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Background: Ductal carcinoma in situ (DCIS) represents 15% of all breast cancers in France. The first national survey was conducted in 2003. The present multi-center real-life practice survey aimed at assessing possible changes in demographic, clinical, pathologic, and treatment features., Material and Methods: From March 2014 to September 2015, patients diagnosed with DCIS from 71 centers with complete information about age, diagnostic features, and treatment modalities were prospectively included., Results: A total of 2125 patients with a median age of 58.6 years from 71 centers were studied. DCIS was diagnosed by mammography in 87.5% of cases. Preoperative biopsy was performed in 96% of cases. The median tumor size was 15 mm. Nuclear grade was low, intermediate, and high in 12%, 36%, and 47% of cases, respectively. Margins were considered to be negative in 83% of cases. Overall mastectomy and lumpectomy rates were 25% and 75%, respectively. The immediate breast reconstruction rate was 50%. Sentinel node biopsy and axillary dissection rates were 41% and 2.6%, respectively. After lumpectomy, 97% of patients underwent radiotherapy, and 32% received a boost dose. Only 1% of patients received endocrine therapy. Compared with our previous survey, the median tumor size remained the same, and the proportion of high-grade lesions increased by 9%. The mastectomy rate decreased by 4%., Conclusions: The clinical practice identified in this survey complies with French DCIS guidelines. About 10% of patients with low-grade DCIS may be eligible to participate in treatment de-escalation trials., (Copyright © 2019 The Authors. Published by Elsevier Inc. All rights reserved.)

Purpose: We evaluated the addition of breast magnetic resonance imaging (MRI) to standard radiologic evaluation on the re-intervention rate in women with ductal carcinoma in situ (DCIS) undergoing breast-conserving surgery., Patients and Methods: Women with biopsy-proven DCIS corresponding to a unifocal microcalcification cluster or a mass less than 30 mm were randomly assigned to undergo MRI or standard evaluation. The primary end point was the re-intervention rate for positive or close margins (< 2 mm) in the 6 months after randomization ( ClinicalTrials.gov identifier: NCT01112254)., Results: A total of 360 patients from 10 hospitals in France were included in the study. Of the 352 analyzable patients, 178 were randomly assigned to the MRI arm, and 174 were assigned to the control arm. In the intent-to-treat analysis, 82 of 345 patients with the assessable end point were reoperated for positive or close margins within 6 months, resulting in a re-intervention rate of 20% (35 of 173) in the MRI arm and 27% (47 of 172) in the control arm. The absolute difference of 7% (95% CI, -2% to 16%) corresponded to a relative reduction of 26% (stratified odds ratio, 0.68; 95% CI, 0.41 to 1.1; P = .13). When considering only the per-protocol population with an assessable end point, the difference was 9% (stratified odds ratio, 0.59; 95% CI, 0.35 to 1.0; P = .05). Total mastectomy rates were 18% (31 of 176) in the MRI arm and 17% (30 of 173) in the control arm (stratified P = .93). For 100 lesions seen on MRI, nonmass-like enhancement was more predominant (82%) than mass enhancement (20%). Nevertheless, no specific morphologic and kinetic parameters for DCIS were identified., Conclusion: The study did not show sufficient surgical improvement with the use of preoperative MRI to be clinically relevant in DCIS staging. However, this could be reconsidered with the improvement of new MRI sequences and new modalities in magnetic resonance techniques.

Aims: Minimum volume thresholds were introduced in France in 2008 to improve the quality of cancer care. We investigated whether/how the quality of treatment decisions in breast cancer surgery had evolved before and after this policy was implemented., Methods: We used Hospital Episode Statistics for all women having undergone breast conserving surgery (BCS) or mastectomy in France in 2005 and 2012. Three surgical procedures considered as better treatment options were analyzed: BCS, immediate breast reconstruction (IBR) and sentinel lymph node biopsy (SLNB). We studied the mean rates and variation according to the hospital profile and volume., Results: Between 2005 and 2012, the volume of breast cancer surgery increased by 11% whereas one third of the hospitals no longer performed this type of surgery. In 2012, the mean rate of BCS was 74% and similar in all hospitals whatever the volume. Conversely, IBR and SLNB rates were much higher in cancer centers (CC) and regional teaching hospitals (RTH) [IBR: 19% and 14% versus 8% on average; SLNB: 61% and 47% versus 39% on average]; the greater the hospital volume, the higher the IBR and SLNB rates (p < 0.0001). Overall, whatever the surgical procedure considered, inter-hospital variation in rates declined substantially in CC and RTH., Conclusions: We identified considerable variation in IBR and SLNB rates between French hospitals. Although more complex and less standardized than BCS, most clinical guidelines recommended these procedures. This apparent heterogeneity suggests unequal access to high-quality procedures for women with breast cancer., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Context and Aims: Breast cancer prognosis and predictive biomarkers development would allow sparing some patients from chemotherapy or identifying patients for whom chemotherapy would be indicated. In this context, in 2009, the French National Cancer Institute, a National Health and Science Agency dedicated to cancer, in collaboration with the French society of senology and breast pathology (SFSPM) published a report on the assessment of the prognostic and the predictive clinical validity of tissular biomarkers, uPA/PAI-1, Oncotype DX™ and MammaPrint(®), in breast cancer management. They concluded that only the uPA/PAI-1 prognosis value reached the highest level of evidence (LOE I according to Hayes 1998 classification). In 2012, it was decided to update this report since new data have emerged and because information disparities among clinicians have been identified. This article aims to present the main conclusions together with the levels of evidence associated with those conclusions., Methods: The updating process was based on literature published since 2009 appraisal and on multidisciplinary and independent experts' opinion. The levels of evidence (LOE) used are those of the classification defined by Simon in 2009 (updated Hayes 1998 classification): LOE IA and LOE IB: high level of evidence; LOE IIB and LOE IIC: intermediate level of evidence; LOE IIIC and LOE IV-VD: low level of evidence., Conclusions: Among patients without lymph-node involvement, uPA/PAI-1, invasion process biomarkers, reach the highest level of evidence for 10 years recurrence free survival prognosis (LOE IA according to Simon). The predictive value to anthracyclins chemotherapy remains to be confirmed. Oncotype DX™ and MammaPrint(®) prognosis and predictive value do not reach the LOE I level. This updating' process confirms the 2009 levels of evidence for all the three biomarkers prognosis value. Besides, concerning Oncotype DX™ and MammaPrint(®), new data do not allow to conclude neither to their complementary clinical information to other clinicopathological existing biomarkers nor to a favorable cost-efficiency ratio in therapeutic decision making and this because of the methodological weakness and uncertainty that are identified in the selected studies. Practically, beyond the prognosis and predictive biomarkers validity, the clinical utility of a new biomarker for chemotherapy indication depends on its clinical added information with regard to validated biomarkers (HR, HER2 and Ki67) and to clinicopathological parameters. Since they are the sole validated biomarkers of the invasion process, uPA/PAI-1 could complete clinical information of other clinicopathological factors and consequently could confer an added clinical value. However, data concerning the impact of this information on chemotherapy clinical indication are lacking., (Copyright © 2014. Published by Elsevier Masson SAS.)

Introduction: Complementary and alternative medicine (CAM) is increasingly popular among cancer patients but can interfere with conventional therapies; timely data are needed to adapt current patients' care., Materials and Methods: This transversal, prospective study evaluated the use of CAM among patients receiving adjuvant chemotherapy or endocrine therapy for early stage breast cancer. We assessed the prevalence of use, the motivations and predictive factors for use, as well as patients' information needs over a three months period., Results: 69/184 responders (37.5%) reported using at least one CAM. CAM use was associated with younger age (p = 0.03) and higher education level (p < 0.001). Pharmacological substances (e.g., homeopathy, phytotherapy) were the most commonly used (79.7%) before physical means (42%) and dietary methods (31.9%). A total of 65.8% of users felt that these treatments have demonstrated evidence of efficacy and 74.8% that they were not associated with side effects. The main goal for use was improvement of treatment-related symptoms (28.3%); secondary goal was increasing the general health status (20.5%). Patients reported high needs for information on CAMs. CAM use was associated with mild differences in secondary adverse events reported by patients., Conclusion: Breast cancer patients are common users of CAM concomitantly to their conventional cancer treatments and should be investigated regarding their current consumption of CAM. Furthermore, they need advice evidence-based data on these treatments and potential interactions with on-going treatments., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Aim of the Study: Our aim was to determine factors influencing physicians and breast cancer patients to respectively propose or accept participation in a clinical trial following proposals made during a multidisciplinary team meeting (MTM) in a Comprehensive Cancer Centre., Patients and Methods: Consecutive patients considered eligible for a clinical trial by a breast cancer-specific MTM were included. A detailed analysis of factors predictive of the physician proposing the trial and the patient's acceptance and final inclusion was conducted., Results: MTM proposed 547 inclusions in 25 clinical trials for 397 patients between March and September 2011. The physician proposed the scheduled clinical trial in only 39% of the cases. The patients accepted the proposal in 74% of the cases, and finally 29% were included. The main reason for non-inclusion was the physician's failure to propose the trial in 45-81%, depending on the type of study. The only factor predictive of both the physician proposing the trial and final inclusion was the type of study (both p < 0.001). Diagnostic/prognostic studies were the most frequently proposed trials. The professional status (of the subject) was predictive of acceptance (p = 0.03) with higher rates among retired patients and executives (84 and 76% respectively)., Conclusion: The major reason for non-inclusion in clinical trials was the physician's failure to propose the trial, while the patient's professional status and the type of study influenced both physicians and patients. Educative measures mostly directed at physicians could be implemented to overcome such poor compliance., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Background: Nipple-sparing mastectomy (NSM) is increasingly popular for the treatment of select breast cancers and prophylactic mastectomy. This study aimed to analyze the authors' 11-year experience with NSM and breast reconstruction in cases of ductal carcinoma in situ (DCIS) with an emphasis on indications, complications, and cancer recurrence rate., Methods: Between January 2000 and December 2010, 41 NSMs were performed in 41 women for DCIS. The mean age of the women was 49.7±8.7 years (range, 33-66 years). The indications for NSM were tumor size greater than 3 cm (18 cases), multifocal tumor (16 cases), and tumor recurrence (7 cases). In all cases, the tumor was located more than 2 cm from the nipple-areola complex (NAC), as shown by preoperative radiologic imaging. Histologic results, secondary NAC resection, complications, and cancer recurrence rates were recorded., Results: The NAC was lost in seven cases (17%) due to postoperative necrosis. In another 10 patients (25%), the NAC was secondarily removed due to proximity of the tumor to the resection margin. Five patients were lost to follow-up evaluation (12%). The authors report the long-term follow-up data for the remaining 19 patients (46%). In this group, they observed one local recurrence (5.3%) and one case of ovarian cancer., Conclusion: Despite the low locoregional recurrence rate for DCIS, NSM remains controversial because of the nipple necrosis observed and the irradical tumor excisions. Given the ethical impossibility of conducting randomized controlled studies to compare NSM with conventional or skin-sparing mastectomy in DCIS, only long-term follow-up evaluations can demonstrate the safety of NSM., Level of Evidence Iv: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Background: Currently, the benefit of chemotherapy (CT) in node-negative breast carcinoma (NNBC) is discussed. The evaluation of classical clinical and histological factors is limited to assess individual outcome. A statistical model was developed to improve the prognostic accuracy of NNBC., Methods: A total of 305 node-negative breast carcinomas who underwent surgery (+/- radiotherapy) but no adjuvant treatment were selected. Putative prognosis factors including age, tumour size, oestrogen receptor (ER), progesterone receptor (PgR), Scarff-Bloom-Richardon (SBR) grading, urokinase plasminogen activator (uPA), plasminogen activator inhibitor 1 (PAI-1) and thymidine kinase (TK) were evaluated. The developed model was internally validated using Harrell's concordance index. A prognosis index (PI) was proposed and compared with Adjuvant! Online program., Results: Age (p < 0.001), pathological tumour size (pT) (p < 0.001), PgR (p = 0.02), and PAI-1 (p ≤ 0.001) were included in the Cox regression model predicting Breast cancer specific survival (BCSS) at 5-years. Internal validation revealed a concordance index of 0.71. A PI score was derived from our nomogram. The PI score was significantly associated with BCSS (hazard ratio (HR): 4.1 for intermediate, p=0.02, HR: 8.8, p < 0.001 for high group) as compared to Adjuvant! Online score (HR: 1.4, p=0.14)., Conclusion: A nomogram can be used to predict probability survival curves for individual breast cancer patients., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Objective: To compare the imaging procedures and surgical strategies used to treat placenta accreta at referral centers in France and Argentina., Method: A total of 52 women suspected of having placenta accreta underwent ultrasound and placental magnetic resonance imaging evaluations at these centers between May 2003 and October 2006. Findings and management were recorded., Results: The use of the 2 imaging technologies was similar in France and Argentina and conservative surgical treatment was predominant in both groups. The placenta was left in situ in 64.7% of cases at the French center whereas resection of the placenta and invaded area were performed in 91.4% of cases in Argentina., Conclusion: The same diagnostic tools were used in the 2 groups, but there were differences in diagnostic accuracy and in the types of surgical procedures performed.

Objective: This study was undertaken to evaluate prevalence of low urinary tract symptoms (LUTS) after Thierry's spatula delivery at first pregnancy., Patients and Methods: A retrospective study of 236 primiparous with instrumental delivery or spontaneous delivery who had delivered from January 2001 to December 2002. Low urinary tract symptoms (LUTS) were evaluated one year after delivery with a questionnaire. Incidence of LUTS was compared depending on mode of delivery., Results: Of the 236 patients included, 88.1% replied to the questionnaire, 106 who delivered spontaneously and 102 who underwent Thierry's spatula delivery. The incidence of urinary incontinence was similar after instrumental deliveries and after spontaneous vaginal deliveries (34.9 versus 24.5%, p=0.10). In univariate analysis, symptoms of urinary urgency and urinary frequency were higher after instrumental delivery than after spontaneous delivery, respectively, 34.9 versus 22.5%, p=0.049 and 19.8 versus 8.8%, p=0.03. After controlling for confounding factors, no difference in LUTS was observed between the two groups; the respective adjusted odds-ratios (95% IC) were 1,5 (0.8-3) for urinary incontinence, 1.7 (0.9-3.5) for urgency and 2.5 (0.9-6.3) for urinary frequency., Discussion and Conclusion: One year after delivery, one third of patients will present urinary incontinence and more than 50% will complain of bladder instability symptoms. Compared to spontaneous vaginal delivery, the use of Thierry's spatulas at first pregnancy does not induce higher risk of LUTS.

Objective: To evaluate the safety and efficacy of termination of pregnancy using mifepristone and misosprostol at more than 15 weeks' gestation in patients with uterine scar due to previous cesarean section., Materials and Methods: This retrospective study was conducted in a tertiary maternity ward between January 2000 and October 2004. A total of 252 women at more than 15 weeks' gestation underwent termination of pregnancy including 50 women with uterine scar due to previous cesarean section (Group 1) and 202 control patients (Group 2) without known uterine scar. Abortion was induced with mifepristone and a prostaglandin analogue. Women between 15 and 34 weeks' gestation received misoprostol intravaginally every 3 h at doses of 200 microg (Group 1) or 400 microg (Group 2). Women at more than 34 weeks' gestation received Prostin E2 vaginal gel. Main end points were hemorrhage, fever, retained placenta, occurrence of complications including uterine rupture and dehiscence, and final outcome., Results: A total of 13 (26%) patients in Group 1 and 79 (39.1%) in Group 2 were at more than 24 weeks' gestation. The abortion failure rate was 2% (1/50) in Group 1 and 0.5% (1/202) in Group 2 (p = .28). The median induction-to-delivery interval was 8.5 h (range, 3.0-114.2 h) for Group 1 and 9.0 h (range, 1.3-124.3 h) in Group 2 (p = .26). One case of uterine rupture and one case of dehiscence were observed, both in women in Group 1. The incidence of hemorrhage was not significantly different between Group 1 and Group 2 (2% vs. 0.9%, respectively, p = .56). The incidence of retained placenta was higher in the Group 1 (70% vs. 52.5%, respectively, p = .025)., Conclusion: In this retrospective series of women who underwent abortion at 15-35 weeks' gestation using mifepristone and a prostaglandin analogue for labor induction abortion, history of cesarean section was not associated with higher morbidity except risk of uterine rupture. However, dose and interval of misoprostol should be determined. A larger study is needed before drawing definitive conclusions about the safety of these regimens.

Objective: To analyse maternal and neonatal morbidity associated with instrumental delivery using Thierry's spatulas., Methods: Between January 2001 and December 2003, 570 nulliparous women with term, singleton, cephalic pregnancies gave birth by either instrumental (n = 279) or spontaneous vaginal delivery (n = 291) and were studied in a retrospective case-control study. Maternal and neonatal morbidity were compared in the instrumental vs. spontaneous delivery groups., Results: Women who underwent instrumental delivery using Thierry's spatula were more likely to have severe perineal tears (ORa 7.5, 95% CI 1.5, 32.3), urinary retention (OR 2.7, 95% CI 1.3, 5.6), postpartum blood loss (ORa 3.4, 2.4, 4.9) and extended hospital stay (OR 3.21, 95% CI 2.3, 4.6) than women having a spontaneous vaginal birth. Regarding the infant, one case of subgaleal haematoma was noted. No significant difference was noted in neonatal period., Conclusion: This data support the safety of Thierry's spatula on infant outcome. Maternal morbidity observed with Thierry spatulas was similar to that reported in the literature for other modes of instrumental delivery but the risk for perineal morbidity was higher than for spontaneous delivery. Neonatal morbidity appeared to be limited.

Objective: The purpose of this prospective study was to evaluate urinary and sexual function after the tension-free vaginal tape (TVT) support procedure for stress urinary incontinence (SUI)., Methods: Between January 1999 and July 2002 a total of 71 patients underwent comprehensive examination including urodynamics and a mailed self-administered questionnaire for assessment of voiding and sexual function before and after treatment of SUI by TVT., Results: Based on objective findings TVT was considered as curative in 48 patients (87.3%). Comparison of preoperative and postoperative urodynamic evidence demonstrated a significant outflow obstruction (<12 ml/s) in 19 patients (34.5%). A significant decrease in peak urinary flow during voiding (p < 0.001) was also observed. Of the 55 women (78.5%) who responded to the questionnaire before and after TVT, 42 (76.3%) reported satisfaction with the outcome. Postoperatively, 60% of patients reported voiding difficulty, 47.2% complained of urgency, and 32.7% of frequency. Regarding sexual function 20% reported impairment after surgery including dyspareunia in 14.5% (none preoperatively vs. eight postoperatively, <0.01) and loss of libido in 5.4%., Conclusion: The TVT procedure is an effective treatment for SUI. However, it can lead to postoperative voiding and sexual impairment.