Prognostic factors for recurrence and cosmesis in 393 patients after radiation therapy for early mammary carcinoma.

Between 1978 and 1985, 393 of 2,765 (14%) patients with operable cancer of the breast (clinical stage T0-3N0-2M0) were irradiated after excisional biopsy and staging axillary dissection. Of 77 patients with microscopic axillary metastases, 68 received systemic adjuvant therapy. Treatment failed locally in 26 cases, and there were seven patients with distant metastasis. The three major factors for increased local treatment failure were (a) age below 40 years (P = .003), (b) negative estrogen receptor assay result (P = .03), and (c) failure to deliver a radiation boost dose when tumor was present at the margin of the specimen (P = .002). The size of the tumor, the nodal status, the progesterone receptor assay result, and the presence of ductal carcinoma in situ mixed with infiltrating carcinoma did not show a significant influence on local recurrence. In 274 of 393 (70%) patients, cosmesis was evaluated. The four major factors affecting cosmesis favorably were (a) utilization of a wedge (P less than .0001); (b) treatment of two fields a day (P less than .0001); (c) failure to use a separate treatment port to the regional lymph nodes, so as to avoid field junctions (P = .0003); and (d) small size of specimen (less than 50 cm2) (P = .0171). A second or third cancer was found in 39 of the 393 (10%) patients; contralateral breast cancer was the most common form (n = 23), followed by genitourinary cancer (n = 5). The most frequent complication was arm edema (6%).

Graded treadmill stress testing. Patterns of physician use and abuse.

Treadmill stress testing is used in assessing the condition of patients with known or suspected heart disease. We did a prospective study to clarify physician ordering and integration of the test. Ordering criteria were always complied with, although most tests were ordered for evaluation of atypical chest pain and only a few for high risk patients with known cardiac dysfunction, indicating a misplaced emphasis on the diagnostic capabilities of the test. Tests in patients with atypical chest pain and stress-induced ischemic changes were always integrated, but in 30 percent of patients with atypical pain and no stress-induced electrocardiographic changes, the tests were not used in patient management. This was often due to the misconception that negative findings on a stress test excluded coronary disease. Physicians should be alerted to this misplaced emphasis and misconception.