Erik Liederbach

Repeat Surgery After Breast Conservation for the Treatment of Stage 0 to II Breast Carcinoma A Report From the National Cancer Data Base, 2004-2010

IMPORTANCE Although complete excision of breast cancer is accepted as the best means to reduce local recurrence and thereby improve survival, there is currently no standard margin width for breast conservation surgery. As a result, significant variability exists in the number of additional operations or repeat surgeries patients undergo to establish tumor-negative margins. OBJECTIVE To determine the patient, tumor, and facility factors that influence repeat surgery rates in US patients undergoing breast conservation surgery. DESIGN, SETTING, AND PATIENTS Patients diagnosed as having breast cancer at a Commission on Cancer accredited center from January 1, 2004, through December 31, 2010, and identified via the National Cancer Data Base, a large observational database, were included in the analysis. A total of 316,114 patients with stage 0 to II breast cancer who underwent initial breast conservation surgery were studied. Patients who were neoadjuvantly treated or whose conditions were diagnosed by excisional biopsy were excluded. MAIN OUTCOMES AND MEASURES Patient, tumor, and facility factors associated with repeat surgeries. RESULTS A total of 241,597 patients (76.4%) underwent a single lumpectomy, whereas 74,517 (23.6%) underwent at least 1 additional operation, of whom 46,250 (62.1%) underwent a completion lumpectomy and 28,267 (37.9%) underwent a mastectomy. The proportion of patients undergoing repeat surgery decreased slightly during the study period from 25.4% to 22.7% (P < .001). Independent predictors of repeat surgeries were age, race, insurance status, comorbidities, histologic subtype, estrogen receptor status, pathologic tumor size, node status, tumor grade, facility type and location, and volume of breast cancer cases. Age was inversely associated with repeat surgery, decreasing from 38.5% in patients 18 to 29 years old to 16.5% in those older than 80 years (P < .001). In contrast, larger tumor size was linearly associated with a higher repeat surgery rate (P < .001). Repeat surgeries were most common at facilities located in the Northeast region (26.5%) compared with facilities in the Mountain region, where only 18.4% of patients underwent repeat surgery (P < .001). Academic or research facilities had a 26.0% repeat surgery rate compared with a rate of 22.4% at community facilities (P < .001). CONCLUSIONS AND RELEVANCE Approximately one-fourth of all patients who undergo initial breast conservation surgery for breast cancer will have a subsequent operative intervention. The rate of repeat surgeries varies by patient, tumor, and facility factors and has decreased slightly during the past 6 years.

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.

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.

The national landscape of human papillomavirus-associated oropharynx squamous cell carcinoma.

The head and neck squamous cell carcinoma (HNC) landscape is evolving with human papillomavirus (HPV) being a rising cause of oropharynx carcinoma (OPC). This study seeks to investigate a national database for HPV‐associated oropharynx carcinoma (HPV‐OPC). Using the National Cancer Data Base, we analyzed 22,693 patients with HPV‐OPC and known HPV status. Chi‐square tests and logistic regression models were utilized to examine differences between HPV positive and HPV negative OPC. 14,805 (65.2%) patients were HPV positive. Mean age at presentation was 58.4 years with HPV‐HNC patients being 2.8 years younger compared to the HPV‐negative cohort (58.4 vs. 61.2 years, p < 0.001). 67.6% of white patients were HPV‐positive compared to 42.3% of African American patients and 57.1% of Hispanics (p < 0.001). When combining race and socioeconomic status (SES), we found African American patients in high SES groups had HPV‐OPC prevalence that was significantly higher than African American patients in low SES groups (56.9% vs. 36.3%, p < 0.001). Geographic distribution of HPV‐OPC was also analyzed and found to be most prevalent in Western states and least prevalent in the Southern states (p < 0.001). The distribution of HPV‐OPC is variable across the country and among racial and socioeconomic groups. A broad understanding of these differences in HPV‐OPC should drive educational programs and improve clinical trials that benefit both prevention and current treatments.

Survey of the deficits in surgeons' knowledge of contralateral prophylactic mastectomy

Author Contributions: Dr Benharash had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Toppen, Sareh, Satou, Benharash. Acquisition, analysis, or interpretation of data: Toppen, Sareh, Johansen, Genovese, Shemin, Benharash. Drafting of the manuscript: Toppen, Sareh, Genovese, Satou. Critical revision of the manuscript for important intellectual content: Toppen, Sareh, Johansen, Genovese, Shemin, Benharash. Statistical analysis: Toppen, Sareh, Johansen, Shemin. Administrative, technical, or material support: Satou, Shemin, Benharash. Study supervision: Benharash.

Increased utilization of postmastectomy radiotherapy in the United States from 2003 to 2011 in patients with one to three tumor positive nodes

There have been few recent studies that have examined the use of postmastectomy radiotherapy (PMRT) for patients with 1–3 positive nodes.

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.

Clinicopathologic features and time interval analysis of contralateral breast cancers

INTRODUCTION We hypothesized that most contralateral breast cancers (CBCs) develop ≥5 years after the primary breast cancer (PBC) and that CBCs have more favorable tumor characteristics. METHODS This is a single-institution retrospective review of 323 patients who were diagnosed with CBC from 1990 to 2014. CBCs were diagnosed at least 1 year after the diagnosis of PBC. Χ(2) tests and one-way analysis of variance were used to examine the time interval and pathologic features between the PBC and CBC. RESULTS The median time interval between the PBC and CBC was 6.2 years (average: 7.1, range: 1.01-23.0), and 189 (58.5%) patients had a time interval ≥5 years. Patients ≥70 years old developed a CBC sooner than patients <50 years (median: 4.3 vs 6.6 years, P < .001). Patients with infiltrating lobular carcinoma developed their CBC in 9.0 years versus 6.2 years for infiltrating ductal carcinoma histology (P = .028). In comparison with the PBC, a greater proportion of CBCs were stage I (50.8%), T1 (72.1%), node negative (67.5%), and estrogen receptor positive (68.7%). Of the 252 patients with available tumor size information for both cancers, only 54 (21.4%) patients developed a CBC that was >1 cm larger than their PBC, and only 25 (9.9%) patients developed a CBC that was >2 cm larger than their PBC. Only 28 of 201 (13.9%) node-negative PBCs developed a node-positive CBC. CONCLUSION A majority of CBCs develop ≥5 years after the diagnosis of the PBC. CBCs have more favorable tumor characteristics than the PBC and tend to be smaller and node negative.

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.