Faculty Bibliography

Preoperative needle diagnosis (PND) is being considered as a quality measure in breast cancer surgery. This criterion has not been thoroughly evaluated in the literature. The purpose of this study is to assess ease of access to these data and rate of compliance in a tertiary care center. We retrospectively reviewed all our breast cancer cases between July 2006 and July 2007. The data were queried for preoperative needle diagnosis. Charts of patients who did not meet this criterion were reviewed to determine the cause for noncompliance. In the year 2006-2007, 396 breast cancer operations were performed (age range 19-96 years). Of 396 cases, 43 (11%) underwent a surgical procedure without diagnosis of cancer. In 19/396 (5%) cases PND was not feasible due to technical reasons. In 22/396 (5.5%) cases, preoperative needle biopsy did not render a malignant diagnosis: the pathology report was discordant with the radiological or clinical findings, or the needle biopsy result necessitated surgical resection. In only 2 of 396 cases (0.5%) was PND not attempted: an 80-year-old woman with a radiologically and clinically malignant mass, and a 43-year-old woman with a clinical and ultrasonographic suggestion of fibroadenoma. We conclude that data for preoperative needle diagnosis were easily accessible in our center. If this criterion is used as a quality measure in breast cancer surgery, 100% compliance may not be an achievable goal

Information is lacking regarding the interaction of established breast cancer risk factors and patient age. We attempted to study this interaction in high-risk women at the extremes of age in our population. The Women-At-Risk Registry was queried for women who were < or =35 and > or =70 years of age. Enrollment criteria included: strong family history of breast cancer (FHBC), and/or biopsy-proven history of atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), or lobular carcinoma in situ (LCIS). Descriptive analyses and Fisher's exact tests were used to analyze these factors and to assess their influence on breast cancer development. Our population included 1,412 high-risk women with median follow-up of 4 years. Of 195 women < or =35 years, 3 (1.5%) developed breast cancer. All three had strong FHBC and none had a prior high-risk lesion. Of 82 women > or =70 years, 6 (7.3%) developed breast cancer. Mean Gail score for women > or =70 years was 4.3, as compared with 4.7 in the subset of older women diagnosed with cancer. Fisher's tests demonstrated that ADH (p = 0.15), ALH (p = 1.0), LCIS (p = 1.0), and FHBC (p = 1.0) were not associated with breast cancer development in older women. We conclude that, for women < or =35 years, a significant FHBC may be a stronger predictor for breast cancer development than high-risk lesions. For women > or =70 years, FHBC and history of ADH, ALH, and LCIS were not predictors of breast cancer. This study emphasizes the importance of defining age-appropriate recommendations for breast cancer risk management, including surveillance and chemoprevention

BACKGROUND: Adjuvant radiotherapy following breast conservation surgery (BCS) is considered to be an indicator of quality of care for the majority of women with breast cancer, but many women do not receive adjuvant radiotherapy. We investigated the association of surgeon-related factors with receipt of adjuvant radiotherapy after BCS. METHODS: We used the linked Surveillance, Epidemiology and End Results (SEER)-Medicare database to identify women aged 65 years or older with stage I/II breast cancer who were diagnosed between 1991 and 2002 and underwent BCS. We collected demographic and clinical data from SEER and treatment information from Medicare claims data. The American Medical Association Masterfile was used to obtain information on surgeons' characteristics, including sex, medical school location (United States or elsewhere), and type of degree (MD or Doctorate in Osteopathic Medicine [DO]). The associations of patient (age, race, rural vs urban residence, comorbidities, marital status), tumor (hormone receptor status, grade, stage), and surgeon-related factors with receipt of adjuvant radiotherapy were analyzed using Generalized Estimating Equations to control for clustering. All statistical tests were two-sided. RESULTS: Of 29,760 women in our sample, 22,207 (75%) received radiotherapy. Patients who received adjuvant radiotherapy were younger, had fewer comorbidities, and were more likely to be white, married, from an urban area, and diagnosed in a later year compared with those who did not. They were also more likely to have a surgeon who was female (79% vs 73%), had an MD degree (75% vs 68%), or was US trained (75% vs 70%). The multivariable analysis confirmed the association of radiotherapy with having a surgeon who was female (odds ratio [OR] = 1.13; 95% confidence interval [CI] = 1.06 to 1.27), had an MD degree (OR = 1.55; 95% CI = 1.24 to 1.91), was US trained (OR = 1.12; 95% CI = 1.01 to 1.25), or had more than 15 patients (OR = 1.18; 95% CI = 1.10 to 1.28). CONCLUSIONS: Surgeon characteristics were associated with patients' receipt of adjuvant radiotherapy after BCS after controlling for patient and tumor characteristics, although the individual effect sizes were small for surgeon sex, location of training, and type of medical degree. More research is warranted to confirm the associations to determine whether they reflect surgeon behavior, patient response, or physician-patient interactions

BACKGROUND: Although black women develop invasive breast cancer at a lower incidence than white women, the cancers they develop tend to be of a higher grade and are more likely estrogen receptor negative. There is very little information with regard to black women and ductal carcinoma in situ (DCIS). In addition, although various reasons have been proposed for the delay to screening for black women, a delay after diagnosis has also been recognized. PURPOSE: The purpose of this study was to investigate disparities in time to treatment between black women and white women once DCIS has been diagnosed. METHODS: A retrospective analysis of 37 black women and 37 matched white women treated for DCIS was performed. Matches were made based on the date of birth, date of diagnosis, date and type of surgery, and age at diagnosis. The time from the date of diagnosis to the date of surgery was ascertained. RESULTS: Black women were 64% more likely to undergo a delay to surgery (>50 days) compared with white women (21% versus 13%, P < .05). CONCLUSION: Black women are more likely not to reach surgery within 50 days of diagnosis, which is concerning, and further studies to investigate the cause of these delays are warranted

BACKGROUND: Malignant phyllodes tumors are an extremely rare breast tumor. Prognostic features and overall survival data have not been consistent across studies. METHODS: Retrospectively, we examined the clinicopathologic features of 27 breast cancer patients treated for malignant phyllodes tumors from 1995 to 2004 and analyzed their recurrence and survival outcomes using contingency tables, a logistic regression model, or a proportional hazard model. RESULTS: The mortality rate was 12% (n = 3) of the cohort and 75% of the group with distant metastases. The median follow-up period was 51 months (range, 12-192 mo). A mitotic index greater than 10 per high-powered field, the presence of stromal overgrowth, mastectomy at initial surgery, and larger tumor size were associated with an increased incidence of distant metastases. Larger tumor size also was associated with an increased incidence of death. CONCLUSIONS: Most patients with malignant phyllodes tumors will enjoy significant long-term survival if treated appropriately with local excision with clear margins

BACKGROUND: The purpose of this study was to investigate the strongest predictors of breast cancer in a high-risk population and to increase our understanding of the possible interactions between risk factors. METHODS: The Women At Risk High-Risk Registry provided the study population. The variables of interest included age at enrollment, presence of lobular carcinoma in situ (LCIS), atypical ductal hyperplasia (ADH), atypical lobular hyperplasia, family history of breast cancer, body mass index, and Gail scores (5-year high-risk > or =1.7%). Univariate and multivariate analyses were conducted with the Cox proportional hazards regression model and years of follow-up evaluation as the time scale. RESULTS: Out of 1553 high-risk women, 79 (5%) developed breast cancer during a median follow-up period of 5 years. Results from the multivariate Cox model demonstrated that FHBC (hazard ratio [HR] = 1.76; 95% confidence interval [CI], 1.05-2.97), ADH (HR = 1.90; 95% CI, 1.16-3.13), LCIS (HR = 1.71; 95% CI, .99-2.95), and a body mass index > or =30 (HR = 2.22; 95% CI, 1.14-4.35) were statistically significant predictors of breast cancer within this high-risk population. CONCLUSIONS: These results support current literature showing the synergistic increase in risk for patients with ADH, LCIS, and a positive family history of breast cancer. Obesity was also a strong predictor of breast cancer risk, which suggests that there may be a potentiating effect of obesity on other risk factors. Obesity may represent a modifiable risk factor, providing women with an opportunity to reduce their risk with lifestyle modification. Women with a strong family history of breast cancer or a diagnosis of ADH or LCIS may benefit most from risk-reduction strategies, chemoprevention, and surveillance