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There is little data exploring the impact of screening mammography on subsequent treatment in the 40-49-year age group with breast cancer. We sought to assess the association between frequency of mammography in young women and extent of surgery and chemotherapy required.An IRB-approved retrospective review was performed of patients diagnosed with breast cancer between ages 40 and 49 years from 1 January 2010 to 19 November 2018 within a single health system. Patients were grouped based on last screening 1-24 months prior to diagnosis (1-24 group),25 months prior to diagnosis (25 group), never screened, and25+ never screened (combination group). Multivariate logistic regression models were used to assess for associations between screening intervals and tumor and nodal stage, chemotherapy use, and extent of surgery.Of 869 patients included for analysis, 20% were never screened, 60% screened 1-24 months, and 19% screened25 months prior to diagnosis. Compared with the 1-24 months group, the never-screened group,25 months group, and combined group were more likely to receive chemotherapy. The never-screened and combined groups were more likely to undergo mastectomy and/or axillary lymph node dissection. Of patients undergoing upfront surgery, the25 months and combined groups were more likely to receive adjuvant chemotherapy, while the never-screened and combined groups were more likely to have nodal disease.Our findings support the initiation of screening mammography at age 40 years to reduce the risk of aggressive treatments for newly diagnosed breast cancers in this group.

Anatomic extent of ductal carcinoma in situ (DCIS) may be uncertain in spite of clinical, pathologic, and imaging data. Consequently close/positive margins are common with lumpectomy for DCIS and often lead to a challenge in deciding whether to perform a re-excision or mastectomy.From a single health system, we identified cases of lumpectomy for DCIS with close/positive margins who underwent re-excision for the purpose of constructing a nomogram. In total, 289 patients were available for analysis. The patients were randomly divided into two sets allocating 70% to the modeling and 30% to the validation set. A multivariable logistic regression model was used to estimate the probability of overall positive margin status using multiple clinicopathologic predictors. Nomogram validation included internal tenfold cross-validation, internal bootstrap validation, and external validation for which a concordance index was calculated to assess the external validity.Significant predictors of persistent positive margins from regression modeling included necrosis at diagnosis (non-comedo or comedo); DCIS not associated with calcifications on core biopsy; high-grade DCIS; progesterone receptor positivity; and number of positive margins at initial surgery. When subjected to internal validation, the nomogram achieved an uncorrected concordance index of 0.7332, a tenfold cross-validation concordance index of 0.6795, and a bootstrap-corrected concordance index of 0.6881. External validation yielded an estimated concordance index of 0.7095.Using clinical and pathologic variables from initial diagnosis and surgery for DCIS, this nomogram predicts persistent positive margins with margin re-excision, and may be a valuable tool in surgical decision-making.

In recent years, actors from across the political spectrum concerned about the expansion of the US carceral state have pointed to the fiscal impacts of incarceration in a time of public austerity. A new regime of public policies pledging to be ‘smart on crime’ has taken root as a result. Advocates of such policies operate on the assumption that fiscal arguments will shift the trajectory of prison expansion because commitments to austerity will override the costly ‘tough on crime’ regime that has driven prison expansion in the USA over the last 40 years. This article reverses this assumption through a consideration of state-level policy in Oregon, a state that has formally embraced a commitment to fiscal restraint and ‘justice reinvestment’ as a strategy to limit prison growth. Our historical analysis reveals that since statehood, commitments to austerity and taxpayer protection have always framed criminal justice policy debates. Understood from this perspective, the story is not that prison reform advocates have discovered a new framework (‘smart on crime’) to restrain prison growth. It is that the longstanding discourse and politics of fiscal austerity has come to incorporate and absorb a portion of the anti-prison movement itself. That is fiscal arguments for prison reform are fully commensurate with the logic that drove mass incarceration in the first place. As a result, the state’s prison population has continued to expand even in the era of ‘smart on crime’ policymaking because commitments to fiscal austerity have not fundamentally challenged the policies and discourses that fueled the initial prison boom in the state. As most prisoners in the USA continue to be confined in state institutions, the analysis of state-level policy development in this article offers important insights into ongoing political debates over decarceration.

Across the USA, a number of states have been reducing the number of juveniles sent to state-run corrections institutions. Findings from a case study on juvenile justice in Texas indicate that the effort to reduce the number of juveniles sent to large state institutions and to invest in “community-based corrections” has entrenched rather than challenged the role of the justice system in the lives of thousands of juveniles. Texas has cut the number of juveniles sent to state-run facilities, but has bolstered and expanded county probation and county detention, which is where the vast majority of juveniles have always been handled. Youth who continue to be sent to state-run facilities or who are housed in county-run institutions experience a high level of violence and are routinely subjected to solitary confinement. The popularity of deinstitutionalizing juveniles from state-run corrections institutions and increasing programming and control of offenders at the local level are animating the landscape of criminal justice policy across the country. The Texas case suggests that this narrow approach further consolidates the extensive role of the justice system in U.S. society.

Purpose: To determine the antileukemic activity of weekly oral aminopterin in patients with refractory acute leukemia; to describe the pharmacodynamic properties of aminopterin; and to contrast the intracellular metabolism of aminopterin and methotrexate by patients' blasts in vitro. Experimental Design: Forty-six patients were enrolled in three strata: children with acute lymphoblastic leukemia (ALL), adults with ALL, and patients with acute myeloid leukemia (AML). Aminopterin was given weekly, in two doses of 2 mg/m2, 12 hours apart. Limited sampling pharmacokinetic analysis was done during the first week of therapy. Accumulation of [3H]aminopterin and [3H]methotrexate by leukemic blasts was studied in vitro. Results: Six of 22 children with ALL (27%; 95% confidence interval, 8-47%) had clinically significant responses. None of those with AML and only two of 11 adults with ALL had responses meeting protocol definitions, although peripheral blast counts tended to decrease with therapy in all groups. Mucosal toxicity was minimal, even with limited use of leucovorin rescue. Complete bioavailability of aminopterin was confirmed, with a mean area under the curve of 0.52 ± 0.03 μmol hour/L after oral dosing. No relationship between aminopterin pharmacokinetics and response was seen. In vitro, aminopterin showed more consistent metabolism by leukemic blasts to polyglutamates than methotrexate. Lineage-specific differences in the pattern of intracellular antifolylpolyglutamates were observed. Conclusions: Weekly oral aminopterin has significant activity among children with refractory ALL. With greater cellular accumulation and metabolism, more reliable bioavailability than methotrexate, and tolerable toxicity at this dose and schedule, aminopterin deserves further study as a potent alternative to methotrexate.