Current margin practice and effect on re-excision rates following the publication of the SSO-ASTRO consensus and ABS consensus guidelines: a national prospective study of 2858 women undergoing breast-conserving therapy in the UK and Ireland.

INTRODUCTION: There is variation in margin policy for breast conserving therapy (BCT) in the UK and Ireland. In response to the Society of Surgical Oncology and American Society for Radiation Oncology (SSO-ASTRO) margin consensus ('no ink on tumour' for invasive and 2 mm for ductal carcinoma in situ [DCIS]) and the Association of Breast Surgery (ABS) consensus (1 mm for invasive and DCIS), we report on current margin practice and unit infrastructure in the UK and Ireland and describe how these factors impact on re-excision rates. METHODS: A trainee collaborative-led multicentre prospective study was conducted in the UK and Ireland between 1st February and 31st May 2016. Data were collected on consecutive BCT patients and on local infrastructure and policies. RESULTS: A total of 79 sites participated in the data collection (75% screening units; average 372 cancers annually, range 70-900). For DCIS, 53.2% of units accept 1 mm and 38% accept 2-mm margins. For invasive disease 77.2% accept 1 mm and 13.9% accept 'no ink on tumour'. A total of 2858 patients underwent BCT with a mean re-excision rate of 17.2% across units (range 0-41%). The re-excision rate would be reduced to 15% if all units applied SSO-ASTRO guidelines and to 14.8% if all units followed ABS guidelines. Of those who required re-operation, 65% had disease present at margin. CONCLUSION: There continues to be large variation in margin policy and re-excision rates across units. Altering margin policies to follow either SSO-ASTRO or ABS guidelines would result in a modest reduction in the national re-excision rate. Most re-excisions are for involved margins rather than close margins.

Conservative mastectomies for breast cancer and risk-reducing surgery: the Memorial Sloan Kettering Cancer Center experience.

Demand for conservative mastectomies continues to increase as more patients choose to undergo breast reconstruction, often with simultaneous contralateral prophylactic mastectomy (CPM). In addition, the increasing use of risk-reducing surgery in high-risk groups has contributed to the increased use of these techniques. We have reviewed the indications and outcomes of a large group of patients undergoing nipple-sparing mastectomy (NSM) at this institution. In total, 728 nipple-sparing mastectomies (NSMs) were performed in 413 patients between 2000 and 2013, for treatment of breast cancer (n=269) or risk reduction (n=459). Of 728 NSMs performed, 177 (24.3%) were in patients known to have a BRCA1 or BRCA2 germline mutation, or a genetic variant of uncertain significance. There was an incidental finding of ductal carcinoma in situ (DCIS) or invasive carcinoma in 22 (4.8%) and 8 (1.7%) of 459 prophylactic NSMs, respectively. In addition, unexpected invasive carcinoma was found in 17 of 98 therapeutic NSMs (17.3%) performed for DCIS. At median follow-up of 49 months, there were no known cases of local recurrence and only one case of regional recurrence. Immediate breast reconstruction was performed in 409 patients, most of whom underwent tissue expander/implant based procedures (n=401). Although 273 breasts (37.5%) had some evidence of skin desquamation at follow-up, most resolved spontaneously with 47 breasts (6.5%) requiring debridement. Other complications included hematoma in seven breasts (1%) and wound infection in 31 breasts (4.3%). Expander/implant removal was required in 20 cases (2.8%). The nipple-areola complex (NAC) was subsequently excised in 10 of 728 breasts (1.4%) due to oncologic concerns following assessment of retroareolar tissue. NSM was successful in most patients with an acceptable complication rate and in few patients subsequently undergoing removal of the NAC. Patients requiring mastectomy for breast cancer or risk reduction may now benefit from conservative mastectomy techniques such as NSM, resulting in improved cosmesis and, possibly, a reduced psychological impact.

Breast cancer screening at the Breast Examination Center of Harlem.

BACKGROUND: This study was designed to describe patient, disease, and treatment characteristics of women diagnosed with breast cancer at the Breast Examination Center of Harlem (BECH) and to determine whether these characteristics have changed over time. METHODS: Retrospective chart review of women diagnosed with breast cancer at BECH from 2000 to 2008 was performed. Comparisons were made to data from an earlier study period (1995-2000). RESULTS: From 2000 to 2008, 339 women were diagnosed with breast cancer following attendance at BECH-55 % were black, 39 % Hispanic, 5 % of other race/ethnicity; 52 % had no health insurance. Hispanic patients were significantly more likely to have no health insurance compared with black patients (p = 0.0091); 29 % of patients had preinvasive disease and 36.5 % had stage I disease. Almost 40 % of the entire group was followed for <1 year. Five-year overall survival for the entire group was 83 % (95 % CI, 75-89 %) and 79 % for 188 Black women (95 % CI, 68-87 %). Compared with the earlier study period (1995-2000), fewer patients presented with palpable masses (45.4 vs. 67 %), and more had either stage 0 or stage I disease (65.6 vs. 46 %). CONCLUSIONS: Women diagnosed with breast cancer at BECH are predominantly Black and Hispanic, and most of these patients do not have health insurance. An increasing proportion of women diagnosed with breast cancer are presenting with nonpalpable, early-stage disease. Despite improved access to breast cancer screening, early stage at diagnosis, and access to appropriate management, these ethnic minorities continue to have poor outcomes and are poorly compliant with follow-up.