Publications by authors named "Julie Margenthaler"

188 Publications

Implementation and sustainability factors of two early-stage breast cancer conversation aids in diverse practices.

Implement Sci 2021 May 10;16(1):51. Epub 2021 May 10.

The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, NH, USA.

Background: Conversation aids can facilitate shared decision-making and improve patient-centered outcomes. However, few examples exist of sustained use of conversation aids in routine care due to numerous barriers at clinical and organizational levels. We explored factors that will promote the sustained use of two early-stage breast cancer conversation aids. We examined differences in opinions between the two conversation aids and across socioeconomic strata.

Methods: We nested this study within a randomized controlled trial that demonstrated the effectiveness of two early-stage breast cancer surgery conversation aids, one text-based and one picture-based. These conversation aids facilitated more shared decision-making and improved the decision process, among other outcomes, across four health systems with socioeconomically diverse patient populations. We conducted semi-structured interviews with a purposive sample of patient participants across conversation aid assignment and socioeconomic status (SES) and collected observations and field notes. We interviewed trial surgeons and other stakeholders. Two independent coders conducted framework analysis using the NOrmalization MeAsure Development through Normalization Process Theory. We also conducted an inductive analysis. We conducted additional sub-analyses based on conversation aid assignment and patient SES.

Results: We conducted 73 semi-structured interviews with 43 patients, 16 surgeons, and 14 stakeholders like nurses, cancer center directors, and electronic health record (EHR) experts. Patients and surgeons felt the conversation aids should be used in breast cancer care in the future and were open to various methods of giving and receiving the conversation aid (EHR, email, patient portal, before consultation). Patients of higher SES were more likely to note the conversation aids influenced their treatment discussion, while patients of lower SES noted more influence on their decision-making. Intervention surgeons reported using the conversation aids did not lengthen their typical consultation time. Most intervention surgeons felt using the conversation aids enhanced their usual care after using it a few times, and most patients felt it appeared part of their normal routine.

Conclusions: Key factors that will guide the future sustained implementation of the conversation aids include adapting to existing clinical workflows, flexibility of use, patient characteristics, and communication preferences.

Trial Registration: ClinicalTrials.gov Identifier: NCT03136367 , registered on May 2, 2017.
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http://dx.doi.org/10.1186/s13012-021-01115-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8108365PMC
May 2021

Radiation-Induced Brachial Plexopathy in Patients With Breast Cancer Treated With Comprehensive Adjuvant Radiation Therapy.

Adv Radiat Oncol 2021 Jan-Feb;6(1):100602. Epub 2020 Oct 27.

Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri.

Purpose: Our purpose was to describe the risk of radiation-induced brachial plexopathy (RIBP) in patients with breast cancer who received comprehensive adjuvant radiation therapy (RT).

Methods And Materials: Records for 498 patients who received comprehensive adjuvant RT (treatment of any residual breast tissue, the underlying chest wall, and regional nodes) between 2004 and 2012 were retrospectively reviewed. All patients were treated with conventional 3 to 5 field technique (CRT) until 2008, after which intensity modulated RT (IMRT) was introduced. RIBP events were determined by reviewing follow-up documentation from oncologic care providers. Patients with RIBP were matched (1:2) with a control group of patients who received CRT and a group of patients who received IMRT. Dosimetric analyses were performed in these patients to determine whether there were differences in ipsilateral brachial plexus dose distribution between RIBP and control groups.

Results: Median study follow-up was 88 months for the overall cohort and 92 months for the IMRT cohort. RIBP occurred in 4 CRT patients (1.6%) and 1 IMRT patient (0.4%) ( = .20). All patients with RIBP in the CRT cohort received a posterior axillary boost. Maximum dose to the brachial plexus in RIBP, CRT control, and IMRT control patients had median values of 56.0 Gy (range, 49.7-65.1), 54.8 Gy (47.4-60.5), and 54.8 Gy (54.2-57.3), respectively.

Conclusions: RIBP remains a rare complication of comprehensive adjuvant breast radiation and no clear dosimetric predictors for RIBP were identified in this study. The IMRT technique does not appear to adversely affect the development of this late toxicity.
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http://dx.doi.org/10.1016/j.adro.2020.10.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7897772PMC
October 2020

Surgical Predictive Model for Breast Cancer Patients Assessing Acute Postoperative Complications: The Breast Cancer Surgery Risk Calculator.

Ann Surg Oncol 2021 Feb 22. Epub 2021 Feb 22.

Clinical and Translational Science Graduate Program, Tufts University's Graduate School of Biomedical Sciences, Boston, MA, USA.

Background: Prognostic tools, such as risk calculators, improve the patient-physician informed decision-making process. These tools are limited for breast cancer patients when assessing surgical complication risk preoperatively.

Objective: In this study, we aimed to assess predictors associated with acute postoperative complications for breast cancer patients and then develop a predictive model that calculates a complication probability using patient risk factors.

Methods: We performed a retrospective cohort study using the National Surgical Quality Improvement Program (NSQIP) database from 2005 to 2017. Women diagnosed with ductal carcinoma in situ or invasive breast cancer who underwent either breast conservation or mastectomy procedures were included in this predictive modeling scheme. Four models were built using logistic regression methods to predict the following composite outcomes: overall, infectious, hematologic, and internal organ complications. Model performance, accuracy and calibration measures during internal/external validation included area under the curve, Brier score, and Hosmer-Lemeshow statistic, respectively.

Results: A total of 163,613 women met the inclusion criteria. The area under the curve for each model was as follows: overall, 0.70; infectious, 0.67; hematologic, 0.84; and internal organ, 0.74. Brier scores were all between 0.04 and 0.003. Model calibration using the Hosmer-Lemeshow statistic found all p-values to be > 0.05. Using model coefficients, individualized risk can be calculated on the web-based Breast Cancer Surgery Risk Calculator (BCSRc) platform ( www.breastcalc.org ).

Conclusion: We developed an internally and externally validated risk calculator that estimates a breast cancer patient's unique risk of acute complications following each surgical intervention. Preoperative use of the BCSRc can potentially help stratify patients with an increased complication risk and improve expectations during the decision-making process.
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http://dx.doi.org/10.1245/s10434-021-09710-8DOI Listing
February 2021

The Landmark Series: Breast Conservation Trials (including oncoplastic breast surgery).

Ann Surg Oncol 2021 Apr 31;28(4):2120-2127. Epub 2021 Jan 31.

Department of Surgery, Tufts Medical Center, Boston, MA, USA.

Significant progress has been made in the treatment and outcome of breast cancer. Some of the most dramatic strides have been in the surgical management of breast cancer. Breast-conserving therapy (BCT), including wide local excision of the tumor followed by irradiation, has become a standard treatment option for women with early-stage invasive breast cancer. Large cooperative group trials have contributed to the paradigm shift from mastectomy to BCT. This review reports the landmark BCT trials that provided the data for current surgical practices. The review also describes the body of literature contributing to the increasing use of oncoplastic techniques for patients undergoing BCT.
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http://dx.doi.org/10.1245/s10434-020-09534-yDOI Listing
April 2021

Randomized controlled trial of a breast cancer Survivor Stories intervention for African American women.

Soc Sci Med 2021 02 29;270:113663. Epub 2020 Dec 29.

Washington University School of Medicine, USA.

Rationale: Video-based interventions hold promise for improving quality of life (QoL) among African American breast cancer patients.

Objective: An interactive, cancer-communication intervention using African American breast cancer survivors' narratives was tested in a randomized controlled trial to determine whether viewing survivor stories improved newly diagnosed African American breast cancer patients' QoL.

Method: Participants were 228 African American women with non-metastatic breast cancer interviewed five times over two years; 120 controls received standard medical care, and 108 intervention-arm participants also received a tablet-computer with survivor stories three times in 12 months. Growth curve models were used to analyze differences between arms in change in eight RAND 36-Item Health Survey subscales, depressive symptoms, and concerns about recurrence. Additional models explored the effects of intervention usage and other intervention-related variables on QoL among patients in the intervention arm.

Results: Models showed no effect of study arm on QoL, depressive symptoms, or concerns about recurrence. Longer use of the intervention was associated with an increase in concerns about recurrence and decline in three QoL subscales: emotional wellbeing, energy/fatigue, and role limitations due to physical health.

Conclusion: Although no significant impact of the intervention on QoL was observed when comparing the two study arms, in the intervention arm longer intervention use was associated with declines in three QoL subscales and increased concerns about recurrence. Women with improving QoL may have interacted with the tablet less because they felt less in need of information; it is also possible that encouraging patients to compare themselves to survivors who had already recovered from breast cancer led some patients to report lower QoL. Future work is warranted to examine whether adding different stories to this cancer-communication intervention or using stories in conjunction with additional health promotion strategies (e.g., patient navigation) might improve QoL for African American breast cancer patients.
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http://dx.doi.org/10.1016/j.socscimed.2020.113663DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8173764PMC
February 2021

What matters most: Randomized controlled trial of breast cancer surgery conversation aids across socioeconomic strata.

Cancer 2021 Feb 10;127(3):422-436. Epub 2020 Nov 10.

Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, New Hampshire.

Background: Women of lower socioeconomic status (SES) with early-stage breast cancer are more likely to report poorer physician-patient communication, lower satisfaction with surgery, lower involvement in decision making, and higher decision regret compared to women of higher SES. The objective of this study was to understand how to support women across socioeconomic strata in making breast cancer surgery choices.

Methods: We conducted a 3-arm (Option Grid, Picture Option Grid, and usual care), multisite, randomized controlled superiority trial with surgeon-level randomization. The Option Grid (text only) and Picture Option Grid (pictures plus text) conversation aids were evidence-based summaries of available breast cancer surgery options on paper. Decision quality (primary outcome), treatment choice, treatment intention, shared decision making (SDM), anxiety, quality of life, decision regret, and coordination of care were measured from T0 (pre-consultation) to T5 (1-year after surgery.

Results: Sixteen surgeons saw 571 of 622 consented patients. Patients in the Picture Option Grid arm (n = 248) had higher knowledge (immediately after the visit [T2] and 1 week after surgery or within 2 weeks of the first postoperative visit [T3]), an improved decision process (T2 and T3), lower decision regret (T3), and more SDM (observed and self-reported) compared to usual care (n = 257). Patients in the Option Grid arm (n = 66) had higher decision process scores (T2 and T3), better coordination of care (12 weeks after surgery or within 2 weeks of the second postoperative visit [T4]), and more observed SDM (during the surgical visit [T1]) compared to usual care arm. Subgroup analyses suggested that the Picture Option Grid had more impact among women of lower SES and health literacy. Neither intervention affected concordance, treatment choice, or anxiety.

Conclusions: Paper-based conversation aids improved key outcomes over usual care. The Picture Option Grid had more impact among disadvantaged patients.

Lay Summary: The objective of this study was to understand how to help women with lower incomes or less formal education to make breast cancer surgery choices. Compared with usual care, a conversation aid with pictures and text led to higher knowledge. It improved the decision process and shared decision making (SDM) and lowered decision regret. A text-only conversation aid led to an improved decision process, more coordinated care, and higher SDM compared to usual care. The conversation aid with pictures was more helpful for women with lower income or less formal education. Conversation aids with pictures and text helped women make better breast cancer surgery choices.
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http://dx.doi.org/10.1002/cncr.33248DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7983934PMC
February 2021

Feasibility and Acceptability of an Interactive Cancer-Communication Video Program Using African American Breast Cancer Survivor Stories.

J Health Commun 2020 07 13;25(7):566-575. Epub 2020 Oct 13.

School of Medicine, Department of Medicine, Washington University in St. Louis , Saint Louis, Missouri, USA.

To examine the feasibility and acceptability of an interactive video program of African American breast cancer survivor stories, we explored story reactions among African American women with newly diagnosed breast cancer and associations between patient factors and intervention use. During a randomized controlled trial, patients in the intervention arm completed a baseline/pre-intervention interview, received the video intervention, and completed a post-intervention 1-month follow-up interview. Additional video exposures and post-exposure interviews occurred at 6- and 12-month follow-ups. Multivariable linear mixed-effects models examined interview and clinical data in association with changes in minutes and actions using the program. After Exposure1, 104 of 108 patients allocated to the intervention reported moderate-to-high levels of positive emotional reactions to stories and identification with storytellers. Exposure1 mean usage was high (139 minutes) but declined over time ( <.0001). Patients receiving surgery plus radiation logged about 50 more minutes and actions over 12-month follow-up than patients receiving surgery only ( <.05); patients reporting greater trust in storytellers logged 18.6 fewer actions over time ( =.04). Patients' topical interests evolved, with patients watching more follow-up care and survivorship videos at Exposure3. The intervention was feasible and evaluated favorably. New videos might satisfy patients' changing interests.
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http://dx.doi.org/10.1080/10810730.2020.1821132DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8043508PMC
July 2020

The Landmark Series: Mastectomy Trials (Skin-Sparing and Nipple-Sparing and Reconstruction Landmark Trials).

Ann Surg Oncol 2021 Jan 4;28(1):273-280. Epub 2020 Sep 4.

Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA.

Despite advances in medical therapy, the foundation of breast cancer treatment is surgery. The landscape of operative intervention for breast cancer has shifted toward less invasive techniques, resulting in improved cosmesis and lower morbidity while maintaining oncologic integrity. In this article, we review the body of literature contributing to landmark advances in mastectomy for the treatment of breast cancer.
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http://dx.doi.org/10.1245/s10434-020-09052-xDOI Listing
January 2021

Indications for readmission following mastectomy for breast cancer: An assessment of patient and operative factors.

Breast J 2020 10 26;26(10):1966-1972. Epub 2020 Aug 26.

Section of Endocrine and Oncologic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA.

We investigated the impact of patient and operative factors on 30-day hospital readmission following mastectomy for breast cancer. Using the 2011 HCUP California State Inpatient Database, we evaluated readmissions in adult women undergoing mastectomy for invasive, in situ, or history of breast cancer. Clinical data assessment was performed using ICD-9-CM codes and the Elixhauser comorbidity index. Chi-square tests and logistic regression were used to analyze patient and operative factors and associations with 30-day hospital readmission. Of 6214 women undergoing mastectomy, 306 (4.9%) were readmitted within 30 days postoperatively, most commonly for surgical site infection (130, 42.5%) and hematoma (29, 9.5%). 30-day readmission was associated with increasing index length of stay (LOS), comorbidities, and non-private insurance (P < .05). Age, mastectomy type (unilateral vs bilateral, with vs without lymph node assessment), immediate reconstruction, and port placement during the index procedure did not significantly influence the odds of 30-day readmission. Multivariable logistic regression showed increased odds of readmission with index LOS > 2 days (OR 1.81, P < .01), metastatic disease (OR 2.16, P = .01), and Medicare insurance (OR 1.72, P < .01). Index LOS > 2 days, metastatic disease, and Medicare insurance are significant predictors of 30-day readmission following mastectomy for breast cancer. Surgical site infection and wound complications were the most common diagnoses requiring readmission and resulted in over half of readmissions in our study population at 30 days.
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http://dx.doi.org/10.1111/tbj.14029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7722119PMC
October 2020

Surgical Oncologists and the COVID-19 Pandemic: Guiding Cancer Patients Effectively through Turbulence and Change.

Ann Surg Oncol 2020 Aug 14;27(8):2600-2613. Epub 2020 Jun 14.

Department of Surgery, Massachusetts General Hospital, Boston, MA, USA.

Background: The COVID-19 pandemic has posed extraordinary demands from patients, providers, and health care systems. Despite this, surgical oncologists must maintain focus on providing high-quality, empathetic care for the almost 2 million patients nationally who will be diagnosed with operable cancer this year. The focus of hospitals is transitioning from initial COVID-19 preparedness activities to a more sustained approach to cancer care.

Methods: Editorial Board members provided observations of the implications of the pandemic on providing care to surgical oncology patients.

Results: Strategies are presented that have allowed institutions to successfully prepare for cancer care during COVID-19, as well as other strategies that will help hospitals and surgical oncologists manage anticipated challenges in the near term. Perspectives are provided on: (1) maintaining a safe environment for surgical oncology care; (2) redirecting the multidisciplinary model to guide surgical decisions; (3) harnessing telemedicine to accommodate requisite physical distancing; (4) understanding interactions between SARS CoV-2 and cancer therapy; (5) considering the ethical impact of professional guidelines for surgery prioritization; and (6) advocating for our patients who require oncologic surgery in the midst of the COVID-19 pandemic.

Conclusions: Until an effective vaccine becomes available for widespread use, it is imperative that surgical oncologists remain focused on providing optimal care for our cancer patients while managing the demands that the COVID-19 pandemic will continue to impose on all of us.
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http://dx.doi.org/10.1245/s10434-020-08673-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7293588PMC
August 2020

A prospective cohort study to analyze the interaction of tumor-to-breast volume in breast conservation therapy versus mastectomy with reconstruction.

Breast Cancer Res Treat 2020 Jun 30;181(3):611-621. Epub 2020 Apr 30.

Division of Plastic & Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, 1020 N. Mason, Ste 110, St. Louis, MO, USA.

Purpose: We explored the impact of the relative volume of a tumor versus the entire breast on outcomes in patients undergoing breast conservation therapy (BCT) versus mastectomy and reconstruction (M + R). We hypothesized that there would be a threshold tumor:breast ratio (TBR) below which patient-reported outcomes (PRO) would favor BCT and above which would favor M + R.

Methods: We conducted a prospective cohort study of patients with ductal carcinoma in situ (DCIS) or invasive breast cancers undergoing BCT or M + R. A prerequisite for inclusion, analysis of tumor and breast volumes was conducted from three-dimensional magnetic resonance imaging reconstructions to calculate the TBR. Three-dimensional photography was utilized to calculate pre- and postoperative volumes and assess symmetry. Oncologic, surgical, and patient-reported outcome data were obtained from relevant BREAST-Q modules administered pre- and postoperatively.

Results: The BCT cohort had significantly smaller tumor volumes (p = 0.001) and lower TBRs (p = 0.001) than patients undergoing M + R overall. The M + R group, however, comprised a broader range of TBRs, characterized at lower values by patients opting for contralateral prophylactic mastectomy. Postoperative satisfaction with breasts, psychosocial, and sexual well-being scores were significantly higher in the BCT cohort, while physical well-being significantly favored the M + R cohort 480.2 ± 286.3 and 453.1 ± 392.7 days later, respectively.

Conclusions: Relative to BCT, M + R was used to manage a broad range of TBRs. The relative importance of oncologic and surgical risk reduction, symmetry, and number of procedures can vary considerably and may limit the utility of TBR as a guide for deciding between BCT and M + R. Clinical Trial StatementThis study was registered with clinicaltrials.gov as "A Prospective Trial to Assess Tumor:Breast Ratio and Patient Satisfaction Following Lumpectomy Versus Mastectomy With Reconstruction", Identifier: NCT02216136.
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http://dx.doi.org/10.1007/s10549-020-05639-wDOI Listing
June 2020

Repurposing Molecular Imaging and Sensing for Cancer Image-Guided Surgery.

J Nucl Med 2020 08 17;61(8):1113-1122. Epub 2020 Apr 17.

Department of Radiology, Washington University, St. Louis, Missouri

Gone are the days when medical imaging was used primarily to visualize anatomic structures. The emergence of molecular imaging (MI), championed by radiolabeled F-FDG PET, has expanded the information content derived from imaging to include pathophysiologic and molecular processes. Cancer imaging, in particular, has leveraged advances in MI agents and technology to improve the accuracy of tumor detection, interrogate tumor heterogeneity, monitor treatment response, focus surgical resection, and enable image-guided biopsy. Surgeons are actively latching on to the incredible opportunities provided by medical imaging for preoperative planning, intraoperative guidance, and postoperative monitoring. From label-free techniques to enabling cancer-selective imaging agents, image-guided surgery provides surgical oncologists and interventional radiologists both macroscopic and microscopic views of cancer in the operating room. This review highlights the current state of MI and sensing approaches available for surgical guidance. Salient features of nuclear, optical, and multimodal approaches will be discussed, including their strengths, limitations, and clinical applications. To address the increasing complexity and diversity of methods available today, this review provides a framework to identify a contrast mechanism, suitable modality, and device. Emerging low-cost, portable, and user-friendly imaging systems make the case for adopting some of these technologies as the global standard of care in surgical practice.
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http://dx.doi.org/10.2967/jnumed.118.220426DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7413229PMC
August 2020

Improving Lifestyle Behaviors After Breast Cancer Treatment Among African American Women With and Without Diabetes: Role of Health Care Professionals.

Ann Behav Med 2021 02;55(1):1-13

Department of Medicine, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA.

Background: Little is known about the effect of health professionals' advice on promoting healthy lifestyle behaviors (diet and exercise) among breast cancer patients.

Purpose: To identify predictors of receiving lifestyle advice from health professionals and its impact on healthy lifestyle behaviors.

Methods: We used data from a randomized controlled trial of an interactive, cancer-communication video program using African American breast cancer survivor stories for newly diagnosed African American breast cancer patients (Stages 0-III). Participants completed five interviews over 2 years. This intervention did not significantly affect changes in quality-of-life outcomes. In secondary analysis, we examined differences in baseline variables between women with and without diabetes. Logistic regression models identified independent predictors of receiving advice from "a doctor or other health professional" to improve diet and exercise and of self-reported change in diet and exercise habits at 2 year follow-up.

Results: Of 193 patients included (85% of 228 enrolled), 53 (28%) had diabetes. At 2 year follow-up, a greater proportion of women with (vs. without) diabetes reported receiving advice by a doctor/health professional to improve their diet (73% vs. 57%, p = .04,). Predictors of receiving dietary advice were obesity, diabetes, and breast-conserving surgery (each p < .05). Women receiving dietary advice were 2.75 times more likely to report improving their diet (95% confidence interval: 1.17, 6.46) at follow-up, but receiving physical activity advice was not significantly associated with patients reporting an increase in exercise.

Conclusions: Although receiving dietary advice predicted dietary improvements, receiving exercise advice did not lead to an increase in physical activity.

Clinical Trial Registration: Trial Number NCT00929084.
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http://dx.doi.org/10.1093/abm/kaaa020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7880224PMC
February 2021

Robotic Mastectomy-Program Malfunction?

JAMA Surg 2020 06;155(6):461-462

Department of Surgery, Washington University School of Medicine, St Louis, Missouri.

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http://dx.doi.org/10.1001/jamasurg.2019.6361DOI Listing
June 2020

Predictors of Distant Metastases in Triple-Negative Breast Cancer Without Pathologic Complete Response After Neoadjuvant Chemotherapy.

J Natl Compr Canc Netw 2020 03;18(3):288-296

Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri.

Background: Pathologic complete response (pCR) after neoadjuvant chemotherapy (NAC) for triple-negative breast cancer (TNBC) predicts decreased distant metastasis. However, most patients do not experience pCR, and other risk factors for distant metastasis after NAC are poorly characterized. This study investigated factors predictive of distant metastasis in TNBC without pCR after NAC.

Methods: Women with TNBC treated with NAC, surgery, and radiation therapy in 2000 through 2013 were reviewed. Freedom from distant metastasis (FFDM) was compared between patients with and without pCR using the Kaplan-Meier method. In patients without pCR, univariate and multivariable Cox analyses were used to determine factors predictive of distant metastasis.

Results: We identified 153 patients with median follow-up of 4.0 years (range, 0.5-14.0 years). After NAC, 108 had residual disease (pCR, 29%). Five-year FFDM was 98% and 55% in patients with and without pCR, respectively (P<.001). Factors independently predicting FFDM in patients without pCR were pathologic nodal positivity (hazard ratio, 3.08; 95% CI, 1.54-6.14; P=.001) and lymphovascular space invasion (hazard ratio, 1.91; 95% CI, 1.07-3.43; P=.030). Patients with a greater number of factors had worse FFDM; 5-year FFDM was 76.5% for patients with no factors (n=38) versus 54.9% and 27.5% for patients with 1 (n=44) and 2 factors (n=26), respectively (P<.001).

Conclusions: Lack of pCR after NAC resulted in worse overall survival and FFDM, despite trimodality therapy. In patients with residual disease after NAC, pathologic lymph node positivity and lymphovascular space invasion predicted worse FFDM.
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http://dx.doi.org/10.6004/jnccn.2019.7366DOI Listing
March 2020

Single-Institution Phase 1/2 Prospective Clinical Trial of Single-Fraction, High-Gradient Adjuvant Partial-Breast Irradiation for Hormone Sensitive Stage 0-I Breast Cancer.

Int J Radiat Oncol Biol Phys 2020 06 19;107(2):344-352. Epub 2020 Feb 19.

Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri. Electronic address:

Purpose: We sought to evaluate the feasibility and tolerability of a novel accelerated partial breast irradiation regimen delivered in a single fraction postoperatively.

Methods And Materials: We enrolled 50 patients with low-risk, hormone-sensitive breast cancer from 2015 to 2018 on a prospective phase 1/2 trial to receive single-fraction, high-gradient partial-breast irradiation (SFHGPBI) 2 to 8 weeks after lumpectomy for node-negative, invasive, or in situ breast cancer. The high gradient was achieved by prescribing 20 Gy to the surgical bed and 5 Gy to the breast tissue within 1 cm of the surgical bed simultaneously in 1 fraction using external beam.

Results: The median age was 65 (range, 52-84). Ten patients (20%) had small-volume ductal carcinoma in situ while the remainder had stage I disease. At a median follow-up of 25 months, we evaluated toxicity, patient- and physician-reported cosmesis, patient-reported quality of life (QOL), and initial tumor control. There was no Common Terminology Criteria for Adverse Events v4.0 grade 3+ toxicity. Only 34% of patients experienced grade 1 erythema. Good-to-excellent pretreatment cosmesis was present in 100% and 98% per physicians and patients, respectively, and did not change post-SFHGPBI. Quantitative cosmesis by percentage of breast retraction assessment significantly improved over time during the post-SFHGPBI period per mixed repeated measures modeling (P = .0026). QOL per European Organization for Research and Treatment of Cancer QOL Questionnaires C30 and BR-23 did not decline other than temporarily in the systemic therapy effects and hair loss domains, both of which returned to pretreatment values. There was 1 noninvasive in-breast recurrence in a separate untreated quadrant 18 months post-SFHGPBI and 1 isolated axillary recurrence 30 months post-SFHGPBI, both salvaged successfully. There were no distant recurrences or cancer-related deaths observed.

Conclusions: Accelerated partial-breast irradiation delivered in a single fraction postoperatively using external beam techniques is a novel, feasible, well-tolerated regimen. SFHGPBI does not adversely affect cosmesis or QOL as reported by both physicians and patients. Initial tumor control rates are excellent, with longer follow-up required to confirm efficacy.
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http://dx.doi.org/10.1016/j.ijrobp.2020.02.021DOI Listing
June 2020

A tale of two operations: re-excision as a quality measure.

Gland Surg 2019 Dec;8(6):593-595

Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA.

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http://dx.doi.org/10.21037/gs.2019.11.24DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6989898PMC
December 2019

Oncologic Safety and Outcomes in Patients Undergoing Nipple-Sparing Mastectomy.

J Am Coll Surg 2020 04 4;230(4):535-541. Epub 2020 Feb 4.

Department of Surgery, Washington University School of Medicine, St Louis, MO.

Background: Nipple-sparing mastectomy (NSM) is an alternative to skin-sparing mastectomy in appropriately selected patients. The aim of this study was to review our experience with NSM and to evaluate for oncologic safety.

Study Design: Patients who underwent NSM at our institution from September 2008 through August 2017 were identified after IRB approval. Data included patient age, tobacco use, tumor size, hormone receptor status, lymph node status, radiation and chemotherapy use, incision type, and reconstruction type. Statistical analyses were performed using ANOVA and chi-square tests.

Results: There were 322 patients who underwent 588 NSM (83% bilateral, 17% unilateral), including 399 (68%) for malignancy (Stage 0 [27%], I [44%], II [25%] and III [4%]). The overall rate of wound complication was 18.9%. Tobacco use increased complication (37.5% vs 16.3%, p < 0.001), as did adjuvant radiation therapy (31.4% vs 17.4%, p = 0.014). Patients with lymph node involvement and larger tumor size had a higher rate of complication (31.3% vs 17.2%, p = 0.016). Patients undergoing circumareolar incisions had a higher rate of complication than those undergoing lateral radial, inframammary fold, or curvilinear incisions (43.5% vs 17.4% vs 17.4% vs 14.3%, respectively, p = 0.018). Six (1%) local chest wall recurrences occurred during the follow-up period, none of which involved the nipple-areolar complex. Four patients (1%) suffered a distant recurrence.

Conclusions: Most NSM performed at our institution are in patients with malignancy. The oncologic safety is confirmed by the low locoregional recurrence rate. Tobacco use and adjuvant radiation therapy remain the most significant risk factors for complication, highlighting the need for careful patient selection and patient counseling regarding modifiable risk factors and expected outcomes.
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http://dx.doi.org/10.1016/j.jamcollsurg.2019.12.028DOI Listing
April 2020

The Landmark Series: Axillary Management in Breast Cancer.

Ann Surg Oncol 2020 Mar 20;27(3):724-729. Epub 2019 Dec 20.

Department of Surgery, St. Louis University, St. Louis, MO, USA.

The evolution in axillary management for patients with breast cancer has resulted in multiple dramatic changes over the past several decades. The end result has been an overall deescalation of surgery in the axilla. Landmark trials that have formed the basis for the current treatment guidelines are reviewed herein.
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http://dx.doi.org/10.1245/s10434-019-08154-5DOI Listing
March 2020

Lipofilling after breast conserving surgery: a comprehensive literature review investigating its oncologic safety.

Gland Surg 2019 Oct;8(5):569-580

Division of Plastic Surgery, Division of Surgical Oncology, Department of Surgery, Tufts Medical Center, Boston, MA, USA.

Lipofilling has regenerative properties used to improve deformities after breast conserving surgery. Our hypothesis is that there is inadequate data to ensure that lipofilling does not increase locoregional cancer recurrence after breast conserving surgery. A PRISMA comprehensive literature review was conducted of articles published prior to October 2019 investigating recurrence in patients who underwent lipofilling after breast conserving surgery. All forms of breast conserving surgery, fat grafting, and injection intervals were included. Patients undergoing mastectomy were excluded. Requirements to define lipofilling as "safe" included (I) a defined interval between resection and lipofilling; (II) a minimum follow-up period of 6 years from tumor resection; (III) a minimum follow-up period of 3 years from lipofilling; (IV) presence of a control group; (V) controls matched for ER/PR/Her-2; (VI) a sub-group analysis focusing on ER/PR/Her-2; (VII) adequate powering. Nineteen studies met inclusion criteria. The range in time from breast conserving surgery to fat injection was 0-76 months. The average time to follow-up after lipofilling was 23 days-60 months. Two studies had a sufficient follow-up time from both primary resection and from lipofilling. Seventeen of the nineteen studies specified the interval between resection and lipofilling, but there is currently no consensus regarding how soon lipofilling can be performed following BCS. Eight studies performed a subgroup analysis in cases of recurrence and found recurrence after lipofilling was associated with number of positive axillary nodes, intraepithelial neoplasia, high grade histology, Luminal A subtype, age <50, Ki-67 expression, and lipofilling within 3 months of primary resection. Of the eleven studies that included a comparison group, one matched patient for Her-2 and there was a statistically significant difference in Her-2 positive cancers in the study arms of two articles. Several studies deemed lipofilling "safe," two showed association of lipofilling and local recurrence, and most studies concluded that further research was needed. Insufficient and contradictory data exists to demonstrate the safety of lipofilling after breast conserving surgery. A multicentered, well designed study is needed to verify the safety of this practice.
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http://dx.doi.org/10.21037/gs.2019.09.09DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6842766PMC
October 2019

Clinical outcomes and toxicity of proton beam radiation therapy for re-irradiation of locally recurrent breast cancer.

Clin Transl Radiat Oncol 2019 Nov 2;19:116-122. Epub 2019 Oct 2.

Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO 63110, United States.

Purpose: Repeat radiation therapy (RT) using photons/X-rays for locally recurrent breast cancer results in increased short and long-term toxicity. Proton beam RT (PBRT) can minimize dose to surrounding organs, thereby potentially reducing toxicity. Here, we report the toxicity and clinical outcomes for women who underwent re-irradiation to the chest wall for locally recurrent breast cancer using PBRT.

Materials And Methods: This was a retrospective study analyzing 16 consecutive patients between 2013 and 2018 with locally recurrent breast cancer who underwent re-irradiation to the chest wall with PBRT. For the recurrent disease, patients underwent maximal safe resection, including salvage mastectomy, wide local excision, or biopsy only per surgeons recommendations. Systemic therapy was used per the recommendation of the medical oncologist. Patients were treated with median dose of 50.4 Cobalt Gray Equivalent (CGyE) in 28 fractions at the time of re-irradiation. Follow-up was calculated from the start of second RT course. Acute toxicities were defined as those occurring during treatment or up to 8 weeks after treatment. Late toxicities were defined as those occurring more than 8 weeks after the completion of therapy. Toxicities were based on CTCAE 4.0.

Results: The median age at original diagnosis and at recurrence was 49.8 years and 60.2 years, respectively. The median time between the two RT courses was 10.2 (0.7-20.2) years. The median follow-up time was 18.7 (2.5-35.2) months. No local failures were observed after re-irradiation. One patient developed distant metastasis and ultimately died. Grade 3-4 acute skin toxicity was observed in 5 (31.2%) patients. Four (25%) patients developed chest wall infections during or shortly (2 weeks) after re-irradiation. Late grade 3-4 fibrosis was observed in only 3 (18.8%) patients. Grade 5 toxicities were not observed. Hyperpigmentation was seen in 12 (75%) patients. Pneumonitis, telangiectasia, rib fracture, and lymphedema occurred in 2 (12.5%), 4 (25%), 1 (6.3%), and 1 (6.3%) patients, respectively.

Conclusions: Re-irradiation with PBRT for recurrent breast cancer has acceptable toxicities. There was a high incidence of acute grade 3-4 skin toxicity and infections, which resolved, however, with skin care and antibiotics. Longer follow-up is needed to determine long-term clinical outcomes.
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http://dx.doi.org/10.1016/j.ctro.2019.09.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6806378PMC
November 2019

Flipping a Coin? Predicting Nodal Status After Neoadjuvant Chemotherapy.

Ann Surg Oncol 2019 Dec 25;26(13):4168-4170. Epub 2019 Sep 25.

Department of Surgery, Washington University in Saint Louis, St. Louis, MO, USA.

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http://dx.doi.org/10.1245/s10434-019-07868-wDOI Listing
December 2019

Long-Term Outcomes with 3-Dimensional Conformal External Beam Accelerated Partial Breast Irradiation.

Pract Radiat Oncol 2020 May - Jun;10(3):e128-e135. Epub 2019 Sep 18.

Department of Radiation Oncology, St Louis, Missouri.

Purpose: Long-term tumor control and cosmetic outcomes for accelerated partial breast radiation (APBI) delivered with 3-dimensional conformal external beam radiation (3D-CRT) remain limited. We seek to address these concerns by reporting our experience of 3D-CRT APBI with extended follow-up.

Methods And Materials: All patients treated with APBI delivered with 3D-CRT from January 2006 through December 2012 at a single institution were identified. Those with more than a year of follow-up were analyzed for ipsilateral breast tumor recurrence (IBTR), progression-free survival (PFS), cosmesis, and pain. Disease outcomes were analyzed by margin status (<2 mm, ≥2 mm), total radiation dose prescribed, presence of invasive disease, and American Society for Radiation Oncology (ASTRO) 2016 updated consensus groupings (suitable, cautionary, and unsuitable).

Results: Two hundred ninety-three patients were identified, of whom 266 had >1 year of follow-up. Median follow-up was 87 months (range, 13-156). Of the 266, 162 (60.9%) were ASTRO "suitable," 87 (32.7%) were "cautionary," and 17 (6.4%) were "unsuitable." Seven-year rates of IBTR and PFS were 1.8% and 95.2%, respectively. Margin status, invasive versus in situ disease, prescribed dose, and ASTRO grouping were not prognostic for either IBTR or PFS on univariate analysis. Cosmesis was good to excellent in 75.2%. Two patients (0.8%) had subsequent plastic surgery owing to poor cosmesis. Narcotic medication for treatment site pain was needed by 6 (2.3%).

Conclusions: External beam APBI results in excellent long-term disease control. Good to excellent cosmetic outcomes are achieved in most patients, although increasing dose per fraction and greater percentage of irradiated breast were predictive of adverse posttreatment cosmetic outcomes. Select patients in "cautionary" and "unsuitable" consensus groupings do not appear to have inferior outcomes.
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http://dx.doi.org/10.1016/j.prro.2019.09.007DOI Listing
December 2020

The 2018 Compensation Survey of the American Society of Breast Surgeons.

Ann Surg Oncol 2019 Oct 24;26(10):3052-3062. Epub 2019 Jul 24.

Hamilton Physician's Group General Surgery, Dalton, GA, USA.

Background: There is limited compensation data for breast surgery benchmarking. In 2018, the American Society of Breast Surgeons conducted its second membership survey to obtain updated compensation data as well as information on practice type and setting.

Methods: In October 2018, a survey was emailed to 2676 active members. Detailed information on compensation was collected, as well as data on gender, training, years in and type of practice, percent devoted to breast surgery, workload, and location. Descriptive statistics and multivariate analyses were performed to analyze the impact of various factors on compensation.

Results: The response rate was 38.2% (n = 1022, of which 73% were female). Among the respondents, 61% practiced breast surgery exclusively and 54% were fellowship trained. The majority of fellowship-trained surgeons within 5 years of completion of training (n = 126) were female (91%). Overall, mean annual compensation was $370,555. On univariate analysis, gender, years of practice, practice type, academic position, ownership, percent breast practice, and clinical productivity were associated with compensation, whereas fellowship training, region, and practice setting were not. On multivariate analysis, higher compensation was significantly associated with male gender, years in practice, number of cancers treated per year, and wRVUs. Compensation was lower among surgeons who practiced 100% breast compared with those who did a combination of breast and other surgery.

Conclusions: Differences in compensation among breast surgeons were identified by practice type, academic position, ownership, years of practice, percent breast practice, workload, and gender. Overall, mean annual compensation increased by $40,000 since 2014.
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http://dx.doi.org/10.1245/s10434-019-07546-xDOI Listing
October 2019

Predictors of Locoregional Recurrence After Failure to Achieve Pathologic Complete Response to Neoadjuvant Chemotherapy in Triple-Negative Breast Cancer.

J Natl Compr Canc Netw 2019 04;17(4):348-356

aDepartment of Radiation Oncology, Washington University School of Medicine, Saint Louis, Missouri.

Background: This study evaluated factors predictive of locoregional recurrence (LRR) in women with triple-negative breast cancer (TNBC) treated with neoadjuvant chemotherapy who do not experience pathologic complete response (pCR).

Methods: This is a single-institution retrospective review of women with TNBC treated with neoadjuvant chemotherapy, surgery, and radiation therapy in 2000 through 2013. LRR was estimated between patients with and without pCR using the Kaplan-Meier method. Patient-, tumor-, and treatment-specific factors in patients without pCR were analyzed using the Cox proportional hazards method to evaluate factors predictive of LRR. Log-rank statistics were then used to compare LRR among these risk factors.

Results: A total of 153 patients with a median follow-up of 48.6 months were included. The 4-year overall survival and LRR were 70% and 15%, respectively, and the 4-year LRR in patients with pCR was 0% versus 22.0% in those without (P<.001). In patients without pCR, lymphovascular space invasion (LVSI; hazard ratio, 3.92; 95% CI, 1.64-9.38; P=.002) and extranodal extension (ENE; hazard ratio, 3.32; 95% CI, 1.35-8.15; P=.009) were significant predictors of LRR in multivariable analysis. In these patients, the 4-year LRR with LVSI was 39.8% versus 15.0% without (P<.001). Similarly, the 4-year LRR was 48.1% with ENE versus 16.1% without (P=.002). In patients without pCR, the presence of both LVSI and ENE were associated with an even further increased risk of LRR compared with patients with either LVSI or ENE alone and those with neither LVSI nor ENE in the residual tumor (P<.001).

Conclusions: In patients without pCR, the presence of LVSI and ENE increases the risk of LRR in TNBC. The risk of LRR is compounded when both LVSI and ENE are present in the same patient. Future clinical trials are warranted to lower the risk of LRR in these high-risk patients.
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http://dx.doi.org/10.6004/jnccn.2018.7103DOI Listing
April 2019

Treatment response as predictor for brain metastasis in triple negative breast cancer: A score-based model.

Breast J 2019 05 28;25(3):363-372. Epub 2019 Mar 28.

Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri.

Background: Triple negative breast cancer (TNBC) has worse prognosis than other subtypes of breast cancer, and many patients develop brain metastasis (BM). We developed a simple predictive model to stratify the risk of BM in TNBC patients receiving neo-adjuvant chemotherapy (NAC), surgery, and radiation therapy (RT).

Methods: Patients with TNBC who received NAC, surgery, and RT were included. Cox proportional hazards method was used to evaluate factors associated with BM. Significant factors predictive for BM on multivariate analysis (MVA) were used to develop a risk score. Patients were divided into three risk groups: low, intermediate, and high. A receiver operating characteristic (ROC) curve was drawn to evaluate the value of the risk group in predicting BM. This predictive model was externally validated.

Results: A total of 160 patients were included. The median follow-up was 47.4 months. The median age at diagnosis was 49.9 years. The 2-year freedom from BM was 90.5%. Persistent lymph node positivity, HR 8.75 (1.76-43.52, P = 0.01), and lack of downstaging, HR 3.46 (1.03-11.62, P = 0.04), were significant predictors for BM. The 2-year rate of BM was 0%, 10.7%, and 30.3% (P < 0.001) in patients belonging to low-, intermediate-, and high-risk groups, respectively. Area under the ROC curve was 0.81 (P < 0.001). This model was externally validated (C-index = 0.79).

Conclusions: Lack of downstaging and persistent lymph node positivity after NAC are associated with development of BM in TNBC. This model can be used by the clinicians to stratify patients into the three risk groups to identify those at increased risk of developing BM and potentially impact surveillance strategies.
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http://dx.doi.org/10.1111/tbj.13230DOI Listing
May 2019

Value-Based Analysis for Breast Cancer Treatment: We Don't Know What We Don't Know.

Ann Surg Oncol 2019 May 23;26(5):1167-1169. Epub 2019 Jan 23.

Department of Surgery, Washington University School of Medicine, St. Louis, MO, 63110, USA.

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http://dx.doi.org/10.1245/s10434-019-07170-9DOI Listing
May 2019

Adapting the Breast Cancer Surgery Decision Quality Instrument for Lower Socioeconomic Status: Improving Readability, Acceptability, and Relevance.

MDM Policy Pract 2018 Jul-Dec;3(2):2381468318811839. Epub 2018 Nov 25.

The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, Lebanon, New Hampshire.

Breast cancer is the second most common malignancy in women. The Decision Quality Instrument (DQI) measures the extent to which patients are informed and involved in breast surgery decisions and receive treatment that aligns with their preferences. There are limited data on the performance of the DQI in women of lower socioeconomic status (SES). Our aims were to 1) examine (and if necessary adapt) the readability, usability, and acceptability of the DQI and 2) explore whether it captures factors important to breast cancer surgery decisions among women of lower SES (relevance). We conducted semistructured cognitive interviews with women of lower SES (based on insurance status, income, and education) who had completed early-stage breast cancer treatments at three cancer centers. We used a two-step thematic analysis with dual independent coding. The study team (including Patient Partners and a Community Advisory Board) reviewed and refined suggested changes. The revised DQI was presented in two focus groups of breast cancer survivors. We conducted 39 interviews. Participants found most parts of the DQI to be helpful and easy to understand. We made the following suggested changes: 1) added a glossary of key terms, 2) added two answer choices and an open text question in the goals and concerns subscale, 3) reworded the treatment intention question, and 4) revised the knowledge subscale instructions since several women disliked the wording and were unsure of what was expected. The readability, usability, acceptability, and relevance of a measure that was primarily developed and validated in women of higher SES required adaptation for optimal use by women of lower SES. Further research will test these adaptations in lower SES populations.
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http://dx.doi.org/10.1177/2381468318811839DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6262751PMC
November 2018