Publications by authors named "Mehra Golshan"

127 Publications

Association of Immunophenotype With Pathologic Complete Response to Neoadjuvant Chemotherapy for Triple-Negative Breast Cancer: A Secondary Analysis of the BrighTNess Phase 3 Randomized Clinical Trial.

JAMA Oncol 2021 Feb 18. Epub 2021 Feb 18.

The University of Texas MD Anderson Cancer Center, Houston.

Importance: Adding carboplatin to standard neoadjuvant chemotherapy (NAC) in triple-negative breast cancer (TNBC) likely benefits a subset of patients; however, determinants of benefit are poorly understood.

Objective: To define the association of molecular subtype, tumor proliferation, and immunophenotype with benefit of carboplatin added to NAC for patients with stages II to III TNBC.

Design, Setting, And Participants: This was a prespecified secondary analysis of a phase 3, double-blind, randomized clinical trial (BrighTNess) that enrolled 634 women across 145 centers in 15 countries. Women with clinical stages II to III TNBC who had undergone pretreatment biopsy were eligible to participate. Whole transcriptome RNA sequencing was performed on the biopsy specimens. The prespecified end point was association of pathologic complete response (pCR) with gene expression-based molecular subtype, with secondary end points investigating established signatures (proliferation, immune) and exploratory analyses of immunophenotype. Data were collected from April 2014 to March 2016. The study analyses were performed from January 2018 to March 2019.

Interventions: Neoadjuvant chemotherapy with paclitaxel followed by doxorubicin and cyclophosphamide, or this same regimen with carboplatin or carboplatin plus veliparib.

Main Outcomes And Measures: Association of gene expression-based molecular subtype (PAM50 and TNBC subtypes) with pCR.

Results: Of the 634 women (median age, 51 [range, 22-78] years) enrolled in BrighTNess, 482 (76%) patients had evaluable RNA sequencing data, with similar baseline characteristics relative to the overall intention-to-treat population. Pathologic complete response was significantly more frequent in PAM50 basal-like vs nonbasal-like cancers overall (202 of 386 [52.3%] vs 34 of 96 [35.4%]; P = .003). Carboplatin benefit was not significantly different in basal-like vs nonbasal-like subgroups (P = .80 for interaction). In multivariable analysis, proliferation (hazard ratio, 0.36; 95% CI, 0.21-0.61; P < .001) and immune (hazard ratio, 0.62; 95% CI, 0.49-0.79; P < .001) signatures were independently associated with pCR. Tumors above the median for proliferation and immune signatures had the highest pCR rate (84 of 125; 67%), while those below the median for both signatures had the lowest pCR rate (42 of 125; 34%). Exploratory gene expression immune analyses suggested that tumors with higher inferred CD8+ T-cell infiltration may receive greater benefit with addition of carboplatin.

Conclusions And Relevance: In this secondary analysis of a randomized clinical trial, triple-negative breast cancer subtyping revealed high pCR rates in basal-like and immunomodulatory subsets. Analysis of biological processes related to basal-like and immunomodulatory phenotypes identified tumor cell proliferation and immune scores as independent factors associated with achieving pCR; the benefit of carboplatin on pCR was seen across all molecular subtypes. Further validation of immunophenotype with existing biomarkers may help to escalate or de-escalate therapy for patients with TNBC.

Trial Registration: ClinicalTrials.gov Identifier: NCT02032277.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamaoncol.2020.7310DOI Listing
February 2021

Prediction of Persistent Pain Severity and Impact 12 Months After Breast Surgery Using Comprehensive Preoperative Assessment of Biopsychosocial Pain Modulators.

Ann Surg Oncol 2021 Jan 15. Epub 2021 Jan 15.

Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.

Background: Persistent post-mastectomy pain (PPMP) is a significant negative outcome occurring after breast surgery, and understanding which individual women are most at risk is essential to targeting of preventive efforts. The biopsychosocial model of pain suggests that factors from many domains may importantly modulate pain processing and predict the progression to pain persistence.

Methods: This prospective longitudinal observational cohort study used detailed and comprehensive psychosocial and psychophysical assessment to characterize individual pain-processing phenotypes in 259 women preoperatively. Pain severity and functional impact then were longitudinally assessed using both validated surgery-specific and general pain questionnaires to survey patients who underwent lumpectomy, mastectomy, or mastectomy with reconstruction in the first postsurgical year. An agnostic, multivariable modeling strategy identified consistent predictors of several pain outcomes at 12 months.

Results: The preoperative characteristics most consistently associated with PPMP outcomes were preexisting surgical area pain, less education, increased somatization, and baseline sleep disturbance, with axillary dissection emerging as the only consistent surgical variable to predict worse pain. Greater pain catastrophizing, negative affect, younger age, higher body mass index (BMI), and chemotherapy also were independently predictive of pain impact, but not severity. Sensory disturbance in the surgical area was predicted by a slightly different subset of factors, including higher preoperative temporal summation of pain.

Conclusions: This comprehensive approach assessing consistent predictors of pain severity, functional impact, and sensory disturbance may inform personalized prevention of PPMP and also may allow stratification and enrichment in future preventive studies of women at higher risk of this outcome, including pharmacologic and behavioral interventions and regional anesthesia.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1245/s10434-020-09479-2DOI Listing
January 2021

Omission of Surgical Axillary Lymph Node Staging in Patients with Tubular Breast Cancer.

Ann Surg Oncol 2020 Oct 19. Epub 2020 Oct 19.

Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.

Background: With more effective screening and treatment strategies, there is debate over whether surgical axillary staging should be deescalated for patients with small favorable breast cancers, such as tubular carcinoma (TC).

Patients And Methods: We identified patients with TC [defined as > 90% tubular tubules (angulated, not multilayered)] and known surgical axillary staging from our institutional database (2000-2018). Using the National Cancer Database (NCDB) (2004-2015), we identified patients with TC, ductal carcinoma in situ (DCIS), and pT1 estrogen receptor (ER)-positive invasive ductal carcinoma (IDC). We determined the rates of lymph node (LN) metastases, and the 5- and 10-year overall survival (OS) for patients with LN-negative versus LN-positive disease using the Kaplan-Meier method and propensity match analysis.

Results: In our institutional cohort, we identified 112 patients with T1 TC; only one (0.9%) patient had nodal involvement. In the NCDB cohort, we identified 6938 patients with T1 TC; 323 (4.7%) patients had axillary LN disease. The rate of axillary LN involvement for TC was comparable to that identified for patients with DCIS (4.2%), and much lower than that found for patients with grade I-III, T1, ER-positive IDC (20.5%), and patients with grade I, T1, ER-positive IDC (14.4%). There was no difference in 5-year (94.6% versus 95.4%, p = 0.67) and 10-year (83.9% versus 85.2%, p = 0.98) OS between TC patients with or without LN involvement. Kaplan-Meier survival curves even after propensity score matching suggest that tubular histology is independently associated with improved survival.

Conclusions: T1 TC is an excellent starting point for deescalation of surgical axillary staging.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1245/s10434-020-09223-wDOI Listing
October 2020

Impact of surgical complications on patient reported outcomes (PROs) following nipple sparing mastectomy.

Am J Surg 2020 11 14;220(5):1230-1234. Epub 2020 Jul 14.

Breast Oncology Program, Dana Farber Cancer Institute, Boston, MA, USA; Division of Breast Surgery, Brigham and Women's Hospital, Boston, MA, USA. Electronic address:

Introduction: Nipple sparing mastectomy (NSM) is oncologically safe and provides excellent cosmetic outcomes. Complications after surgery may impact patient reported outcomes (PROs). We assessed the impact of complications on PROs after NSM.

Methods: We enrolled 63 patients (pts) who met eligibility criteria for NSM from September 2011 until August 2014. PROs were administered before surgery and at 1 year. Clinical data were collected from the electronic health record. Analyses were performed in SPSS Statistics for Windows (version 21.0). Pts with and without complications were compared using a one-way ANOVA.

Data: Sixty-three women were enrolled with a median age of 46. Postoperative complications requiring surgical treatment were seen in 10 patients (15.9%). Two patients required nipple excision due to necrosis (3.1%). No statistically significant differences in BREAST-Q scores were seen between pts with and without complications.

Conclusion: Experiencing a complication after initial NSM surgery is not associated with decrease in PROs.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.amjsurg.2020.06.066DOI Listing
November 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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1245/s10434-020-08673-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7293588PMC
August 2020

Breast Conservation After Neoadjuvant Chemotherapy for Triple-Negative Breast Cancer: Surgical Results From the BrighTNess Randomized Clinical Trial.

JAMA Surg 2020 03 18;155(3):e195410. Epub 2020 Mar 18.

Department of Breast Surgery, Helios Klinikum Berlin-Buch, Berlin, Germany.

Importance: Neoadjuvant systemic therapy (NST) is often administered to enable breast-conserving therapy (BCT) in stages II to III breast cancer.

Objectives: To prospectively evaluate the role of NST in conversion from BCT ineligibility to BCT eligibility and to assess the association of response to NST, germline BRCA (gBRCA) status, and region of treatment with surgical choice in women with triple-negative breast cancer (TNBC).

Design, Setting, And Participants: This prespecified secondary analysis of a multicentered, phase 3, double-blind, randomized clinical trial (BrighTNess) enrolled 634 eligible women across 145 centers in 15 countries in North America, Europe, and Asia. Women with operable, clinical stages II to III TNBC who underwent gBRCA mutation testing before initiating NST were eligible to participate. Data were collected from April 1, 2014, to December 8, 2016. This preplanned analysis was performed from January 5, 2018, to October 28, 2019.

Interventions: Study participants were randomized to receive 12 weeks of weekly paclitaxel alone or with the addition of carboplatin and/or veliparib, followed by 4 cycles of doxorubicin hydrochloride and cyclophosphamide.

Main Outcomes And Measures: Surgeons assessed BCT candidacy by clinical and radiographic criteria before and after NST. Surgical choices and whether BCT eligibility was associated with the likelihood of pathologic complete response were then analyzed.

Results: Among the 634 randomized patients (median age, 51 [range, 22-78] years), pre- and post-NST assessments were available for 604 patients. Of 141 patients deemed BCT ineligible at baseline, 75 (53.2%) converted to BCT eligible. Overall, 342 (68.1%) of 502 patients deemed BCT eligible after NST underwent BCT, including 42 (56.0%) of the 75 who converted to BCT eligible. Patients treated in Europe and Asia were more likely to undergo BCT (odds ratio, 2.66; 95% CI, 1.84-3.84) compared with those treated in North America. Among patients without gBRCA mutation undergoing mastectomy, those treated in North America were more likely to undergo contralateral prophylactic mastectomy (57 of 81 [70.4%] vs 6 of 30 [20.0%]; P < .001). Rates of pathologic complete response were similar between patients deemed BCT eligible at baseline and those who were BCT ineligible but converted to BCT eligibility after NST (55.3 [235 of 425] vs 49.3% [37 of 75]; P = .38).

Conclusions And Relevance: This prospective analysis of NST and BCT eligibility in TNBC demonstrates a conversion from BCT ineligibility to BCT eligibility of 53.2%. Lower BCT rates among eligible patients and higher bilateral mastectomy rates among patients without gBRCA mutation in North America merit investigation.

Trial Registration: ClinicalTrials.gov identifier: NCT02032277.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamasurg.2019.5410DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6990971PMC
March 2020

Comparison of Radio-guided Occult Lesion Localization (ROLL) and Magnetic Occult Lesion Localization (MOLL) for Non-palpable Lesions: A Phantom Model Study.

Clin Breast Cancer 2020 02 16;20(1):e9-e13. Epub 2019 Sep 16.

Breast Surgical Oncology, Dana Farber/Brigham Women's Cancer Center, Boston, MA; Breast Center, Memorial Bahcelievler Hospital, Istanbul, Turkey. Electronic address:

Background: Localization of nonpalpable breast cancers can be achieved with several techniques. We sought to compare radio-guided localization (ROLL) and magnetic tracer localization (MOLL) techniques by using a phantom model we previously developed, which can provide an accurate simulation for excision of nonpalpable breast lesions.

Materials And Methods: We designed 20 phantom models (10 MOLL, 10 ROLL group) for localization. A handheld gamma probe for the ROLL group and a manual magnetometer (SentiMag) for the MOLL group were used to test the ability of the modality to detect olives in turkey breasts. The excision time for each procedure, specimen size, and weight of the specimens removed from the turkey breasts were recorded.

Results: Both techniques resulted in 100% retrieval of the lesions. There was no difference between the groups in the duration of operative excision, specimen weight, or specimen volume.

Conclusion: This experimental trial found similar success rates for ROLL and MOLL in localization of occult lesions using the turkey breast phantom model. MOLL can be performed in clinics without the need for a nuclear medicine team and radiation safety procedures.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.clbc.2019.09.002DOI Listing
February 2020

Early assessment with magnetic resonance imaging for prediction of pathologic response to neoadjuvant chemotherapy in triple-negative breast cancer: Results from the phase III BrighTNess trial.

Eur J Surg Oncol 2020 02 5;46(2):223-228. Epub 2019 Oct 5.

Helios Klinikum Berlin-Buch, Berlin, Germany.

Introduction: The ability of breast magnetic resonance imaging (MRI) to predict pathologic complete response (pCR) to neoadjuvant systemic therapy (NST) varies across biological subtypes. We sought to determine how well breast MRI findings following initial treatment on the phase III BrighTNess trial correlated with pCR in patients with triple negative breast cancer (TNBC).

Methods: Baseline and mid-treatment imaging and pathologic response data were available in 519 patients with stage II-III TNBC who underwent NST as per protocol. MRI complete response (mCR) was defined as disappearance of all target lesion(s) and MRI partial response (mPR) as a ≥50% reduction in the largest tumor diameter.

Results: Overall, mCR was demonstrated in 116 patients (22%), whereas 166 (32%) had mPR and 237 (46%) had stable/progressive disease (SD/PD). The positive predictive value (PPV), negative predictive value, and overall accuracy of the mid-treatment MRI for pCR were 78%, 56%, and 61%, respectively; accuracy did not differ significantly between gBRCA mutation carriers and non-carriers (52% vs. 63%, p = 0.10). When compared to patients with SD/PD, those with mPR or mCR were 3.35-fold (95% CI 2.07-5.41) more likely to have pCR at surgery. MRI response during NST was significantly associated with eligibility for breast-conserving surgery following completion of treatment (93.1% for mCR vs. 81.6% for SD/PD, p < 0.001).

Conclusions: Complete response on mid-treatment MRI in the BrighTNess trial had a PPV of 78% for demonstration of pCR after completion of NST in TNBC. However, a substantial proportion of patients with mPR or SD/PD also achieved a pCR.

Clinical Trial Registration: NCT02032277.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ejso.2019.10.002DOI Listing
February 2020

Patterns of Axillary Management in Stages 2 and 3 Hormone Receptor-Positive Breast Cancer by Initial Treatment Approach.

Ann Surg Oncol 2019 Dec 27;26(13):4326-4336. Epub 2019 Sep 27.

Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.

Background: Data regarding axillary management after neoadjuvant endocrine therapy (NET) are lacking. This study examined axillary management of hormone receptor-positive (HR+) patients based on initial treatment with NET, neoadjuvant chemotherapy (NAC), or upfront surgery.

Methods: Patients with stage 2 or 3 HR+/HER2- breast cancer treated between 2012 and 2015 were identified in the National Cancer Database. The study examined axillary surgery [sentinel lymph node biopsy (SLNB), SLNB followed by axillary lymph node dissection (ALND), or upfront ALND] by initial treatment stratified by cN0/N1 using pairwise comparisons and multivariable logistic regression.

Results: Of 92,204 eligible patients, 2138 (2.3%) received NET, 11,014 (12%) received NAC, and 79,052 (85.7%) received surgery. Among 60,998 cN0 patients, attempted SLNB was more likely for surgery patients (86.2%, 47,159/54,684) and NET patients (85.8%, 1342/1564) than for NAC patients (79.9%, 3793/4750) (both p < 0.001). Among 31,206 cN1 patients, attempted SLNB was more likely for the surgery patients (46.0%, 11,201/24,368) than for the NET patients (41.8%, 240/574; p = 0.05) or the NAC patients (39.8%, 2491/6264; p < 0.0001). The differences between surgery and NET did not persist in the adjusted analyses. Among both the cN0 patients (n = 13,856) and the cN1 patients (n = 8688) with pN1 disease shown by SLNB, the NET patients were treated with ALND less frequently than those receiving NAC or surgery (p < 0.0001 for all comparisons). In the multivariate analysis, for the patients with pN1 disease shown by SLNB, NET use was associated with increased odds of undergoing SLNB alone [cN0 patients: odds ratio (OR), 1.31, 95% confidence interval (CI), 1.04-1.64; cN1 patients: OR 1.45; 95% CI 1.00-2.10].

Conclusions: For stages 2 and 3 HR+/HER2- patients, SLNB use after NET was similar to that for upfront surgery. Among those with pN1 disease, the NET patients were less likely to undergo ALND. Additional outcomes data are needed to guide axillary management after NET.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1245/s10434-019-07785-yDOI Listing
December 2019

Bilateral mastectomy operations and the role for the cosurgeon technique: A Nationwide analysis of surgical practice patterns.

Breast J 2020 02 9;26(2):220-226. Epub 2019 Sep 9.

Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.

Traditionally, bilateral mastectomy (BM) operations are performed by a single surgeon but a two-attending co-surgeon technique (CST) has been described. A questionnaire was sent to members of the American Society of Breast Surgeons to assess national BM practices and analyze utilization and perceived benefits of the CST. Among surgeons responding, most continue to use the single-surgeon approach for BMs; however, 14.1% utilize the CST and up to 31% are interested in future CST use. Time savings, mentorship, cost savings, and opportunity to learn new techniques were identified as perceived CST advantages.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/tbj.13522DOI Listing
February 2020

Long-term outcomes of breast-conserving therapy for women with ductal carcinoma in situ.

Breast Cancer Res Treat 2019 Dec 6;178(3):607-615. Epub 2019 Sep 6.

Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA.

Purpose: Improved imaging, surgical techniques, and pathologic evaluation likely have decreased local recurrence rates for patients with ductal carcinoma in situ (DCIS). We present long-term outcomes of a large single-institution series after breast-conserving surgery (BCS) and adjuvant radiation therapy (RT).

Methods: We retrospectively reviewed the records of 245 women treated for DCIS with BCS and RT between 2001 and 2007. Competing risk analysis was used to calculate local recurrence (LR) as a first event with the development of a second non-breast malignancy, contralateral breast cancer, and death as competing first events.

Results: At a median follow-up of 10.6 years, 4 patients had a LR (2 DCIS, 2 invasive) as a first event with a cumulative LR incidence of 0.0% and 1.5% at 5 and 10 years, respectively. Most patients had > 2 mm margins (90%), specimen radiographs (93%), and received a tumor bed boost (99%). The majority (60%) of patients with hormone receptor-positive disease received adjuvant endocrine therapy. Ten-year cumulative incidence of contralateral breast cancer (CBC) was 7.9%, second non-breast malignancy was 4.5%, and death unrelated to breast cancer was 3.5%. Family history, age at diagnosis, and receipt of endocrine therapy were not significantly associated with the development of CBC (all P > 0.05).

Conclusions: With mature follow-up, our rates of local recurrence following breast-conserving therapy for DCIS remain very low (1.5% at 10 years). The incidence of CBC was higher than the LR incidence. Predisposing factors for the development of CBC are worthy of investigation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s10549-019-05428-0DOI Listing
December 2019

ASO Author Reflections: De-escalation of Breast Cancer Surgery-A Leap Forward.

Ann Surg Oncol 2019 12 29;26(Suppl 3):711-712. Epub 2019 Aug 29.

Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1245/s10434-019-07759-0DOI Listing
December 2019

Surgical Management of the Axilla in Clinically Node-Positive Patients Receiving Neoadjuvant Chemotherapy: A National Cancer Database Analysis.

Ann Surg Oncol 2019 Oct 24;26(11):3517-3525. Epub 2019 Jul 24.

Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.

Background: The feasibility of sentinel lymph node biopsy (SLNB) in patients with clinically node-positive (cN+) disease who convert to clinically node-negative (cN0) disease following neoadjuvant chemotherapy (NAC) has been evaluated in several large clinical trials, but it remains unclear whether the approach has been broadly adopted in the United States.

Methods: The National Cancer Database was used to identify women diagnosed with cN+ breast cancer who received NAC followed by surgery between 2012 and 2015. Trends in axillary surgery were evaluated and multivariable logistic regression analyses performed to determine factors associated with receipt of SLNB.

Results: Of 12,965 women cN+ at baseline, the use of SLNB increased from 31.8% in 2012 to 49% in 2015 (p < 0.001). Using axillary pCR as a surrogate for patients who convert to cN0 following NAC, among 5127 (39.5%) ypN0 patients, SLNB increased from 38.2 to 58.4% over the study period (p < 0.001), resulting in avoidance of axillary dissection in 42.2% of ypN0 patients by 2015. In adjusted analyses, factors significantly associated with SLNB attempt included cN1 disease, age < 45 years, treatment facility type, triple-negative and HER2-positive subtypes, and year of diagnosis. In women with residual isolated tumor cells (ITCs), micrometastases, and ypN1 disease, SLNB was the only axillary procedure performed in 36.9%, 23.6%, and 13.0% of cases.

Conclusions: The use of SLNB in cN+ patients receiving NAC increased significantly between 2012 and 2015. SLNB alone was performed in more than 10% of patients with ypN1 disease, 20% with micrometastases, and 35% with ITCs; the oncologic safety of omitting axillary dissection in these patients requires further evaluation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1245/s10434-019-07583-6DOI Listing
October 2019

National Patterns of Breast Reconstruction and Nipple-Sparing Mastectomy for Breast Cancer, 2005-2015.

Ann Surg Oncol 2019 Oct 24;26(10):3194-3203. Epub 2019 Jul 24.

Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.

Background: The purpose of this study was to explore national patterns in the uptake of breast reconstruction and nipple-sparing mastectomy (NSM).

Methods: We used the National Cancer Database to identify all women who underwent mastectomy for stage 0-III breast cancer between 2005-2015. Multivariable logistic regression was used to determine factors associated with receipt of reconstruction, with subset analyses performed to determine trends and predictors of NSM in those who underwent mastectomy with reconstruction.

Results: Our cohort consisted of 395,815 women, 238,568 (60.3%) who underwent mastectomy alone and 157,247 (39.7%) who underwent mastectomy followed by reconstruction. The use of breast reconstruction increased from 22.3% of mastectomy cases in 2005 to 49.7% of mastectomy cases in 2015 (odds ratio [OR] 9.7, 95% confidence interval [CI] 7.3-12.8). Among those receiving reconstruction, the use of NSM increased from 1.7% in 2005 to 14.3% in 2015 (OR 9.4, 95% CI 7.1-12.5), with increased utilization among those with early-stage and locally advanced disease, such that by 2015, NSM was performed in 15.3% of mastectomies with reconstruction for DCIS, 14.3% of mastectomies with reconstruction for stage I-II breast cancer, and 10.7% of mastectomies with reconstruction for stage III breast cancer. Factors strongly predicting receipt of NSM included age < 45 years, smaller clinical tumor size, clinically node negative disease, use of neoadjuvant therapy, and facility type.

Conclusions: There has been a dramatic increase in the use of breast reconstruction and NSM between 2005-2015. Further prospective studies evaluating oncologic outcomes of NSM in locally advanced breast cancer are warranted.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1245/s10434-019-07554-xDOI Listing
October 2019

Survival Outcomes for Patients With Clinical Complete Response After Neoadjuvant Chemotherapy: Is Omitting Surgery an Option?

Ann Surg Oncol 2019 Oct 24;26(10):3260-3268. Epub 2019 Jul 24.

Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.

Background: Surgery after neoadjuvant chemotherapy (NCT) is an accepted treatment approach for locally advanced and some early-stage breast cancers, even for patients with a clinical complete response (cCR) after NCT. This study sought to evaluate the survival outcomes for patients with cCR to NCT who did not undergo surgery.

Methods: The National Cancer Data Base (NCDB) was used to identify 93,417 women age 18 years or older with a diagnosis of invasive breast cancer who received NCT between 2010 and 2015. The study identified 350 women with cT1-4, N0-3, and M0 tumors who underwent NCT and did not have surgery. A matched surgical cohort was extracted from the NCDB, and overall survival (OS) was compared between the surgical and nonsurgical patients after NCT.

Results: Of the 350 NCT patients who did not undergo surgery, 45 (12.9%) had cCR, 51 (14.6%) had a partial response, 241 (68.9%) had a response but whether complete or partial was not recorded, and 13 (3.7%) had no response/progression. The 5-year OS was better in the cCR group than in the no-cCR group (96.8% vs 69.8%; p = 0.004). A 5-year OS analysis of the cCR patients without surgery (n = 45; median follow-up period, 37 months) compared with the patients with a pathologic complete response who underwent surgery (n = 3938; median follow-up period, 43 months) showed no statistically significant difference (96.8% vs 92.5%, respectively; p = 0.15).

Conclusion: This retrospective cohort study demonstrated that active surveillance or de-escalation therapy may be an option for patients who achieve cCR. Prospective studies are underway to determine whether a subgroup of patients may forgo surgery in the setting of cCR after NCT.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1245/s10434-019-07534-1DOI Listing
October 2019

Benefit of regional anaesthesia on postoperative pain following mastectomy: the influence of catastrophising.

Br J Anaesth 2019 08 28;123(2):e293-e302. Epub 2019 Mar 28.

Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA. Electronic address:

Background: Previous studies suggest that truncal regional anaesthesia (TRA), including techniques such as paravertebral block, may contribute significantly to analgesia after mastectomy. However, the severity and impact of postoperative pain varies markedly amongst individuals, making the identification of patients who would benefit most from TRA a potentially important step toward personalised perioperative care.

Methods: In this prospective observational study, mastectomy patients (n=122) were recruited and systematically assessed for psychosocial characteristics including pain catastrophising before surgery, and either received preoperative TRA (n=57) or no block (n=65).

Results: Age, baseline pain, and psychosocial traits did not differ between these groups. TRA was associated with lower overall pain scores and opioid consumption perioperatively, with a larger proportion of patients without block (50% vs 28%) reporting moderate-severe pain (more than three/10) on the day of surgery. Mixed model analysis of variance revealed a significant interaction between catastrophising and TRA, such that amongst patients with high baseline catastrophising, TRA was associated with substantially lower pain severity score (58% lower), while amongst patients with low baseline catastrophising, TRA was associated with only 18% lower pain severity. At 2 weeks, this interaction between baseline catastrophising and TRA was also observed when examining surgical pain burden, with higher baseline catastrophising patients who had received TRA reporting lower pain and less frequent opioid use (40% vs 70% of patients).

Conclusions: TRA provided immediate analgesic benefit for patients undergoing mastectomy on the day of surgery, but this effect appeared more pronounced and sustained amongst patients with higher baseline catastrophising.

Clinical Trial Registration: NCT02329574.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.bja.2019.01.041DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6676159PMC
August 2019

National trends of synchronous bilateral breast cancer incidence in the United States.

Breast Cancer Res Treat 2019 Nov 19;178(1):161-167. Epub 2019 Jul 19.

Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.

Purpose: Increase in breast cancer survivorship, advancements in diagnostic imaging and standardization of contralateral breast screening before breast cancer surgery have resulted in increased detection of contralateral breast cancer (CBC). The aim of this study was to assess national trends of synchronous bilateral breast cancer (sBBC) and metachronous bilateral breast cancer (mBBC) incidence in newly diagnosed breast cancer patients.

Methods: The Surveillance, Epidemiology, and End Results (SEER) database (1973-2014) was used to identify 11,177 women diagnosed with CBC. CBC was classified as sBBC when primary breast cancer in both breasts is diagnosed in the same year, or as mBBC, when diagnosed more than one year from primary breast cancer. Temporal trends in sBBC incidence were then evaluated using the Cochran-Armitage test for trend.

Results: Of the 11,177 women diagnosed with CBC, 4228 (38%) had sBBC and 6949 (62%) had mBBC. The incidence of sBBC increased significantly from 1.4% in 1975 to 2.9% in 2014 (p < 0.001). sBBC was more likely to be diagnosed as early stage in recent years (78% in 1975 vs. 90% in 2014 [p < 0.001]), and 69% of patients were treated with mastectomy in 2014.

Conclusion: The number of sBBC has increased, and contralateral tumors are more likely to be detected at an early stage with the first primary breast cancer. Despite the early stage findings, most were treated with mastectomy. Further studies are needed to define the best therapy for patients with contralateral disease and optimal surveillance and detection methods.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s10549-019-05363-0DOI Listing
November 2019

Prognostic Significance of Residual Axillary Nodal Micrometastases and Isolated Tumor Cells After Neoadjuvant Chemotherapy for Breast Cancer.

Ann Surg Oncol 2019 Oct 21;26(11):3502-3509. Epub 2019 Jun 21.

Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.

Background: The prognostic significance of low-volume residual nodal disease following neoadjuvant chemotherapy (NAC) is unknown.

Methods: Women with cT1-4N0-1 breast cancer treated with NAC were identified from Dana-Farber/Brigham and Women's Cancer Center (DFBWCC) and the National Cancer Database (NCDB). Disease-free survival (DFS) and overall survival (OS) estimates according to pathologic nodal status were calculated using the Kaplan-Meier method, with Cox proportional hazards regression used to assess the effect of clinical variables on survival outcomes.

Results: Among 967 DFBWCC patients, 27 (2.8%) had residual isolated tumor cells (ITCs) and 61 (6.3%) had micrometastases. Five-year DFS was significantly worse in those with residual ITCs (73.5%) and micrometastases (74.7%) relative to those who were ypN0 following NAC (88.4%, p < 0.001). On adjusted analysis, those with residual ITCs (hazard ratio [HR] 2.4, 95% confidence interval [CI] 1.20-3.81) and micrometastases (HR 2.14, 95% CI 1.20-3.81) had increased risk of recurrence relative to ypN0 patients. Among 35,536 NCDB patients, 543 (1.5%) had ITCs and 1132 (3.2%) had micrometastases. Five-year OS estimates were significantly worse with increasing residual nodal burden: ypN0, 88.9%; ypN0[i+], 82.8%; ypN1mi, 79.5%; ypN1, 77.6% (p < 0.001). Compared with patients with ypN0 disease, NCDB patients with ITCs and micrometastases had 1.9- and 2.2-fold risk of death (p < 0.001). On subgroup analysis, the effect of low-volume residual disease on mortality was most pronounced in patients with triple-negative and human epidermal growth factor receptor 2 (HER2)-positive disease.

Conclusions: Low-volume residual nodal disease following NAC is associated with poorer DFS and OS relative to those who are node negative.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1245/s10434-019-07517-2DOI Listing
October 2019

Impact of a Pre-Operative Exercise Intervention on Breast Cancer Proliferation and Gene Expression: Results from the Pre-Operative Health and Body (PreHAB) Study.

Clin Cancer Res 2019 Sep 24;25(17):5398-5406. Epub 2019 Apr 24.

Yale School of Public Health, New Haven, Connecticut.

Purpose: Exercise after breast cancer diagnosis is associated with lower cancer-specific mortality, but the biological mechanisms through which exercise impacts breast cancer are not fully understood. The Pre-Operative Health and Body (PreHAB) Study was a randomized window-of-opportunity trial designed to test the impact of exercise on Ki-67, gene expression, and other biomarkers in women with breast cancer.

Experimental Design: Inactive women with newly diagnosed breast cancer were randomized to an exercise intervention or mind-body control group, and participated in the study between enrollment and surgery (mean 29.3 days). Tumor and serum were collected at baseline and surgery.

Results: Forty-nine women were randomized (27 exercise, 22 control). At baseline, mean age was 52.6, body mass index was 30.2 kg/m, and exercise was 49 minutes/week. Exercise participants significantly increased exercise versus controls (203 vs. 23 minutes/week, < 0.0001). There were no differences in changes of expression of Ki-67, insulin receptor, and cleaved caspase-3 in exercise participants versus controls. KEGG pathway analysis demonstrated significant upregulation of 18 unique pathways between the baseline biopsy and surgical excision in exercise participants and none in control participants ( < 0.1). Top-ranked pathways included several implicated in immunity and inflammation. Exploratory analysis of tumor immune infiltrates demonstrated a trend toward a decrease in FOXP3 cells in exercise versus control participants over the intervention period ( = 0.08).

Conclusions: A window-of-opportunity exercise intervention did not impact proliferation but led to alterations in gene expression in breast tumors, suggesting that exercise may have a direct effect on breast cancer..
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1158/1078-0432.CCR-18-3143DOI Listing
September 2019

Recommended Cancer Screening in Accountable Care Organizations: Trends in Colonoscopy and Mammography in the Medicare Shared Savings Program.

J Oncol Pract 2019 06 18;15(6):e547-e559. Epub 2019 Apr 18.

1 Brigham and Women's Hospital, Boston, MA.

Purpose: Accountable care organizations (ACOs) are a delivery and payment model designed to encourage integrated, high-value care. We designed a study to test the association between ACOs and two recommended cancer screening tests, colonoscopy for colorectal cancer and mammography for breast cancer.

Methods: Using the random 20% sample of Medicare claims, beneficiaries were attributed to ACO or non-ACO cohorts on the basis of providers' enrollment in the Medicare Shared Savings Program. An inverse probability of treatment weighting was used to balance patient characteristics between ACO and non-ACO cohorts. A propensity score-weighted, difference-in-differences analysis was then performed using the same provider groups in 2010-pre-ACO-as a baseline. A secondary analysis for older-nonrecommended-age ranges was performed.

Results: Prevalence of colonoscopy in recommended age ranges in ACOs from 2010 to 2014 increased from 15.3% (95% CI, 14.9% to 15.6%) to 17.9% (95% CI, 17.3% to 18.5%). This differed significantly from the change in non-ACOs (difference in differences, 1.2%; < .001). Among women in ACOs, mammography prevalence rose from 53.7% (95% CI, 53.0% to 54.4%) to 54.9% (95% CI, 54.2% to 55.7%). In contrast to colonoscopy, the difference in mammography prevalence was not significantly different in ACO versus non-ACOs (difference in differences, 0.49%; < .13). A similar pattern was also observed in older-nonrecommended-age ranges with significant difference in differences (ACO non-ACO) in colonoscopy, but not mammography.

Conclusion: The impact of ACOs on cancer screening varies between screening tests. Our results are consistent with a greater effect of ACOs on high-cost, high-complexity screening services, which may be more sensitive to integrated care delivery models.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1200/JOP.18.00352DOI Listing
June 2019

Association of Care at Minority-Serving vs Non-Minority-Serving Hospitals With Use of Palliative Care Among Racial/Ethnic Minorities With Metastatic Cancer in the United States.

JAMA Netw Open 2019 02 1;2(2):e187633. Epub 2019 Feb 1.

Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

Importance: It is not known whether racial/ethnic differences in receipt of palliative care are attributable to different treatment of minorities or lower utilization of palliative care at the relatively small number of hospitals that treat a large portion of minority patients.

Objective: To assess the association of receipt of palliative care among patients with metastatic cancer with receipt of treatment at minority-serving hospitals (MSHs) vs non-MSHs.

Design, Setting, And Participants: This retrospective cohort study used Participant Use Files of the National Cancer Database, a prospectively maintained, hospital-based cancer registry consisting of all patients treated at more than 1500 US hospitals, to collect data from individuals older than 40 years with metastatic prostate, lung, colon, and breast cancer, diagnosed from January 1, 2004, to December 31, 2015. Data were accessed in October 2017, and the analysis was performed in July 2018.

Exposures: Hospitals in the top decile in terms of the proportion of black and Hispanic patients for each cancer type were defined as MSHs.

Main Outcomes And Measures: A multilevel logistic regression model that estimated the odds of palliative care was fit, adjusting for year of diagnosis, sex, race/ethnicity, insurance, income, educational level, and cancer type, with an interaction term between cancer type and MSH status and a hospital-level random intercept to account for unmeasured hospital characteristics.

Results: A total of 601 680 individuals (mean [SD] age, 67.4 [11.4] years; 95% CI, 67.2-67.6 years; 314 279 [52.2%] male; 475 039 [78.9%] white) were studied. In total, 130 813 patients (21.7%) received palliative care, ranging from 102 019 (25.4%) with lung cancer to 9966 (11.1%) with colon cancer. In total, 16 435 black individuals (20.0%) and 3551 Hispanic individuals (15.9%) received palliative care vs 106 603 non-Hispanic white individuals (22.5%) (P < .001). The MSH patients were less likely than the non-MSH patients to receive palliative care, regardless of race/ethnicity (12 692 [18.0%] vs 118 121 [22.3%]; P = .002). In an adjusted analysis, treatment at an MSH had a statistically significant association with lower odds of receiving palliative care (odds ratio, 0.67; 95% CI, 0.53-0.84).

Conclusions And Relevance: Although the factors associated with minority patients' receipt of palliative care are complex, in this study, treatment at MSHs was associated with significantly lower odds of receiving any palliative care in an adjusted analysis, but black and Hispanic race/ethnicity was not. These findings suggest that the site of care is associated with race/ethnicity-based differences in palliative care.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamanetworkopen.2018.7633DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6484582PMC
February 2019

Association of Bariatric Surgery Status with Reduced HER2+ Breast Cancers: a Retrospective Cohort Study.

Obes Surg 2019 04;29(4):1092-1098

Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, Massachusetts, 02115, United States.

Background: Bariatric surgery is associated with a reduced risk of developing certain malignancies, particularly in women. However, the impact of bariatric surgery on tumor characteristics, cancer treatment, and oncologic outcomes is unknown.

Method: In a retrospective cohort study, 42 subjects diagnosed with breast cancer after bariatric surgery (1989-2014) were matched to 84 subjects with breast cancer (1984-2012) who did not undergo bariatric surgery, based on age, body mass index (BMI), and menopausal status at the time of breast cancer diagnosis, as well as the date of cancer diagnosis. Medical records were reviewed for cancer and bariatric endpoints. Statistical analysis was performed using mixed effects regression models, generalized estimating equation, conditional logistic regression, and Fisher's exact tests.

Results: Women who developed breast cancer after bariatric surgery presented at an earlier stage compared to non-operated, obese controls. In the bariatric surgery group, there were fewer tumors with human epidermal growth factor receptor 2 overexpression (HER2+) (OR 0.16 (0.03-0.76); p = 0.02), with no significant differences seen in estrogen and progesterone receptor positivity. No HER2+ cancers were found in patients who underwent Roux-en-Y gastric bypass (OR 0.00 (0.00-0.43); p = 0.002). On multivariate analysis, bariatric surgery status remained associated with reduced HER2+ breast cancers (OR 0.18 (0.03-0.99); p < 0.05). At a mean follow-up of 5 years, bariatric surgery was associated with trends toward reduced cancer-specific and all-cause mortality.

Conclusions: Bariatric surgery is associated with reduced HER2+ breast cancers, suggesting that bariatric surgery can influence breast cancer characteristics and, potentially, tumor biology.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11695-018-03701-7DOI Listing
April 2019

Epidemiology, Biology, Treatment, and Prevention of Ductal Carcinoma In Situ (DCIS).

JNCI Cancer Spectr 2018 Nov 27;2(4):pky063. Epub 2018 Dec 27.

Surgical Oncology, Division of Breast Surgery, Department of Surgery.

Ductal carcinoma in situ (DCIS) is a highly heterogeneous disease. It presents in a variety of ways and may or may not progress to invasive cancer, which poses challenges for both diagnosis and treatment. On May 15, 2017, the Dana-Farber/Harvard Cancer Center hosted a retreat for over 80 breast specialists including medical oncologists, surgical oncologists, radiation oncologists, radiologists, pathologists, physician assistants, nurses, nurse practitioners, researchers, and patient advocates to discuss the state of the science, treatment challenges, and key questions relating to DCIS. Speakers and attendees were encouraged to explore opportunities for future collaboration and research to improve our understanding and clinical management of this disease. Participants were from Dana-Farber Cancer Institute, Brigham and Women's Hospital, Massachusetts General Hospital, Beth Israel Deaconess Medical Center, Duke University Medical Center, and MD Anderson Cancer Center. The discussion focused on three main themes: epidemiology, detection, and pathology; state of the science including the biology of DCIS and potential novel treatment approaches; and risk perceptions, communication, and decision-making. Here we summarize the proceedings from this event.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/jncics/pky063DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6307658PMC
November 2018

Clinical Impact of Second Opinion Radiology Consultation for Patients With Breast Cancer.

J Am Coll Radiol 2019 Jun 20;16(6):814-823. Epub 2018 Dec 20.

Center for Evidence-Based Imaging and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.

Purpose: To assess the incidence and clinical significance of discrepancy in subspecialty interpretation of outside breast imaging examinations for newly diagnosed breast cancer patients presenting to a tertiary cancer center.

Materials And Methods: This Institutional Review Board-approved retrospective study included patients presenting from July 2016 to March 2017 to a National Cancer Institute-designated comprehensive cancer center for second opinion after breast cancer diagnosis. Outside and second opinion radiology reports of 252 randomly selected patients were compared by two subspecialty breast radiologists to consensus. A peer review score was assigned, modeled after ACR's RADPEER peer review metric: 1-agree; 2-minor discrepancy (unlikely clinically significant); 3-moderate discrepancy (may be clinically significant); 4-major discrepancy (likely clinically significant). Among cases with clinically significant discrepancies, rates of clinical management change (management alterations including change in follow-up, neoadjuvant therapy use, and surgical management as a direct result of image review), and detection of additional malignancy were assessed through electronic medical record review.

Results: A significant difference in interpretation (scores = 3 or 4) was seen in 41 of 252 cases (16%, 95% confidence interval [CI], 11.7%-20.8%). The difference led to additional workup in 38 of 252 cases (15%, 95% CI 10.6%-19.5%) and change in clinical management in 18 of 252 cases (7.1%, 95% CI 4.0%-10.2%), including 15 of 252 with change in surgical management (6.0%, 95% CI, 3.0%-8.9%). An additional malignancy or larger area of disease was identified in 11 of 252 cases (4.4%, 95% CI, 1.8%-6.9%).

Conclusion: Discrepancy between outside and second-opinion breast imaging subspecialists frequently results in additional workup for breast cancer patients, changes in treatment plan, and identification of new malignancies.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jacr.2018.10.010DOI Listing
June 2019

Preoperative Psychosocial and Psychophysical Phenotypes as Predictors of Acute Pain Outcomes After Breast Surgery.

J Pain 2019 05 23;20(5):540-556. Epub 2018 Nov 23.

Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

The severity and impact of acute pain after breast surgery varies markedly among individuals, underlining the importance of comprehensively identifying specific risk factors, including psychosocial and psychophysical traits. In this prospective observational study, women (n = 234) undergoing breast-conserving surgery, mastectomy, or mastectomy with reconstruction completed a brief bedside quantitative sensory testing battery, along with measures of psychosocial characteristics. Postoperative pain severity, impact, and opioid use at 2 weeks were assessed using Brief Pain Inventory and procedure-specific breast cancer pain questionnaires. Moderate-severe average pain (>3/10) was reported by 29% of patients at 2 weeks. Regression analysis of pain outcomes revealed that pain severity was independently predicted by axillary dissection, pre-surgical pain, temporal summation of pain (TSP), (-)positive affect, and behavioral coping style. Pain impact was predicted by age, education, axillary dissection, reconstruction, but also by negative affect and depression scores. Lastly, opioid use was predicted by age, education, axillary dissection, reconstruction, TSP, and reinterpreting coping style. Our findings suggest that, individuals with certain phenotypic characteristics, including high TSP and negative affect, may be at greater risk of significant pain and continued opioid use at 2 weeks after surgery, independent of known surgical risk factors. PERSPECTIVE: We measured differences in the psychosocial and psychophysical processing of pain amongst patients before breast surgery using simple validated questionnaires and brief quantitative sensory testing. Independent of younger age and procedural extent (axillary surgery and reconstruction), affect and greater temporal summation of pain predicted acute postoperative pain and opioid use.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jpain.2018.11.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6511455PMC
May 2019

Going the Distance: Ethical Issues Arising When Patients Seek Cancer Care From International Settings.

J Glob Oncol 2018 09 9;4:1-4. Epub 2017 Jun 9.

Daniel J. Benedetti and Jennifer C. Kesselheim, Dana Farber/Boston Children's Cancer and Blood Disorders Center; and Mehra Golshan, Dana Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1200/JGO.17.00001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6180778PMC
September 2018

Correction to: Margins in Breast-Conserving Surgery After Neoadjuvant Therapy.

Ann Surg Oncol 2018 12;25(Suppl 3):995

Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.

In the original article, there is an error in Jungeun Choi's affiliation. It is corrected as reflected here.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1245/s10434-018-6721-1DOI Listing
December 2018

Implementation of a Venous Thromboembolism Prophylaxis Protocol Using the Caprini Risk Assessment Model in Patients Undergoing Mastectomy.

Ann Surg Oncol 2018 Nov 20;25(12):3548-3555. Epub 2018 Aug 20.

Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.

Background: Guidelines for venous thromboembolism (VTE) prophylaxis are not well-established for breast surgery patients. An individualized VTE prophylaxis protocol using the Caprini score was adopted at our institution for patients undergoing mastectomy ± implant-based reconstruction. In this study, we report our experience during the first year of implementation.

Methods: In August 2016, we adopted a VTE prophylaxis protocol for patients undergoing mastectomy ± implant-based reconstruction. We used the Caprini score, a validated risk assessment tool for VTE, to determine each patient's perioperative prophylaxis regimen. Detailed chart review was performed to record patient and treatment details, the Caprini score, pharmacologic VTE prophylaxis administration, and 30-day incidence of VTE and bleeding complications. We performed univariate analysis to identify factors associated with protocol compliance.

Results: Overall, 522 patients met the inclusion criteria. Median age was 51 years, 486 (93.1%) patients had malignancy, 234 (44.8%) underwent bilateral mastectomy, and 350 (67.0%) underwent reconstruction. Caprini scores ranged from 2 to 11, with 431 (82.6%) patients having a score from 5 to 7. Overall protocol compliance was 60.5%, and was associated with bilateral mastectomy (p = 0.02), reconstruction (p = 0.03), and longer procedures (p < 0.001). The rate of VTE was 0.2% (95% confidence interval [CI] 0.03-1.1%), rate of reoperation for hematoma was 2.7% (95% CI 1.6-4.5%), and rate of blood transfusion was 0.4% (95% CI 0.1-1.4%).

Conclusions: The implementation of an individualized VTE prophylaxis protocol for patients undergoing mastectomy ± implant-based reconstruction is safe and feasible. Despite a high-risk cohort, the incidence of VTE was very low and bleeding complications were consistent with reported rates for breast surgery. Continued evaluation of this strategy is warranted.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1245/s10434-018-6696-yDOI Listing
November 2018

Margins in Breast-Conserving Surgery After Neoadjuvant Therapy.

Ann Surg Oncol 2018 Nov 20;25(12):3541-3547. Epub 2018 Aug 20.

Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.

Background: Optimal margin width for breast-conserving therapy (BCT) after neoadjuvant chemotherapy (NAC) is unknown. We sought to determine the impact of margin width on local recurrence and survival after NAC and BCT.

Methods: Patients treated with NAC and BCT for stage I-III breast cancer from 2002 to 2014 were identified. Multivariate Cox regression was performed to determine the relationship between margin width and local recurrence free-survival (LRFS), disease-free survival (DFS), and overall survival (OS).

Results: A total of 382 patients were included. Median age was 51 years [range 22-79], median tumor size 3.0 cm [range 0.6-11.0], and receptor subtypes included 144 (37.7%) HR-/HER2-, 47 (12.3%) HR-/HER2+, 118 (30.9%) HR+/HER2-, and 70 (18.3%) HR+/HER2+. Breast pathologic complete response (pCR) was achieved in 105 (27.5%) patients. Final margin status was positive in 8 (2.1%) patients, ≤ 1 mm in 65 (17.0%), 1.1-2 mm in 30 (7.9%), and > 2 mm in 174 (45.5%). The 5-year LRFS was 96.3% (95% CI 94.0-98.6), DFS was 85.5% (95% CI 81.8-90.7), and OS was 90.8% (95% CI 87.4-94.2). There was no difference in LRFS, DFS, or OS for margins ≤ 2 versus > 2 mm, and no difference in DFS or OS for margins ≤ 1 versus > 1 mm. HR+ subtype (p = 0.04) and pCR (p = 0.03) were correlated with favorable DFS and node negativity (p < 0.001) with favorable DFS and OS.

Conclusions: In this cohort treated with NAC and BCT, there was no association between margin width and LRFS, DFS, or OS. Although further studies are needed, the excellent long-term outcomes demonstrated in patients with close (≤ 2 mm) margins following NAC suggest that a margin of "no-ink-on-tumor" may be acceptable in appropriately selected patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1245/s10434-018-6702-4DOI Listing
November 2018

Impact of Genomic Assay Testing and Clinical Factors on Chemotherapy Use After Implementation of Standardized Testing Criteria.

Oncologist 2019 05 3;24(5):595-602. Epub 2018 Aug 3.

Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.

Background: For clinically appropriate early-stage breast cancer patients, reflex criteria for Oncotype DX ordering ("the intervention") were implemented at our comprehensive cancer center, which reduced time-to-adjuvant chemotherapy initiation. Our objective was to evaluate Oncotype DX ordering practices and chemotherapy use before and after implementation of the intervention.

Materials And Methods: We examined medical records for 498 patients who had definitive breast cancer surgery at our center. The post-intervention cohort consisted of 232 consecutive patients who had Oncotype DX testing after reflex criteria implementation. This group was compared to a retrospective cohort of 266 patients who were diagnosed and treated prior to reflex criteria implementation, including patients who did and did not have Oncotype DX ordered. Factors associated with Oncotype DX ordering pre- and post-intervention were examined. We used multivariate logistic regression to evaluate factors associated with chemotherapy receipt among patients with Oncotype DX testing.

Results: The distribution of Oncotype DX scores, the proportion of those having Oncotype DX testing (28.9% vs. 34.1%) and those receiving chemotherapy (14.3% vs. 19.4%), did not significantly change between pre- and post-intervention groups. Age ≤65 years, stage II, grade 2, 1-3+ nodes, and tumor size >2 cm were associated with higher odds of Oncotype DX testing. Among patients having Oncotype DX testing, node status and Oncotype DX scores were significantly associated with chemotherapy receipt.

Conclusion: Our criteria for reflex Oncotype DX ordering appropriately targeted patients for whom Oncotype DX would typically be ordered by providers. No significant change in the rate of Oncotype DX ordering or chemotherapy use was observed after reflex testing implementation.

Implications For Practice: This study demonstrates that implementing multidisciplinary consensus reflex criteria for Oncotype DX ordering maintains a stable Oncotype DX ordering rate and chemotherapy rate, mirroring what was observed in a specific clinical practice, while decreasing treatment delays due to additional testing. These reflex criteria appropriately capture patients who would likely have had Oncotype DX ordered by their providers and for whom the test results are predicted to influence management. This intervention serves as a potential model for other large integrated, multidisciplinary oncology centers to institute processes targeting patient populations most likely to benefit from genomic assay testing, while mitigating treatment delays.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1634/theoncologist.2018-0154DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6516114PMC
May 2019