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Background: There are several techniques for localization of non-palpable breast tumors, but comparisons of these techniques in terms of margin positivity and volume of tissue resected are lacking., Methods: Between 2011-2013 and 2016-2018, 2 randomized controlled trials involving 10 centers across the United States accrued 631 patients with stage 0-3 breast cancer, all of whom underwent breast conserving surgery. Of these, 522 had residual non-palpable tumors for which localization was required. The localization technique was left to the discretion of the individual surgeon. We compared margin positivity and volume of tissue resected between various localization techniques., Results: The majority of the patients (n = 465; 89.1%) had wire localization (WL), 50 (9.6%) had radioactive seed (RS) localization, and 7 (1.3%) had Savi Scout (SS) localization. On bivariate analysis, there was no difference in terms of margin positivity (37.8% vs. 28.0% vs. 28.6%, P = .339) nor re-excision rates (13.3% vs. 12.0% vs. 14.3%, P = .961) for the WL, RS, and SS groups, respectively. Further, the volume of tissue removed was not significantly different between the 3 groups (71.9 cm 3 vs. 55.8 cm 3 vs. 86.6 cm 3 for the WL, RS, and SS groups, respectively, P = .340). On multivariate analysis, margin status was affected by tumor size (OR = 1.336; 95% CI: 1.148-1.554, P <.001) but not by type of localization ( P = .670)., Conclusions: While there are a number of methods for tumor localization, choice of technique does not seem to influence volume of tissue resected nor margin status.

Background: Molecular subtype in invasive breast cancer guides systemic therapy. It is unknown whether molecular subtype should also be considered to tailor surgical therapy. The present investigation was designed to evaluate whether breast cancer subtype impacted surgical margins in patients with invasive breast cancer stage I through III undergoing breast-conserving therapy., Methods: Data from 2 randomized trials evaluating cavity shave margins (CSM) on margin status in patients undergoing partial mastectomy (PM) were used for this analysis. Patients were included if invasive carcinoma was present in the PM specimen and data for all 3 receptors (ER, PR, and HER2) were known. Patients were classified as luminal if they were ER and/or PR positive; HER2 enriched if they were ER and PR negative but HER2 positive; and TN if they were negative for all 3 receptors. The impact of subtype on the margin status was evaluated at completion of standard PM, prior to randomization to CSM versus no CSM. Non-parametric statistical analyses were performed using SPSS Version 26., Results: Molecular subtype was significantly correlated with race ( P = .011), palpability ( P = .007), and grade ( P < .001). Subtype did not correlate with Hispanic ethnicity ( P = .760) or lymphovascular invasion ( P = .756). In this cohort, the overall positive margin rate was 33.7%. This did not vary based on molecular subtype (positive margin rate 33.7% for patients with luminal tumors vs 36.4% for those with TN tumors, P = .425)., Discussion: Molecular subtype does not predict margin status. Therefore, molecular subtype should not, independent of other factors, influence surgical decision-making.

Background: Patient and tumor characteristics often coincide with obesity, potentially affecting treatment decision-making in obese breast cancer patients. Independent of all of these factors, however, it is unclear whether obesity itself impacts the decision to offer patients undergoing mastectomy breast reconstruction, postmastectomy radiation therapy (PMRT), or neoadjuvant chemotherapy. We sought to determine whether implicit bias against obese breast cancer patients undergoing mastectomy plays a role in their treatment., Methods: Medical records of breast cancer patients undergoing mastectomy from January 2010 to April 2018 from a single institution were retrospectively reviewed, separated into obese (BMI ≥30) and nonobese (BMI <30) categories, and compared using nonparametric statistical analyses., Results: Of 972 patients, 291 (31.2%) were obese. Obese patients were more likely to have node-positive, triple-negative breast cancers ( P = .026) and were also more likely to have other comorbidities such as a history of smoking ( P = .026), hypertension ( P < .001), and diabetes ( P < .001). Receipt of immediate reconstruction and contralateral prophylactic mastectomy did not vary between obese and nonobese patients. While obese patients were more likely to undergo neoadjuvant chemotherapy (26.5% vs. 18.1%, P = .004) and PMRT (33.0% vs. 23.4%, P = .003), this did not remain significant when controlling for comorbidities and clinicopathologic confounders., Conclusion: Obese patients present with more aggressive tumors and often have concomitant comorbidities. Independent of these factors, however, differences in the treatment of patients undergoing mastectomy do not seem to be affected by an implicit bias against obese patients.

Background: We sought to determine factors affecting time to surgery (TTS) to identify potential modifiable factors to improve timeliness of care., Methods: Patients with clinical stage 0-3 breast cancer undergoing partial mastectomy in 2 clinical trials, conducted in ten centers across the US, were analyzed. No preoperative workup was mandated by the study; those receiving neoadjuvant therapy were excluded., Results: The median TTS among the 583 patients in this cohort was 34 days (range: 1-289). Patient age, race, tumor palpability, and genomic subtype did not influence timeliness of care defined as TTS ≤30 days. Hispanic patients less likely to have a TTS ≤30 days ( P = .001). There was significant variation in TTS by surgeon ( P < .001); those practicing in an academic center more likely to have TTS ≤30 days than those in a community setting (55.1% vs 19.3%, P < .001). Patients who had a preoperative ultrasound had a similar TTS to those who did not (TTS ≤30 days 41.9% vs 51.9%, respectively, P = .109), but those who had a preoperative MRI had a significantly increased TTS (TTS ≤30 days 25.0% vs 50.9%, P < .001). On multivariate analysis, patient ethnicity was no longer significantly associated with TTS ≤30 ( P = .150). Rather, use of MRI (OR: .438; 95% CI: .287-.668, P < .001) and community practice type (OR: .324; 95% CI: .194-.541, P < .001) remained independent predictors of lower likelihood of TTS ≤30 days., Conclusions: Preoperative MRI significantly increases time to surgery; surgeons should consider this in deciding on its use.

Background: Breast cancer survivors may experience sleep disturbances that can affect their physical and mental well-being. We sought to determine the association, if any, between yoga and sleep among breast cancer survivors in a population-based cohort., Methods: The National Health Interview Survey is designed to be representative of the US civilian non-institutionalized population. We evaluated breast cancer survivors in the 2017 cohort to determine the association between yoga and self-reported quality of sleep., Results: Of the 25,905 people surveyed, representing 238,738,039 in the population, 1.59% reported a previous history of breast cancer. Breast cancer survivors were less likely to report having practiced yoga in the preceding 12 months, compared to those without a history of breast cancer (9.98% vs 13.78%, P = .011). In addition, they were more likely to report having had trouble falling asleep (44.64% vs 36.32%, P = .002), staying asleep (53.72% vs 39.43%, P < .001), and using sleep medication on at least 1 day within the previous week (23.80% vs 13.49%, P < .001) than those without breast cancer. Among breast cancer survivors, there were no significant differences in difficulty falling asleep (39.16% vs 44.98%, P = .482), difficulty staying asleep (61.17% vs 52.70%, P = .305), and needing sleep medication (19.03% vs 24.53%, P = .395) between those who practiced yoga and those who did not. Controlling for sociodemographic factors, there remained no association between yoga and difficulty falling or staying asleep among breast cancer survivors., Conclusion: There is no direct association between yoga and sleep quality in breast cancer survivors.

Background: While the optimal time interval between mastectomy and postmastectomy radiation therapy (PMRT) has not been well-elucidated, a delay in PMRT has been associated with increased local recurrence. We sought to determine factors associated with a delay in PMRT beyond 12 weeks in patients not undergoing adjuvant chemotherapy., Methods: Medical records of breast cancer patients who underwent mastectomy at our institution between January 2010 and December 2017 who subsequently received PMRT were retrospectively reviewed. As adjuvant chemotherapy can delay PMRT, patients receiving adjuvant chemotherapy were excluded. Factors associated with a delay in PMRT (defined as > 12 weeks from the time of mastectomy) were analyzed., Results: Among the 89 patients who met our inclusion criteria, the mean time from mastectomy to PMRT was 11.4 weeks. 24 patients (27.0%) had PMRT > 12 weeks after mastectomy. Factors associated with a delay in PMRT included black race ( P = 0.031), younger age ( P = 0.047), higher body mass index ( P = 0.015), contralateral prophylactic mastectomy ( P = 0.033), longer initial hospital length of stay ( P = 0.001), and more complications ( P = 0.025). On multivariable analysis controlling for all of these factors, only initial hospital length of stay (OR 1.63; 95% CI: 1.07-2.49; P = 0.024) was associated with a delay in PMRT., Conclusion: Over a quarter of patients not undergoing adjuvant chemotherapy have a delay in PMRT beyond 12 weeks from the time of mastectomy. Length of initial hospital stay is the key driver in delaying PMRT.

Background: While obesity is thought to increase complication rates in general surgery procedures, its effect in mastectomy patients remains to be fully elucidated. We sought to determine if obesity is associated with a higher complication rate and length of stay after mastectomy, independent of clinicopathologic and treatment factors., Methods: Medical records of breast cancer patients undergoing mastectomy at our institution between January 2010 and December 2017 were retrospectively reviewed. Patients were separated into obese (body mass index [BMI] ≥ 30) and nonobese (BMI < 30) categories and compared using nonparametric statistical analyses., Results: Of 927 patients, 291 (31.2%) were obese. Obese patients had more complications (26.5% vs. 20.0%, P = 0.033) and a greater number of complications per patient ( P = 0.025) than nonobese patients. They were more likely to have infections (10.7% vs. 5.7%, P = .009), flap thrombosis/necrosis (5.5% vs. 2.4%, P = .018), and skin breakdown/wound complications (8.6% vs. 4.6%, P = .022). Additionally, obese patients had longer hospital length of stay (LOS; LOS > 2 days: 77.7% vs. 65.2%, P < .001). Controlling for potential confounders, obesity remained associated with a higher rate of thrombosis/necrosis of flap (odds ratio [OR] = 2.26; 95% confidence interval [CI] 1.01-5.08; P = .047) and LOS ≥ 2 days (OR = 1.82; 95% CI 1.23-2.69; P = .003)., Conclusion: Obese breast cancer patients undergoing mastectomy have more thrombosis/necrosis of flap and a longer hospital LOS than nonobese patients, regardless of other comorbidities and clinicopathologic/treatment factors.

Background: Obesity is a known risk factor for breast cancer development; however, it is unclear whether obesity is associated with more aggressive disease. We sought to determine the relationship between obesity and tumor characteristics in breast cancer patients., Methods: Medical records of invasive breast cancer patients undergoing mastectomy at our institution between January 2010 and April 2018 were reviewed. Patients who had received neoadjuvant therapy were excluded. Patients were separated into obese (body mass index [BMI] ≥ 30 kg/m 2 ) and nonobese (BMI < 30 kg/m 2 ) categories and compared using nonparametric statistical analyses., Results: Of the 415 patients in this cohort, 124 (29.9%) were obese. Obese patients were more likely to present with larger tumors (tumor size ≥ 2 cm: 53.2% vs 41.0%, P = .024) and more node-positive disease (46.8% vs 28.9%, P = .001). Controlling for confounders, obesity was independently associated with node-positive disease (odds ratio [OR] = 2.00; 95% CI 1.24-3.21, P = .004), but not with tumor size ≥ 2 cm (OR = 1.38; 95% CI 0.87-2.21, P = .174)., Conclusion: Obesity is associated with node-positive disease at presentation independent of other factors.

Both skin-sparing mastectomy (SSM) and nipple-sparing mastectomy (NSM) are well accepted in the management of breast cancer. Factors that influence the decision of choosing one of these techniques over the other, however, remain to be well elucidated. From January 2010 to December 2017, 734 patients at our institution underwent one of these two procedures. Factors differentiating these patient cohorts were compared. In this study, 196 (26.7%) underwent NSM and 538 (73.3%) underwent SSM. The median age of patients at the time of surgery was 50 years (range, 22-78 years). On multivariate analysis, younger patient age, insurance type, BRCA+ mutation status, smaller breast size (by weight), and those who did not undergo neoadjuvant chemotherapy were more likely to undergo NSM. Surgeon also was an independent predictor of whether patients had NSM or SSM. There may be many factors that play into the decision to pursue NSM versus SSM, but younger patient age, BRCA mutation status, breast size, and whether the patient had neoadjuvant chemotherapy may be key among them. Insurance status may also be a factor for some patients. Aside from these factors, some surgeons may be more or less inclined to perform NSM.

Ductal carcinoma in situ (DCIS) is a premalignant condition, whose incidence is increasing in the current era of widespread screening mammography. While eminently treatable, there are innumerable controversies that surround this disease in terms of its diagnosis and treatment. We discuss these issues and review the data to date regarding this condition which affects roughly 20 per cent of all patients presenting with breast cancer.

The SHAVE trial is a prospective trial in which 235 women with stage 0 to 3 disease undergoing partial mastectomy were randomized intraoperatively to either have cavity shave`s (CSMs) taken at the time of initial surgery or not. In this study, 9 of the 76 patients (11.8%) with initially negative margins randomized to the "shave" group had occult cancers found in the CSM. Seven of these patients had sufficient primary tumor tissue available for further analysis. These patients were age and stage matched in a 1:2 ratio to other patients in the trial who had no further disease found in their CSM. A tissue microarray was created, stained for E-cadherin, MUC1, and beta-catenin, and evaluated by two independent pathologists (blinded to outcome). There were no significant differences between cases and controls in terms of median invasive tumor size, ductal carcinoma in situ size, volume of initial resection, and volume of CSM. Further, no differences were noted between cases and controls for median (staining intensity × per cent of cells staining) for each marker. Hence, although nearly 12 per cent of breast cancer patients with negative margins will have occult disease, this could not be predicted by primary tumor markers in this study.

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.

Although patients diagnosed with ductal carcinoma In Situ (DCIS) enjoy a favorable prognosis, recurrence after definitive management does occur in a subset of these patients. Factors influencing the development of recurrence remain poorly understood. A retrospective chart review of 205 consecutive patients who presented to an academic breast center with DCIS from 2000 to 2003 was conducted under an Institutional Review Board-approved protocol. With a median follow-up of 8.5 years, 14 (6.8%) of the 205 patients who presented with DCIS between 2000 and 2003 had a recurrence of their DCIS. The median age of all patients at the time of diagnosis of their initial DCIS was 55.5 years (range, 35.8 to 88.9 years). Patients who experienced tumor recurrence were more likely to have Grade 3 DCIS on initial diagnosis compared with patients without recurrence (72.7 vs 35.4%, P = 0.032). The odds ratio of tumor recurrence for high-grade compared with low-grade DCIS was 4.39. Patient age, race, tumor size, tumor histologic subtype, or histopathologic features was not associated with recurrence. Patients with high-grade DCIS are more likely to recur than patients with low-grade DCIS, and this seems to be more predictive of recurrence than other clinicopathologic markers.

As more patients with breast cancer survive treatment, the importance of their long-term quality of life is increasing. One important concern for many survivors is fear of recurrence. To better understand worry about recurrence, we conducted a population-based statistical analysis. The National Health Interview Survey (NHIS) is the largest annual source of health information for the U.S. population. We obtained data from the 2010 survey, which asked breast cancer survivors about their fear of recurrence and quality of life. Data were analyzed using SUDAAN software. The 2010 NHIS sample represented 2,668,697 breast cancer survivors. On univariate analysis, worry about recurrence was correlated with current age (P = 0.03) and radiation therapy (P = 0.04). Worry was strongly associated with perceived risk of recurrence (P < 0.01) and decreased overall quality of life (P < 0.01) as well as lower self-reported physical (P < 0.01) and mental (P < 0.01) health and poor satisfaction with social activities and relationships (P < 0.01). On multivariate analysis, worry was not independently associated with decreased quality of life (P = 0.09). However, those who "always worried" about recurrence had a lower quality of life (odds ratio, 0.06; 95% confidence interval, 0.01 to 0.45). Worry about recurrence among breast cancer survivors is associated with age and radiation therapy and is correlated with self-reported physical health, mental health, social relationships, and overall quality of life. It is a significant predictor of decreased quality of life in those who worry the most. Screening for worry about recurrence is an important measure for the improvement of quality of life among breast cancer survivors.

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.

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.

Lymphovascular invasion (LVI) is not uniformly found or reported in breast cancer tumor reports. We sought to determine the impact of the finding of LVI on various parameters of lymph node status in patients with breast cancer. A chart review was performed of 400 node-positive patients from a cohort of patients in a prospective multicenter national sentinel node registry. The finding of LVI was then correlated to number of positive sentinel nodes, the number of positive nonsentinel nodes, the lymph node ratio, and the size of the largest metastatic deposit. Of the 400 patients, data regarding LVI were missing in 98 (24.5%) cases. Although all of these patients were node-positive, LVI was noted to be present in 155 patients (38.8%) and absent in 147 (36.8%). LVI was found to correlate with more positive sentinel nodes (mean, 1.72 vs 1.35; P < 0.001), more positive nonsentinel nodes (mean, 2.16 vs 0.54; P < 0.001), and a higher lymph node ratio (0.29 vs 0.16; P < 0.001). LVI also correlated with size of largest metastatic deposit (P = 0.002). Although LVI is known to be associated with lymph node status, it is not frequently noted on pathology reports. Given its prognostic value, LVI should be carefully evaluated and reported.

Physical activity in breast cancer survivors has been shown to improve outcomes. This study evaluated breast cancer patients' adherence to physical activity guidelines in a population-based study. Data from the 2007 National Health Interview Survey were used to compare adherence to physical activity guidelines in patients with breast cancer with the general population. Statistical analyses were performed using SUDAAN software. In 2007, 327 breast cancer survivors and 23,030 others from the general population were surveyed. Breast cancer survivors were significantly older than the general population (mean age 64.9 vs. 45.6 years, P < 0.001) and tended to be female (99.4 vs. 51.2%, P < 0.001). Despite being significantly more likely to have interacted with a healthcare professional within the past year (96.7 vs. 82.1%, P < 0.001), fewer breast cancer survivors reported following physical activity guidelines than nonbreast cancer survivors (4.64 vs. 12.0%, P < 0.001). Controlling for age, gender, and interaction with healthcare providers, breast cancer survivors were no more likely to follow physical activity guidelines than the general population (OR: 0.73; 95% CI: 0.41-1.30, P = 0.282). Despite more interaction with healthcare providers, breast cancer survivors are no more likely to adhere to activity guidelines than the general population.

We sought to determine differences in risk perception and use of genetic testing in these individuals compared with those with a family history of female breast cancer (FHxFBC) in a population-based cohort. Data from the 2005 National Health Interview Survey were used to assess risk perception and use of genetic counseling in individuals with a family history of male breast cancer (FHxMBC) versus those with a FHxFBC. Of the 2429 individuals with a first-degree relative with breast cancer surveyed, 21 (0.7%) had a FHxMBC, whereas 2408 (99.3%) had a FHxFBC. Women who had a FHxMBC perceived themselves as being at higher risk for developing breast cancer than those with a FHxFBC (61.5 vs 46.5%, P = 0.011). Fewer individuals with a FHxMBC had heard about genetic testing than those with a FHxFBC (38.4 vs 50.8%, P = 0.322). Of these, none of the individuals with a FHxMBC discussed this with their physician (vs 13% of individuals with a FHxFBC, P = 0.004) and none underwent genetic testing (vs 3% of individuals with a FHxFBC, P = 0.009). Women with a FHxMBC perceive this as being associated with increased cancer risk, but few discuss this with their physicians. Physicians should be proactive in discussing risk with these patients.

Malignant phylloides tumors are exceedingly rare with few cases being reported in pregnancy. We describe the first case ever reported of a malignant phylloides tumor presenting in the first trimester of pregnancy and provide insight into the complexities of management as well as a review of the known literature. An extensive PubMed literature search for "cystosarcoma," "phylloides," and "pregnancy" was performed. References of each citation were reviewed. Only six previous cases of phylloides tumor in pregnancy were found, none of which were in the first trimester. Medical records of a patient presenting to our institution at 9 weeks gestation with a malignant phylloides tumor were reviewed. We further provide a review of the current literature of the management of phylloides tumor in pregnancy. A 27-year-old white G2P0SA1 woman with no family history of breast cancer presented with a right breast mass at her first prenatal examination at 9 weeks of pregnancy. Ultrasound confirmed a solid mass measuring 24 mm. Core needle biopsy demonstrated a malignant phylloides tumor. She previously had a fibroadenoma removed from the same breast 7 years previously. The current tumor was excised to clear margins. Histopathological examination revealed a 4-cm fibroepithelial tumor with marked stromal cellularity and a high mitotic count (five to seven mitoses/high-power field), confirming the diagnosis of malignant phylloides tumor. The patient continued her pregnancy without complications. Six other cases of phylloides tumor presenting in pregnancy have been reported in the literature, one of which had bilateral disease. Of these, the average patient age was 32 years (range, 28 to 35 years). The majority of these patients presented in their third trimester (mean, 29 weeks; range, 20 to 36 weeks) and often had large tumors (mean, 15 cm; range, 5 to 21 cm). Four of the seven tumors (57%) required a mastectomy. Previous cases have shown phylloides tumors to present in the third trimester as large masses that require mastectomy. With early detection, malignant phylloides tumors can present in the first trimester of pregnancy at smaller sizes; in these patients, breast-conserving surgery is possible.

Body mass index (BMI) is associated with breast cancer risk, but its relationship with stage at diagnosis is unclear. BMI was calculated for patients in the North American Fareston and Tamoxifen Adjuvant trial, and was correlated with clinicopathologic factors, including stage at diagnosis. One thousand eight hundred fourteen patients were enrolled in the North American Fareston and Tamoxifen Adjuvant study; height and weight were recorded in 1451 (80%) of them. The median BMI was 27.1 kg/m2 (range, 14.7-60.7). The median patient age was 68 years (range, 42-100); median tumor size was 1.3 cm (range, 0.1-14 cm). One thousand seven hundred ninety-three (99.0%) patients were estrogen receptor positive, and 1519 (84.7%) were progesterone receptor positive. There was no significant relationship between BMI (as a continuous variable) and nodal status (P = 0.469), tumor size (P = 0.497), American Joint Committee on Cancer stage (P = 0.167), grade (P = 0.675), histologic subtype (P = 0.179), or estrogen receptor status (P = 0.962). Patients with palpable tumors, however, had a lower BMI than those with nonpalpable tumors (median 26.4 kg/m2 vs 27.5 kg/m2, P < 0.001). Similar results were found when BMI was classified as a categorical variable (<25 vs 25-29.9 vs > or =30). Increased BMI does not lead to a worse stage at presentation. Obese patients, however, tend to have nonpalpable tumors. Mammography in this population is especially important.

The last several decades have witnessed significant advances in the surgical management of breast cancer. Although many have embraced breast conservation as the procedure of choice, some patients will still opt for mastectomy for a variety of reasons. Recently, the concept of skin sparing mastectomy and immediate breast reconstruction has emerged as an option that provides excellent cosmetic results while being oncologically safe. However, this surgical approach must be considered within a multidisciplinary context, and there are a number of perioperative issues that need to be considered. In addition, newer techniques, which spare the nipple and/or areola, warrant further examination.