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Advocacy in breast cancer has a history going back eight decades, influencing funding for research, giving women a voice in their treatment, and helping destigmatise the disease and its management. We aim to outline this trajectory. This is a retrospective historical narrative. We have identified a number of prominent women diagnosed with breast cancer who have had significant political influence and describe the grassroots movement of patient advocacy groups who now have a seat at the policy table and are integral to the research agenda. We also report on how as surgeons we can advocate for better treatments and care pathways, and importantly help build the evidence-base to inform better practice and policy. Surgical advocacy and consumer advocacy have led to huge improvements in management and outcomes for those affected by breast cancer., (© 2024 The Author(s). ANZ Journal of Surgery published by John Wiley & Sons Australia, Ltd on behalf of Royal Australasian College of Surgeons.)

Background: Contrast enhanced mammography (CEM) and magnetic resonance imaging (MRI) are more accurate than conventional imaging (CI) for breast cancer staging. How adding CEM and MRI to CI might change the surgical plan is understudied., Methods: Surgical plans (breast conserving surgery (BCS), wider BCS, BCS with diagnostic excision (>1BCS), mastectomy) were devised by mock-MDT (radiologist, surgeon and pathology reports) according to disease extent on CI, CI + CEM and CI + MRI. Differences in the mock-MDT's surgical plans following the addition of CEM or MRI were investigated. Using pre-defined criteria, the appropriateness of the modified plans was assessed by comparing estimated disease extent on imaging with final pathology. Surgery performed was recorded from patient records., Results: Contrast imaging modified mock-MDT plans for 20 of 61(32.8%) breasts. The addition of CEM changed the plan in 16/20 (80%) and MRI in 17/20 breasts (85%). Identical changes were proposed by both CEM and MRI in 13/20 (65%) breasts. The modified surgical plan based on CI + CEM was possibly appropriate for 6/16 (37.5%), and CI + MRI in 9/17, (52.9%) breasts. The surgery performed was concordant with the mock-MDT plan for all 10 patients where the plans could be compared (BCS 1, >1 BCS 2 and mastectomy 7)., Conclusion: Adding CEM or MRI to CI changed mock-MDT plans in up to one third of women, but not all were appropriate. Changing surgical plans following addition of contrast imaging to CI without biopsy confirmation could lead to over or under-treatment., (© 2023 The Authors. ANZ Journal of Surgery published by John Wiley & Sons Australia, Ltd on behalf of Royal Australasian College of Surgeons.)

Background: A significant proportion of breast cancers present as impalpable lesions requiring radiological guidance prior to surgical excision, commonly by hook-wire placement. Complete lesion excision is an essential part of treatment, and re-excision may be needed to ensure this and minimize local recurrence. We explore a 1-year audit of re-excision of hook-wire-guided excisions in two large public breast units in Western Australia and define factors associated with the requirement for re-excision., Methods: A retrospective review of wire-localized wide local excisions for early breast cancer in 2009 at two tertiary breast centres in Western Australia., Results: Of 148 localized lesions, 44 (30%) underwent re-excision. The only significant preoperative finding was the location of tumour in the breast. The intra-operative specimen radiograph provided useful information that influenced re-excision. Smaller (≤5 mm) and larger (>20 mm) tumours on final pathological size were more likely to undergo re-excision as well as a larger difference in actual size to predicted size. The presence of ductal carcinoma in situ (DCIS) increased re-operation, as did multifocality., Conclusion: This study highlights factors that should make the surgeon more cautious for re-excision. Suspicion of DCIS, especially at the periphery of tumours, and a central tumour location increase risk. Lesion localization techniques play an important role in minimizing risk while maintaining cosmesis., (© 2015 Royal Australasian College of Surgeons.)

Background: Mortality rates from breast cancer are stabilizing or falling in many developed countries including Australia, however, survival outcomes are known to vary by social, demographic and treatment related factors. The aim of the present study was to investigate how hospital, social and demographic factors were associated with survival outcomes from surgically treated breast cancer for all women living in Western Australia., Methods: The WA Data Linkage System was used to access hospital morbidity, death and cancer information for all women diagnosed with invasive breast cancer in Western Australia 1982-2000. Relative survival and Cox proportional hazards regression analyses were used to identify social, demographic and hospital factors associated with an increased risk of dying from breast cancer or dying from any cause., Results: Survival outcomes improved in all women diagnosed in more recent calendar periods. However, a significantly increased risk of dying was observed for women who underwent initial surgical treatment in regional public hospitals outside of the state capital, Perth. Consistent with other reports, women aged greater than 80 years and younger than 35 years at diagnosis also had poorer survival outcomes. Residential location, socioeconomic status and race were not associated with survival after adjusting for treatment, health and hospital related factors., Conclusions: Despite overall improvements in survival of women diagnosed with breast cancer in Western Australia, initial surgical treatment in public hospitals outside of Perth was associated with significantly poorer outcomes.

Background: In line with current Australian early breast cancer management guidelines, more women are having breast conserving surgery to treat breast cancer when appropriate. Some women will undergo further surgery because of involved margins, early local relapse, or other factors including patient choice. The aim of this study was to investigate whether socio-economic, demographic or hospital factors were associated with the risk of re-excision or subsequent mastectomy., Methods: A record linkage population-based study on 12 711 women diagnosed with breast cancer in Western Australia from 1982 to 2000 who underwent breast surgery within 12 months of diagnosis was performed. Logistic regression was used to identify social, demographic and hospital factors associated with the risk of undergoing further surgery following initial breast conserving surgery., Results: The proportion of women undergoing initial breast conserving surgery doubled from 33% in 1982-1985 to 72% in 1998-2000. The proportion of women who underwent further surgery following initial breast conserving surgery decreased from 50 to 30% over the same period. The risk of re-excision or subsequent mastectomy was between 2.4 (95% CI 1.7-3.4) and 5.0 (95% CI 3.4-7.4) times greater if initial surgery was performed in a non-metropolitan hospital compared to Perth hospitals. Younger women were between 1.7 (95% CI 1.4-2.0) and 2.1 (95% CI 1.5-3.0) times more likely to undergo re-excisions compared to women aged 50-64 years of age., Conclusions: Young women and women initially treated in non-metropolitan hospitals were at an increased risk of re-excision or a subsequent mastectomy following initial breast conserving surgery to treat breast cancer. Efforts need to be directed towards improving specialist health services outside of Perth if women continue to be treated for breast cancer in non-metropolitan hospitals.

Background: A new device, Intrabeam, is available for intraoperative radiotherapy. We have prospectively examined its feasibility and tolerability in delivering adjuvant breast cancer treatment., Methods: Thirty-five patients undergoing breast-conserving surgery received targeted tumour bed irradiation consisting of 5 Gy (at 10 mm) in a single fraction. This single intraoperative treatment was used to replace the external beam radiotherapy "boost" that would usually be given in 10 daily treatments following 5 weeks of whole breast irradiation. Patients later completed external beam radiotherapy as usual. Potential toxicities were prospectively assessed fortnightly prior to external beam radiotherapy, weekly during it, and 3 monthly subsequently., Results: The intraoperative radiotherapy was able to be delivered without difficulty, either at time of initial cancer surgery or as a second procedure. When performed as a separate procedure the median operating time was 56 min. The treatment was well tolerated, with only one patient experiencing any grade 3 or 4 toxicities--this was acute grade three itch. There was an overall early breast infection rate of 17%. No unexpected toxicities were seen., Conclusions: This simple and well-tolerated treatment delivers a useful radiation dose to the area of highest risk of tumour recurrence. The early infection rate is similar to that reported in the literature, for treatments without intraoperative radiotherapy. Whether such a treatment may adequately replace the entire adjuvant radiation therapy treatment for low-risk patients is now being studied in a randomized trial.

Background: The purpose of the present paper was to review the current knowledge of pregnancy concurrent with a diagnosis of breast cancer, and how best to manage this group of women and those breast cancer survivors who may subsequently conceive., Results: Pregnancy-associated breast cancer or gestational breast cancer is defined as breast cancer diagnosed during pregnancy or in the 12 months post-partum. A review of the current literature on breast cancer-related pregnancy suggests an incidence of between 0.7 and 3.9%. The prognosis is thought not to be significantly different from non-pregnancy-associated breast cancer, except in cases where a delay in diagnosis is associated with more advanced disease. The treatment is similar to non-pregnant cases, with the exception of radiotherapy, which is contraindicated throughout pregnancy; and chemotherapy, which is contraindicated during the first trimester. Few breast cancer survivors go on to conceive, but those who do have no worse breast cancer or pregnancy outcomes., Conclusion: Most of the research in this field has come from small, specialized institutions and may not reflect what occurs in the wider community. Further population-based research in this area is needed, and is currently being undertaken in Western Australia.