A population based study of variations in operation rates for breast cancer, of comorbidity and prognosis at diagnosis: failure to operate for early breast cancer in older women.

BACKGROUND: Older women are less likely to have surgery for operable breast cancer. This population-based study examines operation rates by age and identifies groups which present with early or late disease. METHODS: 37 000 cancer registrations for 2007 were combined with Hospital Episode Statistics comorbidity data for England. Operation rates were examined by age, ethnicity, deprivation, comorbidity, screen-detection, tumour size, grade and nodal status. Early and late presentation were correlated with Nottingham Prognostic Index (NPI) groups and tumour size. RESULTS: The proportion of women not having surgery increased from 7-10% at ages 35-69 to 82% from age 90. From age 70, the proportion not having surgery rose by an average of 3.1% per year of age. Women with a Charlson Comorbidity Index score of ≥1 (which increased with age), with tumours >50 mm or who were node positive, were less likely to have surgery. Although women aged 70-79 were more likely to have larger tumours, their tumours were also more likely to have an excellent or good NPI (p < 0.001). Good prognosis tumours were more likely to be screen-detected, and less likely in women aged 0-39, the deprived and certain ethnic groups (p < 0.02). CONCLUSIONS: From age 70 there is an increasing failure to operate for breast cancer. Younger women and certain ethnic groups presented with more advanced tumours. Older women had larger tumours which were otherwise of good prognosis, and this would not account for the failure to operate which may in part be related to comorbidity in this age group.

Radiotherapy or tamoxifen after conserving surgery for breast cancers of excellent prognosis: British Association of Surgical Oncology (BASO) II trial.

BACKGROUND: The incidence of local recurrence (LR) after conservative surgery for early breast cancer without adjuvant therapy is unacceptably high even with favourable tumours. The aim of this study was to examine the effect of adjuvant therapies in tumours with excellent prognostic features. METHODS: Patients with primary invasive breast cancer <2 cm diameter, grade 1 or good prognosis special type, and node negative, treated by wide local excision (WLE) with clear margins were randomised into a 2 × 2 clinical trial of factorial design with or without radiotherapy and with or without tamoxifen. Trial entry was allowed to either comparison or both. FINDINGS: The actuarial breast cancer specific survival in 1135 randomised patients at 10 years was 96%. Analysis by intention to treat showed that LR after WLE was reduced in patients randomised to radiotherapy (RT) (HR 0.37, CI 0.22-0.61 p<0.001) and to tamoxifen (HR 0.33, CI 0.15 - 0.70 p<0.004). Actuarial analysis of patients entered into the four-way randomisation showed that LR after WLE alone was 1.9% per annum (PA) versus 0.7% with RT alone and 0.8% with tamoxifen alone. No patient randomised to both adjuvant treatments developed LR. Analysis by treatment received showed LR at 2.2%PA for surgery alone versus 0.8% for either adjuvant radiotherapy or tamoxifen and 0.2% for both treatments. CONCLUSIONS: Even in these patients with tumours of excellent prognosis, LR after conservative surgery without adjuvant therapy was still very high. This was reduced to a similar extent by either radiotherapy or tamoxifen but to a greater extent by the receipt of both treatments.

Clinical outcome data for symptomatic breast cancer: the Breast Cancer Clinical Outcome Measures (BCCOM) Project.

BACKGROUND: Data collection for screen-detected breast cancer in the United Kingdom is fully funded, which has led to improvements in clinical practice. However, data on symptomatic cancer are deficient, and the aim of this project was to monitor the current practice. METHODS: A data set was designed together with surrogate outcome measures to reflect best practice. Data from cancer registries initially required the consent of clinicians, but in the third year anonymised data were available. RESULTS: The quality of data improved, but this varied by region and only a third of the cases were validated by clinicians. Regional variations in mastectomy rates were identified, and one-third of patients who underwent conservative surgery for the treatment invasive breast cancer were not recorded as receiving radiotherapy. CONCLUSION: National data are essential to ensure that all patients receive appropriate treatment for breast cancer, but variations still exist in the United Kingdom and further improvement in data capture is required.

Is mammography overused in male patients?

There is no agreed protocol for the use of mammography in evaluating the male breast. As a result, the tendency is to use the mammography more often than required. In order to define the role of mammography in men, we carried out a retrospective analysis of all male patients referred to the breast clinic with a history of breast lump between January 2001 and December 2003. The impact of mammography in the evaluation of male breast cancer cases was studied. A total of 220 male patients were referred to the breast clinic during this period. Of these, 134 men had a mammographic examination, with majority (96%) being performed prior to their consultation with the breast clinician as per the clinic protocol. Nine patients under the age of 35 years also had a mammographic evaluation. There were 4 cases of breast cancer diagnosed during this period. Breast cancer was suspected in all patients on clinical examination and was confirmed by biopsy. Breast cancer in men can be suspected on clinical examination in the majority of cases. Mammography appears unnecessary in most men and should not be used as a routine imaging procedure. One should consider imaging only those with clinically suspicious breast lumps to avoid unnecessary imaging particularly in young male patients.

A case-control study to estimate the impact on breast cancer death of the breast screening programme in Wales.

OBJECTIVES: The aim of this study was to estimate the effect of service screening, as provided by the NHS breast screening programme, on breast cancer mortality in Wales. Furthermore, we wished to ascertain whether a reduction in breast cancer mortality consistent with that observed in the randomised screening trials was being achieved. SETTING: The NHS Breast Screening Programme in Wales, managed by Breast Test Wales, with headquarters in Cardiff. METHODS: A case-control study design with 1:2 matching. The cases were deaths from breast cancer in women aged 50-75 years at diagnosis who were diagnosed after the instigation of screening in 1991 and who died after 1998. The controls were women who had not died of breast cancer or any other condition during the study period. One was from the same GP practice and the other from a different GP practice within the same district, matched by year of birth. RESULTS: Based on 419 cases, the odds ratio for risk of death from breast cancer for women who have attended at least one routine screen compared to those never screened was 0.62 (95% confidence interval [CI] 0.47-0.82, p=0.001). After excluding cases diagnosed prior to 1995 and adjusting for self-selection bias, the estimated mortality reduction was 25% (odds ratio=0.75, 95% CI 0.49-1.14, p=0.09). CONCLUSION: The Breast Test Wales screening programme is achieving a reduction in breast cancer mortality of 25% in women attending for screening, which is consistent with the results of the randomized controlled trials of mammographic screening.

Are surgeons effective counsellors for women with a family history of breast cancer?

AIM: In the TRACE (Trial of Genetic Assessment in Breast Cancer) study, the data on the time spent by the surgeon with the women with a family history of breast cancer was analysed with respect to the changes in the anxiety scores and breast cancer worry scores. We wanted to see whether longer consultation times with surgeons improved these scores. METHODS: In the TRACE study, women with a family history of breast cancer attended a standard breast clinic to be seen by a surgeon and nurse specialist. Anxiety scores and breast cancer worry scores of these women were recorded prior to attending the clinic and immediately after their appointment. RESULTS: In the 274 evaluable women, there was a significant improvement in the anxiety and breast cancer worries after surgical consultation but it did not correlate with the length of surgical consultation. However, women in the high-risk group showed a significant reduction of breast cancer worry score with longer consultation (P=0.032). CONCLUSIONS: Spending more time with the women with a family history of breast cancer does not help to reduce anxiety scores and breast cancer worry scores except in the subset of women who were told that their risk of breast cancer was high.

The relevance of reported symptoms in a breast screening programme.

AIM: Although the National Health Service (NHS) Breast Screening Programme is aimed at asymptomatic women, inevitably patients attending screening report symptoms. The study aim was to assess the usefulness of recall based on clinical symptoms. MATERIALS AND METHODS: Information on breast symptoms is recorded at screening and radiologists can make recall decisions based on mammography and symptom history. We identified 1394 women with significant symptoms, between 1991 and 1996. The majority (54%) complained of a lump, 21% had breast distortion, 18% breast pain alone and 6% reported nipple discharge. RESULTS: Of the 1394 women, 262 were recalled because of mammographic suspicion and of these, 45% had breast cancer. The other 1132 women had symptoms and benign mammograms and 44% of these were recalled. Seven breast cancers were diagnosed; all had complained of a breast lump. In two the cancer would have been seen on two-view mammography. Of 638 not recalled, five women went on to develop an interval cancer. CONCLUSION: The results indicate that collecting details on symptoms is useful given the high rate of breast cancer in those with mammographic abnormality. When mammography is benign, however, the low rate of cancer detection means recall should be selective based on only the most relevant symptoms.

Obesity predisposes to increased drainage following axillary node clearance: a prospective audit.

BACKGROUND: Whilst sentinel node biopsy is being evaluated for optimising treatment of the axilla, axillary dissection remains the gold standard. Seroma formation, a common sequel to axillary dissection, has been shown to be associated with an increased incidence of wound infection, delayed healing, and lymphoedema. This study was conducted to evaluate the possible contributory role of obesity in axillary drainage following lymphatic dissection. PATIENTS AND METHODS: This study comprised a prospective review of all patients undergoing axillary dissection in conjunction with mastectomy or wide local excision. The total in-patient axillary drainage and the average daily drainage was correlated with various clinical parameters, including obesity, type of surgery, level of axillary dissection and nodal involvement. The body mass index (BMI) was used as a measure of obesity. RESULTS: During a 6-month period, axillary dissection was performed in 79 women. Nineteen patients were excluded. Patey mastectomy was performed on 33 (55%) and the remaining had breast conservation. The amount or duration of axillary drainage did not correlate with the type of operation, tumour histology, level of axillary dissection or the nodal status. Higher BMI correlated with increased mean daily axillary drainage and total volume drained, whilst in hospital. (Spearman correlation coefficient 0.42; P < 0.01). CONCLUSION: Obesity predisposes to increased axillary drainage following nodal clearance.

Results from 10 years of breast screening in Wales.

OBJECTIVE: To present results from 10 years of breast screening in Wales, including rates of interval cancers. SETTING: All women aged 50-64 years in Wales; approximately 250,000 in each screening round. METHODS: Breast Test Wales (BTW) began mammographic screening in 1989 as part of the National Breast Screening Programme. Two view mammography was introduced at the inception of the Welsh programme for all prevalent screens. Single view mammography was subsequently performed for incident screens. Interval cancers were identified by matching details from the BTW administrative screening database with the BTW database of all incident breast cancers for residents in Wales. RESULTS: For the first and second round prevalent screens, the cancer detection rate was 8.6 per 1000 and 7.4 per 1000 screened, respectively. The interval cancer rates following round one were 4.9 per 10,000 in the first 12 months, 9.0 per 10,000 between 12 and 24 months, and 11.6 per 10,000 between 24 and 36 months after screening. For the second round incident screens the detection rate was 4.6 per 1000 and the standardised detection ratio was 0.89, but the interval cancer rates in the first year after incident screens were not statistically different from those following prevalent screens. There was no change in the proportion of invasive breast cancers which were < 15 mm in diameter, or in the grades of invasive cancer between the first and second rounds, prevalent or incident screens. CONCLUSIONS: Breast Test Wales has achieved the standards set by the National Health Service Breast Screening Programme. Taking two views at the prevalent screen gave high sensitivity and may have resulted in the low standardised detection ratio at subsequent incident screens.

Randomized trial of a specialist genetic assessment service for familial breast cancer.

BACKGROUND: Because of the growing demand for genetic assessment, there is an urgent need for information about what services are appropriate for women with a family history of breast cancer. Our purpose was to compare the psychologic impact and costs of a multidisciplinary genetic and surgical assessment service with those of current service provisions. METHODS: We carried out a prospective randomized trial of surgical consultation with (the trial group) and without (the control group) genetic assessment in 1000 women with a family history of breast cancer. All P: values are from two-sided tests. RESULTS: Although statistically significantly greater improvement in knowledge about breast cancer was found in the trial group (P: =.05), differences between groups in other psychologic outcomes were not statistically significant. Women in both groups experienced statistically significant reductions in anxiety and found attending the clinics to be highly satisfying. An initial specialist genetic assessment cost pound 14.27 (U.S. $22.55) more than a consultation with a breast surgeon. Counseling and genetic testing of affected relatives, plus subsequent testing of family members of affected relatives identified as mutation carriers, raised the total extra direct and indirect costs per woman in the trial group to pound 60.98 (U.S. $96.35) over costs for the control subjects. CONCLUSIONS: There may be little benefit in providing specialist genetics services to all women with a family history of breast cancer. Further investigation of factors that may mediate the impact of genetic assessment is in progress and may reveal subgroups of women who would benefit from specialist genetics services.

The National Breast Referral Guidelines have cut down inappropriate referrals in the under 50s.

AIMS: When the National Breast Referral Guidelines were applied to our local GPs letters immediately prior to their release in January 1996, it was shown that on the basis of the GPs own conclusions that 29% of symptomatic women could have been managed initially by their own GP without missing any carcinomas. We conducted this study at the Rapid Access Breast Clinic at the University Hospital of Wales to determine if the breast referral practices of local GPs have altered due to the breast referral guidelines. METHODS: We studied 2332 referrals from the inception of the Rapid Access Clinic in May 1995 to the issue of the guidelines, and 2421 referrals from May 1996 to the end of the year. Random samples of 600 patients were drawn from each year and the referral letters were scored as within or outside the guidelines. Family history patients were excluded. RESULTS: There was an 11% fall in referrals outside the guidelines in the under 50s (chi-squared=<0.001) but the 7% fall in the over 50s was not significant. CONCLUSIONS: The Breast Referral Guidelines seem to have been effective in reducing the higher level of inappropriate referrals in younger patients at less risk of carcinoma.

Angiosarcoma of the breast following radiation therapy.

Breast carcinoma is increasingly treated by conservation therapy. This includes wide local excision and axilliary node clearance followed by radiotherapy to the remaining breast. Therapeutic irradiation may be complicated by several problems, including the development of other malignant tumours. We report a case of angiosarcoma occurring following such treatment and present a review of the literature.

Psychological distress associated with waiting for results of diagnostic investigations for breast disease.

This paper presents the results of a multi-method research project investigating the psychological distress associated with waiting for results of diagnostic investigations in a delayed-results breast clinic. A cohort of 126 women completed standardized psychometric instruments to assess anxiety, mood and coping over 3 days. Semi-structured interviews were conducted with 20 respondents. The findings indicate that waiting sustained but did not exacerbate psychological distress. Peri-diagnostic anxiety, depression, uncertainty and confusion were associated with anxiety levels immediately following triple assessment. Women leaving the clinic with low anxiety retained this composure throughout the peri-diagnostic period. Those in the moderate and high anxiety groups recorded sustained anxiety, depression, uncertainty and confusion, with mean scores comparable to and exceeding those reported by psychiatric out-patients. Coping during the waiting period was typically accomplished by emotion-focused strategies. Qualitative data suggested the delayed-results clinic structure may facilitate psychological preparation for test results.

Evaluation of general practitioner referrals to a specialist breast clinic according to the UK national guidelines.

The recently published national guidelines to general practitioners for the referral of patients with breast problems were retrospectively applied to letters of all patients attending the Rapid Access Breast Clinic at the University Hospital of Wales. The patients have all had diagnostic investigations performed at the initial visit with a multidisciplinary review of results and provision of a management plan prior to the subsequent visit. Since its inception in May 1995 until the end of the year when the guidelines were published, 2332 new patients had been seen. Overall, 29% of patients with benign breast disease would not have been referred if the guidelines had been strictly followed. Of the 147 symptomatic carcinomas diagnosed from general practitioner referrals (6.3% of total referrals), no invasive cancers would have been missed. One patient with incidental detection of ductal carcinoma in situ (DCIS) in the asymptomatic contralateral breast would not have been referred. Referral for pain without a discrete lump constituted 63% of the patients with a benign diagnosis who fell outside the guidelines. The guidelines also include comprehensive algorithms for the initial management of benign breast symptoms that do not require immediate referral by the general practitioners. Our general practitioners were significantly better at referring patients over 50 years old but the proportion of appropriate referrals were not related to the number referred by each practice. The present guidelines adequately cover referral for the diagnosis of malignant breast disease to a specialist, and may reduce the benign workload of breast clinics.

Role of fine-needle aspiration cytology and needle-core biopsy in the diagnosis of lobular carcinoma of the breast.

Fine-needle aspiration cytology (FNAC) plays a key role in the preoperative diagnosis of carcinoma of the breast but is less reliable in the diagnosis of infiltrating lobular carcinoma. The method of diagnosis was reviewed in 56 patients with lobular carcinoma who had attended screening and symptomatic clinics. In 29 patients FNAC results demonstrated malignant cells; 15 of these had palpable disease and the mean tumour size was 21 mm. In 27 patients FNAC failed to demonstrate malignant cells; 13 lesions were palpable and the mean tumour size was 23 mm. Ten patients were diagnosed by needle-core biopsy when FNAC was not diagnostic. FNAC may fail to diagnose even large lobular carcinoma and needle-core biopsy is strongly recommended in this situation.

Tuberculous peritonitis presenting as coloenteric fistula.

Abdominal tuberculosis can present as tuberculous peritonitis with generalised or loculated ascites, lymphadenitis of the mesenteric or retroperitoneal nodes, or as intestinal tuberculosis. In the last case it could be annular mucosal ulceration, single or multiple strictures or hyperplastic tuberculosis of the bowel, usually involving the terminal ileum or ileocaecal region. Disease higher in the ileum is considered common but involvement of the appendix, stomach, duodenum, jejunum, colon and rectum is unusual. Tuberculous peritonitis presenting as a coloenteric fistula is not a common clinical entity. In this case a patient who presented with peritonitis was found to have tuberculous peritonitis with coloenteric fistula.

West Midlands Oncology Association trial of adjuvant chemotherapy in node-negative breast cancer.

Between 1976 and 1984, 574 patients with operable breast cancer and histologically negative axillary lymph nodes were randomly assigned after mastectomy to receive either no further treatment or chemotherapy with oral LMF (fluorouracil, 500 mg, methotrexate, 25 mg, and chlorambucil, 10 mg, on day 1; fluorouracil, 500 mg, and chlorambucil, 10 mg, on day 2). There is no overall survival or relapse-free survival benefit at a median follow-up of 10 years and 8 years, respectively. There are significantly more local relapses in the control group (P less than .01), but an excess of distant relapses in the treated group is not statistically significant (P = .24). A positive treatment effect in small tumors (relapse-free survival, odds ratio = 0.55, P = .01) and a negative effect in progesterone receptor-positive tumors (survival, odds ratios = 2.04, P = .04) is probably ascribable to chance. Analysis of various prognostic factors shows that tumor size and histological grade have a clear effect on both relapse-free interval and survival.