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BACKGROUND: We sought to identify characteristics of metastatic breast cancer (MBC) patients who may benefit most from primary tumor resection. METHODS: Recursive partitioning analysis (RPA) was used to categorize non-surgical patients with de novo MBC in the NCDB (2010–2015) into 3 groups (I/II/III) based on 3-year overall survival (OS). After bootstrapping (BS), group-level profiles were applied, and the association of surgery with OS was estimated using Cox proportional hazards models. RESULTS: All patients benefitted from surgery (median OS, surgery vs no surgery): 72.7 vs 42.9 months, 47.3 vs 30.4 months, 23.8 vs 14.4 months (all p

Since the 1980s, the mortality rate from breast cancer in the United States has dropped almost 40%. The quality of life and survival gains from early detection and improved treatment have not been shared equally by all ethnic groups, however. Many factors, including social determinants of health, unequal access to screening and oncologic care, and differences in incidence, tumor biology, and risk factors, have contributed to these unequal breast cancer outcomes. As breast radiologists approach their own patients, they must be aware that minority women are disproportionately affected by breast cancer at earlier ages and that non-Hispanic Black and Hispanic women are impacted by greater severity of disease than non-Hispanic White women. Guidelines that do not include women younger than 50 and/or have longer intervals between examinations could have a disproportionately negative impact on minority women. In addition, the COVID-19 pandemic could worsen existing disparities in breast cancer mortality. Increased awareness and targeted efforts to identify and mitigate all of the underlying causes of breast cancer disparities will be necessary to realize the maximum benefit of screening, diagnosis, and treatment and to optimize quality of life and mortality gains for all women. Breast radiologists, as leaders in breast cancer care, have the opportunity to address and reduce some of these disparities for their patients and communities.

IntroductionBreast reconstruction plays an important role for many in restoring form and function of the breast after mastectomy. However, rates of breast reconstruction in the USA vary significantly by race, ethnicity and socioeconomic status. The lower rates of breast reconstruction in non-white women and in women of lower socioeconomic status may reflect a complex interplay between patient and physician factors and access to care. It remains unknown what community-specific barriers may be impacting receipt of breast reconstruction.Methods and analysisThis is a mixed-methods study combining qualitative patient interview data with quantitative practice patterns to develop an actionable plan to address disparities in breast reconstruction in the local community. The primary aims are to (1) capture barriers to breast reconstruction for patients in the local community, (2) quantitatively evaluate practice patterns at the host institution and (3) identify issues and prioritise interventions for change using community-based engagement.Ethics and disseminationEthics approval was obtained at the investigators’ institution. Results from both the quantitative and qualitative portions of the study will be circulated via peer-review publication. These findings will also serve as pilot data for extramural funding to implement and evaluate these proposed solutions.

BACKGROUND. Contralateral axillary nodal metastases (CAM) is classified as stage IV disease, although many centers treat CAM with curative intent. We hypothesized that patients with CAM, treated with multimodality therapy, would have improved overall survival (OS) versus patients with distant metastatic disease (M1) and similar OS to those with locally advanced breast cancer (LABC). METHODS. Using the NCDB (2004–2016), we categorized adult patients with node-positive breast cancer into three study groups: LABC, CAM, and M1. Kaplan-Meier curves were used to visualize the unadjusted OS. Cox proportional hazards models were used to estimate the association of study group with OS. RESULTS. A total of 94,487 patients were identified: 122 with CAM, 12,325 with LABC, and 82,040 with M1 (median follow-up 63.6 months). LABC and CAM patients had similar histology and rates of chemotherapy and endocrine therapy receipt. However, the CAM group had significantly larger tumors, more estrogen-receptor expression, higher T-stage, and more mastectomies than the LABC group. Compared with M1 patients, CAM patients were more likely to have grade 3 and cT4 tumors. Patients with CAM and LABC had similar 5-year unadjusted OS and significantly improved OS vs M1 patients. After adjustment, LABC and CAM patients continued to have similar OS and better OS vs M1 patients. CONCLUSIONS. CAM patients who receive multi-modal therapy with curative intent may have OS more comparable to LABC patients than M1 patients. Out data support a reevaluation of whether CAM should remain classified as M1, as N3 may better reflect disease prognosis and treatment goals.

BACKGROUND: Microaggressions can target individuals based on a variety of differences and these can include sexual orientation, nationality, gender, or personal traits and are often disruptors in the healthcare setting. METHODS: To address this issue, The Society of Black Academic Surgeons (SBAS) convened a series of presentations and a panel discussion by leaders from SBAS regarding the issue of microaggressions in the surgical workplace. This program was part of a monthly diversity, equity, and inclusion series produced by the Advances in Surgery Channel in alliance with the American College of Surgeons. Dr. Yewande Alimi addresses microaggressions in surgical training, Dr. Fabian Johnston talks about microaggressions in the black male physician, Dr. Lola Fayanju speaks to microaggressions and the black female surgeon, Dr. Carla Pugh discusses microaggressions in the surgical workplace, and Dr. Paris Butler presents on allyship, policies, and real solutions. RESULTS: Specifically, through the lens of the Black surgeon experience, SBAS leaders candidly articulate and elaborate on microaggressions’ pervasiveness and the deleterious impact on the profession. Authentic opinions are rendered and constructive techniques to mitigate this challenge are provided. The concept of majority allyship is also introduced, and recommendations on how this can be operationalized is also examined. CONCLUSIONS: There are a lot of experiences that contribute to our understanding of microaggressions. We look forward to finding new ways to partner with our allies and continuing the conversation.

We sought to identify modifiable factors associated with cancer screening in a community-based health assessment.24 organizations at 47 community events in central North Carolina distributed a 91-item survey from April-December 2017. Responses about (1) interest in disease prevention, (2) lifestyle choices (e.g., diet, tobacco), and (3) perceptions of primary care access/quality were abstracted to examine their association with self-reported screening participation and knowledge about breast, prostate, and colorectal cancer.2135/2315 participants (92%; 38.5% White, 38% Black, 9.9% Asian) completed screening questions.70% of screen-eligible respondents reported guideline-concordant screening. Healthy dietary habits were associated with greater knowledge about breast and colorectal cancer screening; reporting negative attitudes about and barriers to healthcare were associated with less breast, prostate, and colorectal cancer screening. Having a place to seek medical care (a proxy for primary care access) was independently associated with being ∼5 times as likely to undergo colorectal screening (OR 4.66, 95% CI 1.58-13.79, all p 0.05).In this diverse, community-based sample, modifiable factors were associated with screening engagement, highlighting opportunities for behavioral intervention.

We sought to examine patient and provider perspectives regarding modifiable contributors to breast cancer treatment and to assess perceptual alignment between these two groups.Participants were women≥18 y with stage 0-IV breast cancer who received all oncologic care in a single health system and physicians and advanced practice providers who provided medical, radiation, or surgical oncology care for breast cancer. All completed ∼45-min semistructured interviews that were recorded and transcribed verbatim. A 5-stage approach to thematic analysis was conducted, with emergent themes and exemplar quotes placed into clinical, psychological, social/logistical, financial, and lifestyle categories using a multilevel conceptual framework.Eighteen patients (9 Black, 9 White, and median age 60 y) and 10 providers (6 physicians and 4 advanced practice providers) were interviewed from May to November 2018. Both patients and providers perceived suboptimal communication, parking and transportation, and competing family-caregiving responsibilities as modifiable barriers to care. Treatment costs were cited by patients as barriers that were inadequately addressed even with referrals to financial counselors, but providers did not raise the issue of cost unless prompted by patients and did not feel prepared to discuss the topic when it arose. Providers cited obesity as a barrier to treatment, a view not shared by patients.Several modifiable factors were recognized by both patients and providers as either promoting or detracting from treatment receipt, but there was also significant incongruence and asymmetry. Alignment of provider and patient perceptions regarding contributors to guideline-concordant care receipt could mitigate disparities in breast cancer treatment and outcomes.

Randomized, clinical trials have established the efficacy of screening mammography in improving survival from breast cancer for women through detection of early, asymptomatic disease. However, disparities in survival rates between black women and women from other racial and ethnic groups following breast cancer diagnosis persist. Various professional groups have different, somewhat conflicting, guidelines with regards to recommended age for commencing screening as well as recommended frequency of screening exams, but the trials upon which these recommendations are based were not specifically designed to examine benefit among black women. Furthermore, these recommendations do not appear to incorporate the unique epidemiological circumstances of breast cancer among black women, including higher rates of diagnosis before age 40 years and greater likelihood of advanced stage at diagnosis, into their formulation. In this review, we examined the epidemiologic and socioeconomic factors that are associated with breast cancer among black women and assess the implications of these factors for screening in this population. Specifically, we recommend that by no later than age 25 years, all black women should undergo baseline assessment for future risk of breast cancer utilizing a model that incorporates race (e.g., Breast Cancer Risk Assessment Tool [BCRAT], formerly the Gail model) and that this assessment should be conducted by a breast specialist or a healthcare provider (e.g., primary care physician or gynecologist) who is trained to assess breast cancer risk and is aware of the increased risks of early (i.e., premenopausal) and biologically aggressive (e.g., late-stage, triple-negative) breast cancer among black women.

The Society of Surgical Oncology is committed to reducing health disparities adversely affecting sexual and gender minorities. Transgender persons represent a socially disadvantaged group who frequently experience discrimination and receive disparate care, resulting in suboptimal cancer outcomes. The rate of breast cancer development in transgender individuals differs from rates observed in their cisgender counterparts, however there is little evidence to quantify these differences and guide evidence-based screening and prevention. There is no consensus for breast cancer screening guidelines in transgender patients. In this review, we discuss barriers to equitable breast cancer care, risk factors for breast cancer development, and existing data to support breast cancer screening in transgender men and women.

BACKGROUND. Although metastatic breast cancer (MBC) remains incurable, advances in therapies have improved survival. Using a contemporary dataset of de novo MBC patients, we explore how overall (OS) and cancer-specific survival (CSS) changed over time. METHODS. All patients with de novo MBC from 1988 to 2016 were selected from Surveillance, Epidemiology, and End Results (SEER) 18. Unadjusted OS and CSS were estimated by Kaplan–Meier method and stratified by disease characteristics. Cox proportional hazards models determined factors associated with survival. RESULTS. 47,034 patients were included, with median OS of 25 months and CSS of 27 months. Survival steadily improved over time (1988: 1-year OS 62%, CSS 65%; 2015: 1-year OS 72%, CSS 74%). Patients with triple-negative breast cancer (TNBC) had the worst prognosis and were most likely to die from MBC [versus human epidermal growth factor receptor 2 (HER2)+ and hormone receptor (HR)+/HER2−]. Those with ≥ 4 sites of metastatic disease were also more likely to die from MBC with nearly identical OS and CSS (5-year OS 9%, CSS 9%), when compared with those with 1 site (5-year OS 31%, CSS 35%). After adjustment, improved CSS was associated with bone-only disease [hazard ratio (HR) 0.88, 95% confidence interval (CI) 0.83–0.94], while TNBC (versus HER2+: HR 3.12, 95% CI 2.89–3.36) and > 3 sites of metastatic disease (versus 1 site: HR 3.24, 95% CI 2.68–3.91) were associated with worse CSS (all p < 0.001). CONCLUSIONS. Accurate prognostic estimates are essential for patient care. As treatments for patients with MBC have expanded, OS and CSS have improved, and more patients, particularly with limited distant disease or favorable tumor subtypes, are also dying from non-MBC causes.

INTRODUCTION: We compared characteristics and outcomes by treatment sequence among patients with metaplastic breast cancer (MBC), an aggressive subtype. METHODS: Women ≥18 years old with newly diagnosed Stage I-III MBC from 2003 to 2018 who received any treatment in our health system were identified. Unadjusted overall survival (OS) was estimated with the Kaplan-Meier method; the log-rank test was used to compare survival differences between recipients of neoadjuvant (NACT) and adjuvant chemotherapy (ACT). RESULTS: Of the 91 MBC patients identified, 60 received chemotherapy. NACT recipients (n = 20, median age 46.5 y) were younger than ACT recipients (n = 40, median age 60.5 y, p < 0.001) but similar with regards to race and radiation receipt. There was no significant OS difference between NACT and ACT recipients (log-rank p = 0.15), which remained true when patients were stratified by age (≥50 y vs < 50 y). CONCLUSIONS: Among MBC patients, NACT recipients were younger than ACT recipients, but there was no survival difference by treatment sequence.

BACKGROUND: Women of color with breast cancer are less likely to undergo post-mastectomy reconstruction compared with White women, but it is unclear whether their perioperative outcomes are worse. The goal of this study was to investigate differences in preoperative comorbidities and postoperative complications by race/ethnicity among women with breast cancer undergoing postmastectomy reconstruction. STUDY DESIGN: Data were collected from the National Inpatient Sample database of the Healthcare Cost and Utilization Project from 2012 to 2016. Patient demographics, types of reconstruction, comorbid conditions, Charlson-Deyo Combined Comorbidity (CDCC) scores, length of stay (LOS), and perioperative complications were abstracted. Multivariate linear and logistic regression were performed to model LOS and likelihood of postoperative complications, respectively. RESULTS: Compared with White women (n = 19,730), Black women (n = 3,201) underwent autologous reconstruction more frequently (40.7% vs 28.3%), had more perioperative comorbidities (eg diabetes: 12.9% vs 5.8%), higher CDCC scores (% CDCC ≥ 4: 5.5% vs 2.7%), and longer LOS (median 3 vs 2 days, all p < 0.001). Being Black (vs white: +0.13 adjusted days, 95% CI 0.06 to 0.19) was also associated with longer LOS and an increased likelihood of surgical complications (vs White: odds ratio 1.24, 95% CI 1.09 to 1.42, both p < 0.01), but this association did not persist when outcomes were limited to microsurgical complications. CONCLUSION: Disparities in postmastectomy breast reconstruction between Black and White women extend beyond access to care and include perioperative factors and outcomes. These findings suggest an important opportunity to mitigate inequities in reconstruction through perioperative health optimization and improved access to and co-management with primary care.

PURPOSE: Time to surgery (TTS) is a potentially modifiable factor associated with survival after breast cancer diagnosis and can serve as a proxy for quality of oncologic care coordination. We sought to determine whether factors associated with delays in TTS vary between patients who receive neoadjuvant systemic therapy (NST) vs upfront surgery and whether the impact of these delays on overall survival (OS) varies with treatment sequence. METHODS: Women ≥18 years old with Stage I-III breast cancer were identified in the National Cancer Database (2004–2014). Multivariate linear regression stratified by treatment sequence (upfront-surgery vs NST [neoadjuvant chemotherapy {NAC}, neoadjuvant endocrine therapy {NAE}, or both {NACE}]) was used to identify factors associated with TTS. Cox proportional hazards models were used to estimate the effect of TTS on overall survival (OS). RESULTS: Of 693,469 patients, 14.8% (n=102,326) received NST (NAC n=85,143, NAE n=10,004, NACE n=7179). Non-White race/ethnicity, no or government-issued insurance, more extensive surgery (i.e., mastectomy and contralateral prophylactic mastectomy vs breast-conserving surgery), and post-mastectomy reconstruction were associated with significantly longer adjusted TTS for NAC and upfront-surgery recipients, but only upfront-surgery patients had progressively worse OS with increasing TTS (>180 vs ≤30 days: HR=1.31, all p

BACKGROUND: We examined whether the National Comprehensive Cancer Network distress thermometer (DT), a patient-reported outcome measure, could be used to identify levels and causes of distress associated with racial/ethnic disparities in time to care among patients with breast cancer. METHODS: We identified women aged ≥18 years with stage O-IV breast cancer who were diagnosed in a single health system between January 2014 and July 2016. The baseline visit was defined as the first postdiagnosis, pretreatment clinical evaluation. Zero-inflated negative binomial (ZINB) regression (modeling non-zero DT scores and DT scores = 0) and logistic regression (modeling DT score ≥ 4, threshold for social services referral) were used to examine associations between baseline score (0 = none to 10 = extreme) and types of stressors (emotional, familial, practical, physical, spiritual) after adjustment for race/ethnicity and other characteristics. Linear regression with log transformation was used to identify predictors of time to evaluation and time to treatment. RESULTS: A total of 1029 women were included (median baseline DT score = 4). Emotional, physical, and practical stressors were associated with distress in both the ZINB and logistic models (all P < .05). Black patients (n = 258) were more likely to report no distress than Whites (n = 675; ZINB zero model odds ratio, 2.72; 95% CI, 1.68-4.40; P < .001) despite reporting a similar number of stressors (P = .07). Higher DT scores were associated with shorter time to evaluation and time to treatment while being Black and having physical or practical stressors were associated with delays in both (all P < .05). CONCLUSIONS: Patient-reported stressors predicted delays in time to care, but patient-reported levels of distress did not, with Black patients having delayed time to care despite reporting low levels of distress. We describe anticipatory, culturally responsive strategies for using patient-reported outcomes to address observed disparities.

BACKGROUND: Elderly women with clinically node-positive (cN+) breast cancer (BC) often have comorbidities that limit life expectancy and complicate treatment. We sought to determine whether the number of lymph nodes (LNs) retrieved among older women with node-positive breast cancer was associated with overall survival (OS). METHODS: Using the National Cancer Database (2010–2015), women 70–90y with cN+ BC and ≥1 LN removed were categorized by treatment sequence: upfront surgery or neoadjuvant chemotherapy (NAC). Multivariable Cox proportional hazards models with restricted cubic splines characterized the functional association of LN retrieval with OS; threshold values of LN retrieval were estimated. Cox proportional hazards models were used to estimate the association of LN retrieval groups with OS. RESULTS: In the upfront surgery cohort, a non-linear association was identified between LNs retrieved and OS. In the NAC cohort, no association was identified. For the upfront surgery cohort, the optimal threshold value of LN retrieval was 21 LN (90% CI 18–23). Based on this estimate, LN retrieval groups were created: 23 LNs. After adjustment, retrieval of

Malignant phyllodes (MP) and primary breast sarcomas (PBS) are rare neoplasms with overlapping histopathologic features. We compared overall survival (OS) and estimated the association of surgery and therapies with OS.We utilized the National Cancer Database (2004-2016). Patients without surgery, unknown surgery, or margins, or Stage IV disease were excluded. Kaplan-Meier curves and Cox proportional hazards models were used to estimate unadjusted and adjusted OS, respectively.A total of 3209 (59.5%) MP, and 2185 (40.5%) PBS were identified. Despite a larger median tumor size in MP (46 vs. 40 mm PBS, p 0.001), lumpectomy rate was higher for MP (52.9% vs. 27.0% PBS, p 0.001). Compared to MP, PBS patients more frequently received radiation (28.9% vs. 24%), and chemotherapy (28.1% vs. 4%), both p 0.001. Unadjusted OS was lower for PBS (57% vs. 85% MP, log-rank p 0.001). PBS (vs. MP) had persistently worse survival (hazard ratio [HR]: 1.98, 95% confidence interval [CI]: 1.69-2.31) after adjustment. Receipt of adjuvant therapies was not associated with OS (either neoplasm); however, lumpectomy was associated with improved OS (vs. mastectomy) for both PBS (HR: 0.59, 95% CI: 0.50-0.75) and MP (HR: 0.65, 95% CI: 0.53-0.81). Positive margins had no association with OS for MP (HR: 1.09, 95% CI: 0.75-1.60), but was associated with worse survival for PBS (HR: 2.35, 95% CI: 1.82-3.02).We found significant survival differences between MP and PBS, with PBS having a consistently worse OS. Our findings support surgery as the mainstay of treatment for both tumor types and suggest that lumpectomy may be a reasonable option for select patients without compromising outcomes.

OBJECTIVE To determine the role of race and gender in the career experience of Black/AA academic surgeons and to quantify the prevalence of experience with racial and gender bias stratified by gender. SUMMARY OF BACKGROUND DATA Compared to their male counterparts, Black/African American women remain significantly underrepresented among senior surgical faculty and department leadership. The impact of racial and gender bias on the academic and professional trajectory of Black/AA women surgeons has not been well-studied. METHODS A cross-sectional survey regarding demographics, employment, and perceived barriers to career advancement was distributed via email to faculty surgeon members of the Society of Black American Surgeons (SBAS) in September 2019. RESULTS Of 181 faculty members, 53 responded (29%), including 31 women (58%) and 22 men (42%). Academic positions as a first job were common (men 95% vs women 77%, P = 0.06). Men were more likely to attain the rank of full professor (men 41% vs women 7%, P = 0.01). Reports of racial bias in the workplace were similar (women 84% vs men 86%, not significant); however, reports of gender bias (women 97% vs men 27%, P < 0.001) and perception of salary inequities (women 89% vs 63%, P = 0.02) were more common among women. CONCLUSIONS AND RELEVANCE Despite efforts to increase diversity, high rates of racial bias persist in the workplace. Black/AA women also report experiencing a high rate of gender bias and challenges in academic promotion.

OBJECTIVE: We aim to identify prognostic groups within a de novo metastatic cohort, incorporating both anatomic and biologic factors. BACKGROUND: Staging for breast cancer now includes anatomic and biologic factors, although the guidelines for stage IV disease do not account for how these factors may influence outcomes. METHODS: Adults with de novo metastatic breast cancer were selected from the National Cancer DataBase (2010–2013). Recursive partitioning analysis was used to group patients with similar overall survival (OS) based on clinical T/N stage, tumor grade, ER, PR, HER2, number of metastatic sites, and presence of bone-only metastases. Categories were created by amalgamating homogeneous groups based on 3-year OS rates (stage IVA: >50%, stage IVB: 30%–50%, stage IVC: 1) as the first stratification point, and ER status as the second stratification point for both resulting groups. Additional divisions were made based on HER2 status, PR status, cT stage, tumor grade, and presence of bone-only metastases. After bootstrapping, significant differences in 3-year OS were noted between the 3 groups [stage IVB vs IVA: HR 1.58 (95% confidence interval 1.50–1.67), stage IVC vs IVA: HR 3.54 (95% confidence interval 3.33–3.77)]. CONCLUSIONS: Both anatomic and biologic factors yielded reliable and reproducible prognostic estimates among patients with metastatic disease. These findings support formal stratification of de novo stage IV breast cancer into 3 distinct prognosis groups.

Objective To determine the representation of Black/AA women surgeons in academic medicine among U.S. medical school faculty and to assess the number of NIH grants awarded to Black/AA women surgeon-scientists over the past 2 decades. Summary of background data Despite increasing ethnic/racial and sex diversity in U.S. medical schools and residencies, Black/AA women have historically been underrepresented in academic surgery. Methods A retrospective review of the Association of American Medical Colleges 2017 Faculty Roster was performed and the number of grants awarded to surgeons from the NIH (1998-2017) was obtained. Data from the Association of American Medical Colleges included the total number of medical school surgery faculty, academic rank, tenure status, and department Chair roles. Descriptive statistics were performed. Results Of the 15,671 U.S. medical school surgical faculty, 123 (0.79%) were Black/AA women surgeons with only 11 (0.54%) being tenured faculty. When stratified by academic rank, 15 (12%) Black/AA women surgeons were instructors, 73 (59%) were assistant professors, 19 (15%) were associate professors, and 10 (8%) were full professors of surgery. Of the 372 U.S. department Chairs of surgery, none were Black/AA women. Of the 9139 NIH grants awarded to academic surgeons from 1998 and 2017, 31 (0.34%) grants were awarded to fewer than 12 Black/AA women surgeons. Conclusion A significant disparity in the number of Black/AA women in academic surgery exists with few attaining promotion to the rank of professor with tenure and none ascending to the role of department Chair of surgery. Identifying and removing structural barriers to promotion, NIH grant funding, and academic advancement of Black/AA women as leaders and surgeon-scientists is needed.

Background: Meta-analyses have demonstrated that young women ≤40 (YW) derive the most benefit from chemotherapy (EBCTCG, Lancet. 1998). Oncotype DX was designed to determine the benefit of chemotherapy in women with ER+/HER2-, node-negative (LN-) breast cancer based on recurrence score (RS). TAILORx reported clinically meaningful benefits in freedom-from-distant recurrence in women Methods: Using the National Cancer Data Base (NCDB), we identified individuals age 25) RS. Age categories were classified as ≤40, 41-50, and >50. Chi-square tests or Fisher’s exact tests were used to compare categorical variables. Logistic regression was used to estimate the association of RS score and age group with adjuvant chemotherapy use, after adjustment for known covariates. Kaplan-Meier curves were used to visualize unadjusted overall survival (OS), and Cox proportional hazards models were used to estimate adjusted OS. Results: 120,051 women were identified, of whom 4,781 were ≤40 years, 24,846 were 41-50, and 90,424 were >50. By age group, 20% of YW had a high RS compared to 12% of women age 41-50 and 15% of women >50 (p50 to receive chemotherapy (p Conclusions: High RS is more common in YW (≤40) than those age 41-50 or >50, and is associated with worse OS. YW with an int or low RS are more likely to receive chemotherapy despite unclear benefit. Chemotherapy was omitted in over half of YW with RS of 16-25, highlighting the uncertainty in clinical practice which will remain until further studies inform optimal systemic treatment specific to YW. 1. Sparano, J.A., et al., Clinical and Genomic Risk to Guide the Use of Adjuvant Therapy for Breast Cancer. New England Journal of Medicine, 2019. 380(25): p. 2395-2405. Citation Format: Sarah Sammons, Yi Ren, Jeremy Force, Oluwadamilola M. Fayanju, Laura H. Rosenberger, Jennifer K. Plichta, Gretchen Kimmick, Kelly Westbrook, Susan Dent, Carey Anders, Samantha M. Thomas, Terry Hyslop, E. S. Hwang, P. K. Marcom, Rachel A. Greenup. Characterization of oncotype DX recurrence score and chemotherapy utilization patterns in young women (≤40) with early stage ER+/HER-, lymph node negative breast cancer [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P3-08-10.

Pathologic complete response (pCR) after neoadjuvant chemotherapy (NACT) is associated with improved overall survival (OS) in patients with breast cancer, but it is unclear how post-NACT response influences radiation therapy administration in patients presenting with node-positive disease. We sought to determine whether nodal pCR is associated with likelihood of receiving nodal radiation and whether radiation therapy among patients experiencing nodal pCR is associated with improved OS.Clinical N1 (cN1) female breast cancer patients diagnosed during 2010 to 2015 who were ypN0 (ie, nodal pCR; n = 12,341) or ypN1 (ie, residual disease; n = 13,668) after NACT were identified in the National Cancer Database. Multivariate logistic regression was used to identify factors associated with receiving radiation therapy. Cox proportional hazards modeling was used to estimate the association between radiation therapy and adjusted OS.The study included 26,009 patients; 43.9% (n = 5423) of ypN0 and 55.3% (n = 7556) of ypN1 patients received nodal radiation. Rates of nodal radiation remained the same over time among ypN0 patients (trend test, P = .29) but increased among ypN1 patients from 49% in 2010 to 59% in 2015 (trend test, P.001). After adjusting for covariates, nodal pCR (vs no stage change) was associated with decreased likelihood of nodal radiation after mastectomy (∼20% decrease) and lumpectomy (∼30% decrease; both P.01). After mastectomy, nodal (vs no) radiation conferred no significant survival benefit in ypN0 patients, but it approached significance for ypN1 patients (hazard ratio [HR], 0.83; 95% confidence interval [CI], 0.69-0.99, P = .04; overall P = .11). After lumpectomy, nodal radiation was associated with improved adjusted OS for ypN0 (HR, 0.38; 95% CI, 0.22-0.66) and ypN1 patients (HR, 0.44; 95% CI, 0.30-0.66; both P.001), but this improvement was not significantly greater than that associated with breast-only radiation.ypN0 patients were less likely to receive nodal radiation than ypN1 patients were, suggesting that selective omission already occurs and, in the context of limited survival data, could potentially be appropriate for select patients.

BACKGROUND: Given presumed differences in disease severity between young (≤ 45 years) and elderly (≥ 75 years) women with breast cancer, we sought to compare tumor histopathology, stage at presentation, patterns of care, and survival at the extremes of age. METHODS: Adults with stages 0–IV breast cancer in the National Cancer Database (2004–2015) were categorized by age (18–45 years, 46–74 years, ≥ 75 years) and compared. Kaplan–Meier curves were used to visualize unadjusted overall survival (OS). A Cox proportional-hazards model was used to estimate the effect of age group, including adjustment for tumor subtype [hormone receptor [HR]+/HER2−, HER2+, triple-negative (TN)]. RESULTS: Of the 1,201,252 patients identified, 13% were ≤ 45 years and 17.5% were ≥ 75 years. Women ≤ 45 years were more likely to have higher pT/N stages and grade 3 disease compared to older patients; however, rates of de novo cM1 disease were comparable (3.7% vs 3.5%). HER2+ and TN tumors were more common in those ≤ 45 years (HER2+ : 18.6% vs 9.2%; TN: 14.9% vs 8.2%), while HR+/HER2− tumors were more likely in women ≥ 75 years (69.3% vs 51.3%) (all p < 0.001). Younger patients were more likely to undergo mastectomy vs lumpectomy (56% vs 34%), and receive chemotherapy (65.8% vs 10.2%) and radiation (56.2% vs 39.5%). After adjustment, OS was worse in older patients (older HR 2.94, CI 2.86–3.03). CONCLUSIONS: High-risk tumor subtypes and comprehensive multimodal treatment remain significantly more common among younger women (≤ 45 years) with breast cancer, yet, elderly women are similarly diagnosed with incurable de novo metastatic disease. Tailored screening and treatment strategies are critical to prevent age-related disparities in breast cancer care.

INTRODUCTION. The opioid epidemic in the United States is a public health crisis. Breast surgeons are obligated to provide good pain control for their patients after surgery but also must minimize administration of narcotics to prevent a surgical episode of care from becoming a patient’s gateway into opioid dependence. METHODS. A survey to ascertain pain management practice patterns after breast surgery was performed. A review of currently available literature that was specific to breast surgery was performed to create recommendations regarding pain management strategies. RESULTS. A total of 609 surgeons completed the survey and demonstrated significant variations in pain management practices, specifically within regards to utilization of regional anesthesia (e.g., nerve blocks), and quantity of prescribed narcotics. There is excellent data to guide the use of local and regional anesthesia. There are, however, fewer studies to guide narcotic recommendations; thus, these recommendations were guided by prevailing practice patterns. CONCLUSIONS. Pain management practices after breast surgery have significant variation and represent an opportunity to improve patient safety and quality of care. Multimodality approaches in conjunction with standardized quantities of narcotics are recommended.

PURPOSE: Inflammatory breast cancer (IBC) is an aggressive variant for which axillary lymph node dissection following neoadjuvant chemotherapy (NACT) remains standard of care. But with increasingly effective systemic therapy, it is unclear whether more limited axillary surgery may be appropriate in some IBC patients. We sought to examine whether extent of axillary lymph node (LN) surgery was associated with overall survival (OS) for IBC. METHODS: Female breast cancer patients with non-metastatic IBC (cT4d) diagnosed 2010–2014 were identified in the National Cancer Data Base. Cox proportional hazards modeling was used to estimate the association between extent of axillary surgery (≤9 vs ≥10 LNs removed) and OS after adjusting for covariates, including post-NACT nodal status (ypN0 vs ypN1–3) and radiotherapy receipt (yes/no). RESULTS: 3,471 patients were included: 597 (17.2%) had cN0 disease, 1,833 (52.8%) had cN1 disease, and 1,041 (30%) had cN2–3 disease. 49.9% of cN0 patients were confirmed to be ypN0 on post-NACT surgical pathology. Being ypN0 (vs ypN1–3) was associated with improved adjusted OS for all patients. Radiotherapy was associated with improved adjusted OS for cN1 and cN2–3 patients but not for cN0 patients. Regardless of ypN status, there was a trend towards improved adjusted OS with having ≥10 (vs ≤9) LNs removed for cN2–3 patients (HR 0.78, 95% CI 0.60–1.01, p=0.06) but not for cN0 patients (p=0.83). CONCLUSIONS: A majority of IBC patients in our study presented with node-positive disease, and for those presenting with cN2–3 disease, more extensive axillary surgery is potentially associated with improved survival. For cN0 patients, however, more extensive axillary surgery was not associated with a survival benefit, suggesting an opportunity for more personalized care.

Members of the Translational Breast Cancer Research Consortium conducted an expert-driven literature review to identify a list of domains and to evaluate potential measures of these domains for inclusion in a list of preferred measures. Measures were included if they were easily available, free of charge, and had acceptable psychometrics based on published peer-reviewed analyses. A total of 22 domains and 52 measures were identified during the selection process. Taken together, these measures form a reliable and validated list of measurement tools that are easily available and used in multiple cancer trials to assess patient-reported outcomes in relevant patients.

Background We aim to determine clinical and pathological stage discordance rates and to evaluate factors associated with discordance. Methods Adults with clinical stages I-III breast cancer were identified from the National Cancer Data Base. Concordance was defined as cTN = pTN (discordance: cTN≠pTN). Multivariate logistic regression was used to identify factors associated with discordance. Results Comparing clinical and pathological stage, 23.1% were downstaged and 8.7% were upstaged. After adjustment, factors associated with downstaging (vs concordance) included grade 3 (OR 10.56, vs grade 1) and HER2-negative (OR 3.79). Factors associated with upstaging (vs concordance) were grade 3 (OR 10.56, vs grade 1), HER2-negative (OR 1.25), and lobular histology (OR 2.47, vs ductal). ER-negative status was associated with stage concordance (vs downstaged or upstaged, OR 0.52 and 0.87). Conclusions Among breast cancer patients, nearly one-third exhibit clinical-pathological stage discordance. This high likelihood of discordance is important to consider for counseling and treatment planning.

This cohort study uses existing data on race, ethnicity, and sex among US surgical faculty members and medical students to identify changes between 2011 and 2020.

Asian women with breast cancer are often studied in aggregate, belying significant intragroup diversity. The authors sought to examine differences in breast cancer characteristics and outcomes among Asian women.Asian, non-Hispanic Black, Hispanic, and non-Hispanic White women aged 18 years and older who were diagnosed with breast cancer from 1990 to 2016 were identified in the Surveillance, Epidemiology, and End Results 18 database. Asian patients were subclassified as Chinese, Japanese, Korean, Filipino, Vietnamese, South Asian (Asian Indian or Pakistani), Southeast Asian (SEA, i.e., Cambodian, Laotian, Hmong, or Thai), or other Asian. Unadjusted overall survival (OS) and cancer-specific survival (CSS) were estimated using the Kaplan-Meier method. Cox proportional hazards models were used to estimate adjusted OS and CSS.In total, 910,415 women were included (Asian, n = 63,405; Black, n = 92,226; Hispanic, n = 84,451; White, n = 670,333). Asian women had higher rates of human epidermal growth factor receptor 2 (HER2)-positive disease compared with White women (18.7% vs 13.8%) and had the highest 10-year unadjusted OS and CSS among all racial/ethnic groups (all P.001). SEA women had the highest rates of stage IV disease at presentation, whereas Japanese women had the lowest rates (5.9% vs 2.7%; P.001). Japanese women had the highest 10-year unadjusted CSS (89.4%; 95% confidence interval, 88.7%-90.1%) of any distinct Asian group, whereas SEA women had the worst unadjusted CSS (78%; 95% confidence interval, 74.1%-81.3%; P.001). After adjustment, SEA women had the worst OS of any Asian group and were the only Asian group without improved OS compared with White women (reference category; P = .08).Breast cancer characteristics and outcomes vary significantly among Asian women. Future research should consider disaggregation by country or region of origin to identify subgroups that are at risk for worse outcomes than aggregated data may suggest.Asian women with breast cancer are frequently studied as a single entity. However, Asian ethnic groups differ greatly by country of origin, genetic ancestry, disease frequency, socioeconomic status, patterns of immigration, as well as dietary and cultural practices. Women of different Asian ethnicities vary significantly with regard to cancer characteristics, such as mortality and tumor subtype. Future research should disaggregate these populations to better understand, treat, and counsel Asian patients with breast cancer.

Although evidence suggests worse breast cancer-specific survival associated with treatment delay beyond 90 days, little is known regarding the sociodemographic predictors of delays in cancer-directed surgery among young women with breast cancer. This is particularly notable, given that 5-10% of new diagnoses occur in younger women aged40 years, commonly with more aggressive features than in older women.We used the National Cancer Database (2004-2017) to assess sociodemographic disparities in delay of upfront surgery beyond 90 days among young women with non-metastatic breast cancer, using multivariable logistic regression and predictive marginal modeling.Black women experienced treatment delays more frequently than white women (aOR: 1.93 [95% CI: 1.76-2.11], p 0.001). Adjusted rates of treatment delay were 4.91% [95% CI: 4.51%-5.30%] and 2.60% [95% CI: 2.47%-2.74%] for Black and white women, respectively, and 2.97% [95% CI: 2.83%-3.12%], 2.36% [95% CI: 2.03%-2.68%], and 1.18% [95% CI: 0.54%-1.81%] for women from metro, urban, and rural areas, respectively.These results suggest that improving access to timely treatment may be leveraged as a means through which to lessen the breast cancer disparities experienced by Black women.