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ABSTRACT: BACKGROUND: Recent retrospective, claims-based analyses have suggested a potential increased rate of toxicities associated with brachytherapy-based accelerated partial breast irradiation (APBI). The purpose of this analysis was to examine cosmesis and toxicity data from the prospective American Society of Breast Surgeons (ASBS) breast brachytherapy registry trial to compare to the findings from the claims analyses. METHODS: The ASBS breast brachytherapy registry is a prospective nonblinded multi-institutional registry trial. Patients with Stage 0-II breast cancer undergoing breast conserving therapy were eligible. A total of 1665 patients were enrolled and 1449 treated between 2002 and 2004 with a median followup of 63 months. All patients were treated with the MammoSite (Hologic, Inc.) single-lumen device to deliver adjuvant APBI (34Gy in 3.4Gy fractions). RESULTS: The rate of excellent/good cosmesis was 90.6% at 84 months. The rate of a complication (symptomatic seroma, infection, fat necrosis, telangiectasias) at 1 year/any time point was 24.2%/38.5%, whereas the rate of noninfectious complications at 1 year/any time point was 14.8%/28.9%. The rate of symptomatic seroma, fat necrosis, infection, and telangiectasia at any time was 13.4%, 2.5%, 9.6%, and 13.0%, respectively. CONCLUSIONS: The final toxicity analysis from ASBS breast brachytherapy registry trial confirms the previously noted excellent cosmesis and toxicity profiles and fails to confirm retrospective claims analyses that have suggested higher rates of toxicity for brachytherapy-based APBI.
Brachytherapy 05/2013; · 1.47 Impact Factor
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ABSTRACT: PURPOSE: To develop clinical guidelines for the quality practice of accelerated partial breast irradiation (APBI) as part of breast-conserving therapy for women with early-stage breast cancer. METHODS AND MATERIALS: Members of the American Brachytherapy Society with expertise in breast cancer and breast brachytherapy in particular devised updated guidelines for appropriate patient evaluation and selection based on an extensive literature search and clinical experience. RESULTS: Increasing numbers of randomized and single and multi-institution series have been published documenting the efficacy of various APBI modalities. With more than 10-year followup, multiple series have documented excellent clinical outcomes with interstitial APBI. Patient selection for APBI should be based on a review of clinical and pathologic factors by the clinician with particular attention paid to age (≥50 years old), tumor size (≤3cm), histology (all invasive subtypes and ductal carcinoma in situ), surgical margins (negative), lymphovascular space invasion (not present), and nodal status (negative). Consistent dosimetric guidelines should be used to improve target coverage and limit potential for toxicity following treatment. CONCLUSIONS: These guidelines have been created to provide clinicians with appropriate patient selection criteria to allow clinicians to use APBI in a manner that will optimize clinical outcomes and patient satisfaction. These guidelines will continue to be evaluated and revised as future publications further stratify optimal patient selection.
Brachytherapy 04/2013; · 1.47 Impact Factor
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ABSTRACT: The purpose of this study was to analyze the cost-efficacy of multiple accelerated partial-breast irradiation (APBI) techniques compared with whole breast irradiation (WBI) delivered utilizing 3-dimensional conformal radiotherapy (3D-CRT) and intensity-modulated radiation therapy (IMRT). A previously reported matched-pair analysis consisting of 199 patients receiving WBI and 199 patients receiving interstitial APBI formed the basis of this analysis. Cost analyses included a cost minimization analysis, incremental cost- effectiveness ratio (ICER) analysis, and cost per quality adjusted life year (QALY) analysis. Per 1,000 patients treated, the cost savings with the utilization of APBI compared to WBI IMRT is $14.9 million, $10.9 million, $8.8 million, $5.0 million, and $9.7 million for APBI 3D-CRT, APBI IMRT, APBI single-lumen (SL), APBI multi-lumen (ML), and APBI interstitial, respectively. Per 1,000 patients treated, the cost savings with the utilization of APBI compared to WBI 3D-CRT is $6.0 million, $2.0 million, and $0.7 million for APBI 3D-CRT, APBI IMRT, and APBI interstitial, respectively. The cost per QALY for APBI SL, APBI ML, and APBI interstitial compared with APBI 3D-CRT are $12,273, $66,032, and $546, respectively. When incorporating non-medical costs and cost of recurrences the cost per QALY was $54,698 and $49,009 for APBI ML compared with APBI 3D-CRT. When compared to WBI IMRT, all APBI techniques are cost-effective based on cost minimization, ICER, and QALY analyses. When compared to WBI 3D-CRT, external beam APBI techniques represent a more cost-effective approach based on cost minimization with brachytherapy representing a cost-effective approach based on cost per QALY.
Breast Cancer Research and Treatment 01/2013; · 4.43 Impact Factor
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ABSTRACT: The aim of this study is to perform a cost analysis to compare adjuvant radiation therapy schedules following breast conserving surgery. Treatment planning and delivery utilization data were modeled for a series of 10 different breast RT techniques. The whole breast (WB) regimens consisted of: (1) Wedge based WB (25 fractions [fx]), (2) WB using IMRT, (3) WBRT with a boost (B), (4) WBRT using IMRT with a B, (5) Canadian WB (16 fx) with 3D-CRT, and (6) Canadian using IMRT. The accelerated partial breast irradiation (APBI) regimens included (7): APBI using 3D-CRT, (8) IMRT, (9) single channel balloon, and (10) multi-channel balloon. Costs incurred by the payer (i.e., direct medical costs) were taken from the 2011 Medicare Fee Schedule. Among all the different regimens examined, Canadian 3D-CRT and APBI 3D-CRT were the least costly whereas WB using IMRT with a B was the most expensive. Both APBI brachytherapy techniques were less costly than conventional WB with a B. In terms of direct medical costs, the technical component accounted for most, if not all, of the disparity among the various treatments. A general trend of decreasing RT costs was observed with further reductions in overall treatment time for WBRT techniques, but not all of the alternative treatment regimens led to similar total cost savings. APBI using brachytherapy techniques was less costly than conventional WBRT with a standard boost.
The Breast Journal 01/2013; · 1.64 Impact Factor
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The Breast Journal 01/2013; 19(1):119-20. · 1.64 Impact Factor
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ABSTRACT: PURPOSE:: To compare reimbursement and cost efficacy between accelerated partial breast irradiation (APBI) techniques. MATERIALS/METHODS:: Four hundred fifty-three patients were treated with APBI using either 3-dimensional conformal radiotherapy (3D-CRT, n=207) or balloon-based brachytherapy (BB) [single-lumen (SL, n=161) and multilumen (ML, n=85)] between March 2000 and October 2011. To evaluate cost-effectiveness, reimbursement by treatment technique was calculated based on 2011 Medicare schedules. Facility costs were generated by technique based on ICD-9 codes. Incremental cost effectiveness ratios (ICER), which compares cost with clinical outcomes, were calculated according to the difference in reimbursement to the criteria being evaluated. RESULTS:: With a median follow-up of 3.6 years, the 5-year rate of local recurrence was 1.9% for all patients (3D-CRT, 0%; BB, 4.1%; P=0.23). When pooled, BB patients had a significant improvement in excellent/good cosmesis (91.6% vs. 80.0%; P=0.03). Rates of combined grade 2 or higher dermatitis, hyper/hypopigmentation, pain, or fibrosis per technique were 62%, 28%, and 34% for 3D-CRT, SL, and ML patients, respectively (P=0.26). The ICER per percent improved cosmesis for SL/ML was $519/$850 based on reimbursement and $301/$643 based on cost compared with 3D-CRT. CONCLUSIONS:: On the basis of ICER, brachytherapy for APBI is a cost-effective option with regard to cosmesis and toxicity. This economic analysis suggests the increased cost of applicator-based brachytherapy may be justified in appropriately selected patients.
American journal of clinical oncology 12/2012; · 2.21 Impact Factor
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J Ben Wilkinson,
Peter D Beitsch, Chirag Shah,
Doug Arthur,
Bruce G Haffty,
David E Wazer,
Martin Keisch,
Simona F Shaitelman,
Maureen Lyden,
Peter Y Chen,
Frank A Vicini
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ABSTRACT: PURPOSE: To determine whether the American Society for Radiation Oncology (ASTRO) Consensus Statement (CS) recommendations for accelerated partial breast irradiation (APBI) are associated with significantly different outcomes in a pooled analysis from William Beaumont Hospital (WBH) and the American Society of Breast Surgeons (ASBrS) MammoSite® Registry Trial. METHODS AND MATERIALS: APBI was used to treat 2127 cases of early-stage breast cancer (WBH, n=678; ASBrS, n=1449). Three forms of APBI were used at WBH (interstitial, n=221; balloon-based, n=255; or 3-dimensional conformal radiation therapy, n=206), whereas all Registry Trial patients received balloon-based brachytherapy. Patients were divided according to the ASTRO CS into suitable (n=661, 36.5%), cautionary (n=850, 46.9%), and unsuitable (n=302, 16.7%) categories. Tumor characteristics and clinical outcomes were analyzed according to CS group. RESULTS: The median age was 65 years (range, 32-94 years), and the median tumor size was 10.0 mm (range, 0-45 mm). The median follow-up time was 60.6 months. The WBH cohort had more node-positive disease (6.9% vs 2.6%, P<.01) and cautionary patients (49.5% vs 41.8%, P=.06). The 5-year actuarial ipsilateral breast tumor recurrence (IBTR), regional nodal failure (RNF), and distant metastasis (DM) for the whole cohort were 2.8%, 0.6%, 1.6%. The rate of IBTR was not statistically higher between suitable (2.5%), cautionary (3.3%), or unsuitable (4.6%) patients (P=.20). The nonsignificant increase in IBTR for the cautionary and unsuitable categories was due to increased elsewhere failures and new primaries (P=.04), not tumor bed recurrence (P=.93). CONCLUSIONS: Excellent outcomes after breast-conserving surgery and APBI were seen in our pooled analysis. The current ASTRO CS guidelines did not adequately differentiate patients at an increased risk of IBTR or tumor bed failure in this large patient cohort.
International journal of radiation oncology, biology, physics 11/2012; · 4.59 Impact Factor
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ABSTRACT: BACKGROUND: Limited 5-year data exist on clinical outcomes and toxicities for patients undergoing 3-dimensional conformal radiation therapy (3D-CRT) APBI. PATIENTS AND METHODS: Two hundred five patients were treated with 3D-CRT APBI between August, 2000 and December, 2011. Cases with > 1 year of follow-up were analyzed for cosmesis, chronic toxicities, and clinical outcomes. Outcome by American Society for Radiation Oncology (ASTRO) Consensus Panel (CP) group were also compared. Rates of excellent and good cosmesis for 3D-CRT were evaluated over time for stability. RESULTS: One hundred ninety-two patients were evaluated; median follow-up was 4.8 years (range, 1.0-11.2 years). Seventy-two patients (37.5%) were categorized as ASTRO CP subgroup 'suitable,' 89 (46.4%) 'cautionary,' and 31 (16.1%) 'unsuitable.' At 5 years, the rate of IBTR, regional recurrence, distant metastases, cause-specific survival, and overall survival were 0%, 0%, 2%, 99%, and 92%, respectively. Thirty-seven percent of patients had excellent cosmesis, 44% good cosmesis, 15% fair cosmesis, and 4% poor cosmesis. No statistically significant differences in excellent (37% vs. 37%; P = .99) or good (49% vs. 37%; P = .28) cosmesis were noted between patients with < 5 years follow-up and those with ≥ 5 years follow-up. The rates of grade III fibrosis and telangiectasia were 7.5% and 7.6%, respectively. CONCLUSION: In the largest group of patients published to date using 3D-CRT to deliver APBI, no local recurrences were noted at 5 years. More than 80% of patients had excellent or good cosmesis.
Clinical Breast Cancer 10/2012; · 2.38 Impact Factor
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ABSTRACT: PURPOSE: Limited outcomes exist in patients who develop an ipsilateral breast tumor recurrence (IBTR) after accelerated partial breast irradiation (APBI). The purpose of this study was to evaluate these outcomes and patterns of failure in our cohort of patients undergoing APBI. METHODS AND MATERIALS: A total of 534 patients with early-stage breast cancer were treated with APBI between 1993 and 2010. Clinical, pathologic, and treatment-related variables were analyzed. Clinical outcomes, including further IBTR, regional recurrence, disease-free survival, cause-specific survival, and overall survival were analyzed. RESULTS: Eighteen (3.3%) patients developed an IBTR, for a 5-year actuarial rate of 2.0%; 14 (77.8%) of the recurrences were thought to represent new primary cancers. After IBTR, 13 (72.2%) patients were managed with salvage mastectomy and 4 (22.2%) patients with a second attempt at breast-conserving therapy. Five-year rates of disease-free survival, cause-specific survival, and overall survival after salvage mastectomy for IBTR were 81%, 100%, and 100%, respectively. In the 4 patients treated with a second attempt at breast-conserving therapy, no IBTR, axillary failure, regional recurrence, or distant metastases were noted at 5 years. CONCLUSIONS: IBTRs that developed after APBI resulted in excellent clinical outcomes comparable with those observed after whole-breast irradiation.
Clinical Breast Cancer 10/2012; · 2.38 Impact Factor
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ABSTRACT: BACKGROUND: This study reports the rate of breast reconstruction failure and cosmetic outcomes after postmastectomy radiation therapy (PMRT) with temporary tissue expanders (TEs) or implants in place. PATIENTS AND METHODS: Ninety-four patients underwent mastectomy (93 unilateral, 1 bilateral; 95 cases total) and immediate TE reconstruction followed by PMRT. Ninety TEs and 5 permanent implants were irradiated. All patients received a dose of 5400 cGy given in 180-cGy fractions to the reconstructed breast. Twenty-one patients (22%) received tangents alone and 74 patients (78%) were treated with tangents and a supraclavicular field using a monoisocentric technique. Bolus was used in 91 patients (96%). Eighty-eight patients (93%) received chemotherapy and 78 patients (82%) received endocrine therapy. RESULTS: With a median follow-up of 24.1 months, 19 patients (20%) experienced failure of reconstruction. The 1-, 2-, and 3-year actuarial rate of reconstruction failure was 9.7%, 19.3%, and 25.5%, respectively. Infection was the most common cause of failure. Of the 19 failures, 8 patients underwent salvage procedures with flap reconstruction. Univariate analysis was performed examining age, chemotherapy use, hormone therapy use, use of a supraclavicular field, smoking status, diabetes, hypertension, and menopausal status. No risk factors were found to be associated with reconstruction failure. In patients who did not experience reconstruction failure, good/excellent cosmesis was observed in 75% of patients. CONCLUSION: In the current series of women with a high risk of locoregional recurrence, PMRT with a TE/implant in place provides good cosmesis in the majority of women, with an acceptable risk of expander or implant loss.
Clinical Breast Cancer 10/2012; · 2.38 Impact Factor
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ABSTRACT: A lack of consistent data are available about optimizing cosmetic outcomes, reducing potential treatment-related toxicities, and defining important prognostic factors for women undergoing postmastectomy radiation therapy (PMRT) following breast reconstruction. A Medline search was conducted to summarize the latest data on the topic with a focus on both autologous and tissue expander/implant (E/I) reconstructions. Autologous tissue reconstructions (ATR) represent less than 20 % of all breast reconstructions and include several techniques. A multitude of small studies have suggested that ATR is associated with improved cosmetic outcomes and similar rates of complications compared with E/I reconstructions. With regards to ATRs, the addition of PMRT has been suggested but not definitively associated with a decrement in cosmetic outcome compared with patients not receiving radiation. Expander/implant-based reconstruction appears to be the most common form of breast reconstruction with large, prospective, and retrospective series demonstrating that 20-30 % of patients may require some type of revision/replacement with long-term follow-up based on large series from Memorial Sloan Kettering Cancer Center and the Cleveland Clinic. Whereas PMRT and the addition of regional irradiation has been traditionally associated with increased complications and worse outcomes with E/I reconstruction, recent data suggest that no difference in perioperative complications exists in patients receiving PMRT using modern techniques.
Annals of Surgical Oncology 10/2012; · 4.17 Impact Factor
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ABSTRACT: PURPOSE: To analyze outcomes in patients with ductal carcinoma-in-situ (DCIS) treated with accelerated partial breast irradiation (APBI) within a pooled set of patients. METHODS: A total of 300 women with DCIS underwent APBI between April 1993 and November 2010 as part of American Society of Breast Surgeons MammoSite Registry Trial (n = 192) or at William Beaumont Hospital (n = 108). Patients with pure DCIS <3 cm (n = 125) were assigned to the cautionary risk group per American Society of Radiation Oncology consensus panel guidelines for off-protocol use of APBI and analyzed compared to a pooled invasive suitable (n = 653) risk group and pooled invasive suitable/cautionary (n = 1,298) risk group. RESULTS: The rate of ipsilateral breast tumor recurrence (IBTR) for all 300 DCIS patients was 2.6 % at 5 years with no regional recurrences, while cause-specific survival was 99.5 % and overall survival (OS) was 96.4 %. When comparing the cautionary DCIS group to the invasive suitable/cautionary group, no difference in IBTR was noted (2.6 vs. 3.1 %, P = 0.90) with significant improvements in distant metastases (0 vs. 2.5 %, P = 0.05), disease-free survival (98.5 vs. 94.4 %, P = 0.05), and OS (95.7 vs. 90.8 %, P = 0.03) noted for DCIS patients. When comparing cautionary DCIS patients to invasive suitable patients, no difference in IBTR were noted (2.6 vs. 2.4 %, P = 0.76), while improved OS for DCIS patients was noted (95.7 vs. 90.9 %, P = 0.02). CONCLUSIONS: This analysis of the largest cohort of patients with DCIS treated with APBI supports previously reported excellent outcomes; as a result of small numbers of events, further data are necessary to confirm these findings.
Annals of Surgical Oncology 09/2012; · 4.17 Impact Factor
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ABSTRACT: PURPOSE: To examine the impact of margin status on clinical outcomes for patients enrolled in the American Society of Breast Surgeons (ASBrS) MammoSite(®) Registry Trial. METHODS AND MATERIALS: One thousand four hundred forty-nine cases of early-stage breast cancer underwent breast-conserving therapy with a single-lumen balloon-based applicator used to deliver adjuvant accelerated partial breast irradiation (34Gy in 10, bid fractions). One thousand two hundred fifty-five cases (87%) had invasive breast cancer (median size=10mm) and 194 cases (13%) had ductal carcinoma in situ (DCIS; median size=8mm). RESULTS: Patients were stratified by margin status into negative (n=1326), close (<2mm; n=110), and positive (n=13) margins. One hundred twenty-three cases (8.5%) had close or positive margins. Overall, no statistical difference in the 6-year rate of ipsilateral breast tumor recurrence (IBTR) was noted for close margins compared with that of margin-negative patients (8.7% vs. 4.1%, p=0.10) or for positive margins compared with that of margin-negative patients (14.3% vs. 4.1%, p=0.41). In patients with DCIS, there was a statistically significant increase in IBTR with close margins (17.6% vs. 4.2%, p=0.004) and when close and positive margins were pooled (15.7% vs. 4.2%, p=0.01 with a nonsignificant reduction in disease-free survival for DCIS patients with close margins (82.4% vs. 90.8%, p=0.12). The increase in IBTR for close and close/positive patients was secondary to statistically significant increases in elsewhere failures rather than true recurrences/marginal misses. CONCLUSION: Nonsignificant increases in the rates of IBTR were noted with close and positive margins for invasive cancer with further data required to validate these findings.
Brachytherapy 08/2012; · 1.47 Impact Factor
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American journal of clinical oncology 08/2012; 35(4):406. · 2.21 Impact Factor
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ABSTRACT: With improved outcomes following treatment of breast cancer, chronic toxicities including breast cancer related lymphedema (BCRL), gain increased significance with limited evidence-based guidelines present. This review attempts to summarize data addressing these concerns and provides recommendations based on currently published data. Substantial differences exist in rates of BCRL reported in the literature ranging from less than 5% to 65% based on locoregional therapy. Based on recent data, early diagnosis of BCRL appears critical and requires careful attention to patient risk factors and the use of newer diagnostic tools. Initial treatment with decongestive lymphatic therapy/compressive stockings can provide significant improvement in patient symptoms and volume reduction of edematous extremities. At this time, consensus recommendations for disease classification, diagnostic testing and treatment are still lacking. Awareness of the frequency of this toxicity is now important as more accurate clinical aids have become accessible to diagnose the condition at an earlier stage allowing timely intervention providing the opportunity for treatment strategies to be more effective.
The Breast Journal 07/2012; 18(4):357-61. · 1.64 Impact Factor
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ABSTRACT: PURPOSE: To evaluate the cost-effectiveness and outcomes of low-dose-rate (LDR) and high-dose-rate (HDR) brachytherapy compared with intensity-modulated radiation therapy (IMRT) in patients with low/intermediate risk of prostate cancer. METHODS AND MATERIALS: One thousand three hundred twenty-eight patients with low or intermediate risk of prostate cancer were treated with LDR (n=207), HDR with four fractions (n=252), or IMRT (n=869) between January 1992 and December 2008. LDR patients were treated with palladium seeds to a median dose of 120Gy, whereas HDR patients were treated to a median dose 38.0Gy (four fractions). IMRT patients received 42-44 fractions with a median dose of 75.6Gy. Clinical outcomes were compared, including biochemical failure, cause-specific survival, and overall survival. RESULTS: Overall, no differences in 5-year biochemical control (BC) or cause-specific survival were noted among treatment modalities. The calculated reimbursement for LDR brachytherapy, HDR brachytherapy with four fractions, and IMRT was $9,938; $17,514; and $29,356, respectively. HDR and LDR brachytherapy were statistically less costly to Medicare and the institution than IMRT (p<0.001), and LDR brachytherapy was less costly than HDR brachytherapy (p=0.01 and p<0.001). Incremental cost-effectiveness ratios for cost to Medicare for BC with IMRT were $4045 and $2754 per percent of BC for LDR and HDR brachytherapy, respectively. Incremental cost-effectiveness ratio using institutional cost comparing IMRT with LDR and HDR brachytherapy was $4962 and $4824 per 1% improvement in BC. CONCLUSIONS: In this study of patients with low and intermediate risk of prostate cancer, comparable outcomes at 5 years were noted between modalities with increased costs associated with IMRT.
Brachytherapy 06/2012; · 1.47 Impact Factor
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ABSTRACT: Limited data exist on the use of accelerated partial breast irradiation (APBI) in patients with ductal carcinoma in situ (DCIS). The purpose of this analysis was to evaluate clinical outcomes after APBI in patients with DCIS.
Between December 2002 and December 2010, 99 patients with DCIS underwent APBI as part of their breast-conserving therapy (BCT). Partial breast irradiation techniques included interstitial brachytherapy, balloon-based brachytherapy, and 3-dimensional conformal radiotherapy (3D-CRT). Clinical outcomes including local recurrence, regional recurrence, disease-free survival (DFS), cause-specific survival, and overall survival (OS) were analyzed.
Mean follow up was 3.0 years, with a mean patient age of 61.8 years. At 5 years, the rates of local recurrence and regional recurrence were 1.4% and 0%, respectively. Overall survival was 94%, whereas cause-specific survival was 100%. No difference was noted in local control for each treatment technique. When comparing rates using the Eastern Cooperative Oncology Group (ECOG) E-5194 trial groupings, the rate of local recurrence in our cohort was 2.0% for patients with grade I/II disease < 2.5 cm and 0% for grade III < 1.0 cm, representing a 50% and 100% decrease, respectively, in local recurrence compared with excision alone.
Patients with DCIS treated with APBI had excellent clinical outcomes regardless of the APBI technique used. Until the publication of prospective phase III trials, these data confirm previous reports highlighting the efficacy of APBI in the treatment of noninvasive carcinoma of the breast.
Clinical Breast Cancer 05/2012; 12(4):259-63. · 2.38 Impact Factor
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J Ben Wilkinson,
Frank A Vicini, Chirag Shah,
Simona Shaitelman,
Maha S Jawad,
Hong Ye,
Larry L Kestin,
Neal S Goldstein,
Alvaro A Martinez,
Pamela Benitez,
Peter Y Chen
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ABSTRACT: Management of mammographically detected ductal carcinoma in situ (DCIS) at a single institution was reviewed to determine long-term clinical outcomes after treatment with breast-conserving therapy (BCT).
Data from all patient-cases with DCIS who received BCT between 1980 and 1993 were reviewed. Patient demographics and pathologic factors were analyzed for their effect on outcomes, including ipsilateral breast tumor recurrence (IBTR) and survival. BCT included breast-conserving surgery followed by external-beam radiotherapy to the whole breast, with 86 % of patients receiving a lumpectomy cavity boost. The median dose to the whole breast was 50 Gy and 60.4 Gy to the lumpectomy cavity.
A total of 129 cases were evaluated; the median follow-up was 19.3 years. Twenty-one patients developed an ipsilateral breast tumor recurrence (IBTR), 76.2 % of which were invasive (n = 16). Fourteen recurrences (66 %) were within the same breast quadrant (true recurrence), while an additional 7 cases developed an IBTR elsewhere in the breast. True recurrences were more prevalent in women <45 years of age (20 %/24 % vs. 5.1 %/8 %) at 10 and 20 years (p = 0.02). The 5-, 10-, 15-, and 20-year actuarial rates of IBTR for this cohort were 8.7, 10.4, 12.1, and 16.3 % (IBTR), while overall survival at 5, 10, and 20 years was 97.6, 96.8, and 96.8 %, respectively.
Mammographically detected DCIS remains a clinically distinct subset of noninvasive breast cancer. With 20 year follow-up, local control and overall survival are excellent after BCT.
Annals of Surgical Oncology 05/2012; 19(12):3785-91. · 4.17 Impact Factor
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ABSTRACT: Limited data are available on the implementation of a high-risk assessment program in the construct of a community clinical oncology program. The development of a high-risk breast cancer screening program at our institution identified 15%-20% of patients screened as high risk, with limited increases in structural or personnel requirements. Identification of patients as high risk could potentially improve outcomes by allowing for individualized prevention strategies and more appropriate high-risk surveillance.
The implementation of a program that incorporates a risk assessment questionnaire (RAQ) to identify high-risk patients in a community-based health system was evaluated.
Women with no history of breast cancer or ductal carcinoma in situ who were undergoing annual screening mammography were offered an RAQ. Cases determined to be high risk (Gail lifetime risk ≥20% or as indicated through personal and/or family history) were offered referral to our High-risk Breast Cancer Program. A retrospective data review was conducted on completed questionnaires.
A total of 5878 women underwent evaluation with the RAQ between September 2009 and August 2010. The mean age of the cohort was 55 years old, with 84.9% (4990) of participants being white, and 6.8% (400) African American. In the entire population, 45.7% (2446) had at least 1 first-degree relative with breast cancer (BC), and 923 (17.2%) women were found to be high risk by the Gail model. Beyond the Gail model, 53 (0.9%) women had undergone prior chest radiation, 34 (0.6%) had a male relative with BC, 200 (3.4%), had 3 or more relatives with BC on one side of their family, 308 (5.2%) had a relative with breast and ovarian cancer on one side of the family, and 105 (1.8%) noted 2 relatives with BC with onset under age 50 years on the same side of the family.
Our experience indicates that the identification of women at high risk for BC can be easily incorporated into an annual screening mammography visit. Identification of these patients as high risk can allow for individualized, more-appropriate surveillance and prevention.
Clinical Breast Cancer 04/2012; 12(3):215-8. · 2.38 Impact Factor
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ABSTRACT: Single-frequency bioelectrical impedance (BI) has been used to measure extracellular fluid in the upper limbs. The purpose of the study was to evaluate BI's ability to detect and monitor upper limb changes in based upon the extent of various treatments and to assess its practicality.
Patients with newly diagnosed breast cancer were evaluated at baseline and after procedures that could potentially affect fluid accumulation in the arm and signal the possible development of early lymphedema. The magnitude of the change in lymphedema index ratios (LIR) from these procedures was evaluated to determine the sensitivity of BI.
A total of 64 patients were evaluated. Although no difference in LIRs was noted by the extent of surgical procedure (lumpectomy 2.1 vs. mastectomy 1.1; P = .49), a trend was noted for increased LIRs with more aggressive axillary staging when sentinel lymph node was compared with axillary lymph node dissection (1.3 vs. 3.4; P = .08). A trend for an increased LIR with more aggressive local therapy also was noted when using a cutoff of less than 4 lymph nodes sampled compared with 4 or more nodes sampled (1.2 vs. 2.6; P = .09).
In this limited analysis, L-Dex readings paralleled the extent of surgical interventions and suggest that they can be used to monitor patients for the early onset of edema. Further studies are needed to help validate the extent, degree, and chronologic time frame of these changes to help define recommendations for closer monitoring of patients and possible early intervention.
Clinical Breast Cancer 04/2012; 12(2):133-7. · 2.38 Impact Factor
