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Importance There is currently no guidance on how to approach surveillance mammography for older breast cancer survivors, particularly when life expectancy is limited. Objective To develop expert consensus guidelines that facilitate tailored decision-making for routine surveillance mammography for breast cancer survivors 75 years or older. Evidence After a literature review of the risk of ipsilateral and contralateral breast cancer events among breast cancer survivors and the harms and benefits associated with mammography, a multidisciplinary expert panel was convened to develop consensus guidelines on surveillance mammography for breast cancer survivors 75 years or older. Using an iterative consensus-based approach, input from clinician focus groups, and critical review by the International Society for Geriatric Oncology, the guidelines were refined and finalized. Findings The literature review established a low risk for ipsilateral and contralateral breast cancer events in most older breast cancer survivors and summarized the benefits and harms associated with mammography. Draft mammography guidelines were iteratively evaluated by the expert panel and clinician focus groups, emphasizing a patient’s risk for in-breast cancer events, age, life expectancy, and personal preferences. The final consensus guidelines recommend discontinuation of routine mammography for all breast cancer survivors when life expectancy is less than 5 years, including those with a history of high-risk cancers; consideration to discontinue mammography when life expectancy is 5 to 10 years; and continuation of mammography when life expectancy is more than 10 years. Individualized, shared decision-making is encouraged to optimally tailor recommendations after weighing the benefits and harms associated with surveillance mammography and patient preferences. The panel also recommends ongoing clinical breast examinations and diagnostic mammography to evaluate clinical findings and symptoms, with reassurance for patients that these practices will continue. Conclusions and Relevance It is anticipated that these expert guidelines will enhance clinical practice by providing a framework for individualized discussions, facilitating shared decision-making regarding surveillance mammography for breast cancer survivors 75 years or older.

The 2014 publication of the Society of Surgical Oncology-American Society for Radiation Oncology (SSO-ASTRO) Consensus Guideline on Margins for Breast-Conserving Surgery recommended a negative margin definition of no ink on tumor. Adoption of this guideline would represent a major change in surgical practice that could lower the rates of reoperation.To assess changes in reoperation rates after publication of the SSO-ASTRO guideline.A systematic search of Embase, PREMEDLINE, Evidence-Based Medicine Reviews, Scopus, and Web of Science for biomedical literature published from January 2014 to July 2019 was performed. This search was supplemented by web searches and manual searching of conference abstracts.Included studies compared the reoperation rates in preguideline vs postguideline cohorts (actual change), retrospectively applied the SSO-ASTRO guideline to a preguideline cohort (projected change), or described the economic outcomes of the guideline.Study characteristics and reoperation rates were extracted independently by 2 reviewers. Odds ratios (ORs) were pooled by random effects meta-analysis. Analyses were stratified by study setting (institutional or population) and preguideline accepted margins. The economic outcomes of the guideline were summarized narratively. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline was followed.Odds ratios for postguideline vs preguideline reoperation rates.From 1114 citations, 30 studies (with 599 016 participants) reported changes in reoperation rates. Studies included a median (range) of 487 (100-521 578) participants, and 20 studies were undertaken in the US, 6 in the UK, 3 in Canada, and 1 in Australia. Among 21 studies of actual changes, pooled ORs showed a statistically significant reduction in reoperation, with an OR lower in institution-based studies than in population-based studies (OR, 0.62 [95% CI, 0.52-0.74] vs 0.76 [95% CI, 0.72-0.80]; P = .04 for subgroup differences). Among 9 studies of projected changes, the pooled OR was lower for preguideline margin thresholds of 2 mm or more compared with 1 mm (OR, 0.47 [95% CI, 0.40-0.56] vs 0.85 [95% CI, 0.79-0.91; P .001 for subgroup differences). Projected changes were likely to overestimate actual changes. Six studies that estimated the postguideline economic outcome found the guideline to be potentially cost saving, with a median (range) saving of US $3540 ($1800-$25 650) per woman avoiding reoperation.This study found a decrease in reoperation rates after the publication of the SSO-ASTRO guideline; this reduction was greater at an institutional level than a population level, the latter reflecting the differences in guideline adoption between centers. These early outcomes may be conservative estimates of longer-term implications.

Importance The American College of Surgeons Oncology Group (ACOSOG) Z0011 study demonstrated the safety of sentinel node biopsy alone in clinically node-negative women with metastases in 1 or 2 sentinel nodes treated with breast conservation. Little is known about surgeon perspectives regarding when axillary lymph node dissection (ALND) can be omitted. Objectives To determine surgeon acceptance of ACOSOG Z0011 findings, identify characteristics associated with acceptance of ACOSOG Z0011 results, and examine the association between acceptance of the Society of Surgical Oncology and American Society for Radiation Oncology negative margin of no ink on tumor and surgeon preference for ALND. Design, Setting, and Participants A survey was sent to 488 surgeons treating a population-based sample of women with early-stage breast cancer (N = 5080). The study was conducted from July 1, 2013, to August 31, 2015. Main Outcomes and Measures Surgeons were categorized as having low, intermediate, or high propensity for ALND according to the outer quartiles of ALND scale distribution. A multivariable linear regression model was used to confirm independent associations. Results Of the 488 surgeons invited to participate, 376 (77.0%) responded and 359 provided complete information regarding propensity for ALND derived from 5 clinical scenarios. Mean surgeon age was 53.7 (range, 31-80) years; 277 (73.7%) were male; 142 (37.8%) treated 20 or fewer breast cancers annually and 108 (28.7%) treated more than 50. One hundred seventy-five (49.0%) recommended ALND for 1 macrometastasis. Of low-propensity surgeons who recommended ALND, only 1 (1.1%) approved ALND for any nodal metastases compared with 69 (38.6%) and 85 (95.5%) of selective and high-propensity surgeons ( P 51: −0.48; 95% CI, −0.71 to −0.24; P P 9%: −0.37; 95% CI, −0.63 to −0.11; P = .02), and Los Angeles Surveillance, Epidemiology, and End Results site (−0.18; 95% CI, −0.35 to −0.01; P = .04). Conclusions and Relevance This study shows substantial variation in surgeon acceptance of more limited surgery for breast cancer, which is associated with higher breast cancer volume and multidisciplinary interactions, suggesting the potential for overtreatment of many patients and the need for education targeting lower-volume breast surgeons.

Importance The results of the American College of Surgeons Oncology Group Z0011 (ACOSOG Z0011) trial were first reported in 2005 with a median follow-up of 6.3 years. Longer follow-up was necessary because the majority of the patients had estrogen receptor–positive tumors that may recur later in the disease course (the ACOSOG is now part of the Alliance for Clinical Trials in Oncology). Objective To determine whether the 10-year overall survival of patients with sentinel lymph node metastases treated with breast-conserving therapy and sentinel lymph node dissection (SLND) alone without axillary lymph node dissection (ALND) is noninferior to that of women treated with axillary dissection. Design, Setting, and Participants The ACOSOG Z0011 phase 3 randomized clinical trial enrolled patients from May 1999 to December 2004 at 115 sites (both academic and community medical centers). The last date of follow-up was September 29, 2015, in the ACOSOG Z0011 (Alliance) trial. Eligible patients were women with clinical T1 or T2 invasive breast cancer, no palpable axillary adenopathy, and 1 or 2 sentinel lymph nodes containing metastases. Interventions All patients had planned lumpectomy, planned tangential whole-breast irradiation, and adjuvant systemic therapy. Third-field radiation was prohibited. Main Outcomes and Measures The primary outcome was overall survival with a noninferiority hazard ratio (HR) margin of 1.3. The secondary outcome was disease-free survival. Results Among 891 women who were randomized (median age, 55 years), 856 (96%) completed the trial (446 in the SLND alone group and 445 in the ALND group). At a median follow-up of 9.3 years (interquartile range, 6.93-10.34 years), the 10-year overall survival was 86.3% in the SLND alone group and 83.6% in the ALND group (HR, 0.85 [1-sided 95% CI, 0-1.16]; noninferiorityP = .02). The 10-year disease-free survival was 80.2% in the SLND alone group and 78.2% in the ALND group (HR, 0.85 [95% CI, 0.62-1.17];P = .32). Between year 5 and year 10, 1 regional recurrence was seen in the SLND alone group vs none in the ALND group. Ten-year regional recurrence did not differ significantly between the 2 groups. Conclusions and Relevance Among women with T1 or T2 invasive primary breast cancer, no palpable axillary adenopathy, and 1 or 2 sentinel lymph nodes containing metastases, 10-year overall survival for patients treated with sentinel lymph node dissection alone was noninferior to overall survival for those treated with axillary lymph node dissection. These findings do not support routine use of axillary lymph node dissection in this patient population based on 10-year outcomes. Trial Registration clinicaltrials.gov Identifier:NCT00003855

This cohort study identifies patients with breast cancer and a pathologic complete response to neoadjuvant chemotherapy with a low risk for axillary metastases and possibly eligible for omission of surgery.

Importance Guidelines assert that contralateral prophylactic mastectomy (CPM) should be discouraged in patients without an elevated risk for a second primary breast cancer. However, little is known about the impact of surgeons discouraging CPM on patient care satisfaction or decisions to seek treatment from another clinician. Objective To examine the association between patient report of first-surgeon recommendation against CPM and the extent of discussion about it with 3 outcomes: patient satisfaction with surgery decisions, receipt of a second opinion, and receipt of surgery by a second surgeon. Design, Setting, and Participants This population-based survey study was conducted in Georgia and California. We identified 3880 women with stages 0 to II breast cancer treated in 2013-2014 through the Surveillance, Epidemiology, and End Results registries of Georgia and Los Angeles County. Surveys were sent approximately 2 months after surgery (71% response rate, n = 2578). In this analysis conducted from February to May 2016, we included patients with unilateral breast cancer who considered CPM (n = 1140). Patients were selected between July 2013 and September 2014. Main Outcomes and Measures We examined report of surgeon recommendations, level of discussion about CPM, satisfaction with surgical decision making, receipt of second surgical opinion, and surgery from a second surgeon. Results The mean (SD) age of patients included in this study was 56 (10.6) years. About one-quarter of patients (26.7%; n = 304) reported that their first surgeon recommended against CPM and 30.1% (n = 343) reported no substantial discussion about CPM. Dissatisfaction with surgery decision was uncommon (7.6%; n = 130), controlling for clinical and demographic characteristics. One-fifth of patients (20.6%; n = 304) had a second opinion about surgical options and 9.8% (n = 158) had surgery performed by a second surgeon. Dissatisfaction was very low (3.9%; n = 42) among patients who reported that their surgeon did not recommend against CPM but discussed it. Dissatisfaction was substantively higher for those whose surgeon recommended against CPM with no substantive discussion (14.5%; n = 37). Women who received a recommendation against CPM were not more likely to seek a second opinion (17.1% among patients with recommendation against CPM vs 15.1% of others; P = .52) nor to receive surgery by a second surgeon (7.9% among patients with recommendation against CPM vs 8.3% of others; P = .88). Conclusions and Relevance Most patients are satisfied with surgical decision making. First-surgeon recommendation against CPM does not appear to substantively increase patient dissatisfaction, use of second opinions, or loss of the patient to a second surgeon.

Importance Contralateral prophylactic mastectomy (CPM) use is increasing among women with unilateral breast cancer, but little is known about treatment decision making or physician interactions in diverse patient populations. Objective To evaluate patient motivations, knowledge, and decisions, as well as the impact of surgeon recommendations, in a large, diverse sample of patients who underwent recent treatment for breast cancer. Design, Setting, and Participants A survey was sent to 3631 women with newly diagnosed, unilateral stage 0, I, or II breast cancer between July 2013 and September 2014. Women were identified through the population-based Surveillance Epidemiology and End Results registries of Los Angeles County and Georgia. Data on surgical decisions, motivations for those decisions, and knowledge were included in the analysis. Logistic and multinomial logistic regression of the data were conducted to identify factors associated with (1) CPM vs all other treatments combined, (2) CPM vs unilateral mastectomy (UM), and (3) CPM vs breast-conserving surgery (BCS). Associations between CPM receipt and surgeon recommendations were also evaluated. All statistical models and summary estimates were weighted to be representative of the target population. Main Outcomes and Measures Receipt of CPM was the primary dependent variable for analysis and was measured by a woman’s self-report of her treatment. Results Of the 3631 women selected to receive the survey, 2578 (71.0%) responded and 2402 of these respondents who did not have bilateral disease and for whom surgery type was known constituted the final analytic sample. The mean (SD) age was 61.8 (12) years at the time of the survey. Overall, 1301 (43.9%) patients considered CPM (601 [24.8%] considered it very strongly or strongly); only 395 (38.1%) of them knew that CPM does not improve survival for all women with breast cancer. Ultimately, 1466 women (61.6%) received BCS, 508 (21.2%) underwent UM, and 428 (17.3%) received CPM. On multivariable analysis, factors associated with CPM included younger age (per 5-year increase: odds ratio [OR], 0.71; 95% CI, 0.65-0.77), white race (black vs white: OR, 0.50; 95% CI, 0.34-0.74), higher educational level (OR, 1.69; 95% CI, 1.20-2.40), family history (OR, 1.63; 95% CI, 1.22-2.17), and private insurance (Medicaid vs private insurance: OR, 0.47; 95% CI, 0.28-0.79). Among 1569 patients (65.5%) without high genetic risk or an identified mutation, 598 (39.3%) reported a surgeon recommendation against CPM, of whom only 12 (1.9%) underwent CPM, but among the 746 (46.8%) of these women who received no recommendation for or against CPM from a surgeon, 148 (19.0%) underwent CPM. Conclusions and Relevance Many patients consider CPM, but knowledge about the procedure is low and discussions with surgeons appear to be incomplete. Contralateral prophylactic mastectomy use is substantial among patients without clinical indications but is low when patients report that their surgeon recommended against it. More effective physician-patient communication about CPM is needed to reduce potential overtreatment.

Importance Most women undergoing mastectomy for breast cancer do not undergo breast reconstruction. Objective To examine correlates of breast reconstruction after mastectomy and to determine if a significant unmet need for reconstruction exists. Design, Setting, and Participants We used Surveillance, Epidemiology, and End Results registries from Los Angeles, California, and Detroit, Michigan, for rapid case ascertainment to identify a sample of women aged 20 to 79 years diagnosed as having ductal carcinoma in situ or stages I to III invasive breast cancer. Black and Latina women were oversampled to ensure adequate representation of racial/ethnic minorities. Eligible participants were able to complete a survey in English or Spanish. Of 3252 women sent the initial survey a median of 9 months after diagnosis, 2290 completed it. Those who remained disease free were surveyed 4 years later to determine the frequency of immediate and delayed reconstruction and patient attitudes toward the procedure; 1536 completed the follow-up survey. The 485 who remained disease free at follow-up underwent analysis. Exposures Disease-free survival of breast cancer. Main Outcomes and Measures Breast reconstruction at any time after mastectomy and patient satisfaction with different aspects of the reconstruction decision-making process. Results Response rates in the initial and follow-up surveys were 73.1% and 67.7%, respectively (overall, 49.4%). Of 485 patients reporting mastectomy at the initial survey and remaining disease free, 24.8% underwent immediate and 16.8% underwent delayed reconstruction (total, 41.6%). Factors significantly associated with not undergoing reconstruction were black race (adjusted odds ratio [AOR], 2.16 [95% CI, 1.11-4.20]; P = .004), lower educational level (AOR, 4.49 [95% CI, 2.31-8.72]; P P P = .048), and chemotherapy (AOR, 1.82 [95% CI, 0.99-3.31]; P = .05). Only 13.3% of women were dissatisfied with the reconstruction decision-making process, but dissatisfaction was higher among nonwhite patients in the sample (AOR, 2.87 [95% CI, 1.27-6.51]; P = .03). The most common patient-reported reasons for not having reconstruction were the desire to avoid additional surgery (48.5%) and the belief that it was not important (33.8%), but 36.3% expressed fear of implants. Reasons for avoiding reconstruction and systems barriers to care varied by race; barriers were more common among nonwhite participants. Residual demand for reconstruction at 4 years was low, with only 30 of 263 who did not undergo reconstruction still considering the procedure. Conclusions and Relevance Reconstruction rates largely reflect patient demand; most patients are satisfied with the decision-making process about reconstruction. Specific approaches are needed to address lingering patient-level and system factors with a negative effect on reconstruction among minority women.

Importance The growing rate of contralateral prophylactic mastectomy (CPM) among women diagnosed as having breast cancer has raised concerns about potential for overtreatment. Yet, there are few large survey studies of factors that affect women’s decisions for this surgical treatment option. Objective To determine factors associated with the use of CPM in a population-based sample of patients with breast cancer. Design, Setting, and Participants A longitudinal survey of 2290 women newly diagnosed as having breast cancer who reported to the Detroit and Los Angeles Surveillance, Epidemiology, and End Results registries from June 1, 2005, to February 1, 2007, and again 4 years later (June 2009 to February 2010) merged with Surveillance, Epidemiology, and End Results registry data (n = 1536). Multinomial logistic regression was used to evaluate factors associated with type of surgery. Primary independent variables included clinical indications for CPM (genetic mutation and/or strong family history), diagnostic magnetic resonance imaging, and patient extent of worry about recurrence at the time of treatment decision making. Main Outcomes and Measures Type of surgery received from patient self-report, categorized as CPM, unilateral mastectomy, or breast conservation surgery. Results Of the 1447 women in the analytic sample, 18.9% strongly considered CPM and 7.6% received it. Of those who strongly considered CPM, 32.2% received CPM, while 45.8% received unilateral mastectomy and 22.8% received breast conservation surgery (BCS). The majority of patients (68.9%) who received CPM had no major genetic or familial risk factors for contralateral disease. Multivariate regression showed that receipt of CPM (vs either unilateral mastectomy or breast conservation surgery) was significantly associated with genetic testing (positive or negative) (vs UM, relative risk ratio [RRR]: 10.48; 95% CI, 3.61-3.48 and vs BCS, RRR: 19.10; 95% CI, 5.67-56.41; P P = .001), receipt of magnetic resonance imaging (vs UM RRR: 2.07; 95% CI, 1.21-3.52 and vs BCS, RRR: 2.14; 95% CI, 1.28-3.58; P = .001), higher education (vs UM, RRR: 5.04; 95% CI, 2.37-10.71 and vs BCS, RRR: 4.38; 95% CI, 2.07-9.29; P P = .001). Conclusions and Relevance Many women considered CPM and a substantial number received it, although few had a clinically significant risk of contralateral breast cancer. Receipt of magnetic resonance imaging at diagnosis contributed to receipt of CPM. Worry about recurrence appeared to drive decisions for CPM although the procedure has not been shown to reduce recurrence risk. More research is needed about the underlying factors driving the use of CPM.

Axillary lymph node dissection (ALND) reliably identifies lymph node metastases and results in a high rate of local cancer control, even in patients who initially present with node-postive disease. In patients initially presenting with node-negative breast cancer, ALND has been replaced by sentinel lymph node (SLN) biopsy. Sentinel lymph node biopsy involves injecting dye or tracer substances into the breast to selectively identify and remove the lymph nodes most likely to contain metastases. This is a much less morbid procedure than ALND.

There is concern that mastectomy is overused in the United States.To evaluate the association of patient-reported initial recommendations by surgeons and those given when a second opinion was sought with receipt of initial mastectomy; and to assess the use of mastectomy after attempted breast-conserving surgery (BCS).A survey of women aged 20 to 79 years with intraductal or stage I and II breast cancer diagnosed between June 2005 and February 2007 and reported to the National Cancer Institute's Surveillance, Epidemiology, and End Results registries for the metropolitan areas of Los Angeles, California, and Detroit, Michigan. Patients were identified using rapid case ascertainment, and Latinas and blacks were oversampled. Of 3133 patients sent surveys, 2290 responded (73.1%). A mailed survey was completed by 96.5% of respondents and 3.5% completed a telephone survey. The final sample included 1984 female patients (502 Latinas, 529 blacks, and 953 non-Hispanic white or other).The rate of initial mastectomy and the perceived reason for its use (surgeon recommendation, patient driven, medical contraindication) and the rate of mastectomy after attempted BCS.Of the 1984 patients, 1468 had BCS as an initial surgical therapy (75.4%) and 460 had initial mastectomy, including 13.4% following surgeon recommendation and 8.8% based on patient preference. Approximately 20% of patients (n = 378) sought a second opinion; this was more common for those patients advised by their initial surgeon to undergo mastectomy (33.4%) than for those advised to have BCS (15.6%) or for those not receiving a recommendation for one procedure over another (21.2%) (P.001). Discordance in treatment recommendations between surgeons occurred in 12.1% (n = 43) of second opinions and did not differ on the basis of patient race/ethnicity, education, or geographic site. Among the 1459 women for whom BCS was attempted, additional surgery was required in 37.9% of patients, including 358 with reexcision (26.0%) and 167 with mastectomy (11.9%). Mastectomy was most common in patients with stage II cancer (P.001).Breast-conserving surgery was recommended by surgeons and attempted in the majority of patients evaluated, with surgeon recommendation, patient decision, and failure of BCS all contributing to the mastectomy rate.

THE WOMEN’S HEALTH INITIATIVE (WHI) TRIAL OF EStrogen plus progestin hormone therapy represents a major landmark in medical research. The study demonstrates that alteration of a woman’s basic hormonal physiology over decades in the interest of long-term disease prevention is fraught with hazard. The WHI investigators terminated the trial after an assessment of the overall risk-benefit ratio of this combined hormone therapy regimen failed to demonstrate a benefit. A statistically significant 26% increase in breast cancer incidence contributed to the overall negative effect of estrogen plus progestin. In the past, women and their physicians had been reassured that although combined hormone therapy increases breast cancer risk, this increase is observed in cancers of a favorable type, is associated with long duration of use, and does not result in increased mortality. In this issue of THE JOURNAL, the study by Chlebowski and colleagues provides more detailed information on breast cancer outcomes with estrogen plus progestin. With a mean (SD) follow-up of 5.6 years (1.3) (compared with 5.2 years [1.3] in the initial article), 349 invasive and 84 in situ breast cancers were available for this analysis. A 24% increase in breast cancer risk was observed in the estrogen plus progestin group, but this increased risk was not evident until the third year of the study. This risk estimate is remarkably close to estimates derived from well-conducted observational research, such as the study by Li and colleagues, which is also reported in this issue. What is new here, apart from the strong confirmation that the association between combined hormone therapy and breast cancer is causal, and probably not due to unappreciated differences between combined hormone therapy users and nonusers? The expanded report from the WHI trial is significant because it strongly suggests that the breast cancers related to estrogen plus progestin use are not “good” ones, that they occur earlier than expected based on some previous studies, that there are no easily identified subgroups at higher risk, and that, to top it off, women using estrogen plus progestin experience a much higher rate of mammographic abnormalities leading to anxiety and further costly workups. The use of combined menopausal hormone therapy has been documented to decrease both the sensitivity and the specificity of mammography, because of an increase in radiographic breast density. Changes in breast density in response to combined therapy appear to occur during a relatively short interval. In the Postmenopausal Estrogen/ Progestin Interventions trial, the 16% to 26% of women taking estrogen plus progestin who experienced an increase in breast density did so within 12 months of initiating treatment. The finding by Chlebowski et al that significantly more women had an abnormal mammogram after 1 year is consistent with the results of case-control studies and is biologically plausible, given the well-documented effects of estrogen and progestin on the proliferation of normal breast epithelium. It is tempting to speculate that the findings of a delayed time to diagnosis as well as an increase in abnormal mammograms are because of an increase in breast density, but density was not measured in the WHI trial. The ability of combined hormone therapy to decrease mammographic sensitivity creates an almost unique situation in which an agent increases the risk of developing a disease while simultaneously delaying its detection. Thus, the incidence curves presented in the report by Chlebowski et al show a striking crossover. The incidence of breast cancer diagnosis is actually lower in the estrogen plus progestin group for the first 2 years, after which the slope of the incidence curve for estrogen plus progestin begins to increase, leading to a crossover in cumulative breast cancer occurrence at year 4 and continuing divergence in risk at the end of follow-up. Given these nonproportional hazards over time, the summary risk ratio of 1.24 from the proportional hazards model is probably conservative. The authors, having anticipated this problem, also provide a weighted analysis that down-weights the importance of the early years of follow-up. A simplified but conservative analysis based on an a priori analysis plan is justifiable, particularly in an initial study.

We conducted a prospective controlled clinical trial in an urban academic general medicine practice to test the effect of same-day mammography availability on adherence to physicians' screening mammography recommendations.Participants were a consecutive sample of 920 female patients aged 50 years or older who had received a physician's recommendation for screening mammography at an office visit and had no active breast symptoms, history of breast cancer, or a mammogram within the previous 12 months. Women were assigned to same-day screening mammography availability (intervention group) or usual screening mammography scheduling (control group).Three-, 6-, and 12-month rates of adherence to physicians' recommendations for screening mammography.Twenty-six percent of women in the intervention group obtained a same-day screening mammogram. At 3 months, 58% of the women in the intervention group underwent the recommended screening mammography compared with 43% of the women in the control group (P.001), increasing to 61% and 49% at 6 months (P.001), and 268 (66%) of 408 vs 287 (56%) of 512 at 12 months (P = .003). The difference between the intervention and control groups 3-month adherence rates was most marked among women aged 65 years or older (58% vs 34%; P.001), women who were not employed (54% vs 36%; P.001), and women with a history of having had either no mammograms (39% vs 20%; P = .02) or only 1 to 2 mammograms (57% vs 38%; P.001) within the last 5 years.Same-day mammography availability increased 3-, 6-, and 12-month screening mammography adherence rates in this urban academic general medicine practice. The effect was most marked among women aged 65 years or older, women who were not employed, and those who had had fewer than 3 mammograms in the last 5 years. The efficacy of this intervention in other settings still needs to be demonstrated.

Objective: To prospectively evaluate a program of additional mammographic views, interval follow-up, and stereotactic biopsy in the management of abnormalities detected on mammograms. Methods: From June 1988 to September 1991, 267 consecutive women who were referred for surgical consultation because of an abnormal mammographic finding were evaluated. Mammographic abnormalities were assessed as benign or as requiring interval follow-up, stereotactic biopsy, open surgical biopsy, or additional views. Women having additional mammographic views were reassigned to the preceding groups. The mean follow-up for women who did not have a biopsy was 37 months. Results: Only 129 (48%) of the women who were sent for surgical consultation underwent open biopsy, and 46 (36%) of the biopsy specimens revealed carcinoma. Forty-one (89%) of the cancers were ductal carcinoma in situ or stage I lesions. Of the 117 women who were assigned to follow-up, six (5%) subsequently required biopsy and two cancers were identified. Conclusion: Rigorous mammographic evaluation and the use of stereotactic biopsy for selected lesions can prevent breast biopsy for low-suspicion mammographic abnormalities while still allowing the detection of early-stage breast cancer. (Arch Surg. 1994;129:1091-1096)

• Thirty-one women with stage III breast cancer were prospectively treated with two cycles of cyclophosphamide (Cytoxan), doxorubicin hydrochloride (Adriamycin), fluorouracil, and tamoxifen citrate followed by a simple mastectomy with level I axillary dissection. Postoperatively, four additional cycles of the combination chemotherapy alternating with three cycles of 1500 rad (15 Gy) to the chest wall and lymphatics were given. Seventy-seven percent of patients had a greater than 50% reduction in tumor size after the initial chemotherapy. No tumor size progressed during therapy, and a single patient remained inoperable. Pathologic findings revealed nine patients with only microscopic residual tumor. Nuclear vacuolization was present in 42.8% of tumor cells after chemotherapy vs 14.2% of cells before chemotherapy. The mean follow-up for the groups is 24.3 months. To date, nine patients have had recurrence with only one isolated local recurrence. This therapy is effective in reducing primary tumor size and allows a limited mastectomy to be done with minimal morbidity. (Arch Surg1986;121:1291-1296)