Incidence of Brain Metastases in Women Treated With Neoadjuvant Chemotherapy for Breast Cancer: Implications for Screening.

PURPOSE: Patients with metastatic breast cancer may develop brain metastases. Our study identified high-risk patients to refine selection criteria for BM screening approaches. PATIENTS: We reviewed breast cancer patients treated with neoadjuvant chemotherapy (NAC) at a single university center between 2005 and 2019. METHODS: Competing risks analysis was performed with the Fine and Gray model to analyze the cumulative incidence of BM and loco-regional recurrence. Overall survival (OS) and progression-free survival (PFS) were calculated using Kaplan-Meier and log-rank tests. Multivariable analysis was performed with Cox proportional hazards regression to identify factors predictive for development of BM. Statistical significance was determined as a 2-sided P value of <.05. RESULTS: In total, 112 patients experienced distant failure (DF) and 49 patients developed BM. Twenty patients with BM (41%) presented with symptoms requiring craniotomy +/- whole brain radiation treatment. Patients with BM were significantly more likely to have local (P < .01) and regional (P < .01) failure. On multivariable analysis, age <40 years (P = .011), presence of lung metastases (P < .0001), and residual nodal disease with >4 lymph nodes positive after NAC (P = .024) all predicted for increased likelihood of BM. Patients with these criteria had higher likelihoods of having BM (P = .013) and worse PFS (P = .044). On multivariable analysis for OS, presence of lung metastases was the most significant predictor of poor outcome (P < .0001). CONCLUSION: We propose a study of screening brain MRI for young (<40 years) patients with breast cancer receiving NAC and patients who develop metastatic disease post-NAC, especially those with lung involvement.

Impact of Insurance on Stage of Breast Cancer Presentation for Different Races and Ethnicities.

PURPOSE: Survival in breast cancer is largely stage-dependent. Lack of insurance and Medicaid have been associated with later-stage breast cancer, but it is unknown to what degree this association varies by race or ethnicity. METHODS: We conducted a retrospective single-institution cohort analysis of women undergoing breast radiotherapy from 2012 to 2017 (n = 1,019). Patients were categorized as having private insurance (n = 540), Medicare (n = 332), Medicaid (n = 122), or self-pay (n = 25). Ordinal logistic regression analysis identified variables associated with later-stage presentation, including age, race or ethnicity, insurance, the interaction between insurance and race or ethnicity, body mass index, education, and language. RESULTS: The association between insurance and breast cancer stage varied on the basis of a patient's race or ethnicity (P = .0114). White and Asian patients with Medicaid had significantly higher odds of later-stage breast cancer than those with private insurance (White odds ratio [OR], 2.10; 95% CI, 1.02 to 4.34; Asian OR, 3.22; 95% CI, 1.56 to 6.67). However, the inverse was true for Hispanic patients who had lower odds of later-stage disease with Medicaid than private insurance (OR, 0.36; 95% CI, 0.16 to 0.90). Hispanic patients with Medicaid had lower odds than either White or Asian patients with Medicaid. These findings persisted across all ages. CONCLUSION: The association between insurance and later-stage presentation is significantly influenced by race or ethnicity. Medicaid was generally associated with later-stage breast cancer diagnosis, but this was not true across all races and ethnicities. Although White and Asian patients with Medicaid presented with later stage, Hispanic patients fared better with Medicaid than private insurance. Future work should investigate how Medicaid is successfully targeting Hispanic patients in breast cancer care.

Locoregional and Distant Outcomes in Women With cT1-3N1 Breast Cancer Treated With Neoadjuvant Chemotherapy With or Without Adjuvant Radiotherapy.

BACKGROUND: We evaluated the impact of postmastectomy radiotherapy (PMRT) or supraclavicular radiation therapy (SCV RT) in women with cT1-3N1 breast cancer (BC) who became node negative (ypN0) after neoadjuvant chemotherapy (NAC). PATIENTS AND METHODS: We retrospectively reviewed 485 women treated with NAC for BC between 2005 and 2019. Radiation treatment fields were reviewed in detail. Pathologic complete response (pCR) was defined as ypT0/Tis ypN0. Patients who had residual nodal disease were defined as ypN+. Those who achieved complete response in the lymph nodes but not in the breast were defined as ypT+ypN0. RESULTS: After excluding patients with cT4 and cN0 disease at diagnosis, a total of 185 patients with cT1-3N1 BC were included. Patients were more likely to receive PMRT if they had ypN+ disease (P < .001) and/or lymphovascular invasion (P = .03). Patients who underwent lumpectomy were more likely to receive SCV RT if they did not achieve pCR (P = .04) and/or if they had ypN+ disease (P = .01). The 5-year rates of locoregional recurrence (LRR) were 15% for all patients, 14% for patients who attained ypT+ypN0, and 5% for patients who achieved pCR. Of ypT+ypN0 patients (n = 98), 53 received PMRT or SCV RT and 45 did not. For these patients, there were no differences in LRR based on whether a patient did or did not receive PMRT or SCV RT (P = .23). CONCLUSION: Recommendations for or against PMRT or SCV RT after NAC vary based on final pathologic response. We await the results of ongoing randomized clinical trials to help guide clinical decision making in this context.

Association Between Patient Education Videos and Knowledge of Radiation Treatment.

PURPOSE: Patient knowledge of radiation therapy (RT) before consult is typically limited, with many having misconceptions or fears. There exists a need to improve patient education in RT. Our purpose was to study the impact of patient education videos on patient-reported knowledge of RT, anxiety/fear, and satisfaction. METHODS AND MATERIALS: At our institution, we created 2 RT educational videos: a general RT video and a breast cancer-specific video. Patients presenting for breast RT who agreed to participate (n = 107) were randomly assigned to receive a link to the videos (video group; n = 58) or not (no-video group; n = 49) before consultation. Pre- and postconsult surveys were administered assessing patient-reported measures on a 5-point Likert-type scale. RESULTS: Patients in the video group reported significantly higher levels of confidence in their knowledge of radiation side effects, with 45.6.% at least somewhat confident versus 21.3% in the no-video group (P = .009; median on a 5-point Likert-type scale, 2 [interquartile range {IQR}, 2-3] versus 2 [IQR, 1-2], respectively [P = .012]). There was a trend toward higher knowledge of the radiation treatment process in the video group (median, 3 [IQR, 2-3] versus 2 [IQR, 2-3] for no-video group; P = .064). There were no significant differences in preconsult anxiety or fear between the groups, but of those who were assigned videos, 46.8% reported decreased anxiety afterward, and 66.0% felt more comfortable coming to a consult. While those in the no-video group hypothesized that a video would be helpful (median, 3; IQR, 3-4), those in the video group found them to be very helpful in real life (median, 4; IQR, 45; P = .0009). After the consult, all patients in both groups were satisfied. CONCLUSIONS: Patient education videos increase patient-reported knowledge of RT and are found to be very helpful.