Sentinel node biopsy after neoadjuvant chemotherapy in biopsy-proven node-positive breast cancer: the SN FNAC study.

PURPOSE: An increasing proportion of patients (> 30%) with node-positive breast cancer will obtain an axillary pathologic complete response after neoadjuvant chemotherapy (NAC). If sentinel node (SN) biopsy (SNB) is accurate in this setting, completion node dissection (CND) morbidity could be avoided. PATIENTS AND METHODS: In the prospective multicentric SN FNAC study, patients with biopsy-proven node-positive breast cancer (T0-3, N1-2) underwent both SNB and CND. Immunohistochemistry (IHC) use was mandatory, and SN metastases of any size, including isolated tumor cells (ypN0[i+], ≤ 0.2 mm), were considered positive. The optimal SNB identification rate (IR) ≥ 90% and false-negative rate (FNR) ≤ 10% were predetermined. RESULTS: From March 2009 to December 2012, 153 patients were accrued to the study. The SNB IR was 87.6% (127 of 145; 95% CI, 82.2% to 93.0%), and the FNR was 8.4% (seven of 83; 95% CI, 2.4% to 14.4%). If SN ypN0(i+)s had been considered negative, the FNR would have increased to 13.3% (11 of 83; 95% CI, 6.0% to 20.6%). There was no correlation between size of SN metastases and rate of positive non-SNs. Using this method, 30.3% of patients could potentially avoid CND. CONCLUSION: In biopsy-proven node-positive breast cancer after NAC, a low SNB FNR (8.4%) can be achieved with mandatory use of IHC. SN metastases of any size should be considered positive. The SNB IR was 87.6%, and in the presence of a technical failure, axillary node dissection should be performed. We recommend that SN evaluation with IHC be further evaluated before being included in future guidelines on the use of SNB after NAC in this setting.

Breast conservation therapy rates are no different in medically indigent versus insured patients with early stage breast cancer.

PURPOSE: Multiple prospective, randomized studies show that breast conservation therapy (BCT) results in survival rates equal to mastectomy (Mx) for patients with early stage breast cancer (ESBC). Nevertheless, BCT remains underused in certain areas of the nation, without clearly definable reasons. Several studies have implicated socioeconomic status as one potential cause for this disparity in BCT usage. We sought to compare BCT rates in the medically indigent versus insured patients, within the same institution. METHODS: Data from 1993 to 2000, collected from the institutional tumor registry and the hospital's claims records, were analyzed for 928 patients with ESBC (Stages 0, I, and II), treated at a single medical center. The same surgeons treated both insured and indigent patients. Patients treated by BCT or Mx were compared for age, race, stage, insurance status, access to a radiation therapy center, surgeon, and year of diagnosis. RESULTS: Patient age, race, surgeon, or insurance status did not significantly affect the rate of mastectomy. Stage I patients (P < 0.001) and those treated after 1995 had higher BCT rates (54.9% in 1993-95 vs. 70.7% in 1996-2000; P < 0.001). Travel distance to a radiation therapy center had no significant impact on BCT rates, except for patients >40 miles distant. CONCLUSIONS: These data refute the hypothesis that socioeconomic status, as reflected by medical insurance, is a determinant of BCT in women with ESBC. Distance of <40 miles to a radiation therapy facility, Stage I disease, and diagnosis after 1995 were factors associated with higher BCT rates.