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JAMA Surgery Jun 2022Treatment options for early breast cancer include breast-conserving surgery with radiation therapy (RT) or mastectomy and breast reconstruction without RT. Despite...
IMPORTANCE
Treatment options for early breast cancer include breast-conserving surgery with radiation therapy (RT) or mastectomy and breast reconstruction without RT. Despite marked differences in these treatment strategies, little is known with regard to their association with long-term quality of life (QOL).
OBJECTIVE
To evaluate the association of treatment with breast-conserving surgery with RT vs mastectomy and reconstruction without RT with long-term QOL.
DESIGN, SETTING, AND PARTICIPANTS
This comparative effectiveness research study used data from the Texas Cancer Registry for women diagnosed with stage 0-II breast cancer and treated with breast-conserving surgery or mastectomy and reconstruction between 2006 and 2008. The study sample was mailed a survey between March 2017 and April 2018. Data were analyzed from August 1, 2018 to October 15, 2021.
EXPOSURES
Breast-conserving surgery with RT or mastectomy and reconstruction without RT.
MAIN OUTCOMES AND MEASURES
The primary outcome was satisfaction with breasts, measured with the BREAST-Q patient-reported outcome measure. Secondary outcomes included BREAST-Q physical well-being, psychosocial well-being, and sexual well-being; health utility, measured using the EuroQol Health-Related Quality of Life 5-Dimension, 3-Level questionnaire; and local therapy decisional regret. Multivariable linear regression models with weights for treatment, age, and race and ethnicity tested associations of the exposure with outcomes.
RESULTS
Of 647 patients who responded to the survey (40.0%; 356 had undergone breast-conserving surgery, and 291 had undergone mastectomy and reconstruction), 551 (85.2%) confirmed treatment with breast-conserving surgery with RT (n = 315) or mastectomy and reconstruction without RT (n = 236). Among the 647 respondents, the median age was 53 years (range, 23-85 years) and the median time from diagnosis to survey was 10.3 years (range, 8.4-12.5 years). Multivariable analysis showed no significant difference between breast-conserving surgery with RT (referent) and mastectomy and reconstruction without RT in satisfaction with breasts (effect size, 2.71; 95% CI, -2.45 to 7.88; P = .30) or physical well-being (effect size, -1.80; 95% CI, -5.65 to 2.05; P = .36). In contrast, psychosocial well-being (effect size, -8.61; 95% CI, -13.26 to -3.95; P < .001) and sexual well-being (effect size, -10.68; 95% CI, -16.60 to -4.76; P < .001) were significantly worse with mastectomy and reconstruction without RT. Health utility (effect size, -0.003; 95% CI, -0.03 to 0.03; P = .83) and decisional regret (effect size, 1.32; 95% CI, -3.77 to 6.40; P = .61) did not differ by treatment group.
CONCLUSIONS AND RELEVANCE
The findings support equivalence of breast-conserving surgery with RT and mastectomy and reconstruction without RT with regard to breast satisfaction and physical well-being. However, breast-conserving surgery with RT was associated with clinically meaningful improvements in psychosocial and sexual well-being. These findings may help inform preference-sensitive decision-making for women with early-stage breast cancer.
Topics: Breast Neoplasms; Female; Humans; Mammaplasty; Mastectomy; Mastectomy, Segmental; Middle Aged; Patient Satisfaction; Quality of Life
PubMed: 35416926
DOI: 10.1001/jamasurg.2022.0631 -
BMJ (Clinical Research Ed.) Sep 2022To determine if margin involvement is associated with distant recurrence and to determine the required margin to minimise both local recurrence and distant recurrence in... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
To determine if margin involvement is associated with distant recurrence and to determine the required margin to minimise both local recurrence and distant recurrence in early stage invasive breast cancer.
DESIGN
Prospectively registered systematic review and meta-analysis of literature.
DATA SOURCES
Medline (PubMed), Embase, and Proquest online databases. Unpublished data were sought from study authors.
ELIGIBILITY CRITERIA
Eligible studies reported on patients undergoing breast conserving surgery (for stages I-III breast cancer), allowed an estimation of outcomes in relation to margin status, and followed up patients for a minimum of 60 months. Patients with ductal carcinoma in situ only or treated with neoadjuvant chemotherapy or by mastectomy were excluded. Where applicable, margins were categorised as tumour on ink (involved), close margins (no tumour on ink but <2 mm), and negative margins (≥2 mm).
RESULTS
68 studies from 1 January 1980 to 31 December 2021, comprising 112 140 patients with breast cancer, were included. Across all studies, 9.4% (95% confidence interval 6.8% to 12.8%) of patients had involved (tumour on ink) margins and 17.8% (13.0% to 23.9%) had tumour on ink or a close margin. The rate of distant recurrence was 25.4% (14.5% to 40.6%) in patients with tumour on ink, 8.4% (4.4% to 15.5%) in patients with tumour on ink or close, and 7.4% (3.9% to 13.6%) in patients with negative margins. Compared with negative margins, tumour on ink margins were associated with increased distant recurrence (hazard ratio 2.10, 95% confidence interval 1.65 to 2.69, P<0.001) and local recurrence (1.98, 1.66 to 2.36, P<0.001). Close margins were associated with increased distant recurrence (1.38, 1.13 to 1.69, P<0.001) and local recurrence (2.09, 1.39 to 3.13, P<0.001) compared with negative margins, after adjusting for receipt of adjuvant chemotherapy and radiotherapy. In five studies published since 2010, tumour on ink margins were associated with increased distant recurrence (2.41, 1.81 to 3.21, P<0.001) as were tumour on ink and close margins (1.44, 1.22 to 1.71, P<0.001) compared with negative margins.
CONCLUSIONS
Involved or close pathological margins after breast conserving surgery for early stage, invasive breast cancer are associated with increased distant recurrence and local recurrence. Surgeons should aim to achieve a minimum clear margin of at least 1 mm. On the basis of current evidence, international guidelines should be revised.
SYSTEMATIC REVIEW REGISTRATION
CRD42021232115.
Topics: Breast; Breast Neoplasms; Female; Humans; Margins of Excision; Mastectomy; Mastectomy, Segmental; Neoplasm Recurrence, Local
PubMed: 36130770
DOI: 10.1136/bmj-2022-070346 -
The Cochrane Database of Systematic... Oct 2021Oncoplastic breast-conserving surgery (O-BCS) involves removing the tumour in the breast and using plastic surgery techniques to reconstruct the breast. The adequacy of... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Oncoplastic breast-conserving surgery (O-BCS) involves removing the tumour in the breast and using plastic surgery techniques to reconstruct the breast. The adequacy of published evidence on the safety and efficacy of O-BCS for the treatment of breast cancer compared to other surgical options for breast cancer is still debatable. It is estimated that the local recurrence rate is similar to standard breast-conserving surgery (S-BCS) and also mastectomy, but the aesthetic and patient-reported outcomes may be improved with oncoplastic techniques.
OBJECTIVES
Our primary objective was to assess oncological control outcomes following O-BCS compared with other surgical options for women with breast cancer. Our secondary objective was to assess surgical complications, recall rates, need for further surgery to achieve adequate oncological resection, patient satisfaction through patient-reported outcomes, and cosmetic outcomes through objective measures or clinician-reported outcomes.
SEARCH METHODS
We searched the Cochrane Breast Cancer Group's Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (via OVID), Embase (via OVID), the World Health Organization's International Clinical Trials Registry Platform and ClinicalTrials.gov on 7 August 2020. We did not apply any language restrictions.
SELECTION CRITERIA
We selected randomised controlled trials (RCTs) and non-randomised comparative studies (cohort and case-control studies). Studies evaluated any O-BCS technique, including volume displacement techniques and partial breast volume replacement techniques compared to any other surgical treatment (partial resection or mastectomy) for the treatment of breast cancer.
DATA COLLECTION AND ANALYSIS
Four review authors performed data extraction and resolved disagreements. We used ROBINS-I to assess the risk of bias by outcome. We performed descriptive data analysis and meta-analysis and evaluated the quality of the evidence using GRADE criteria. The outcomes included local recurrence, breast cancer-specific disease-free survival, re-excision rates, complications, recall rates, and patient-reported outcome measures.
MAIN RESULTS
We included 78 non-randomised cohort studies evaluating 178,813 women. Overall, we assessed the risk of bias per outcome as being at serious risk of bias due to confounding; where studies adjusted for confounding, we deemed these at moderate risk. Comparison 1: oncoplastic breast-conserving surgery (O-BCS) versus standard-BCS (S-BCS) The evidence in the review found that O-BCS when compared to S-BCS, may make little or no difference to local recurrence; either when measured as local recurrence-free survival (hazard ratio (HR) 0.90, 95% confidence interval (CI) 0.61 to 1.34; 4 studies, 7600 participants; very low-certainty evidence) or local recurrence rate (HR 1.33, 95% CI 0.96 to 1.83; 4 studies, 2433 participants; low-certainty evidence), but the evidence is very uncertain due to most studies not controlling for confounding clinicopathological factors. O-BCS compared to S-BCS may make little to no difference to disease-free survival (HR 1.06, 95% CI 0.89 to 1.26; 7 studies, 5532 participants; low-certainty evidence). O-BCS may reduce the rate of re-excisions needed for oncological resection (risk ratio (RR) 0.76, 95% CI 0.69 to 0.85; 38 studies, 13,341 participants; very low-certainty evidence), but the evidence is very uncertain. O-BCS may increase the number of women who have at least one complication (RR 1.19, 95% CI 1.10 to 1.27; 20 studies, 118,005 participants; very low-certainty evidence) and increase the recall to biopsy rate (RR 2.39, 95% CI 1.67 to 3.42; 6 studies, 715 participants; low-certainty evidence). Meta-analysis was not possible when assessing patient-reported outcomes or cosmetic evaluation; in general, O-BCS reported a similar or more favourable result, however, the evidence is very uncertain due to risk of bias in the measurement methods. Comparison 2: oncoplastic breast-conserving surgery (O-BCS) versus mastectomy alone O-BCS may increase local recurrence-free survival compared to mastectomy but the evidence is very uncertain (HR 0.55, 95% CI 0.34 to 0.91; 2 studies, 4713 participants; very low-certainty evidence). The evidence is very uncertain about the effect of O-BCS on disease-free survival as there were only data from one study. O-BCS may reduce complications compared to mastectomy, but the evidence is very uncertain due to high risk of bias mainly resulting from confounding (RR 0.75, 95% CI 0.67 to 0.83; 4 studies, 4839 participants; very low-certainty evidence). Data on patient-reported outcome measures came from single studies; it was not possible to meta-analyse the data. Comparison 3: oncoplastic breast-conserving surgery (O-BCS) versus mastectomy with reconstruction O-BCS may make little or no difference to local recurrence-free survival (HR 1.37, 95% CI 0.72 to 2.62; 1 study, 3785 participants; very low-certainty evidence) or disease-free survival (HR 0.45, 95% CI 0.09 to 2.22; 1 study, 317 participants; very low-certainty evidence) when compared to mastectomy with reconstruction, but the evidence is very uncertain. O-BCS may reduce the complication rate compared to mastectomy with reconstruction (RR 0.49, 95% CI 0.45 to 0.54; 5 studies, 4973 participants; very low-certainty evidence) but the evidence is very uncertain due to high risk of bias from confounding and inconsistency of results. The evidence is very uncertain for patient-reported outcome measures and cosmetic evaluation.
AUTHORS' CONCLUSIONS
The evidence is very uncertain regarding oncological outcomes following O-BCS compared to S-BCS, though O-BCS has not been shown to be inferior. O-BCS may result in less need for a second re-excision surgery but may result in more complications and a greater recall rate than S-BCS. It seems that O-BCS may give better patient satisfaction and surgeon rating for the look of the breast, but the evidence for this is of poor quality, and due to lack of numerical data, it was not possible to pool the results of different studies. It seems O-BCS results in fewer complications compared with surgeries involving mastectomy. Based on this review, no certain conclusions can be made to help inform policymakers. The surgical decision for what operation to proceed with should be made jointly between clinician and patient after an appropriate discussion about the risks and benefits of O-BCS personalised to the patient, taking into account clinicopathological factors. This review highlighted the deficiency of well-conducted studies to evaluate efficacy, safety and patient-reported outcomes following O-BCS.
Topics: Breast Neoplasms; Cohort Studies; Disease-Free Survival; Female; Humans; Mastectomy; Mastectomy, Segmental
PubMed: 34713449
DOI: 10.1002/14651858.CD013658.pub2 -
The Journal of Thoracic and... Jun 2020
Topics: Carcinoma, Non-Small-Cell Lung; Humans; Lung Neoplasms; Mastectomy, Segmental
PubMed: 32033820
DOI: 10.1016/j.jtcvs.2019.11.118 -
The Medical Journal of Australia Sep 2022Breast cancer is the commonest human cancer globally and one in seven Australian women will develop it in their lifetime. Surgery is the mainstay of management both for... (Review)
Review
Breast cancer is the commonest human cancer globally and one in seven Australian women will develop it in their lifetime. Surgery is the mainstay of management both for women who are at high risk of breast cancer and for those who have been diagnosed. Increased understanding of how to predict who is most at risk of breast cancer is leading to the possibility of risk-based screening, allowing better and more targeted early detection for women at high risk, and contrast imaging techniques are proving more accurate in diagnosing and staging cancer. The evolution of surgical practice includes the widespread use of oncoplastic surgery, allowing better cosmetic and oncological outcomes; reconstructive surgical advances, using free flap techniques; and sequencing of systemic and local therapies to better tailor treatments to the patient's cancer and improve outcomes. Recognition of side effects of breast cancer treatment have led to improvement in the management of conditions such as chronic pain and lymphoedema, as well as addressing the psychosocial, body image and sexual complications caused by the cancer and its treatment.
Topics: Australia; Breast Neoplasms; Female; Humans; Mammaplasty; Mastectomy; Mastectomy, Segmental; Neoplasm Staging
PubMed: 35988063
DOI: 10.5694/mja2.51678 -
Ugeskrift For Laeger Aug 2023Lifetime risk of developing breast cancer for Danish women is approx. 9%. Diagnostics are done by mammography, biopsy, and examination. Breast-conserving surgery... (Review)
Review
Lifetime risk of developing breast cancer for Danish women is approx. 9%. Diagnostics are done by mammography, biopsy, and examination. Breast-conserving surgery followed by radiotherapy is standard for treatment of early-stage breast cancer. Studies report unsatisfying outcomes in up to one third of the patients. This review summarises the current surgical techniques. Oncoplastic breast surgery makes it possible to combine wide-margin oncological surgery with immediate partial breast reconstruction, thus improving cosmetic outcome. Techniques involve volume reduction, volume displacement and volume replacement, depending on breast size and tumour characteristics.
Topics: Humans; Female; Breast Neoplasms; Mammography; Mammaplasty; Mastectomy, Segmental; Biopsy
PubMed: 37622607
DOI: No ID Found -
Interactive Cardiovascular and Thoracic... Jun 2022Completion lobectomy (CL) after anatomical segmentectomy in the same lobe can be complicated by severe adhesions around the hilar structures and may lead to fatal...
OBJECTIVES
Completion lobectomy (CL) after anatomical segmentectomy in the same lobe can be complicated by severe adhesions around the hilar structures and may lead to fatal bleeding and lung injury. Therefore, we aimed to investigate the perioperative outcomes of CL after anatomical segmentectomy.
METHODS
Among 461 patients who underwent anatomical segmentectomy (thoracotomy, 62 patients; thoracoscopic surgery, 399 patients) between January 2005 and December 2019, data of patients who underwent CL after segmentectomy were extracted and analysed in this study.
RESULTS
Eight patients underwent CL after segmentectomy. CL was performed via video-assisted thoracic surgery in 3 patients and thoracotomy in 5 patients. In each case, there were moderate to severe adhesions. Four patients required simultaneous resection of the pulmonary parenchyma and pulmonary artery. Thoracotomy was not required after thoracoscopic surgery in any patient. Two patients experienced complications (air leakage and arrhythmia). The median duration of hospitalization after CL was 6 (range, 5-7) days. No postoperative mortality or recurrence of lung cancer was observed. All the patients with lung cancer were alive and recurrence-free at the time of publication.
CONCLUSIONS
Although individual adhesions render surgery difficult, CL after anatomical segmentectomy shows acceptable perioperative outcomes. However, CL by video-assisted thoracoscopic surgery may be considered on a case-by-case basis depending on the initial surgery.
Topics: Humans; Lung Neoplasms; Mastectomy, Segmental; Pneumonectomy; Retrospective Studies; Thoracic Surgery, Video-Assisted; Thoracotomy
PubMed: 34962577
DOI: 10.1093/icvts/ivab323 -
Ugeskrift For Laeger Mar 2024Surgical treatment of breast cancer has changed towards less invasive procedures as summarised in this review. Breast conserving surgery (BCS) and radiotherapy (RT) are... (Review)
Review
Surgical treatment of breast cancer has changed towards less invasive procedures as summarised in this review. Breast conserving surgery (BCS) and radiotherapy (RT) are now recommended as standard of care. Several flexible marking methods for removal of non-palpable tumours have gradually replaced wire-guided localisation. Neoadjuvant systemic treatment increases tumour shrinkage and BCS and may lead to omission of axillary clearance (AC). The prognostic significance of AC in patients with metastases to 1-2 sentinel nodes at primary surgery is questioned. Results from the SENOMAC trial are expected to change guidelines from AC to axillary RT.
Topics: Female; Humans; Axilla; Breast Neoplasms; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Mastectomy, Segmental; Sentinel Lymph Node Biopsy
PubMed: 38533870
DOI: 10.61409/V01230033 -
Breast (Edinburgh, Scotland) Jun 2023Breast cancer is the most common cancer in women worldwide. Over the past few decades, remarkable progress has been made in understanding the biology and pathology of... (Review)
Review
Breast cancer is the most common cancer in women worldwide. Over the past few decades, remarkable progress has been made in understanding the biology and pathology of breast cancer. A personalized conservative approach has been currently adopted addressing the patient's individual risk of relapse. After postoperative whole breast irradiation for early-stage breast cancer, a rate of recurrences outside the initial tumour bed lower than 4% was observed. Thus, the highest benefits of breast irradiation seem to result from the dose delivered to the tissue neighbouring the tumour bed. Nonetheless, reducing treatment morbidity while maintaining radiation therapy's ability to decrease local recurrences is an important challenge in treating patients with radiation therapy. In this regard, strategies such as partial-breast irradiation have been developed to reduce toxicity without compromising oncologic outcomes. According to the national and international published guidelines, clinical oncologists can refer to specific dose/fractionation schedules and eligible criteria. However, there are still some areas of open questions. Breast cancer represents a multidisciplinary paradigm; it should be considered a heterogeneous disease where a "one-treatment-fits-all" approach cannot be considered an appropriate option. This is a wide overview on the main partial breast irradiation advantages, risks, timings, techniques, and available recommendations. We aim to provide practical findings to support clinical decision-making, exploring future perspectives, towards a balance for optimisation of breast cancer.
Topics: Female; Humans; Breast; Breast Neoplasms; Combined Modality Therapy; Mastectomy, Segmental; Neoplasm Recurrence, Local
PubMed: 37116401
DOI: 10.1016/j.breast.2023.04.007 -
Expert Review of Anticancer Therapy May 2022As breast cancer treatment options have multiplied and biologic diversity within breast cancer has been recognized, the use of the same treatment strategies for patients... (Review)
Review
INTRODUCTION
As breast cancer treatment options have multiplied and biologic diversity within breast cancer has been recognized, the use of the same treatment strategies for patients with early-stage and favorable disease, and for those with biologically aggressive disease, has been questioned. In addition, as patient-reported outcome measures have called attention to the morbidity of many common treatments, and as the cost of breast cancer care has continued to increase, reduction in the overtreatment of breast cancer has assumed increasing importance.
AREAS COVERED
Here we review selected aspects of surgery, radiation oncology, and medical oncology for which scientific evidence supports de-escalation for invasive carcinoma and ductal carcinoma in situ, and assess strategies to address overtreatment.
EXPERT OPINION
The problems of breast cancer overtreatment we face today are based on improved understanding of the biology of breast cancer and abandonment of the 'one-size-fits-all' approach. As breast cancer care becomes increasingly complex, and as our knowledge base continues to increase exponentially, these problems will only be magnified in the future. To continue progress, the move must be made from advocating the maximum-tolerated treatment to advocating the minimum-effective one.
Topics: Breast Neoplasms; Carcinoma, Intraductal, Noninfiltrating; Female; Humans; Mastectomy, Segmental; Overtreatment
PubMed: 35588396
DOI: 10.1080/14737140.2022.2064277