control group and 5/40 (12.5%) in the study group. The association between the use of the radiopaque tissue transfer system and the lower re-excision rate was statistically significant (p = 0.023). Conclusion: Our analysis provides a rationale for the routine use of a radiopaque tissue transfer system for specimen radiography in BCS after neoadjuvant chemotherapy for invasive breast cancer in order to reduce re-excision rates.

It is now increasingly common for breast cancer patients to receive adjuvant tamoxifen therapy for a period of up to 10 years. As survival rate increases, managing tamoxifen ocular toxicities is important for patients' quality of life. Macular pigments in photoreceptor cells protect against free radical damage, which can cause macular degeneration. By reducing macular pigment concentration, tamoxifen may increase the risk of macular degeneration. Here, we compared macular pigment optical density (MPOD) and central macular thickness between breast cancer patients on tamoxifen adjuvant therapy (n = 70), and a control group (n = 72). Multiple regression analysis indicated that MPOD decreases with increasing tamoxifen dosage, up to a threshold of about 20 g, after which MPOD plateaus out. Mean MPOD in the treatment group (mean = 0.40) was significantly lower (p-value = 0.02) compared to the control group (mean = 0.47) for the left eye, and for the right eye (treatment mean = 0.39; control mean = 0.48; p-value = 0.009). No significant difference in mean central macular thickness was found between the treatment and the control group (p-values 0.4). In the control group, MPOD and central macular thickness showed significant correlation (r∼0.30; p-values 0.01) for both eyes. However, in the treatment group, loss of significant correlation was observed in the left eye (r = 0.21; p-value = 0.08). The present results show that MPOD decreases non-linearly as a function of tamoxifen dosage, and highlight the potential of tamoxifen to reduce macular pigment concentration through an unknown mechanism that does not depend on macular thinning solely.

ContextNumerous studies have shown that gratitude can reduce stress and improve quality of life.ObjectiveOur study aimed to examine the effect of mindful gratitude journaling on suffering, psychological distress and quality of life of patients with advanced cancer.MethodsWe conducted a parallel-group, blinded, randomised controlled trial at the University of Malaya Medical Centre, Malaysia. Ninety-two adult patients with advanced cancer, and an overall suffering score ≥4/10 based on the Suffering Pictogram were recruited and randomly assigned to either a mindful gratitude journaling group (N=49) or a routine journaling group (N=43).ResultsAfter 1 week, there were significant reductions in the overall suffering score from the baseline in both the intervention group (mean difference in overall suffering score=−2.0, 95% CI=−2.7 to −1.4, t=−6.125, p=0.000) and the control group (mean difference in overall suffering score=−1.6, 95% CI=−2.3 to −0.8, t=−4.106, p=0.037). There were also significant improvements in the total Hospital Anxiety and Depression Scale score (mean difference=−3.4, 95% CI=−5.3 to −1.5, t=−3.525, p=0.000) and the total Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being score (mean difference=7.3, 95% CI=1.5 to 13.1, t=2.460, p=0.014) in the intervention group after 7 days, but not in the control group.ConclusionThe results provide evidence that 7 days of mindful gratitude journaling could positively affect the state of suffering, psychological distress and quality of life of patients with advanced cancer.Trial registration numberThe trial was registered with the Australian and New Zealand Clinical Trials Registry (ACTRN1261800172191) and conducted in accordance with the Declaration of Helsinki.

Background: The rate of contralateral risk reducing mastectomy (CRRM) is increasing in the West with controversial evidence of improved survival in early breast cancer patients. Although uptake of CRRM in Asia appears low, the trends may rise and there is currently an urgent need to provide evidence for informed decision making in clinical practice. This study aims to determine the risk of contralateral breast cancer (CBC), and its associated factors in an Asian setting.Method: 2937 newly diagnosed patients with stage I and stage II breast cancer in University Malaya Medical Centre between Jan 1993 to Dec 2012 were included in the study. Multinomial logistic regression analysis allowing death to compete with CBC as a study outcome was used; patients with unilateral breast cancer who were alive were taken as reference. A stepwise backward regression analysis including age at diagnosis, ethnicity, family history of breast cancer, TNM stage, hormonal receptor status, HER2 status, chemotherapy, radiotherapy, and hormone therapy was conducted.Results: Fifty women developed CBC, over a median follow-up of 6 years. The 5-year-, and 10-year cumulative risk of contralateral breast cancer was 1.0% (95% CI: 0.6%-1.4%) and 2.8% (95% CI: 2.0%-3.6%), respectively. Young age at diagnosis of first cancer, positive family history and stage I disease, were independent predictors of CBC. Discussion: The current study suggests that the risk of CBC is very low in a Southeast Asian setting. Any recommendations or practice of CRRM should be reviewed with caution and patients must be counseled appropriately.

Reproductive factors are associated with risk of breast cancer, but the association with breast cancer survival is less well known. Previous studies have reported conflicting results on the association between time since last childbirth and breast cancer survival. We determined the association between time since last childbirth (LCB) and survival of women with premenopausal and postmenopausal breast cancers in Malaysia. A historical cohort of 986 premenopausal, and 1123 postmenopausal, parous breast cancer patients diagnosed from 2001 to 2012 in University Malaya Medical Centre were included in the analyses. Time since LCB was categorized into quintiles. Multivariable Cox regression was used to determine whether time since LCB was associated with survival following breast cancer, adjusting for demographic, tumor, and treatment characteristics. Premenopausal breast cancer patients with the most recent childbirth (LCB quintile 1) were younger, more likely to present with unfavorable prognostic profiles and had the lowest 5-year overall survival (OS) (66.9; 95% CI 60.2–73.6%), compared to women with longer duration since LCB (quintile 2 thru 5). In univariable analysis, time since LCB was inversely associated with risk of mortality and the hazard ratio for LCB quintile 2, 3, 4, and 5 versus quintile 1 were 0.53 (95% CI 0.36–0.77), 0.49 (95% CI 0.33–0.75), 0.61 (95% CI 0.43–0.85), and 0.64 (95% CI 0.44–0.93), respectively; P trend = 0.016. However, this association was attenuated substantially following adjustment for age at diagnosis and other prognostic factors. Similarly, postmenopausal breast cancer patients with the most recent childbirth were also more likely to present with unfavorable disease profiles. Compared to postmenopausal breast cancer patients in LCB quintile 1, patients in quintile 5 had a higher risk of mortality. This association was not significant following multivariable adjustment. Time since LCB is not independently associated with survival in premenopausal or postmenopausal breast cancers. The apparent increase in risks of mortality in premenopausal breast cancer patients with a recent childbirth, and postmenopausal patients with longer duration since LCB, appear to be largely explained by their age at diagnosis.

Prior investigation of the suitability of optical fibres as thermoluminescent dosimeters for diagnostic and therapeutic radiation beams has not included detailed study of the effect of beam angulation. Present study of such response has made use of optical fibre of cylindrical shape, exposed to 30 kVp photons from an X-ray tube and a 6 MV photon beam from a linear accelerator. The effect of the irradiation medium was also studied, comparing response free-in-air against on-surface and in-depth irradiations through use of solid-water ™ phantom. Standard optical fibre (o =125 µm) shows non-uniform response to beams delivered at different incident angles. Monte Carlo simulation provided support for the experimental results, also obtaining absorbed dose in the fibres. The results of free-in-air condition simulated with mono-energy beam show angle-independent response for photons within the energy range 100–500 keV, while dependency has been observed for beam energies of 500 keV. Experimentally, the angular dependency up to 35% is observed in 30 kVp free-in-air, while in 6 MeV beam, this is reduced to 20%, 10%, and 3% in free-in-air, on phantom surface, and in-depth conditions, respectively. The observations have been justified by considering the range of secondary electrons in the dosimeter and the effect of scattered radiation.

Introduction Breast-conserving surgery (BCS) with radiation therapy is the procedure of choice for early-stage breast cancer. Survival and locoregional recurrence is non-inferior to mastectomy, with superior cosmetic and psycho-social outcomes. Differing health systems have demonstrated a wide variation in the rate of BCS. Little is known about the rate of BCS and factors influencing its practice in middle resource countries. This study aims to examine the BCS rates in Malaysia and to identify factors influencing its uptake. Methodology This is a multi-centre, cross-sectional study involving the University of Malaya Medical Centre (UMMC), Queen Elizabeth II Hospital (QEH), and Tengku Ampuan Rahimah Hospital (TARH). Patients diagnosed with invasive breast cancer from January 2014 to December 2015 were included, excluding stromal cancers and lymphomas. Univariate and multivariate analyses identified factors influencing BCS. Results A total of 1005 patients were diagnosed with breast cancer in the allocated time frame. Excluding incomplete records and those who did not have surgery, 730 patients were analysed. Overall BCS rate was 32.9%. The BCS rate was highest at QEH (54.1%), followed by UMMC (29.5%), and TARH (17.4%). 16.9% had BCS after neoadjuvant therapy. Factors influencing BCS uptake included age, ethnic group, breast-surgeon led services, AJCC Stage, tumour size, HER-2 expression, and tumour grade. Conclusions The rate of BCS in Malaysia is low. A wide variation of rate exists among the studied hospitals. Younger age, earlier AJCC stage, and the presence of a Breast sub-specialist surgeon, would make it more likely that the patient has her breast conserved.

Pre-operative status of axillary lymph node (ALN) in early breast cancer is usually initially assessed by pre-operative ultrasound, followed by ultrasound-guided needle biopsy (UNB) confirmation. Patients with positive nodal status will undergo axillary lymph node dissection (ALND), while those with negative nodal status will have sentinel lymph node biopsy. ALND is associated with higher morbidity than Sentinel lymph node biopsy. The objective of this study is to determine if axillary ultrasound alone without UNB is predictive enough to assign patients to ALND and to identify ultrasound features that are significantly associated with pathologically positive ALN. 383 newly diagnosed primary breast cancer patients between 2012 and 2014, and who had undergone pre-operative axillary ultrasound in University Malaya Medical Centre with a complete histopathology report of the axillary surgery were retrospectively reviewed. ALN was considered positive if it had any of these features: cortical thickening > 3 mm, loss of fatty hilum, hypoechoic solid node, mass-like appearance, round shape and lymph node size > 5 mm. Post-operative histopathological reports were then analyzed for nodal involvement. The overall sensitivity, specificity, and accuracy of pre-operative axillary ultrasound in detecting diseased nodes were 45.5%, 80.7%, and 60.3% respectively. The positive (PPV) and negative predictive values were 76.5% and 51.8%. Round shape, loss of fatty hilum and mass-like appearance had the highest PPVs of 87%, 83% and 81.6% respectively and significant odds ratios (ORs) of 5.22 (95% confidence interval [CI]: 1.52 - 17.86), ORs of 4.77 (95% CI: 2.62 - 8.70) and ORs of 4.26 (95% CI: 2.37 - 7.67) respectively (P-value 3 mm was identified to have low PPV at 69.1%, ORs of 1.71 (95% CI: 0.86 - 3.41, P = .126). There are features on axillary ultrasound that confer high PPV for axillary involvement i.e. round shape, loss of fatty hilum, and mass-like appearance. In a low resource setting, these features may benefit from ALND without further pre-operative biopsies. However, pre-operative UNB for features with low PPV that is, cortical thickness > 3 mm should be considered to obviate the unnecessary morbidity associated with ALND.

Factors associated with surgery, adjuvant radiotherapy, and chemotherapy and whether there were missed opportunities for treatment in elderly patients were determined in an Asian setting. All 5616 patients, diagnosed with breast cancer in University Malaya Medical Centre from 1999 to 2013 were included. In 945 elderly patients (aged 65 years and above), multivariable logistic regression was performed to identify factors associated with treatment, following adjustment for age, ethnicity, tumor, and other treatment characteristics. The impact of lack of treatment on survival of the elderly was assessed while accounting for comorbidities. One in five elderly patients had comorbidities. Compared to younger patients, the elderly had more favorable tumor characteristics, and received less loco-regional treatment and chemotherapy. Within stage I–IIIa elderly breast cancer patients, 10 % did not receive any surgery. These patients were older, more likely to be Malays, have comorbidities, and bigger tumors. In elderlies with indications for adjuvant radiotherapy, no irradiation (30 %) was associated with increasing age, comorbidity, and the absence of systemic therapy. Hormone therapy was optimal, but only 35 % of elderly women with ER negative tumors received chemotherapy. Compared to elderly women who received adequate treatment, those not receiving surgery (adjusted hazard ratio: 2.30, 95 %CI: 1.10–4.79), or radiotherapy (adjusted hazard ratio: 1.56, 95 %CI: 1.10–2.19), were associated with higher mortality. Less than 25 % of the survival discrepancy between elderly women receiving loco-regional treatment and no treatment were attributed to excess comorbidities in untreated patients. While the presence of comorbidities significantly influenced loco-regional treatment decisions in the elderly, it was only able to explain the lower survival rates in untreated patients up to a certain extent, suggesting missed opportunities for treatment.

Introduction The rates of contralateral prophylactic mastectomy (CPM)appears to be higher in the west as compared to the east.1,2There is a suggestion of an improved survival benefit of CPM. 1The trends are increasing in the west and little is known in Asia. In western data a rate of 0.5 to 1% per year is often quoted. However, There is scarcity of epidemiological data on rates of contralateral breast cancer (CBC) in Asia. Known predictors of CBC in the west include high stage at diagnosis, early age at diagnosis, presence of family history, genetic predisposition, time from first diagnosis and hormone receptor status. Little is known in Asia. Population based registries are not available in Malaysia as in many Southeast Asian countries. This study aims to provide CBC rates to provide evidence for informed decision making of CPM in Asians. Method A prospective database of newly diagnosed Stage I and II breastcancer patients diagnosed in University Malaya Medical Centre between 1993 to 2012 were analysed. Data on CBC were obtained from institutional database and medical records. Multivariate analysis used Cox regression was applied to observe for any associations with multiple variables such as age at diagnosis, time from diagnosis, presence of family history, menopausal status, ethnic groups, parity and hormone status. Results A total of 3060 Stage I and II patients were prospectively followed up. 127 (4.2%) women developed contralateral breast cancer.At 5 years, 57 (1.9%) and at 10 years, 100(3.4%) developed CBC. Using a multivariate model, the only independent predictor of developing contralateral breast cancer at 5 years was a positive family history OR 1.97(CI 1.02-3.80). However, at 10 years we found the effect of positive family history diminished OR1.57 (CI 0.94-2.64) and younger women were more likely to develop cancer, those aged 51 to 64 years OR 0.29 (CI 0.11-0.73) , >65 years OR 0.20 (CI 0.07-0.60)compared to those less than 35 years. The other factors in the model were not significant. Discussion There is an increasing rate of CPM at 22% from 9% in the west1. A study in Singapore showed a low CPM rate of 1.25%2 . Although uptake of CPM in Asia has not been reported extensively and appears low, the trends may rise and that evidence is needed to counsel patients on the benefits and harms of CPM if patients request for CPM. Given the lower incidence of breast cancer in Malaysia ie 5% average risk compared to 10% in the west, an urgent need to document the risk of contralateral breast cancer, and this data from a single institution is the first to report this rates in Southeast Asia. Conclusion The data shows that risk of contralateral breast cancer is low in this Southeast Asian country. Any recommendations or practice of CPM should be dealt with extreme caution. References 1. Kauffmann R, Nelson R, Smith D, et al: Improved survival with contralateral prophylactic mastectomy. Abstract in 2014 Society of Surgical Oncology Cancer Symposium. 2. Sim Y, Tan VK, Ho GH, Wong CY, Madhukumar P, Tan BK, Yong WS, Ng YY, OngKW.Contralateral prophylactic mastectomy in an Asian population: a single institution review. Breast. 2014 Feb;23(1):56-62. doi: 10.1016/j.breast.2013.10.008. Epub 2013 Nov 23. Citation Format: Taib NA, See MH, Bhoo Pathy N, Yahya A, Tan GH, Jamaris S, Yip CH. Low risk of contralateral breast cancer rates in Asian women- A case for not recommending contralateral prophylactic mastectomy. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-08-39.

Percutaneous biopsy in breast cancer has been associated with an increased risk of malignant cell seeding. However, the importance of these observations remains obscure due to lack of corroborating evidence from clinical studies. We determined whether method of biopsy is associated with breast cancer survival. This hospital registry-based cohort study included 3416 non-metastatic breast cancer patients diagnosed from 1993 to 2011 in a tertiary setting. Factors associated with biopsy methods were assessed. Multivariable Cox regression analysis was used to determine the independent prognostic impact of method of biopsy. Overall, 990 patients were diagnosed by core needle biopsy (CNB), 1364 by fine needle aspiration cytology (FNAC), and 1062 by excision biopsy. Excision biopsy was significantly associated with more favorable tumor characteristics. Radiotherapy modified the prognostic impact of biopsy method (Pinteraction < .001). Following multivariable analysis, excision biopsy was consistently associated with lower risk of mortality compared to FNAC in women receiving adjuvant radiotherapy (adjusted hazard ratio: 0.81, 95%CI: 0.66-0.99), but not in those who did not receive adjuvant radiotherapy (adjusted hazard ratio: 0.87, 95%CI: 0.65-1.17). While the risk of mortality was not different between patients undergoing FNAC and CNB when radiotherapy is administered, in the absence of radiotherapy, CNB was associated with higher risk of mortality than FNAC (adjusted hazard ratio: 1.57, 95%CI: 1.16-2.12). Given that our results contradict with findings of previous clinical studies assessing the prognostic impact of method of biopsy in women with breast cancer, further studies are warranted.

OBJECTIVES Patient-reported outcomes (PROs) in high-income countries (HICs) suggest that physical, emotional, and psychological needs are important in cancer care. To date, there have been few inconsistent descriptions of PROs in low-income and middle-income Asian countries. Using a standard questionnaire developed by the International Consortium for Health Outcomes Measurement (ICHOM), we compared the perceived importance of PROs between patients in Malaysia and those in HICs and between clusters of Malaysian women. METHODS Breast cancer patients were recruited from three Malaysian hospitals between June and November 2017. We compared the proportion of patients who rated PROs as very important (scored 7-9 on a 9-point Likert scale) between Malaysian patients and data collected from patients in HICs via the ICHOM questionnaire development process, using logistic regression. A two-step cluster analysis explored differences in PROs among Malaysian patients. RESULTS The most important PROs for both cohorts were survival, overall well-being, and physical functioning. Compared with HIC patients (n = 1177), Malaysian patients (n = 969) were less likely to rate emotional (78% vs 90%), cognitive (76% vs 84%), social (72% vs 81%), and sexual (30% vs 56%) functioning as very important outcomes (P

Breast cancer can be divided into four subtypes based on the expressions of estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor-2 (HER2). Each subtype has different clinicopathological features and outcomes. To compare the clinicopathological features and survival of ER and/or PR positive HER2 negative (ER+PR+HER2−, ER+PR−HER2− or ER−PR+HER2−), ER and/or PR positive HER2 positive (ER+PR+HER2+, ER+PR−HER2+ or ER−PR+HER2+), ER negative PR negative HER2 positive (ER−PR−HER2+), and ER negative PR negative HER2 negative (ER−PR−HER2−) subtypes. 1957 patients with Stage 1–3 breast carcinoma diagnosed between Jan 2005 and Dec 2011 were categorized into the four subtypes. The clinicopathological features between the subtypes were compared using χ 2 test. Kaplan–Meier analysis was performed to estimate 5-year overall survival. Multivariate Cox regression was used to determine the association between subtypes and mortality adjusted for age, ethnicity, stage, pathological features, and treatment. ER−PR−HER2+ and ER−PR−HER2− subtypes were associated with younger age, larger tumors, and higher grade. There was no difference in the 5-year survival of the ER−PR−HER2+ and ER−PR−HER2− subtypes (75.1 and 74.4 %, respectively) and survival was poorer than in the ER and/or PR positive HER2 negative and ER and/or PR positive HER2 positive subtypes (87.1 and 83.1 %, respectively). Only 9.5 % of women with HER2 positive breast cancer had access to trastuzumab. In a low resource setting with limited access to trastuzumab, there is no difference in survival between the ER−PR−HER2+ and ER−PR−HER2− subtypes of breast cancer.

Background: The risk of febrile neutropaenia (FN) and treatment related death (TRD) with first line palliative chemotherapy for de novo metastatic breast cancer (MBC) remains unknown outside of a clinical trial setting despite its widespread usage. This study aimed to determine rates in a large cohort of patients treated in the University of Malaya Medical Centre (UMMC). Materials and Methods: Patients who were treated with first line palliative chemotherapy for de novo MBC from 2002-2011 in UMMC were identified from the UMMC Breast Cancer Registry. Information collected included patient demographics, histopathological features, treatment received, including the different chemotherapy regimens, and presence of FN and TRD. FN was defined as an oral temperature >38.5°C or two consecutive readings of >38.0°C for 2 hours and an absolute neutrophil count

Although the spliceogenic nature of the BRCA2 c.68‐7T > A variant has been demonstrated, its association with cancer risk remains controversial. In this study, we accurately quantified by real‐time PCR and digital PCR (dPCR), the BRCA2 isoforms retaining or missing exon 3. In addition, the combined odds ratio for causality of the variant was estimated using genetic and clinical data, and its associated cancer risk was estimated by case‐control analysis in 83,636 individuals. Co‐occurrence in trans with pathogenic BRCA2 variants was assessed in 5,382 families. Exon 3 exclusion rate was 4.5‐fold higher in variant carriers (13%) than controls (3%), indicating an exclusion rate for the c.68‐7T > A allele of approximately 20%. The posterior probability of pathogenicity was 7.44 × 10−115. There was neither evidence for increased risk of breast cancer (OR 1.03; 95% CI 0.86–1.24) nor for a deleterious effect of the variant when co‐occurring with pathogenic variants. Our data provide for the first time robust evidence of the nonpathogenicity of the BRCA2 c.68‐7T > A. Genetic and quantitative transcript analyses together inform the threshold for the ratio between functional and altered BRCA2 isoforms compatible with normal cell function. These findings might be exploited to assess the relevance for cancer risk of other BRCA2 spliceogenic variants.

In settings with limited resources, sentinel lymph node biopsy (SNB) is only offered to breast cancer patients with small tumors and a low a priori risk of axillary metastases. We investigated whether CancerMath, a free online prediction tool for axillary lymph node involvement, is able to identify women at low risk of axillary lymph node metastases in Malaysian women with 3–5 cm tumors, with the aim to offer SNB in a targeted, cost-effective way. Women with non-metastatic breast cancers, measuring 3–5 cm were identified within the University Malaya Medical Centre (UMMC) breast cancer registry. We compared CancerMath-predicted probabilities of lymph node involvement between women with versus without lymph node metastases. The discriminative performance of CancerMath was tested using receiver operating characteristic (ROC) analysis. Out of 1,017 patients, 520 (51 %) had axillary involvement. Tumors of women with axillary involvement were more often estrogen-receptor positive, progesterone-receptor positive, and human epidermal growth factor receptor (HER)-2 positive. The mean CancerMath score was higher in women with axillary involvement than in those without (53.5 vs. 51.3, p = 0.001). In terms of discrimination, CancerMath performed poorly, with an area under the ROC curve of 0.553 (95 % confidence interval CI 0.518–0.588). Attempts to optimize the CancerMath model by adding ethnicity and HER2 to the model did not improve discriminatory performance. For Malaysian women with tumors measuring 3–5 cm, CancerMath is unable to accurately predict lymph node involvement and is therefore not helpful in the identification of women at low risk of node-positive disease who could benefit from SNB.

Background Breast-conserving surgery (BCS) plus radiotherapy is equivalent to modified radical mastectomy (MRM) in terms of outcome. However there is wide variation in mastectomy rates dependent both on tumour and patient characteristics. Objective This study aimed to assess the determinants of surgery choice in Asian patients with early breast cancer in a middle-income country. Materials and methods 184 patients with early breast cancer treated between Jan 2008 and Dec 2010 were recruited to complete a questionnaire. Chi-square test was used to analyze the association between surgery choice and demographic and tumour factors, surgeon recommendation, family member and partner opinions, fear of recurrence, avoidance of second surgery, fear of disfigurement, interference with sex life, fear of radiation and loss of femininity. Results 85 (46%) had BCS while 99 (54%) had mastectomy. Age >60, Chinese ethnicity, lower education level, and larger tumour size were significantly associated with mastectomy. Surgeon recommendation was important in surgery choice. Although both groups did not place much importance on interference with sex life, 14.1% of the BCS group felt it was very important compared to 5.1% in the mastectomy group and this was statistically significant. There was no statistical difference between the two groups in terms of the other factors. When analyzed by ethnicity, significantly more Malay and Indian women considered partner and family member opinions very important and were more concerned about loss of femininity compared to Chinese women. There were no statistical differences between the three ethnic groups in terms of the other factors. Conclusions When counseling on surgical options, the surgeon has to take into account the ethnicity, social background and education level, age and reliance on partner and family members. Decision-making is usually a collective effort rather than just between the patient and surgeon, and involving the whole family into the process early is important.

Ge-doped silica fibre (GDSF) thermoluminescence dosimeters (TLD) are non-hygroscopic spatially high-resolution radiation sensors with demonstrated potential for radiotherapy dosimetry applications. The INTRABEAM® system with spherical applicators, one of a number of recent electronic brachytherapy sources designed for intraoperative radiotherapy (IORT), presents a representative challenging dosimetry situation, with a low keV photon beam and a desired rapid dose-rate fall-off close-up to the applicator surface. In this study, using the INTRABEAM® system, investigations were made into the potential application of GDSF TLDs for in vivo IORT dosimetry. The GDSFs were calibrated over the respective dose- and depth-range 1 to 20 Gy and 3 to 45 mm from the x-ray probe. The effect of different sizes of spherical applicator on TL response of the fibres was also investigated. The results show the GDSF TLDs to be applicable for IORT dose assessment, with the important incorporated correction for beam quality effects using different spherical applicator sizes. The total uncertainty in use of this type of GDSF for dosimetry has been found to range between 9.5% to 12.4%. Subsequent in vivo measurement of skin dose for three breast patients undergoing IORT were performed, the measured doses being below the tolerance level for acute radiation toxicity.

Background: Host inflammatory response affects disease progression and survival in cancer. While the elevation of neutrophil/lymphocyte ratio (NLR) and platelet/lymphocyte ratio (PLR) have been associated with poor prognosis in colorectal cancer, evidence on prognostic significance of these indicators in breast cancer is sparse. We determined whether the initial, pretreatment NLR and PLR impact survival of patients presenting with primary breast cancer. Methods: Of 2059 consecutive patients, newly diagnosed with breast cancer in University Malaya Medical Centre, Malaysia between January 2000 and December 2008, we only included 1447 patients with available differential blood count at time of diagnosis (∼70%). Data on tumor characteristics and treatment were obtained from the hospital-based breast cancer registry whereas vital status was verified with the national mortality registry. Patients were stratified into quintiles of NLR and PLR. Differences in demography, tumor characteristics and treatment patterns between the quintiles were assessed. Relative survival rates (RSR) were estimated using the Malaysian population mortality data. Multivariable Cox regression was used to determine the independent prognostic significance of NLR and PLR. Results: Median age at presentation was 52 years, whereas median tumor size at diagnosis was 3.5 cm with 48% of patients presenting with axillary lymph node involvement. Both NLR and PLR were positively correlated (p Conclusion: High NLR seems to be an independent prognostic factor for breast cancer but not PLR. These findings warrant further validation. Citation Format: Cher Hui Koh, Nirmala Bhoo-Pathy, Khoon Leong Ng, Mee Hoong See, Gie Hooi Tan, Suniza Jamaris, Nur Aishah Taib. Elevated neutrophil lymphocyte ratio predicts survival in breast cancer [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P6-08-32.

Background Depression and anxiety are common psychiatric morbidity among breast cancer patient. There is a lack of study examining the correlation between depression, anxiety and quality of life (QoL) with perceived social support (PSS) among breast cancer patients. This study aims to study the level of depression, anxiety, QoL and PSS among Malaysian breast cancer women over a period of 12 months and their associations at baseline, 6 and 12 months. Methods It is a 12 months prospective cohort study. Two hundred and twenty one female patients were included in the study. They were assessed at the time of diagnosis, 6 months and 12 month using Hospital Anxiety and Depression Scale (HADS), Quality-of-Life Questionnaire (QLQ–C30), Version 3.0 of the EORTC Study Group and Multidimensional Scale of Perceived Social Support (MSPSS). The information of age, ethnicity, types of treatment, and staging of cancer were collected. Results The HADS anxiety and depression subscales scores of the subjects were relatively low. The level of anxiety reduced significantly at 6 and 12 months (Baseline – 6 months, p = 0.002; Baseline - 12 months, p

Metformin, an AMPK activator, has been reported to improve pathological response to chemotherapy in diabetic breast cancer patients. To date, its mechanism of action in cancer, especially in cancer stem cells (CSCs) have not been fully elucidated. In this study, we demonstrated that metformin, but not other AMPK activators (e.g. AICAR and A-769662), synergizes 5-fluouracil, epirubicin, and cyclophosphamide (FEC) combination chemotherapy in non-stem breast cancer cells and breast cancer stem cells. We show that this occurs through an AMPK-dependent mechanism in parental breast cancer cell lines. In contrast, the synergistic effects of metformin and FEC occurred in an AMPK-independent mechanism in breast CSCs. Further analyses revealed that metformin accelerated glucose consumption and lactate production more severely in the breast CSCs but the production of intracellular ATP was severely hampered, leading to a severe energy crisis and impairs the ability of CSCs to repair FEC-induced DNA damage. Indeed, addition of extracellular ATP completely abrogated the synergistic effects of metformin on FEC sensitivity in breast CSCs. In conclusion, our results suggest that metformin synergizes FEC sensitivity through distinct mechanism in parental breast cancer cell lines and CSCs, thus providing further evidence for the clinical relevance of metformin for the treatment of cancers.

Background: Breast cancer is the leading cause of cancer deaths in women world-wide. In low and middle income countries, where there are no population-based mammographic screening programmes, late presentation is common, and because of inadequate access to optimal treatment, survival rates are poor. Mammographic screening is well-studied in high-income countries in western populations, and because it has been shown to reduce breast cancer mortality, it has become part of the healthcare systems in such countries. However the performance of mammographic screening in a developing country is largely unknown. This study aims to evaluate the performance of mammographic screening in Malaysia, a middle income country, and to compare the stage and surgical treatment of screen-detected and symptomatic breast cancer. Methods: A retrospective review of 2510 mammograms performed from Jan to Dec 2010 in a tertiary medical centre is carried out. The three groups identified are the routine (opportunistic) screening group, the targeted (high risk) screening group and the diagnostic group. The performance indicators of each group is calculated, and stage at presentation and treatment between the screening and diagnostic group is analyzed. Results: The cancer detection rate in the opportunistic screening group, targeted screening group, and the symptomatic group is 0.5 %, 1.25 % and 26 % respectively. The proportion of ductal carcinoma in situ is 23.1 % in the two screening groups compared to only 2.5 % in the diagnostic group. Among the opportunistic screening group, the cancer detection rate was 0.2 % in women below 50 years old compared to 0.65 % in women 50 years and above. The performance indicators are within international standards. Early-staged breast cancer (Stage 0–2) were 84.6 % in the screening groups compared to 61.1 % in the diagnostic group. Conclusion: From the results, in a setting with resource constraints, targeted screening of high risk individuals will give a higher yield, and if more resources are available, population-based screening of women 50 and above is effective. Opportunistic mammographic screening is feasible and effective in a middle income country with performance indicators within international standards. Waiting until women are symptomatic will lead to more advanced cancers.

Background: Peripheral blood-derived inflammation-based scores such as the neutrophil–lymphocyte ratio (NLR) and platelet–lymphocyte ratio (PLR) have recently been proposed as prognostic markers in solid tumours. Although evidence to support these markers as unfavourable prognostic factors is more compelling in gastrointestinal cancers, very little is known of their impact on breast cancer. We investigated the association between the NLR and PLR, and overall survival after breast cancer. Methods: Data from the University of Malaya Medical Centre Breast Cancer Registry was used. Of 2059 consecutive patients diagnosed from 2000 to 2008, we included 1435 patients with an available pre-treatment differential blood count (∼70%). Patients were stratified into quintiles of the NLR/PLR. Multivariable Cox regression was used to determine the independent prognostic significances of the NLR/PLR. Results: Compared with the first quintile of the NLR, women in quintile 5 were younger, had bigger tumours, nodal involvement, distant metastases and higher tumour grades. Higher NLR quintiles were significantly associated with poorer survival with a 5-year relative survival ratio (RSR) of 76.4% (95% CI: 69.6–82.1%) in quintile 1, 79.4% (95% CI: 74.4–83.7%) in quintile 2, 72.1% (95% CI: 66.3–77.3%) in quintile 3, 65.6% (95% CI: 59.8–70.8%) in quintile 4 and 51.1% (95% CI: 43.3–58.5%) in quintile 5. Following adjustment for demography, tumour characteristics, treatment and the PLR, the adjusted hazard ratio (HR) for quintile 5 vs quintile 1 was 1.50 (95% CI: 1.08–1.63); Ptrend=0.004. Results were unchanged when the NLR was analysed as a dichotomous variable using different cutoff points. Although patients in PLR quintile 5 had lower survival than in quintile 1 (5-year RSR: 53.2% (95% CI: 46.9–59.2%) vs 77.0% (95% CI: 70.9–82.2%)), this association was not significant after multivariable adjustment. However, a PLR >185 was significantly associated with poorer survival; adjusted HR: 1.25 (95% CI: 1.04–1.52). Conclusions: Both the NLR and PLR are independently associated with an increased risk of mortality in breast cancer. Their added value in the prognostication of breast cancer in clinical practice warrants investigation.

Up to 25% of breast cancer patients in Asia present with de novo metastatic disease. We examined the survival trends of Asian patients with metastatic breast cancer over fifteen years. The impact of changes in patient’s demography, tumor characteristics, tumor burden and treatment on survival trend were examined. Patients with de novo metastatic breast cancer from three hospitals in Malaysia and Singapore (N = 856) were grouped by year of diagnosis: 1996–2000, 2001–2005 and 2006–2010. Step-wise multivariable Poisson regression was used to estimate the contribution of above-mentioned factors on the survival trend. Proportions of patients presenting with metastatic breast cancer were 10% in 1996–2000, 7% in 2001–2005 and 9% in 2006–2010. Patients in 2006–2010 were significantly older, appeared to have higher disease burden and received more chemotherapy, endocrine therapy and surgery of primary tumor. The three-year relative survival in the above periods were 20·6% (95% CI: 13·9%–28·2%), 28·8% (95% CI: 23·4%–34·2%) and 33·6% (95% CI: 28·8%–38·5%), respectively. Adjustment for treatment considerably attenuated the relative excess risk of mortality in recent years, compared to other factors. Substantial improvements in survival were observed in patients with de novo metastatic breast cancer in this study.

Introduction Changes in the American Joint Commission on Cancer staging for breast cancer occurred when the 5th Edition was updated to the 6th Edition. Objective To investigate how these changes affected stage and survival. Methods 3127 cases of breast cancer were restaged. Results Late stages increased from 27.7% to 38.1%. The five-year survival improved in Stage 2 (82.9–86.1%) and Stage 3 (50.6–59%). Discussion Stage shift leads to an erroneous impression that women are presenting with later stages and stage-specific survival is improving. Conclusion Standardizing cancer staging is important when reporting stage and survival in different time periods.