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Background Guidelines for follow-up after locoregional breast cancer treatment recommend imaging for distant metastases only in the presence of patient signs and/or symptoms. However, guidelines have not been updated to reflect advances in imaging, systemic therapy, or the understanding of biological subtype. We assessed the association between mode of distant recurrence detection and survival. Methods In this observational study, a stage-stratified random sample of women with stage II-III breast cancer in 2006-2007 and followed through 2016 was selected, including up to 10 women from each of 1217 Commission on Cancer facilities (n = 10 076). The explanatory variable was mode of recurrence detection (asymptomatic imaging vs signs and/or symptoms). The outcome was time from initial cancer diagnosis to death. Registrars abstracted scan type, intent (cancer-related vs not, asymptomatic surveillance vs not), and recurrence. Data were merged with each patient’s National Cancer Database record. Results Surveillance imaging detected 23.3% (284 of 1220) of distant recurrences (76.7%, 936 of 1220 by signs and/or symptoms). Based on propensity-weighted multivariable Cox proportional hazards models, patients with asymptomatic imaging compared with sign and/or symptom detected recurrences had a lower risk of death if estrogen receptor (ER) and progesterone receptor (PR) negative, HER2 negative (triple negative; hazard ratio [HR] = 0.73, 95% confidence interval [CI] = 0.54 to 0.99), or HER2 positive (HR = 0.51, 95% CI = 0.33 to 0.80). No association was observed for ER- or PR-positive, HER2-negative (HR = 1.14, 95% CI = 0.91 to 1.44) cancers. Conclusions Recurrence detection by asymptomatic imaging compared with signs and/or symptoms was associated with lower risk of death for triple-negative and HER2-positive, but not ER- or PR-positive, HER2-negative cancers. A randomized trial is warranted to evaluate imaging surveillance for metastases results in these subgroups.

Background Inflammatory breast cancer (IBC) is a rare breast malignancy with poor outcomes compared with non-IBC. Age-related differences in tumor biology, treatment, and clinical outcomes have been described in non-IBC. This study evaluated age-related differences in IBC. Methods From an institutional prospective database, patients with an IBC diagnosed from 2010 to 2019 were identified. Age was categorized as 40 years or younger, 41 to 64 years, and 65 years or older. Demographics, clinicopathologic features, and treatment received were compared. Recurrence and survival outcomes were analyzed using the log-rank test and the Cox proportional hazards model. Results Of 523 IBC patients, 113 (21.6%) were age 40 years or younger, and 72 (13.8%) were age 65 years or older. The groups did not differ statistically by race/ethnicity, N stage, clinical stage, or tumor subtype. The younger patients included a higher proportion of Hispanic and Asian patients, triple-negative breast cancer (TNBC), and clinical N2/N3. Trimodality therapy was received by 92% of the stage 3 patients, with no difference in pathologic complete response (pCR) by age (23.3% vs 28.6%; p = 0.46). During a median follow-up period of 40 months, 17% of the patients experienced locoregional recurrence and 42.8% had distant metastasis. No difference in 3-year recurrence-free survival (57.9% vs 42.6% vs 54%; p = 0.42, log rank) or overall survival (OS) (75.6% vs 77.1% vs 64.4%; p = 0.31, log rank) by age was observed, and no difference in OS by age in de novo stage 4 disease was observed. In the multivariate analysis, worse OS was associated with TNBC (hazard ratio [HR], 1.99, 95% confidence interval [CI], 1.31-3.05) and no pCR (HR, 4.45; 95% CI, 2.16-9.18). Conclusion No significant differences were observed in demographics, treatment patterns, or clinical outcomes for IBC patients age 40 years or younger compared with those age 65 years or older treated by a specialized multidisciplinary team. These findings do not support age-related treatment de-escalation in IBC.

Nearly one-third of patients with inflammatory breast cancer (IBC) present with de novo stage IV disease. There are limited data on frequency and clinical outcomes of contralateral axillary metastasis (CAM) in IBC with no consensus diagnostic and treatment guidelines. Frequency of synchronous CAM was calculated in unilateral IBC patients at a single center (10/2004–6/2019). Clinicopathologic variables, diagnostic evaluation, treatment received, and overall survival (OS) were assessed and compared. Of 588 unilateral IBC patients, 49 (8.3%) had synchronous CAM. Of these, 32 (65.3%) also presented with metastatic disease at another distant site. CAM was not associated with age, tumor laterality, breast cancer subtype, grade, or cN stage (p > 0.05). The sensitivity/specificity to detect CAM was as follows: mammography (18.2%/99.2%), ultrasound (92.3%/95.5%), PET (90.1/99.1%), and MRI (76.0%/98.6%). Following systemic therapy, 22 patients had contralateral axillary surgery, and 18 received adjuvant contralateral nodal radiation. On multivariable analysis including tumor receptor subtypes, patients with stage IV-isolated CAM has statistically similar survival to stage III patients (HR 1.37, 95% CI 0.70–2.69, p = 0.36). Patients with Stage IV non-CAM (HR 2.18, 95% CI 1.66–2.85, p < 0.001) and stage IV-CAM plus other distant metastasis (HR 2.57, 95% CI 1.59–4.16, p < 0.001) had higher risk of death (reference: stage III disease). CAM in IBC was diagnosed in 8.3% of patients at presentation and was best identified by ultrasound and PET. We recommend routine contralateral axillary ultrasound as part of staging for all IBC patients. Diagnosis of CAM is a key first step toward much-needed prospective clinical trials evaluating management and outcomes of CAM in IBC.

Purpose: Surgeon and patient-related factors have been shown to influence patient experiences, quality of life (QoL), and surgical outcomes. We examined the association between surgeon-patient race- and gender-concordance with QoL after breast reconstruction. Methods: We conducted a retrospective cross-sectional analysis of patients who underwent lumpectomy or mastectomy followed by breast reconstruction over a 3-year period. We created the following categories with respect to the race and gender of a patient-surgeon triad: no-, intermediate-, and perfect-concordance. Multivariable regression was used to correlate post-operative global (SF-12) and condition-specific (BREAST-Q) QoL performance with patient-level covariates, gender- and race-concordance. Results: We identified 375 patients with a mean (±SD) age of 57.6±11.9 years, median (IQR) body mass index of 27.5 (24.0, 32.0), and median morbidity burden of 3 (2, 4). The majority of encounters were of intermediate concordance for gender (70%) and race (52%). Compared with gender discordant triads, intermediate gender concordance was associated with higher SF-Mental scores (b, 2.60; 95% CI, 0.21 to 4.99, p=0.003). Perfect race concordance (35% of encounters) was associated with significantly higher adjusted SF-Physical scores (b, 2.14; 95% CI, 0.50 to 4.22, p=0.045) than the race-discordant group. There were no significant associations observed between race- or gender-concordance and BREAST-Q performance. Conclusions: Race concordant relationships following breast cancer surgery were more likely to have improved global QoL. Perfect gender concordance was not associated with variation in QoL outcomes. Policy-level interventions are needed to facilitate personalized care and optimize breast cancer surgery outcomes.

Surgeon- and patient-related factors have been shown to influence patient experiences, quality of life (QoL), and surgical outcomes. We examined the association between patient-surgeon race and gender concordance with QoL after breast reconstruction.We conducted a retrospective cross-sectional analysis of patients who underwent lumpectomy or mastectomy followed by breast reconstruction over a 3-year period. We created the following categories with respect to the race and gender of a patient-surgeon triad: no, intermediate, and perfect concordance. Multivariable regression was used to correlate postoperative global (SF-12) and condition-specific (BREAST-Q) QoL performance with patient-level covariates, gender and race concordance.We identified 375 patients with a mean (± SD) age of 57.6 ± 11.9 years, median (IQR) body mass index of 27.5 (24.0, 32.0), and median morbidity burden of 3 (2, 4). The majority of encounters were of intermediate concordance for gender (70%) and race (52%). Compared with gender-discordant triads, intermediate gender concordance was associated with higher SF-Mental scores (β, 2.60; 95% CI, 0.21-4.99, p = 0.003). Perfect race concordance (35% of encounters) was associated with significantly higher adjusted SF-Physical scores (β, 2.14; 95% CI, 0.50-4.22, p = 0.045) than the race-discordant group. There were no significant associations observed between race or gender concordance and BREAST-Q performance.Race-concordant relationships following breast cancer surgery were more likely to have improved global QoL. Perfect gender concordance was not associated with variation in QoL outcomes. Policy-level interventions are needed to facilitate personalized care and optimize breast cancer surgery outcomes.

Breast cancer-related lymphedema (BCRL) is a debilitating sequela of breast cancer treatment and is becoming a greater concern in light of improved long-term survival. Inflammatory breast cancer (IBC) is a rare and aggressive malignancy for which systemic therapy, surgery, and radiotherapy remain the standard of care, thereby making IBC patients highly susceptible to developing BCRL. This study evaluated BCRL in IBC following trimodal therapy.IBC patients treated from 2016 to 2019 were identified from an institutional database. Patients were excluded if they presented with recurrent disease, underwent bilateral axillary surgery, did not complete trimodal therapy, or were lost to follow-up. Demographic, clinicopathologic factors, oncologic outcomes, and perometer measurements were recorded. BCRL was defined by clinician diagnosis and/or objective perometer measurements when available. Time to development of BCRL and treatment received were captured.Eighty-three patients were included. Median follow-up was 33 months. The incidence of BCRL was 50.6% (n = 42). Mean time to BCRL from surgery was 13 (range 2-24) months. Demographic and clinicopathologic features were similar between patients with and without BCRL with exception of higher proportion receiving delayed reconstruction in the BCRL group (38.1% vs. 14.6%, p = 0.03). Forty patients (95.2%) underwent BCRL treatment, which included physical therapy (n = 39), compression (n = 38), therapeutic lymphovenous bypass (n = 13), and/or vascularized lymph node transfer (n = 12).IBC patients are at high-risk for BCRL after treatment, impacting 51% of patients in this cohort. Strategies to reduce or prevent BCRL and improve real-time diagnosis should be implemented to better direct early management in this patient population.

The purpose of this review is to outline the surgical management of inflammatory breast cancer (IBC) including the clinical decision making, operative approach and current controversies.IBC is a rare and aggressive form of breast cancer. Trimodality therapy consisting of neoadjuvant therapy, modified radical mastectomy (MRM) and radiation therapy improves survival and is the recommended course of treatment. Advancements in systemic therapy and de-escalation strategies in non-IBC have accelerated discussions regarding several aspects of care in IBC including feasibility of de-escalation of surgical care, timing of reconstruction and the role of surgery in de novo stage IV disease. We discuss the evidence to support the surgical approach and decision-making in this rare disease.We reviewed existing literature using multiple electronic databases and clinical consensus guidelines to identify historical and current publications addressing current management recommendations and clinical controversies in IBC.Breast conserving surgery (BCS), skin- or nipple-sparing mastectomy should not be performed in IBC as surgical resection to negative margins results in improved locoregional recurrence rates. Level I and II axillary lymph node dissection should be performed regardless of response to therapy and initial nodal status. Reconstruction should be delayed and contralateral prophylactic mastectomy (CPM) is discouraged in IBC. Surgery may be considered for de novo stage IV IBC patients who demonstrate durable response to neoadjuvant therapy to improve local-regional control.

Inflammatory breast cancer (IBC) is a rare and aggressive breast cancer characterized by erythema and edema of at least one-third of the breast. The diagnosis remains a clinical one. Standard of care involves trimodality therapy with anthracycline-based neoadjuvant chemotherapy and human epidermal growth factor receptor 2 (HER2)-directed therapy if HER2 positive, followed by modified radical mastectomy and post-mastectomy radiation therapy to the chest wall in addition to regional nodal basins including supraclavicular and internal mammary nodes. Current evidence does not support de-escalation of surgical therapy in the breast and axilla in IBC, and positive surgical margins have been associated with worse outcomes. Furthermore, sentinel node biopsy for axillary staging has a high false negative rate prohibiting its use in IBC. Delayed reconstruction is recommended for IBC due to a high recurrence rate and a potential for delay in adjuvant therapy. Contralateral prophylactic mastectomy may be considered at the time of delayed reconstruction. In this paper, we discuss available evidence and controversies in the current surgical management of patients with IBC.

Nearly one-third of patients with inflammatory breast cancer (IBC) present with de novo stage IV disease. There are limited data on frequency and clinical outcomes of contralateral axillary metastasis (CAM) in IBC with no consensus diagnostic and treatment guidelines.Frequency of synchronous CAM was calculated in unilateral IBC patients at a single center (10/2004-6/2019). Clinicopathologic variables, diagnostic evaluation, treatment received, and overall survival (OS) were assessed and compared.Of 588 unilateral IBC patients, 49 (8.3%) had synchronous CAM. Of these, 32 (65.3%) also presented with metastatic disease at another distant site. CAM was not associated with age, tumor laterality, breast cancer subtype, grade, or cN stage (p0.05). The sensitivity/specificity to detect CAM was as follows: mammography (18.2%/99.2%), ultrasound (92.3%/95.5%), PET (90.1/99.1%), and MRI (76.0%/98.6%). Following systemic therapy, 22 patients had contralateral axillary surgery, and 18 received adjuvant contralateral nodal radiation. On multivariable analysis including tumor receptor subtypes, patients with stage IV-isolated CAM has statistically similar survival to stage III patients (HR 1.37, 95% CI 0.70-2.69, p = 0.36). Patients with Stage IV non-CAM (HR 2.18, 95% CI 1.66-2.85, p0.001) and stage IV-CAM plus other distant metastasis (HR 2.57, 95% CI 1.59-4.16, p0.001) had higher risk of death (reference: stage III disease).CAM in IBC was diagnosed in 8.3% of patients at presentation and was best identified by ultrasound and PET. We recommend routine contralateral axillary ultrasound as part of staging for all IBC patients. Diagnosis of CAM is a key first step toward much-needed prospective clinical trials evaluating management and outcomes of CAM in IBC.

Although not guideline recommended, studies suggest 50% of locoregional breast cancer patients undergo systemic imaging during follow-up, prompting its inclusion as a Choosing Wisely measure of potential overuse. Most studies rely on administrative data that cannot delineate scan intent (prompted by signs/symptoms vs. asymptomatic surveillance). This is a critical gap as intent is the only way to distinguish overuse from appropriate care. Our aim was to assess surveillance systemic imaging post-breast cancer treatment in a national sample accounting for scan intent. A stage-stratified random sample of 10 women with stage II–III breast cancer in 2006–2007 was selected from each of 1217 Commission on Cancer-accredited facilities, for a total of 10,838 patients. Registrars abstracted scan type (computed tomography [CT], non-breast magnetic resonance imaging, bone scan, positron emission tomography/CT) and intent (cancer-related vs. not, asymptomatic surveillance vs. not) from medical records for 5 years post-diagnosis. Data were merged with each patient’s corresponding National Cancer Database record, containing sociodemographic and tumor/treatment information. Of 10,838 women, 30% had one or more, and 12% had two or more, systemic surveillance scans during a 4-year follow-up period. Patients were more likely to receive surveillance imaging in the first follow-up year (lower proportions during subsequent years) and if they had estrogen receptor/progesterone receptor-negative tumors. Locoregional breast cancer patients undergo asymptomatic systemic imaging during follow-up despite guidelines recommending against it, but at lower rates than previously reported. Providers appear to use factors that confer increased recurrence risk to tailor decisions about systemic surveillance imaging, perhaps reflecting limitations of data on which current guidelines are based. ClinicalTrials.gov Identifier: NCT02171078.

Annual mammography is recommended after breast cancer treatment. However, studies suggest its under-utilization for Medicare patients. Utilization in the broader population is unknown, as is the role of breast magnetic resonance imaging (MRI). Understanding factors associated with imaging use is critical to improvement of adherence to recommendations. A random sample of 9835 eligible patients receiving surgery for stages 2 and 3 breast cancer from 2006 to 2007 was selected from the National Cancer Database for primary data collection. Imaging and recurrence data were abstracted from patients 90 days after surgery to 5 years after diagnosis. Factors associated with lack of imaging were assessed using multivariable repeated measures logistic regression with generalized estimating equations. Patients were censored for death, bilateral mastectomy, new cancer, and recurrence. Of 9835 patients, 9622, 8702, 8021, and 7457 patients were eligible for imaging at surveillance years 1 through 4 respectively. Annual receipt of breast imaging declined from year 1 (69.5%) to year 4 (61.0%), and breast MRI rates decreased from 12.5 to 5.8%. Lack of imaging was associated with age 80 years or older and age younger than 50 years, black race, public or no insurance versus private insurance, greater comorbidity, larger node-positive hormone receptor-negative tumor, excision alone or mastectomy, and no chemotherapy (p

Author(s): Choo, Esther K; Girgis, Christina; Han, Christina S; Simard, Julia F; Adesoye, Taiwo; Linos, Eleni; Mangurian, Christina; Physician Moms Group Study Group

The prognosis and management of neuroendocrine carcinoma are largely driven by histologic grade as assessed by mitotic activity. The authors reviewed their institutional experience to determine whether the histologic grade of neuroendocrine carcinoma can differ between primary and metastatic tumors.This study examined patients who underwent operative resection of both primary and metastatic foci of neuroendocrine carcinoma. Resected tumors were independently reviewed and categorized as low, intermediate, or high grade as determined by mitotic count.The authors identified 20 patients with metastatic neuroendocrine carcinoma treated at their institution between 1997 and 2013 for whom complete pathologic review of primary and metastatic tumors was possible. Primary lesions were found in the small intestine (n = 12), pancreas (n = 7), ampulla (n = 1), stomach (n = 1), and rectum (n = 1). The timing of hepatic metastasis was synchronous in 15 cases and metachronous in 5 cases. The histologic grade was concordant between primary and metastatic tumors in 9 cases and discordant in 11 cases. Among the discordant cases, 7 had a higher metastatic grade than primary grade, and 4 had a lower metastatic grade than primary grade. Metachronous presentation was associated with a higher likelihood of grade discordance (p = 0.03). The histologic grade of all metachronous metastases differed from that of the primary tumors.There is a high prevalence of histologic grade discordance between primary and metastatic foci of neuroendocrine carcinoma, particularly among patients with a metachronous metastatic presentation. Given the importance of histologic grade in disease prognostication and treatment planning, this finding may be informative for the management of patients with metastatic neuroendocrine carcinoma.

To compare geographic variation in healthcare spending and utilization between the Military Health System (MHS) and Medicare across hospital referral regions (HRRs).Retrospective analysis.Data on age-, sex-, and race-adjusted Medicare per capita expenditure and utilization measures by HRR were obtained from the Dartmouth Atlas for 2007 to 2010. Similarly, adjusted data from 2007 and 2010 were obtained from the MHS Data Repository and patients assigned to HRRs. We compared high- and low-spending regions, and computed coefficient of variation (CoV) and correlation coefficients for healthcare spending, hospital inpatient days, hip surgery, and back surgery between MHS and Medicare patients.We found significant variation in spending and utilization across HRRs in both the MHS and Medicare. CoV for spending was higher in the MHS compared with Medicare, (0.24 vs 0.15, respectively) and CoV for inpatient days was 0.36 in the MHS versus 0.19 in Medicare. The CoV for back surgery was also greater in the MHS compared with Medicare (0.47 vs 0.29, respectively). Per capita Medicare spending per HRR was significantly correlated to adjusted MHS spending (r = 0.3; P.0001). Correlation in inpatient days (r = 0.29; P.0001) and back surgery (r = 0.52; P.0001) was also significant. Higher spending markets in both systems were not comparable; lower spending markets were located mostly in the Midwest.In comparing 2 systems with similar pricing schemes, differences in spending likely reflect variation in utilization and the influence of local provider culture.

Author(s): Adesoye, Taiwo; Mangurian, Christina; Choo, Esther K; Girgis, Christina; Sabry-Elnaggar, Hala; Linos, Eleni; Physician Moms Group Study Group

We evaluated the reliability and predictive ability of an objective structured clinical examination (OSCE) in the assessment of medical students at the completion of a neurology clerkship.We analyzed data from 195 third-year medical students who took the OSCE. For each student, the OSCE consisted of 2 standardized patient encounters. The scores obtained from each encounter were compared. Faculty clinical evaluations of each student for 2 clinical inpatient rotations were also compared. Hierarchical regression analysis was applied to test the ability of the averaged OSCE scores to predict standardized written examination scores and composite clinical scores.Students' OSCE scores from the 2 standardized patient encounters were significantly correlated with each other (r = 0.347, p0.001), and the scores for all students were normally distributed. In contrast, students' faculty clinical evaluation scores from 2 different clinical inpatient rotations were uncorrelated, and scores were skewed toward the highest ratings. After accounting for clerkship order, better OSCE scores were predictive of better National Board of Medical Examiners standardized examination scores (R(2)Δ = 0.131, p0.001) and of better faculty clinical scores (R(2)Δ = 0.078, p0.001).Student assessment by an OSCE provides a reliable and predictive objective assessment of clinical performance in a neurology clerkship.

Although breast cancer follow-up guidelines emphasize the importance of clinical examinations, prior studies suggest a small fraction of local–regional events occurring after breast conservation are detected by examination alone. Our objective was to examine how local–regional events are detected in a contemporary, national cohort of high-risk breast cancer survivors. A stage-stratified sample of stage II/III breast cancer patients diagnosed in 2006–2007 (n = 11,099) were identified from 1217 facilities within the National Cancer Data Base. Additional data on local–regional and distant breast events, method of event detection, imaging received, and mortality were collected. We further limited the cohort to patients with breast conservation (n = 4854). Summary statistics describe local–regional event rates and detection method. Local–regional events were detected in 5.5 % (n = 265) of patients. Eighty-three percent were ipsilateral or contralateral in-breast events, and 17 % occurred within ipsilateral lymph nodes. Forty-eight percent of local–regional events were detected on asymptomatic breast imaging, 29 % by patients, and 10 % on clinical examination. Overall, 0.5 % of the 4854 patients had a local–regional event detected on examination. Examinations detected a higher proportion of lymph node events (8/45) compared with in-breast events (18/220). No factors were associated with method of event detection. Clinical examinations, as an adjunct to screening mammography, have a modest effect on local–regional event detection. This contradicts current belief that examinations are a critical adjunct to mammographic screening. These findings can help to streamline follow-up care, potentially improving follow-up efficiency and quality.

The 2013 Institute of Medicine report investigating cancer care concluded that the cancer care delivery system is in crisis due to an increased demand for care, increasing complexity of treatment, decreasing work force, and rising costs. Engaging patients and incorporating evidence-based care into routine clinical practice are essential components of a high-quality cancer delivery system. However, a gap currently exists between the identification of beneficial research findings and the application in clinical practice. Implementation research strives to address this gap. In this review, we discuss key components of high-quality implementation research. We then apply these concepts to a current cancer care delivery challenge in women’s health, specifically the implementation of a surgery decision aid for women newly diagnosed with breast cancer.

Video-assisted thoracoscopic surgery is increasingly accepted as an alternative to open thoracotomy and has established efficacy in the management of non-small-cell lung cancer, but the presence of extensive intrapleural adhesions has been considered a deterrent to a minimally invasive approach. We report the successful use of video-assisted thoracoscopic surgery in 3 patients with history of open thoracic aortic aneurysm repair who presented with left lower lobe stage I non-small-cell lung cancer. While this approach is feasible, it is technically demanding and thus, at the present time, we recommend that its use be limited to high-volume video-assisted thoracoscopic surgery centers.

Purpose of review This review examines recent literature on the psychosocial needs of and interventions for young women. We focus on the active treatment period given the toxicity of treatment, the incidence of anxiety, and depressive symptoms in these women during treatment. This review summarizes research relevant to addressing their social and emotional concerns. Recent findings Young women undergoing treatment for breast cancer remain understudied despite unique needs. Psychoeducational interventions help to relieve symptoms and emotional distress during treatment, but effects do not appear to persist over the longer term. In the clinical context, the performance of prognostic-risk prediction models in this population is poor. Surgical decision-making is often driven by fear of recurrence and body image rather than prognosis, and decision aids may help young women to synthesize information to preserve their role in the treatment process. Summary First, shared decision-making, second, balancing body image, fear of recurrence, and recommended treatment, and third, palliative care for metastasis are essential research priorities for the clinical setting. In the larger social context, unique family/partner dynamics as well as financial and insurance concerns warrant particular attention in this population.

6576Background: National Comprehensive Cancer Network (NCCN) guidelines recommend systemic imaging for local-regional recurrence after breast cancer treatment. Limited data exists to support this r...