Faculty Bibliography

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

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

Purpose. This study identifies women with breast cancer who utilized chemoprevention agents prior to diagnosis and describes their patterns of disease. Methods. Our database was queried retrospectively for patients with breast cancer who reported prior use of chemoprevention. Patients were divided into primary (no history of breast cancer) and secondary (previous history of breast cancer) groups and compared to patients who never took chemoprevention. Results. 135 (6%) of 2430 women used chemoprevention. In the primary chemoprevention group (n = 18, 1%), 39% had completed >5 years of treatment, and fully 50% were on treatment at time of diagnosis. These patients were overwhelmingly diagnosed with ER/PR positive cancers (88%/65%) and were diagnosed with equal percentages (44%) of IDC and DCIS. 117 (87%) used secondary chemoprevention. Patients in this group were diagnosed with earlier stage disease and had lower rates of ER/PR-positivity (73%/65%) than the nonchemoprevention group (84%/72%). In the secondary group, 24% were on chemoprevention at time of diagnosis; 73% had completed >5 years of treatment. Conclusions. The majority of patients who used primary chemoprevention had not completed treatment prior to diagnosis, suggesting that the timing of initiation and compliance to prevention strategies are important in defining the pattern of disease in these patients.

Objective: The standard technique for localization of nonpalpable breast lesions is wire localization (WL), which has been found to have several procedural and workflow-related pitfalls. Radioactive seed localization (RSL) and intraoperative ultrasound (IOUS) have been shown to result in lower margin positivity, fewer reexcisions, increased patient satisfaction, and better patient care coordination, but they too have challenges that have adversely impacted their adoption. The SAVI SCOUT surgical guidance system is a new FDA-cleared medical device that utilizes nonradioactive, electromagnetic wave and infrared light technology to provide real-time guidance during excisional breast procedures. The purpose of this study is to evaluate the performance of SCOUT in guiding the removal of nonpalpable breast lesions across multiple sites and physicians. Methods: Institutional Review Board approval was granted for all institutions to enroll women with a nonpalpable breast lesion requiring preoperative localization for excision. Participating patients underwent localization and excision with SCOUT, which consists of an infrared-activated electromagnetic wave reflective device (reflector), handpiece, and console. Using mammographic or ultrasound guidance, the reflector was implanted into the target tissue up to 7 days prior to the scheduled excisional procedure. Before making an incision, the surgeon used the handpiece, which emits infrared light and electromagnetic waves, to detect the location of the reflector and subsequently plan the surgical incision. During the procedure, the surgeon used the handpiece to guide the localization and removal of the reflector along with the surrounding breast tissue. The console provides audible feedback on handpiece-to-reflector proximity. Primary endpoints included successful reflector placement, localization, and retrieval. Results: To date, 128 pts have participated in the study, along with 17 surgeons and 23 radiologists from 11 institutions. The reflectors were successfully placed in 127 (99%) pts under either radiographic (mammography or stereotactic) or ultrasound guidance, either on the day of surgery or up to 7 days (avg, 2.6 days) before surgery. Thirty-seven pts underwent excisional biopsy and 85 pts had a lumpectomy. The intended lesion and reflector were successfully removed in all pts. No adverse events occurred. For 83 pts with in situ and/or invasive cancer and complete data, 13 (15.7%) had positive margins and 12 (14.5%) were recommended for reexcision. Conclusion: The preliminary data show that real-time surgical guidance with SCOUT is an accurate technique for directing the removal of nonpalpable breast lesions and reproducible at multiple sites. The study has yielded 100% surgical success with a re-excision rate comparable to that of RSL and IOUS. Ongoing accrual to this study will validate these findings with planned enrollment of 150 pts from 11 sites

PURPOSE: To evaluate the relationship between mammographic breast density (MBD), background parenchymal enhancement (BPE), and fibroglandular tissue (FGT) in women with breast cancer (BC) and at high risk for developing BC. METHODS: Our institutional database was queried for patients who underwent mammography and MRI. RESULTS: Four hundred three (85%) had BC and 72 (15%) were at high risk. MBD (P=.0005), BPE (P<.0001), and FGT (P=.02) were all higher in high-risk women compared to the BC group. CONCLUSIONS: Higher levels of MBD, BPE and FGT are seen in women at higher risk for developing BC when compared to women with BC.