Eleni A. Tousimis

New Breast Cancer Radiotherapy Technology Confers Higher Complications and Costs Before Effectiveness Proven: A Medicare Data Analysis

A new breast cancer treatment, brachytherapy-based accelerated partial breast radiotherapy (RT), was adopted before long-term effectiveness evidence, potentially increasing morbidity and costs compared with whole breast RT. The aim of this study was to estimate complication rates and RT-specific and 1-year costs for a cohort of female Medicare beneficiaries diagnosed with breast cancer (N = 47 969). We analyzed 2005-2007 Medicare claims using multivariable logistic regression for complications and generalized linear models (log link, gamma distribution) for costs. Overall, 11% (n = 5296) underwent brachytherapy-based RT; 9.4% had complications. Odds of any complication were higher (odds ratio [OR]: 1.62; 95% confidence interval [CI]: 1.49-1.76) for brachytherapy versus whole breast RT, similarly to seroma (OR: 2.85; 95% CI: 1.97-4.13), wound complication/infection (OR: 1.72; 95% CI: 1.52-1.95), cellulitis (OR: 1.48; 95% CI: 1.27-1.73), and necrosis (OR: 2.07; 95% CI: 1.55-2.75). Mean RT-specific and 1-year total costs for whole breast RT were

Overview of indications for nipple sparing mastectomy

6375, and

Delayed Recurrent and Bilateral Breast Cancer in Patients With Partial Poland's Anomaly: Report of 2 Rare Cases and Review of the Literature

19 917,

Timing of radiation therapy in nipple-sparing mastectomy influences outcomes and patient-reported quality of life

4886, and

Nipple-Sparing Mastectomy in the Previously Radiated Patient

4803 lower than brachytherapy (P < .0001). Multivariable analyses indicated brachytherapy yielded 76% higher RT costs (risk ratio: 1.76; 95% CI: 1.74-1.78, P < .0001) compared with whole breast RT. Brachytherapy had higher complications and costs before long-term evidence proved its effectiveness. Policies should require treatment registries with reimbursement incentives to capture surveillance data for new technologies.

Diffusion of accelerated partial breast radiotherapy in the United States: physician-level and patient-level analyses.

The introduction of more targeted systemic therapies, better screening modalities with earlier diagnosis and dramatically improved reconstructive techniques has allowed more minimally invasive approaches to breast surgery. The recent introduction of nipple sparing mastectomy (NSM) has dramatically improved the cosmetic outcomes and quality of life (QoL) for patients undergoing mastectomy. This technique involves preservation of both the skin envelope including the nipple areolar complex commonly through a barely visible inframammary skin incision followed by immediate breast reconstruction. An ideal candidate includes women with small breasts, absence of ptosis, low BMI and not actively smoking. High risk patients include those with radiation treatment, active smokers, macromastia, high BMI >30 kg/m2, grade 2 or 3 ptosis and active smokers. There are several new techniques to approach complex high risk patients which have expanded the candidates for NSM.

TARGIT-R (Retrospective): North American Experience with Intraoperative Radiation Using Low-Kilovoltage X-Rays for Breast Cancer

Patients with Poland’s anomaly are at risk for developing cancer in the ipsilateral hypoplastic/normal, contralateral, and reconstructed breasts. To date, however, only 16 cases of concurrent breast cancer in patients with Poland’s anomaly have been described. We report the first cases of (1) recurrent ipsilateral and (2) bilateral breast cancer in 2 patients with mild variants of partial Poland’s sequence. In both cases, localized, hormone-sensitive, ductal-based carcinoma was identified and effectively treated with mastectomy, direct lymph node assessment, and autologous reconstruction with regional pedicled flaps. No adjuvant therapies were administered in either case, and both patients remained disease-free at long-term follow-up. Recommendations regarding diagnostic screening for breast cancer in patients with Poland’s anomaly should follow those of the general population. Underlying anatomical abnormalities in these patients require special consideration, as skeletal and/or soft tissue derangements may influence decisions regarding appropriate diagnostic imaging, surgical treatment planning, adjunct oncologic therapies, and strategies for breast/chest wall reconstruction.

Management of synchronous phyllodes tumors with invasive breast carcinoma: A review of the literature and a case report breast

The aim of this study is to assess the complication profile and impact on patient‐reported quality of life in those undergoing nipple‐sparing mastectomy (NSM) with immediate breast reconstruction and subsequent prosthetic reconstruction in patients with prior breast radiation therapy (pRT) vs those receiving adjuvant post‐mastectomy radiation therapy (PMRT). An IRB‐approved, retrospective analysis was performed from 2002 to 2014 to identify NSM patients that underwent pRT or PMRT. A 22‐item Likert scale questionnaire was administered by a third party to register patient‐reported quality of life. Forty patients met criteria for outcomes analysis, and 30 patients answered the questionnaire. Mean age was 45.6 years old and mean follow‐up was 3.8 years. Complication rates for the PMRT cohort were 61.9% vs 31.6% in the pRT cohort, P = .067, and those requiring operative intervention were PMRT 38.1% vs pRT 5.3%, P = .021. Nipple‐areolar complex survival was 100% in the pRT vs 85.7% in the PMRT, P = .233. Breast‐related quality of life scores were superior in the pRT group within multiple domains. Patients are more likely to develop complications requiring an operative intervention and have decreased breast‐related quality of life when undergoing NSM with PMRT compared to patients undergoing NSM having received pRT.

Abstract 61: Hyperbaric Oxygen Therapy Does Not Decrease Progression of Skin Flap and Nipple Areolar Ischemia to Necrosis in Nipple-sparing Mastectomy

There is very limited clinical experience with nipple-sparing mastectomy in previously radiated patients since local recurrences are rare after lumpectomy and radiation therapy. In addition, few previously radiated patients are considered appropriate candidates for nipple sparing mastectomy because of preoperative asymmetry, poor quality of skin, and a known association with a high risk of postoperative complications.

Breast Cancer following Augmentation Mammaplasty: A Case-Control Study

Purpose:To evaluate diffusion of brachytherapy-based accelerated partial breast radiotherapy (RT) in the United States, a new breast cancer treatment requiring 5 days twice daily, rather than daily treatment for 6–7 weeks. It has limited long-term effectiveness data compared with standard whole breast RT. Data and Methods:We used 2005–2008 Medicare claims for female Medicare beneficiaries receiving RT after breast-conserving surgery merged with physician and area-based data (n=74,254 patient-subjects; n=1901 physicians), applying logistic regression to estimate: (1) proportion of patients for whom the radiation oncologist used brachytherapy-based accelerated RT, and (2) probability a patient received brachytherapy-based accelerated RT, clustering on physician. Results:Use of accelerated partial breast RT increased over time (8% in 2005 to 17% in 2008). Physician-level analysis indicates rural physicians were less likely to perform accelerated RT [odds ratio (OR): 0.35–0.49; P<0.002)]; as were those licensed 20+years [OR: 0.54; 95% confidence interval (CI), 0.39–0.74]. Overall, 11.7% of patients received accelerated RT. Treatment post 2005 was associated with increasing odds of receiving accelerated RT (P<0.0001). Older age was associated with lower odds of receiving accelerated RT (reference, 66–69 years old, OR: 0.90, P<0.006), as was black (OR: 0.73;95% CI, 0.63–0.85) or other race (OR: 0.80; 95% CI, 0.65–1.00), living in rural areas (OR: 0.8; P<0.0001), or seeing an older physician [20+years postgraduation (OR: 0.7; 95% CI, 0.5–0.9)]. Patients living in counties with more hospitals with advanced RT facilities were more likely to undergo accelerated RT (OR: 1.4; 95% CI, 1.1–1.8). Discussion:This new technology appears to be in the early phase of diffusion across the United States and is more rapidly being taken up in younger, white patients living in urban and suburban areas with availability of advanced RT facilities. Rural and older patient populations are not tending to undergo the treatment.