Sarah P. Cate

The SSO/ASTRO Consensus on Breast Margins: Has it affected clinical practice?

148 Background: Adequate margin width remains a subject of much controversy in breast conserving surgery. The Society of Surgical Oncology (SSO) and the American Society for Radiation Oncology (ASTRO) presented a consensus statement on margins in December 2014. This guideline stated that re-excision is recommended only in cases where tumor is present on inked margin. In this study, we sought to determine the consensus statements impact on re-excision practices at our institution. We examined re-excision rates eleven months before the release and 17 months after the release of the statement. METHODS Patients included in this IRB approved study had a diagnosis of invasive breast carcinoma, underwent breast conserving surgery, and were treated with adjuvant radiotherapy. Patients with pure DCIS were excluded. RESULTS One hundred and two women treated from January to November 2013 were included in the pre-consensus group. One hundred and three women were treated from December 2013 to May 2015 in the post-consensus group. The women treated prior to the consensus statement (n = 102) and those women treated after the statement (n = 103) were equally matched in terms of patient age, hormone positivity, and tumor size. A close margin at our institution is defined as < 2mm from the tumor edge. There were 16/102 women prior to the consensus who had close margins and 32/103 women in the post-consensus group. Of these, 68.8% (11/16) underwent re-excision for close margins in the pre-consensus group compared to 3.1% (1/32) after the consensus statement was released (p value < 0.01). CONCLUSIONS The rapid adoption of the SSO/ASTRO margin consensus statement at our institution, although not statistically significant, led to a decrease in the number of patients who underwent a re-excision for close margins. Women with a close surgical margin were less likely to undergo additional surgery for re-excision after the guidelines were released. In our institution, using a standard criterion for re-excision, the re-excision rate for close margins decreased from 68.8% to 3.1%. Further studies are needed to examine the impact of the consensus statement on re-excision practices in a larger group of patients.

Abstract P6-02-01: Screening mammography in women over age 75: Is it beneficial?

Background: In 2015 the U.S. Preventive Services Task Force (USPSTF) stated that there was insufficient evidence for the use of screening mammography in women aged 75 and older. This statement was based on the lack of randomized controlled trials demonstrating survival benefit in this population. As per the American College of Radiology, the acceptable cancer detection rate via screening mammography is at least 2.5 cases per 1000 examinations for an institution, with reported rates as high as 4.7 cases per 1000. Aim: In this study, we sought to examine our institution9s practice of screening mammography for women 75 years and older. We aimed to determine the incidence of cancer detection in this age group through screening mammography. Methods: A search was performed to identify women aged 75 and above who underwent screening mammography at Mount Sinai Beth Israel Medical Center between January 1, 2013 and December 31, 2014. Patients classified as BIRADS 0 on initial screening were reclassified based on their subsequent diagnostic imaging, if performed. A chart review was performed for those patients who underwent breast biopsies to obtain their pathology results. Results: In this two year period, 2057 patients aged 75 and older underwent screening mammography. The majority of women in this age group had non-actionable results of their screening mammography, and were classified as BIRADS 1 or 2 (96%). There were a total of 49 patients who had BIRADS 3 final results (2.4%). Twenty-two patients had screening mammograms that were classified as BIRADS 4 (1.1%). Biopsies revealed 6 invasive ductal carcinomas, 4 cases of in situ carcinoma, 2 cases of duct ectasia, 2 intraductal papillomas, 3 fibrocystic biopsies, and 3 fibroadenomas. In total, 10 of 2057 patients were diagnosed with breast cancer (0.5%). Conclusions: In our institution, 98.4% of women aged 75 and older had screening mammography with benign results. Ten women in this group were found to have breast cancer. The breast cancer detection rate in this cohort was 4.9 per 1000 screening examinations, which is nearly double the cited recommendation put forth by the American College of Radiology. These results are certainly relevant when considering appropriateness of annual screening mammography in this age group. Citation Format: Cate SP, Kohli MK, Gillego A, Chadha M, Fulop T, Boolbol SK. Screening mammography in women over age 75: Is it beneficial?. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-02-01.

Abstract P1-16-03: Residual disease after breast conservation surgery: To excise or not to excise?

Background: The definition of adequate margins after breast conservation surgery for invasive breast cancer has been a highly debated topic. A recent consensus statement by the SSO/ASTRO recommends re-excision only for positive margins, defined as tumor at ink. In light of this consensus statement, we studied the characteristics of patients undergoing breast conservation surgery with subsequent re-excision at our institution in order to examine factors predictive for residual disease (RD+) in the re-excision specimen, as well as a second re-excision. Methods: In this IRB approved retrospective chart review of our breast cancer cases from 1998-2013, we reviewed 828 patients who underwent breast conservation surgery with re-excision for invasive breast carcinoma. A close margin was defined as less than 2mm from the inked margins, and a positive margin was defined as tumor at ink. We analyzed various clinicopathologic features. RD+ was missing in 7 patients (0.8%), who were excluded from that analysis. Pearson chi-square was used to test significance in univariate analysis. Binary logistic regression was applied in multivariate analysis of factors significant at p Results: Overall, 230 patients (28%) had RD+, and 103 patients required a second re-excision (12.4%) due to persistently positive or close margins (44% of RD+). Factors not significant for RD+ were: diagnosis era (before June 2007 vs. after), menstrual status, age In multivariate analysis, the number of positive or close margins was significant, (p Conclusions: Residual disease at re-excision for positive or close margins was present in approximately one-fourth of patients. The probability of residual disease was unrelated to margin positivity or margin width within 2mm. Consideration of re-excision should take into account the burden of intraductal disease in the specimen, its presence at or close to the margin, and the number of positive or close margins. Citation Format: Catherine R Campo, Erika Reategui, Sarah P Cate, John Rescigno, Priyanka Mittar, Alyssa Gillego, Susan K Boolbol. Residual disease after breast conservation surgery: To excise or not to excise? [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P1-16-03.

Abstract P4-14-08: Race as an independent factor affecting post-mastectomy reconstruction in Asian women

BACKGROUND: Racial disparities exist in many areas of breast cancer treatment. Multiple factors influence whether Asian women with breast cancer undergo immediate reconstruction after mastectomy. This study aims to evaluate breast reconstruction trends at a comprehensive cancer center and to determine whether race is an independent predictor of breast reconstruction. METHODS: Using an IRB-approved, prospectively maintained database, post-mastectomy reconstruction rates were determined for 2003 to 2013. This database was compiled from three university-affiliated hospitals serving a diverse urban population. A total of 5379 patients were identified who were treated for breast cancer during the 10-year period. The odds-ratio for immediate breast reconstruction was compared among different races. The data was examined to identify factors influencing the decision for post-mastectomy reconstruction, including age, stage of presentation, marital status, and family history of breast cancer. RESULTS: Thirty percent (n=1614) of women treated for breast cancer underwent mastectomy, while seventy percent (n=3765) received breast-conserving therapy. In the mastectomy group, a unilateral procedure was performed in 93.1% (n=1503) of women and a bilateral procedure in 6.9% (n=111). The immediate reconstruction rate after mastectomy was 70% (n=1130), with only 30% (n=484) of women not undergoing reconstruction. Of the women undergoing mastectomy, 58.5% were white, 14.9% were black, 13.1% were Hispanic, 7.5% were Asian and 6% of women did not report race. Of the women who underwent breast reconstruction after mastectomy, 60.5% were white women, 13.4% were black women, 13% were Hispanic women, 6.9% were Asian women and 6.2% of women did not report race. The immediate reconstruction rate by race was 72.2% for white women, 63.2% for black women, 69.8% of Hispanic for women, and 64.8% for Asian women. The remainder did not receive breast reconstruction. The unadjusted odds ratio (OR) for immediate breast reconstruction, including both unilateral and bilateral cases, for black versus white women was 0.62 (95% confidence interval 0.46-0.84; P=0.001). The OR for breast reconstruction for Hispanic versus white women was 0.88 (95% confidence interval; 0.63-1.22; .P=0.45). The OR for unilateral breast reconstruction for Asian versus white women was 0.66 (95% confidence interval 0.44-0.99; P=0.04.) CONCLUSION: Reconstruction rates vary by race, with Asian women being less likely to undergo immediate breast reconstruction after mastectomy. Compared to white women, Asian and black women were both significantly less likely to have immediate breast reconstruction following mastectomy. Many variables may contribute to this disparity in breast cancer care. Language and cultural beliefs may be unique factors that influence Asian women’s decision for post-mastectomy reconstruction and warrant further study. Citation Format: Carmen F Fong, Alyssa Gillego, Theresa Shao, Erika Reategui, Catherine Campo, Sarah Cate, Christopher Mills, Mark L Smith, Gina Aharonoff, Susan K Boolbol. Race as an independent factor affecting post-mastectomy reconstruction in Asian women [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P4-14-08.

Preoperative MRI: Much ado about nothing?

16 Background: Preoperative MRI has been used to identify mammographically occult lesions and to determine extent of disease. However, the role of preoperative MRI in breast cancer remains controversial. We previously found that preoperative MRI does not increase total mastectomy (TM) rate. In this study we sought to identify a specific subgroup of patients in which preoperative MRI may be useful. METHODS In this IRB approved study, we conducted a retrospective review of 257 patients with breast cancer who underwent preoperative MRI from 2010 to 2012. We evaluated whether additional imaging and biopsies were recommended after MRI and whether it influenced the final surgical plan and decreased re-excision rate after partial mastectomy (PM). We collected data on several clinical factors and tested these for significant associations with both upgrading to TM and with the need for post-MRI imaging and biopsy using crosstab analysis and Fishers Exact test. Age as a continuous variable was also evaluated using binary logistic regression. RESULTS In our study cohort, 158 patients (62%) had additional imaging and 78 patients (30%) had additional biopsies recommended based on the MRI report. Of those biopsies prompted by MRI, 32 of them (39%) revealed cancer. The clinical significance, however, is subject to further study as only 3% of the 257 patients, eight upgraded to TM. We did not find any statistically significant differences in patients who were upgraded to TM by clinical factors such as age, menopausal status, mammographic breast density, ER/PR, HER2/neu status, or pathologic T stage; though there was a trend towards upgrade to TM in those who required additional imaging (p = 0.16). We found no clinical factors associated with the need for additional biopsies. CONCLUSIONS We did not find a specific subgroup of patients in which preoperative MRI influenced management. Although preoperative MRI slightly increased the rate of TM, it does lead to numerous additional imaging studies and biopsies. Given these results, we are no longer using preoperative MRI routinely at our institution. Additional studies will be needed to determine strict indications for the use of MRI in the preoperative setting.