John Boyages

Quality of life three months and one year after first treatment for early stage breast cancer: Influence of treatment and patient characteristics

This paper reports the quality of life (QoL) of a large cohort of Australian women three and twelve months after surgery for early stage breast cancer (ESBC), and shows that the impact of disease and treatment on QoL differed by age, education and marital status. Eighty-three percent of eligible patients were recruited; 86% had breast conserving surgery and 14% mastectomy. Response rates were 93% (n = 305) at three months and 88% (n = 291) at one year. Quality of life was measured with the EORTC core questionnaire (QLQ-C30) and an ESBC-specific questionnaire. Multilevel analysis was used to estimate the effects and interactions of time, treatment and patient characteristics. Most symptoms declined between three months and one year, but arm and menopausal symptoms persisted. Emotional, social and role functioning improved over time, and fear of disease recurrence diminished. Younger women faired worse than older women on a broad range of QoL dimensions. Single women and those with less education faired worse on a number of dimensions. The negative impact of mastectomy on body image was greatest among married women, particularly young married women. These sociodemographic distinctions are relevant when discussing treatment options with women facing a diagnosis of ESBC.

Multifocal and Multicentric Breast Cancer: Does Each Focus Matter?

PURPOSE The identification of multiple tumors in the breast is associated with increased nodal involvement when compared with similar staged unifocal disease. This study compares two methods of tumor size assessment to predict tumor behavior in the relationship between size and axillary node involvement for patients with multifocal and multicentric breast cancer. METHODS The histologic reports of every patient with multifocal breast cancer treated in New South Wales between April 1995 and September 1995 were examined. Tumors were assessed using two size estimates: (1) largest tumor focus diameter and (2) the aggregate diameters of all tumor foci. The dimensions were compared with unifocal tumors and against node positivity. RESULTS Ninety-four (11.1%) of 848 women had multifocal breast cancer and of these 49 women (52.1%) had axillary node involvement compared with 37.5% with unifocal breast cancer (P =.007). The use of aggregate dimension reclassified significant numbers of multifocal tumors at a more advanced stage. Use of this method to stage cancers, rather than the largest tumor size, removed the excess node positivity when compared with unifocal, stage-matched breast carcinomas. CONCLUSION The tendency of breast tumors to metastasize is a reflection of the total tumor load. Failure to measure the additional tumor burden provided by multiple small foci may understage a womans disease. This may deny patients the opportunity of adjuvant therapies if the contribution of the smaller foci to the incidence of node positivity and survival is ignored.

Effect of margins on ipsilateral breast tumor recurrence after breast conservation therapy for lymph node-negative breast carcinoma.

Breast conservative surgery (CS) with radiotherapy (RT) is the most commonly used treatment for early‐stage breast carcinoma. However, there is controversy regarding the importance of the pathologic margin status on the risk of ipsilateral breast tumor recurrence (IBTR). The current study evaluated the effect of the pathologic margin status on IBTR rates in a cohort of women with lymph node‐negative breast carcinoma treated with CS and RT.

Breast cancer survival and stage at diagnosis in Australia, Canada, Denmark, Norway, Sweden and the UK, 2000-2007: A population-based study

Background:We investigate whether differences in breast cancer survival in six high-income countries can be explained by differences in stage at diagnosis using routine data from population-based cancer registries.Methods:We analysed the data on 257 362 women diagnosed with breast cancer during 2000–7 and registered in 13 population-based cancer registries in Australia, Canada, Denmark, Norway, Sweden and the UK. Flexible parametric hazard models were used to estimate net survival and the excess hazard of dying from breast cancer up to 3 years after diagnosis.Results:Age-standardised 3-year net survival was 87–89% in the UK and Denmark, and 91–94% in the other four countries. Stage at diagnosis was relatively advanced in Denmark: only 30% of women had Tumour, Nodes, Metastasis (TNM) stage I disease, compared with 42–45% elsewhere. Women in the UK had low survival for TNM stage III–IV disease compared with other countries.Conclusion:International differences in breast cancer survival are partly explained by differences in stage at diagnosis, and partly by differences in stage-specific survival. Low overall survival arises if the stage distribution is adverse (e.g. Denmark) but stage-specific survival is normal; or if the stage distribution is typical but stage-specific survival is low (e.g. UK). International differences in staging diagnostics and stage-specific cancer therapies should be investigated.

Frequency and predictors of axillary lymph node metastases in invasive breast cancer

Background:  The objectives of the present study were to evaluate the incidence and predictors of axillary lymph node metastases (ALNM) in patients with breast cancer, and to identify if axillary surgery could be safely omitted in selected patients.

Malignant spinal cord compression: A prospective evaluation

PURPOSE To determine the influence of treatment on ambulancy, pain control and functional outcome of patients with Malignant Spinal Cord Compression. METHODS AND MATERIALS One hundred and thirty-seven patients with Malignant Spinal Cord Compression presenting or referred to the Department of Radiation Oncology, Westmead Hospital between August 1, 1989 and August 1, 1990 were studied prospectively. Patients were treated with palliative radiation therapy alone, surgery followed by radiotherapy or surgery alone. Two patients were not treated. Post-treatment outcome was assessed in terms of ambulatory status, improvement in pain and functional independence using the Functional Independence Measure. RESULTS Thirteen of 16 patients (81%) who were ambulant pre-treatment remained ambulant after treatment. Two of 16 patients (16.5%) who were non-ambulant pre-treatment became ambulant following treatment. Pain improved following treatment in 22 of 30 patients (73%). This benefit was seen equally for ambulant and non-ambulant patients. A high level of functional independence was maintained in patients who remained ambulant. CONCLUSION We conclude that prompt treatment of patients with Malignant Spinal Cord Compression while still able to walk is effective in maintaining ambulancy and functional independence, and that treatment improves pain in most patients.

Is age at diagnosis an independent prognostic factor for survival following breast cancer

Background:  Previous studies of patients with breast cancer have examined age at diagnosis as a prognostic factor for survival with contradictory results. The current study examines the effect of age in conjunction with pathological tumour size, lymph node status and histological grade to clarify whether age at diagnosis is an independent factor for overall survival.

‘Well, have I got cancer or haven't I?’ The psycho‐social issues for women diagnosed with ductal carcinoma in situ

Objectives  To explore womens experience of being diagnosed with ductal carcinoma in situ (DCIS) in relation to the following: response to the diagnosis; understanding about the diagnosis; satisfaction with information; satisfaction with the level of involvement in treatment decision‐making and satisfaction with support services.

Multifocal breast cancer and survival: Each focus does matter particularly for larger tumours

PURPOSE The objective of this study is to determine whether the aggregate tumour size of every focus in multifocal breast cancer more accurately predicts 10-year survival than current staging systems which use the largest or dominant tumour size. PATIENTS AND METHODS This study examined the original histological reports of 848 consecutive patients with invasive breast cancer treated in New South Wales (NSW), Australia between 1 April 1995 and 30 September 1995. Multifocal tumours were assessed using two estimates of pathologic tumour size: largest tumour focus diameter and the aggregate diameter of every tumour focus. The 10-year survival of patients with multifocal tumours measured in both ways was compared to that with unifocal tumours. RESULTS At a median follow-up of 10.4 years, 27 of 94 patients (28.7%) with multifocal breast cancer have died of breast cancer compared to 141 of 754 (18.7%) with unifocal breast cancer (P=.022). Ten-year survival was not affected by size for tumours measuring 20mm or less, whether or not dominant tumour size (87.9%) or aggregate tumour size (87.0%) was used for multifocal tumours, compared to unifocal tumours (88.1%). For tumours larger than 20mm, 10-year survival was 72.1% for unifocal tumours compared to 54.7% (P=.008) for multifocal tumours using dominant tumour size, but this was 69.5% and not significant when multifocal tumours were classified using aggregate tumour size (P=.49). Multivariate analysis also confirmed the above-mentioned results after adjustment for important prognostic factors. CONCLUSION Aggregate size of every focus should be considered along with other prognostic factors for metastasis when treatment is planned. The current convention of using the largest (dominant) lesion as a measure of stage and associated breast cancer survival needs further validation.

Long-term survival of women with breast cancer in New South Wales

Several long-term studies of breast cancer survival have shown continued excess mortality from breast cancer up to 20-40 years following treatment. The purpose of this report was to investigate temporal trends in long-term survival from breast cancer in all New South Wales (NSW) women. Breast cancer cases incident in 1972-1996 (54,228) were derived from the NSW Central Cancer Registry-a population-based registry which began in 1972. All cases of breast cancer not known to be dead were matched against death records. The expected survival for NSW women was derived from published annual life tables. Relative survival analysis compared the survival of cancer cases with the age, sex and period matched mortality of the total population. Cases were considered alive at the end of 1996, except when known to be dead. Proportional hazards regression was employed to model survival on age, period and degree of spread at diagnosis. Survival at 5, 10, 15, 20 and 25 years of follow-up was 76 per cent, 65 per cent, 60 per cent, 57 per cent and 56 per cent. The annual hazard rate for excess mortality was 4.3 per cent in year 1, maximal at 6.5 per cent in year 3, declining to 4.7 per cent in year 5, 2.7 per cent in year 10, 1.4 per cent in year 15, 1.0 per cent for years 16-20, and 0.4 per cent for years 20-25 of follow-up. Relative survival was highest in 40-49 year-olds. Cases diagnosed most recently (1992-1996) had the highest survival, compared with cases diagnosed in previous periods. Five-year survival improved over time, especially from the late 1980s for women in the screening age group (50-69 years). Survival was highest for those with localised cancer at diagnosis: 88.4 per cent, 79.1 per cent, 74.6 per cent, 72.7 per cent and 72.8 per cent at 5, 10, 15, 20 and 25 years follow-up (excluding those aged >or=70 years). There was no significant difference between the survival of the breast cancer cases and the general population at 20-25 years follow-up. Degree of spread was less predictive of survival 5-20 years after diagnosis, compared with 0-5 years after diagnosis, and was not significant at 20-25 years of follow-up. Relative survival from breast cancer in NSW women continues to decrease to 25 years after diagnosis, but there is little excess mortality after 15 years follow-up, especially for those with localised cancer at diagnosis, and the minimal excess mortality at 20-25 years of follow-up is not statistically significant.