Faculty Bibliography

PURPOSE: The purpose was to evaluate the relationship between body mass index (BMI), mammographic breast density, magnetic resonance (MR) background parenchymal enhancement (BPE), and MR fibroglandular tissue (FGT) in women with breast cancer. METHODS: Our institutional database was queried for patients with preoperative mammography and breast MR imaging. RESULTS: There were 573 women eligible for analysis. Elevated BMI was associated with advanced stage of disease (P=.01), lower mammographic density (P<.0001), lower FGT (P<.0001), higher BPE (P=.005), and nonpalpable lesions (P=.04). CONCLUSIONS: Higher BMI was associated with decreased breast density and FGT. Higher BMI was also associated with advanced stage disease and nonpalpable tumors on clinical exam.

OBJECTIVES: This study was a multicenter evaluation of the SAVI SCOUT(R) breast localization and surgical guidance system using micro-impulse radar technology for the removal of nonpalpable breast lesions. The study was designed to validate the results of a recent 50-patient pilot study in a larger multi-institution trial. The primary endpoints were the rates of successful reflector placement, localization, and removal. METHODS: This multicenter, prospective trial enrolled patients scheduled to have excisional biopsy or breast-conserving surgery of a nonpalpable breast lesion. From March to November 2015, 154 patients were consented and evaluated by 20 radiologists and 16 surgeons at 11 participating centers. Patients had SCOUT(R) reflectors placed up to 7 days before surgery, and placement was confirmed by mammography or ultrasonography. Implanted reflectors were detected by the SCOUT(R) handpiece and console. Presence of the reflector in the excised surgical specimen was confirmed radiographically, and specimens were sent for routine pathology. RESULTS: SCOUT(R) reflectors were successfully placed in 153 of 154 patients. In one case, the reflector was placed at a distance from the target that required a wire to be placed. All 154 lesions and reflectors were successfully removed during surgery. For 101 patients with a preoperative diagnosis of cancer, 86 (85.1 %) had clear margins, and 17 (16.8 %) patients required margin reexcision. CONCLUSIONS: SCOUT(R) provides a reliable and effective alternative method for the localization and surgical excision of nonpalpable breast lesions using no wires or radioactive materials, with excellent patient, radiologist, and surgeon acceptance.

Background: There has been growing attention to the informational priorities of patients in a shared decision making model of care. Patients report adequate information provision as an unmet need throughout their cancer experience. This is especially of concern when faced with complex decision making based on an understanding of medical information in an unfamiliar learning environment. This project is designed to identify informational priorities of patients related to diagnosis and treatment decisions. Methods: Patients' perceived preparedness for surgery was measured to determine whether information needs were addressed and illustrate overall satisfaction with the surgical experience. A self-administered questionnaire was used to measure satisfaction with information related to diagnosis, treatment and recovery. Results: An active role in decision making that considers patients' information needs increases satisfaction with treatment choices, preparedness for surgery and outcomes. Methods of providing information are often limited to written and verbal with written generally non-specific and not tailored to patients' informational needs. Providers are also unable to control for access to other information sources such as the internet. Conclusions: A treatment plan developed through a shared decision making model should be evidence based including an assessment of the patient's informational priorities. A combination of written and verbal information may be optimal with the written building on the verbal and not introducing new information. Encouraging recording of meetings may be helpful when stress becomes a barrier to comprehending and retaining the information. The patient should also be provided with reliable websites to supplement this information. This results in greater patient satisfaction with the interaction and overall surgical experience

Introduction: Nipple-sparing mastectomy (NSM) is the latest advancement in the treatment of breast cancer. Long-term oncologic outcomes in nipple-sparing mastectomy (NSM) continue to be defined. Rates of locoregional recurrence for skin-sparing mastectomy (SSM) and NSM in the literature range from 0 to 14.3%. We investigated the outcomes of NSM at our institution. Methods: Patients undergoing NSM at our institution from 2006 to 2014 were identified. Patient demographics, tumor characteristics, and outcomes were collected. Locoregional recurrence was compared to previously published NSM and SSM results compiled from 14 and 11 studies in the literature. Institutional review board approval was obtained prior to the initiation of this study. Results: From 2006 to 2014, 319 patients (555 breasts) underwent NSM. 149 patients (248 breasts) had long-term follow-up available. Average patient age and BMI were 47.4 and 24.28. Eighty-five percent of patients underwent mastectomy primarily for a therapeutic indication. Average tumor size was 1.41 centimeters with the most common histologic type being invasive ductal carcinoma (66.7%) followed by DCIS (23.8%). Nodal disease was present in 14.8% of patients. Average patient follow-up was 30.72 months. There was one (0.7%) incidence of ipsilateral chest-wall recurrence in a 44 year-old (p<0.0001, compared to aggregate NSM and SSM data). There were 0.36 complications per patient. There were 3 incidences of nipple-areola complex (NAC) necrosis: 2 partial thickness necrosis and 1 full thickness necrosis. (Table Presented) Conclusions: We examined our institutional outcomes with NSM and found a locoregional recurrence rate of 0.7% with no nipple-areolar complex recurrence. This rate is significantly lower than aggregate published rates for both NSM and SSM

Background Well-established risk factors for breast cancer (BC) include family history, BRCA mutations and biopsies with atypical hyperplasia (AH) or lobular carcinoma in situ (LCIS). Several institutions have registries of these high-risk women but outcomes from these registries require large numbers and long follow-up. We sought to compare characteristics between high-risk populations and evaluate early outcomes. Methods Women enrolled in IRB-approved high risk registries at NYU Langone Medical Center (NYU) and University of Vermont (UVM) were evaluated for risk category, uptake of prevention and development of breast cancer. Descriptive statistics were used to summarize the data and Pearson's Chi-Square and Fisher's Exact Tests were performed to compare the variables of interest among the two high risk registries. Results Between 2003-14, 1035 women enrolled in these high risk registries. There were significant differences in age and risk characteristics but we found a 99% concordance of variables collected between both high risk registries. Among all risk groups there was a low uptake of prevention opportunities, with 8% taking chemoprevention and 7% undergoing risk-reducing surgeries. Women with AH/LCIS accounted for 66% of those choosing chemoprevention while women with BRCA mutations accounted for 76% of those undergoing risk-reducing surgeries. To date, 43 women (4%) have been diagnosed with breast cancer. 86% were diagnosed with stage 0-1 disease and 70% had moderate or poorly differentiated cancers. There was no significant difference in background risk characteristics when comparing those with breast cancer to those who have not yet developed breast cancer. (Table presented) Conclusions Despite the low uptake of chemoprevention and risk reducing surgery, only 4% of patients went on to develop breast cancer in the study period. The majority of cancers involved moderate or high-grade lesions and were early stage, suggesting a benefit to participation in surveillance programs. We have demonstrated a high degree of concordance between high risk registries, suggesting no barriers to multi-institutional collaboration. High risk registries represent an important resource for studies into methods to prevent breast cancer and improve outcomes from this disease

Introduction: Ductal carcinoma in situ (DCIS) and invasive breast cancer have long been viewed as representing two points on the spectrum of one disease. A recent study published by Narod et al. found that women diagnosed with DCIS who developed an invasive recurrence were 18.1 times more likely to die of breast cancer than women who did not. In light of this controversial topic, we investigated DCIS in a contemporary cohort of newly diagnosed women at our institution spanning a five year period. Methods: The institutional Breast Cancer Database was queried for all women with newly diagnosed breast cancer from 2010-2015. Variables included age, race, body mass index (BMI), risk factors, tumor characteristics and outcomes. Statistical analyses included Pearson's Chi Square and Fisher's Exact Tests. Results: Out of a total of 2190 patients, 475 (22%) had pure DCIS while 1715 (78%) had invasive cancer. The median follow up was 3 years. The median age was 59 years (range 22-95). Of the patients with invasive cancer, 36 (2%) had any recurrence. Similarly, of the patients with DCIS, 9 (2%) developed recurrent disease (ipsilateral or contralateral), with 4 patients diagnosed with invasive recurrence (44%). Of the 36 recurrences in patients with invasive cancer, 33% presented with chest wall or distant metastasis. Patients with pure DCIS had a slightly higher proportion of African Americans and Hispanics (11% v. 8%) and higher proportion of women with BMI>30 who developed an invasive recurrence (78% v. 50%). All recurrences in the pure DCIS cohort were detected by routine screening surveillance, with a majority detected by mammography (89%). Conclusions: Within a relatively short follow up period, we found that the rates of in-breast recurrences were the same in women with pure DCIS compared to women with invasive breast cancer. Also, 44% of women developed invasive breast cancer recurrence after an initial DCIS diagnosis, potentially altering their long term survival. These findings suggest that women with all breast cancers, including DCIS, requires intensive surveillance after initial treatment, as consequences of delayed diagnosis may impact on their long term survival

BACKGROUND: Despite current advances in cancer treatment, many breast cancer survivors still face long-term post-operative challenges as a result of suffering from daily pain and other distressing symptoms related to lymphedema, ie, abnormal accumulation of lymph fluid in the ipsilateral upper limb or body. Grounded in research-driven behavioral strategies, The-Optimal-Lymph-Flow is a unique Web- and mobile-based system focusing on self-care strategies to empower, rather than inhibit, how breast cancer survivors manage daily pain and symptoms. It features a set of safe, feasible, and easily-integrated-into-daily-routine exercises to promote lymph flow and drainage, as well as guidance to maintain an optimal body mass index (BMI). OBJECTIVE: To conduct a randomized clinical trial (RCT) to evaluate the efficacy of the Web- and mobile-based The-Optimal-Lymph-Flow system for managing chronic pain and symptoms related to lymphedema. The primary outcome includes pain reduction, and the secondary outcomes focus on symptom relief, limb volume difference by infra-red perometer, BMI, and quality of life (QOL) related to pain. We hypothesize that participants in the intervention group will have improved pain and symptom experiences, limb volume difference, body mass index, and QOL. METHODS: A parallel RCT with a control-experimental, pre- and post-test, repeated-measures design is used in this study. A total of 120 patients will be randomized according to the occurrence of pain. Participants will be recruited face-to-face at the point of care during clinical visits. Participants in the intervention group will receive the Web- and mobile-based The-Optimal-Lymph-Flow intervention and will have access to and learn about the program during the first in-person research visit. Participants in the control group will receive the Web- and mobile-based Arm Precaution program and will have access to and learn about the program during the first in-person research visit. Participants will be encouraged to enhance their learning by accessing the program and following the daily exercises during the study period. Participants will have monthly online self-report of pain and symptoms at 4 and 8 weeks post-intervention. During the two in-person research visits prior to and 12 weeks post-intervention, participants will be measured for limb volume difference, BMI, and complete self-report of pain, symptoms, self-care behaviors, and QOL. RESULTS: This trial is currently open for recruitment. The anticipated completion date for the study is July 2017. The primary endpoint for the study is absence or reduction of pain reported by the participants at week 12 post-intervention. CONCLUSIONS: The-Optimal-Lymph-Flow is a unique Web- and mobile-based self-care and patient-reported outcome system designed to effectively help women treated for breast cancer manage daily pain and symptoms related to lymphedema. Patients learn self-care strategies from a Web- and mobile-based program and track their symptoms. The RCT will directly benefit all women treated for breast cancer who suffer from or at risk for pain and symptoms related to lymph fluid accumulation. TRIAL REGISTRATION: Clinicaltrials.gov NCT02462226; https://clinicaltrials.gov/ct2/show/NCT02462226 (Archived by WebCite at http://www.webcitation.org/6du4IupG5).

INTRODUCTION: Long-term oncologic outcomes in nipple-sparing mastectomy (NSM) continue to be defined. Rates of locoregional recurrence for skin-sparing mastectomy (SSM) and NSM in the literature range from 0% to 14.3%. We investigated the outcomes of NSM at our institution. METHODS: Patients undergoing NSM at our institution from 2006 to 2014 were identified and outcomes were analyzed. RESULTS: From 2006 to 2014, 319 patients (555 breasts) underwent NSM. One-hundered and fourty-one patients (237 breasts) had long-term follow-up available. Average patient age and BMI were 47.78 and 24.63. Eighty-four percent of patients underwent mastectomy primarily for a therapeutic indication. Average tumor size was 1.50 cm with the most common histologic type being invasive ductal carcinoma (62.7%) followed by DCIS (23.7%). Average patient follow-up was 30.73 months. There was one (0.8%) incidence of ipsilateral chest-wall recurrence. There were 0.37 complications per patient. CONCLUSIONS: We examined our institutional outcomes with NSM and found a locoregional recurrence rate of 0.8% with no nipple-areolar complex recurrence. This rate is lower than published rates for both NSM and SSM. J. Surg. Oncol. (c) 2015 Wiley Periodicals, Inc.