Catherine Pesce

Contralateral Prophylactic Mastectomy Provides No Survival Benefit in Young Women with Estrogen Receptor-Negative Breast Cancer

BackgroundSeveral studies have shown that contralateral prophylactic mastectomy (CPM) provides a disease-free and overall survival (OS) benefit in young women with estrogen receptor (ER)-negative breast cancer. We utilized the National Cancer Data Base to evaluate CPM’s survival benefit for young women with early -stage breast cancer in the years that ER status was available.MethodsWe selected 14,627 women ≤45 years of age with American Joint Committee on Cancer stage I–II breast cancer who underwent unilateral mastectomy or CPM from 2004 to 2006. Five-year OS was compared between those who had unilateral mastectomy and CPM using the Kaplan–Meier method and Cox regression analysis.ResultsA total of 10,289 (70.3 %) women underwent unilateral mastectomy and 4,338 (29.7 %) women underwent CPM. Median follow up was 6.1 years. After adjusting for patient age, race, insurance status, co-morbidities, year of diagnosis, ER status, tumor size, nodal status, grade, histology, facility type, facility location, use of adjuvant radiation and chemohormonal therapy, there was no difference in OS in women <45 years of age who underwent CPM compared towith those who underwent unilateral mastectomy (hazard ratio [HR] = 0.93; p = 0.39). In addition, Tthere was no improvement in OS in women <45 years of age with T1N0 tumors who underwent CPM versus unilateral mastectomy (HR = 0.85; p = 0.37) after adjusting for the aforementioned factors. Among women ≤45 years of age with ER-negative tumors who underwent CPM, there was no improvement in OS compared with women who underwent unilateral mastectomy (HR = 1.12; p = 0.32) after adjusting for the same aforementioned factors.ConclusionsCPM provides no survival benefit to young patients with early-stage breast cancer, and no benefit to ER-negative patients. Future studies with longer follow-up are required in this cohort of patients.

Impact of the American College of Surgeons Oncology Group Z0011 Randomized Trial on the Number of Axillary Nodes Removed for Patients with Early-Stage Breast Cancer

BACKGROUND The Z0011 trial showed similar outcomes between sentinel node biopsy (SNB) alone and axillary node dissection (ALND) for early-stage breast cancer, but few studies have examined Z0011s impact on practice patterns. STUDY DESIGN Using the National Cancer Data Base, we examined use of SNB alone in patients who did and did not fulfill Z0011 eligibility criteria from 1998 to 2011. Because the National Cancer Data Base does not specifically identify SNB vs ALND, we categorized removal of ≤4 nodes as SNB only and ≥10 nodes as ALND. RESULTS Of 74,309 lumpectomy patients who fulfilled Z0011 criteria; 17,630 (23.7%) had a ≤4 nodes removed, 15,619 (21.0%) had 5 to 9 nodes removed, and 41,060 (55.3%) had ≥10 nodes removed. The proportion of lumpectomy patients receiving SNB increased from 6.1% in 1998 to 23.0% in 2009 to 56.0% in 2011 (p < 0.001). Independent predictors of ALND in lumpectomy patients were triple-negative tumors, younger than 50 years old, African-American race, size ≥3.0 cm, ≥2 positive nodes, invasive lobular carcinoma, grade III disease, and lymph node macrometastases. Patients outside of Z0011 criteria also underwent SNB alone: 54% of patients with tumors >5 cm, 52.5% who received no radiation therapy or accelerated partial breast irradiation, 35.9% with clinically positive nodes, 22.3% who underwent mastectomy, and 12.9% who had >3 tumor-positive nodes. CONCLUSIONS The use of SNB alone for patients fulfilling Z0011 criteria has increased substantially from 2009 to 2011. A considerable proportion of patients falling outside of Z0011 eligibility criteria were also treated with SNB alone.

Postoperative Pain and Length of Stay Lowered by Use of Exparel in Immediate, Implant-Based Breast Reconstruction.

Background: Patients undergoing mastectomy and prosthetic breast reconstruction have significant acute postsurgical pain, routinely mandating inpatient hospitalization. Liposomal bupivacaine (LB) (Exparel; Pacira Pharmaceuticals, Inc., Parsippany, N.J.) has been shown to be a safe and effective pain reliever in the immediate postoperative period and may be advantageous for use in mastectomy and breast reconstruction patients. Methods: Retrospective review of 90 immediate implant-based breast reconstruction patient charts was completed. Patients were separated into 3 groups of 30 consecutively treated patients who received 1 of 3 pain treatment modalities: intravenous/oral narcotic pain control (control), bupivacaine pain pump, or LB injection. Length of hospital stay, patient-reported Visual Analog Scale (VAS) pain scores, postoperative patient-controlled analgesia usage, and nausea-related medication use were abstracted and subjected to analysis of variance and multiple linear-regression analysis, as appropriate. Results: Subjects were well-matched for age (P = 0.24) regardless of pain-control modality. Roughly half (53%) of control and pain pump–treated subjects had bilateral procedures, as opposed to 80% of LB subjects. Mean length of stay for LB subjects was significantly less than control (1.5 days vs 2.00 days; P = 0.016). LB subjects reported significantly lower VAS pain scores at 4, 8, 12, 16, and 24 hours compared with pain pump and control (P < 0.01). There were no adverse events in the LB group. Conclusion: Use of LB in this group of immediate breast reconstruction patients was associated with decreased patient VAS pain scores in the immediate postoperative period compared with bupivacaine pain pump and intravenous/oral narcotic pain management and reduced inpatient length of stay.

Variation in Contralateral Prophylactic Mastectomy Rates According to Racial Groups in Young Women with Breast Cancer, 1998 to 2011: A Report from the National Cancer Data Base

BACKGROUND The rate of contralateral prophylactic mastectomy (CPM) for unilateral breast cancer has increased over the past decade, particularly for young women. This study investigates the impact of race and socioeconomic status (SES) on use of CPM. STUDY DESIGN Using the National Cancer Data Base (NCDB), we selected 1,781,409 stage 0 to II unilateral breast cancer patients between 1998 and 2011. Trends in use of CPM by race and SES were analyzed using chi-square tests and logistic regression models. RESULTS For women of all ages, rates of CPM increased, from 1.9% in 1998 to 10.2% in 2011 (p < 0.001), with higher rates in women ≤45 years old, rising from 3.7% in 1998 to 26.2% in 2011 (p < 0.001). Among young women, white women had the greatest increase in CPM from 4.3% in 1998 to 30.2% in 2011 (p < 0.001). In 2011, CPM rates were 30.2% for white, 18.5% for Hispanic, 16.5% for black, and 15.2% for Asian patients (p < 0.001). The gap in CPM use between white and minority patients persisted in every SES classification, geographic region, and facility type. On multivariate analysis, minority women were 50% less likely to undergo CPM than white women were. CONCLUSIONS Young, white, breast cancer patients are twice as likely to undergo CPM compared with women in other racial groups, even after accounting for pathologic, patient, and facility factors. Variations in shared decision-making processes between women of different backgrounds may contribute to these trends, supporting the need for future studies investigating decision-making processes and decisional aids.

Are the ACOSOG Z0011 Trial Findings Being Applied to Breast Cancer Patients Undergoing Neoadjuvant Chemotherapy

In 2010, the ACOSOG Z0011 trial showed equivalent survival and recurrence between sentinel lymph node biopsy (SLNB) alone versus axillary lymph node dissection (ALND) for those with a tumor positive sentinel node (SN). We examined national trends in axillary surgery following neoadjuvant chemotherapy (NAC) for clinically node positive disease in the years prior to and after the Z0011 trial publication. 12,063 women with cT1‐4N1M0 invasive breast cancer who underwent NAC from 2006 to 2013 and had 1‐3 positive nodes on pathology were selected from the National Cancer Data Base. We defined SLNB as 1–4 nodes and ALND as ≥10 nodes examined. 2,704 women (22.4%) underwent SLNB alone and 9,359 (77.6%) underwent ALND. The rate of SLNB increased from 25.6% in 2006 to 33.3% in 2012 in patients that underwent lumpectomy (p < 0.01) and increased from 20.6% to 22.8% in patients that underwent mastectomy (p = 0.25). Patients treated at Community centers (30.4% versus 19.2% at Academic centers) and those with less positive nodes (32.2% for 1 positive node versus 10.1% for 3 positive nodes, p < 0.01) were more likely to have SLNB alone compared to ALND. On multivariate analysis, treatment with lumpectomy (OR 1.46, CI 1.28–1.67), lower number of positive nodes (OR 3.98, CI 3.29–4.82) and lobular subtype (OR 1.82, CI 1.42–2.34) were independent predictors of receiving SLNB alone after NAC. Approximately 22% of patients with cN1 breast cancer underwent SLNB alone for pN1 disease after NAC. Ongoing clinical trials will determine if recurrence and survival rates are equivalent between SLNB and ALND groups.

Post-mastectomy radiation therapy and overall survival after neoadjuvant chemotherapy

The role of postmastectomy radiation therapy (PMRT) after neoadjuvant chemotherapy (NAC) and mastectomy is unclear, especially in patients that have post‐treatment tumor negative axillary nodes (ypN0).

Axillary Surgery for Early-Stage, Node-Positive Mastectomy Patients and the Use of Postmastectomy Chest Wall Radiation Therapy

BackgroundWe examined axillary surgery in mastectomy patients with tumor-positive nodes and how the type of axillary surgery impacted use of postmastectomy chest wall radiation therapy (PMRT).MethodsUsing the National Cancer Data Base, we selected patients with AJCC cT1/T2c N0 breast cancer with one to three tumor-positive lymph nodes treated between 2013 and 2014. Type of axillary surgery was analyzed using the FORDS scope of regional lymph node surgery variable. Multivariable logistic regression modeling was used to identify independent predictors associated with SNB alone and the use of PMRT.ResultsOf 8089 patients, 2482 (30.7%) underwent SNB alone, 1339 (16.6%) underwent axillary dissection (ALND) alone, and 4268 (52.7%) underwent SNB followed by ALND. Fifty-seven percent of patients with micrometastases underwent SNB alone compared with 22.6% of patients with macrometastases. Independent predictors of SNB alone for patients with micrometastases were African American race, number of nodes positive, and PMRT. For patients with macrometastases, age, facility type and location, and PMRT were independent predictors for SNB alone. Of 2449 patients who underwent SNB alone, 1538 (62.8%) had no PMRT, 261 (10.7%) had PMRT alone, and 650 (26.5%) had PMRT with regional nodal irradiation. Patients undergoing SNB alone were 1.70 times [96% confidence interval (CI) 1.45–2.00] more likely to undergo PMRT than upfront ALND and 1.51 times (96% CI 1.34–1.71) more likely than SNB followed by ALND.ConclusionsSurgeons are omitting completion ALND in a third of early-stage, node-positive mastectomy patients. SNB alone patients are more likely to undergo PMRT than patients undergoing ALND.

Clinical accuracy of preoperative breast MRI for breast cancer

It is unclear if breast magnetic resonance imaging (MRI) is more accurate than mammography (MGM) and ultrasound (U/S) in aggregate for patients with invasive cancer.

Erratum to: Impact of an In-visit Decision Aid on Patient Knowledge about Contralateral Prophylactic Mastectomy: A Pilot Study (ANN SURG ONCOL, (2017), 24, (91–99), 10.1245/S10434-016-5556-X)

Department of Surgery, NorthShore University HealthSystem, Evanston, IL; University of California San Francisco School of Medicine, San Francisco, CA; Department of Surgery, MD Anderson Cancer Center, Houston, TX; Dana Farber Cancer Institute, Boston, MA; Mayo Clinic, Rochester, MN; Center for Biomedical Research Informatics, NorthShore University HealthSystem, Evanston, IL; Massachusetts General Hospital, Health Decision Sciences Center, Boston, MA

Abstract 37: Pain Control Using Liposomal Bupivacaine vs Bupivacaine Pain Pump and a Control Group in Implant Based Breast Reconstruction Patients

Daniel R. Butz, MD; Deana S. Shenaq, MD; Veronica L. M. Rundell, PhD; Brittany Kepler; Eric Liederbach, BS; Jeff Thiel, PharmD; Catherine Pesce, MD; Glenn S. Murphy, MD; Mark Sisco, MD; Michael A. Howard, MD Section of Plastic and Reconstructive Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL, USA, Division of Plastic and Reconstructive Surgery, NorthShore University HealthSystem, Evanston, IL, USA, Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA, Department of Pharmacy, NorthShore University HealthSystem, Evanston, IL, USA, Department of Anesthesia, NorthShore University HealthSystem, Evanston, IL, USA