Innovations for the future of breast surgery.

BACKGROUND: Future innovations in science and technology with an impact on multimodal breast cancer management from a surgical perspective are discussed in this narrative review. The work was undertaken in response to the Commission on the Future of Surgery project initiated by the Royal College of Surgeons of England. METHODS: Expert opinion was sought around themes of surgical de-escalation, reduction in treatment morbidities, and improving the accuracy of breast-conserving surgery in terms of margin status. There was emphasis on how the primacy of surgical excision in an era of oncoplastic and reconstructive surgery is increasingly being challenged, with more effective systemic therapies that target residual disease burden, and permit response-adapted approaches to both breast and axillary surgery. RESULTS: Technologies for intraoperative margin assessment can potentially half re-excision rates after breast-conserving surgery, and sentinel lymph node biopsy will become a therapeutic procedure for many patients with node-positive disease treated either with surgery or chemotherapy as the primary modality. Genomic profiling of tumours can aid in the selection of patients for neoadjuvant and adjuvant therapies as well as prevention strategies. Molecular subtypes are predictive of response to induction therapies and reductive approaches to surgery in the breast or axilla. CONCLUSION: Treatments are increasingly being tailored and based on improved understanding of tumour biology and relevant biomarkers to determine absolute benefit and permit delivery of cost-effective healthcare. Patient involvement is crucial for breast cancer studies to ensure relevance and outcome measures that are objective, meaningful, and patient-centred.

This article describes how future innovations in science and technology influence the management of breast cancer from a surgical perspective. This work was undertaken in response to the Commission on the Future of Surgery project initiated by the Royal College of Surgeons of England.

Trends in breast-conserving surgery in Mexico after the implementation of a public health insurance system.

Although breast conserving surgery is the standard of care for patients with localized breast cancer in high-income countries, little is known about its use in developing countries, where disparities in access to treatment may lead to an increased use of mastectomy. We examined the use of breast conserving surgery at a Mexican cancer center after the implementation of a public insurance program aimed at providing coverage for previously uninsured patients. Between 2006 and 2016, 4519 women received surgical treatment for breast cancer, of which 39% had early-stage disease. The proportion of patients treated with breast conserving surgery increased from 10% in the 2006-2009 period to 33% in the 2013-2016 period, with most of this increase occurring among women with early-stage disease (17-52%). Improving access to care and reducing the financial burden of breast cancer in developing countries may lead to an increased use of breast conserving surgery.

Trends in Peripheral Nerve Block Usage in Mastectomy and Lumpectomy: Analysis of a National Database From 2010 to 2018.

BACKGROUND: Compared to general anesthesia, regional anesthesia confers several benefits including improved pain control and decreased postoperative opioid consumption. While the benefits of peripheral nerve blocks (PNB) have been well studied, there are little epidemiological data on PNB usage in mastectomy and lumpectomy procedures. The primary objective of our study was to assess national trends of the annual proportion of PNB use in breast surgery from 2010 to 2018. We also identified factors associated with PNB use for breast surgery. METHODS: We identified lumpectomy and mastectomy surgical cases with and without PNB between 2010 and 2018 using the Anesthesia Quality Institute National Anesthesia Clinical Outcomes Registry (AQI NACOR). We modeled the nonlinear association between year of procedure and PNB use with segmented mixed-effects logistic regression clustered on facility identifier. The association between PNB use and year of procedure, age, sex, American Society of Anesthesiologists physical status (ASA PS), facility type, facility region, weekday, and tissue expander use was also modeled using mixed-effects logistic regression. RESULTS: Of the 189,854 surgical cases from 2010 to 2018 that met criteria, 86.2% were lumpectomy cases and 13.8% were mastectomy cases. The proportion of lumpectomy cases with PNB was <0.1% in 2010 and increased each subsequent year to 1.9% in 2018 (trend P < .0001). The proportion of mastectomy cases with PNB was 0.5% in 2010 and 13% in 2018 (trend P < .0001). The year 2014 was the breakpoint selected for segmented regression. Before 2014, the odds of PNB among the mastectomy cases was not significantly different from year to year. After 2014, the odds of PNB increased by 2.24-fold each year (95% confidence interval [CI], 2.00-2.49; P < .001); interaction test for pre-2014 versus post-2014 was P < .001. Similar trends were seen in the lumpectomy cases, where after 2014, the odds of PNB increased by 2.03-fold (95% CI, 1.81-2.27; P < .001); interaction test for pre-2014 versus post-2014 was P < .001. In the mastectomy cohort, year of procedure ≥2014, female sex, facility region, and tissue expander use were associated with higher odds of PNB. For lumpectomy cases, year of procedure ≥2014 and facility region were associated with higher odds of PNB use. CONCLUSIONS: We found increased annual utilization of PNB for mastectomy and lumpectomy since 2010, although absolute prevalence is low. PNB use was associated with year of procedure for both lumpectomy and mastectomy, particularly post-2014.

Breast-contour preserving procedures for early-stage breast cancer: a population-based study of the trends, variation in practice and predictive characteristics in Denmark and the Netherlands.

PURPOSE: Breast-contour preservation (BCP) is possible for most women treated for early-stage breast cancer. BCP can be defined as primary breast-conserving treatment (BCT), neoadjuvant chemotherapy (NAC) followed by BCT and immediate postmastectomy breast reconstruction (IBR). This study provides insight in current BCP strategies in Denmark and the Netherlands and aims to identify opportunities for improvement within both countries. METHODS: A total of 92,881 patients with early-stage breast cancer who were operated in Denmark and the Netherlands between 2012 and 2017 were selected from the Danish Breast Cancer Group and the Dutch National Breast Cancer Audit databases. BCP procedures and predictive factors were analyzed within and between both countries. RESULTS: BCP was achieved in 76.7% (n = 16,355) of the Danish and in 74.5% (n = 53,328) of the Dutch patients. While BCP rate did not change significantly over time in Denmark (p = 0.250), a significant increase in BCP rate from 69.5% in 2012 to 78.5% in 2017 (p < 0.001) was observed in the Netherlands. In both countries, variation in BCP rates between hospitals decreased over time. NAC followed by BCT and postmastectomy IBR was substantially more often used in the Netherlands compared to Denmark, specifically in patients younger than 50 years. CONCLUSIONS: In more than 75% of all Danish and Dutch patients, surgically treated for early-stage breast cancer, the breast-contour was preserved. The different use of BCP strategies within Denmark and the Netherlands and the differences observed between hospitals in both countries emphasize the need for more (inter)national consensus on treatment modalities.

Comparison of breast-conserving therapy vs mastectomy in women under age 40: National trends and potential survival implications.

INTRODUCTION: Despite initial increased rates of breast-conserving therapy compared to mastectomy after 1990, mastectomy rates have increased in women under age 40 since 2000. Our study explores the demographic and survival implications of this trend. METHODS: The National Cancer Database was used to study stage 1 breast cancer diagnosed in women under age 40 between 2004 and 2014. Demographic and clinical data were obtained. Multivariable regression and survival analyses were performed. RESULTS: Of 11 859 patients under age 40, 57.2% underwent mastectomy (39.0% unilateral and 61.0% bilateral) rather than breast-conserving therapy (42.8%). The rate of mastectomy was significantly higher in 2014 compared to 2004 (43.6% in 2004 vs 62.4% in 2014; P < 0.001). The rate of bilateral mastectomy was significantly higher in 2014 compared to 2004 in contrast to unilateral mastectomy (31.7% in 2004 vs 73.0% in 2014; P < 0.001). Non-Hispanic Caucasian ethnicity and private insurance status were predictors of bilateral mastectomy (OR 2.06 [95% CI: 1.84-2.30], P < 0.001; OR 1.39 [95% CI: 1.21-1.59], P < 0.001). Controlling for demographics, tumor grade, and adjuvant therapies, bilateral mastectomy was associated with significantly increased 10-year survival vs unilateral mastectomy (HR 0.75 [0.59-0.96], P = 0.023). Additionally, breast-conserving therapy was associated with significantly increased 10-year survival vs unilateral (HR 2.36 [95% CI: 1.83-3.05]; P < 0.001) and bilateral mastectomy (HR 2.30 [95% CI: 1.61-3.27]; P < 0.001). CONCLUSIONS: The majority of women under age 40 with stage 1 invasive breast cancer underwent mastectomy instead of breast-conserving therapy. This largely reflects increased rates of contralateral prophylactic mastectomy. Bilateral mastectomy and breast-conserving therapy vs unilateral mastectomy were associated with a small but significant increase in survival. This finding warrants further investigation to determine the clinical implications of decision-making in younger women.

Breast-Conserving Surgery in Patients With Mammary Paget's Disease.

BACKGROUND: We aimed to analyze the association between Paget's disease (PD) and breast cancer (BC) subtypes and compare the effect of breast-conserving surgery (BCS) as a local treatment with mastectomy for PD. MATERIALS AND METHODS: Data of patients with histologic type International Classification of Diseases-0-3 8540-8543 who were treated from 1973 to 2014 were retrieved from the Surveillance, Epidemiology, and End Results database of the National Cancer Institute. A chi-square test was used to identify differences in categorical data among different groups. Overall survival (OS) was analyzed using the Kaplan-Meier method, log-rank test, Cox proportional hazards models, sequential landmark analysis, and propensity score-matched analysis. RESULTS: The study cohort included 5398 patients. Triple-negative BC accounted for the fewest patients with PD-only (1/22, 4.54%), Paget's disease-ductal carcinoma in situ (PD-DCIS) (3/48, 6.25%), and Paget's disease-invading ductal carcinoma (PD-IDC) (23/352, 6.53%). According to the results of the log-rank test and Cox analysis, the 10-year OS rates were similar for the BCS and mastectomy subgroups among patients with PD-DCIS or PD-IDC. Furthermore, there were no significant differences in survival benefits among the different surgeries after propensity score matching. Landmark analyses for OS of patients with PD-DCIS or PD-IDC surviving more than 1, 3, and 5 y showed no significant differences in survival. There were statistical differences in 10-year OS rates for patients with PD-DCIS or PD-IDC who underwent radiation therapy, or not, following BCS (both, P < 0.001). CONCLUSIONS: For patients with PD-DCIS or PD-IDC, breast conservation therapy with lumpectomy and radiation is an effective local treatment strategy, compared with mastectomy.

Growing Trends of Contralateral Prophylactic Mastectomy and Reconstruction in Young Breast Cancer.

BACKGROUND: The aim of this study was to evaluate the trends of surgical treatments among young patients in T1N0-1M0 stage based on the Surveillance, Epidemiology, and End Results database. MATERIALS AND METHODS: Patients aged less than 40 y diagnosed between 1998 and 2015 were enrolled, with tumors in T1N0-1M0 stage and not located in the central area. Differences in clinical-pathological characteristics were evaluated using chi-square tests. Multivariate logistic regression was used to measure the various factors associated with contralateral prophylactic mastectomy (CPM). Independent prognostic factors were evaluated by Cox model. RESULTS: The total rate of breast-conserving surgery (BCS) was 51.6%, which declined from 64.5% in 1998 to 39.6% in 2015. The total rate of CPM was 22.7%, which increased from 3.7% in 1998 to 38.7% in 2014 despite a decline to 32.7% in 2015. Meanwhile, the rate of reconstruction increased in line with that of CPM, from 9.4% in 1998 to 35.0% in 2015. There was a trend of increasing use of implant-based reconstruction. Significant higher odds of CPM were found in recent year of diagnosis between 2010 and 2015 and in implant-based reconstruction. Patients undergoing CPM had similar survival outcomes compared with those undergoing BCS and unilateral mastectomy, whereas those undergoing BCS had better survival outcomes compared with those undergoing unilateral mastectomy. CONCLUSIONS: A trend of growing preference for CPM and reconstruction was observed among young patients in early stage in recent years without survival benefits. Efforts should be made to promote efficient communication and evidence-based decision-making.

Breast-conserving surgery versus mastectomy in young women with breast cancer in Asian settings.

Background: Mastectomy rates among women with early breast cancer in Asia have traditionally been high. This study assessed trends in the surgical management of young women with early-stage breast cancer in Asian settings. Survival in women treated with breast-conserving surgery (BCS; lumpectomy with adjuvant radiotherapy) and those undergoing mastectomy was compared. Methods: Young women (aged less than 50 years) newly diagnosed with stage I or II (T1-2 N0-1 M0) breast cancer in four hospitals in Malaysia, Singapore and Hong Kong in 1990-2012 were included. Overall survival (OS) was compared for patients treated by BCS and those who had a mastectomy. Propensity score analysis was used to account for differences in demographic, tumour and treatment characteristics between the groups. Results: Some 63·5 per cent of 3536 women underwent mastectomy. Over a 15-year period, only a modest increase in rates of BCS was observed. Although BCS was significantly associated with favourable prognostic features, OS was not significantly different for BCS and mastectomy; the 5-year OS rate was 94·9 (95 per cent c.i. 93·5 to 96·3) and 92·9 (91·7 to 94·1) per cent respectively. Inferences remained unchanged following propensity score analysis (hazard ratio for BCS versus mastectomy: 0·81, 95 per cent c.i. 0·64 to 1·03). Conclusion: The prevalence of young women with breast cancer treated by mastectomy remains high in Asian countries. Patients treated with BCS appear to survive as well as those undergoing mastectomy.

[Breast cancer management before 40 years: what change in one decade? A retrospective study at the "Institut de cancérologie de Lorraine": 2002-2012]. / Prise en charge du cancer du sein avant 40 ans : quelle évolution en une décennie ? Étude rétrospective réalisée à l'Institut de cancérologie de Lorraine : 2002-2012.

INTRODUCTION: Breast cancer of young women has medico-psychological issues, particularly in the perspective of "after cancer" period. The objective of the study was to analyze the changes in management, in a decade including the publication of Cancer Plans I and II. METHODS: This retrospective unicentric study involved two populations of women aged 40 and treated at the "Institut de cancérologie de Lorraine" in 2002-2004 (P1) and 2012-2014 (P2). Epidemiological-demographic, histological, diagnostic and therapeutic sequences were analyzed. RESULTS: 216 patients were included. The mean age was 35.7 years (range 22-40), with no significant epidemiological difference, except for an increased rate of obesity in P2. Preoperative biopsies became almost systematic and the pre-therapeutic care plan rate increased over the decade from 3.8% to 8% (p < 0.001). The rate of breast-conserving treatment remained stable. The sentinel lymph node rate increased from 4.4% in P1 to 31.9% in P2 (p < 0.001), while the rate of lymph node dissection decreased (p < 0.001) between the two periods. Resort to breast nurses, psycho-oncologists, fertility experts and oncogenetic consultations has also increased. CONCLUSION: There is an improvement in the care and management of young women under 40 because of the first Cancer Plans. A study about the impact on the prognosis and a reflection to improve the experience of illness for these women are to lead.

Breast conservation versus mastectomy in patients with T3 breast cancers (> 5 cm): an analysis of 37,268 patients from the National Cancer Database.

PURPOSE: Breast conservation therapy (BCT) is standard for T1-T2 tumors, but early trials excluded breast cancers > 5 cm. This study was performed to assess patterns and outcomes of BCT for T3 tumors. METHODS: We reviewed the National Cancer Database (NCDB) for noninflammatory breast cancers > 5 cm, between 2004 and 2011 who underwent BCT or mastectomy (Mtx) with nodal evaluation. Patients with skin or chest wall involvement were excluded. Patients having clinical T3 tumors were analyzed to determine outcomes based upon presentation, with those having pathologic T3 tumors, subsequently assessed, irrespective of presentation. Overall survival (OS) was analyzed using multivariable Cox proportional hazards models, with adjusted survival curves estimated using inverse probability weighting. RESULTS: After exclusions, 37,268 patients remained. Median age and tumor size for BCT versus Mtx were 53 versus 54 years (p < 0.001) and 6.0 versus 6.7 cm (p < 0.001), respectively. Predictors of BCT included age, race, location, facility type, year of diagnosis, tumor size, grade, histology, nodes examined and positive, and administration of chemotherapy and radiotherapy. OS was similar between Mtx and BCT (p = 0.36). This held true when neoadjuvant chemotherapy patients were excluded (p = 0.39). BCT percentages declined over time (p < 0.001), while tumor sizes remained the same (p = 0.77). Median follow-up was 51.4 months. CONCLUSIONS: OS for patients with T3 breast cancers is similar whether patients received Mtx or BCT, confirming that tumor size should not be an absolute BCT exclusion. Declining use of BCT for tumors > 5 cm in younger patients may be accounted for by recent trends toward mastectomy.

Oncoplastic and reconstructive breast surgery in Canada: breaking new ground in general surgical training

Summary: Oncoplastic breast surgery combines certain plastic surgery procedures with a breast cancer resection to minimize the cosmetic penalty. We compared current practices in breast surgery in Canada and the UK, looking at the classification of oncoplastic breast surgery, management of larger tumours that would otherwise mandate a mastectomy, and the breast surgeon's role in immediate breast reconstruction. Reconstructive breast surgery has always fallen within the domain of the plastic surgeon, but surgical subspecialization and more focused fellowship training have meant that breast surgeons with the appropriate skillset can offer these procedures. This evolution of the breast surgeon has led to the birth of a new field of breast surgery known as oncoplastic and reconstructive breast surgery. Those tasked with developing surgical training programs in Canada must now decide whether to train breast surgeons in these techniques to improve long-term quality of life among Canadian patients with breast cancer.

Trends in Lumpectomy and Oncoplastic Breast-Conserving Surgery in the US, 2011-2016.

BACKGROUND: Oncoplastic breast surgery aims to optimize efficacy of surgical resection and cosmesis to maximize patient satisfaction; however, despite the benefits, oncoplastic techniques have not been widely adopted in the US. This study examined trends in the incidence of lumpectomy (partial mastectomy) with or without oncoplastic techniques from 2011 to 2016. METHODS: This was a retrospective analysis of claims from the Optum Clinformatics database (January 2010-March 2017). Female patients with no history of breast surgery in the prior year were categorized into three independent cohorts: isolated lumpectomy (Lx), lumpectomy with tissue transfer (LxTT), or lumpectomy with mammaplasty and/or mastopexy (LxMM). Oncoplastic techniques (in cohorts two and three) were performed at either time of the initial lumpectomy or during 90-day follow-up. RESULTS: Overall, 19,253 patients met the inclusion criteria (91.1% Lx, 5.2% LxTT, and 3.7% LxMM). Significantly fewer patients with Lx had a family history of breast cancer compared with patients with oncoplastic techniques (26.4% vs. 33.7% and 37.9%, respectively; p < 0.001). The incidence of Lx declined significantly from 2011 (92.9%) to 2016 (88.1%), while LxTT and LxMM increased from 4.2 to 7.2% and 2.8 to 4.7%, respectively (both p < 0.001). The greatest utilization of oncoplastic techniques was observed in the Pacific census division (19.2%), while lowest utilization was in the East South Central division (3.2%; p < 0.001). CONCLUSIONS: While increased adoption of oncoplastic techniques was observed, the compound annual growth rate remained below 10% and varied significantly by region. Further adoption of oncoplastic techniques is necessary to improve cosmetic outcomes and patient satisfaction following breast-conserving surgery.

Nationwide population-based study of trends and regional variation in breast-conserving treatment for breast cancer.

BACKGROUND: Landmark trials have shown breast-conserving surgery (BCS) combined with radiotherapy to be as safe as mastectomy in breast cancer treatment. This population-based study aimed to evaluate trends in BCS from 1989 to 2015 in nine geographical regions in the Netherlands. METHODS: All women diagnosed between 1989 and 2015 with primary T1-2 N0-1 breast cancer, treated with BCS or mastectomy, were identified from the Netherlands Cancer Registry. Crude and case mix-adjusted rates of BCS were evaluated and compared between nine Dutch regions for two time intervals: 1989-2002 and 2003-2015. The annual percentage change in BCS per region over time was assessed by means of Joinpoint regression analyses. Explanatory variables associated with the choice of initial surgery were evaluated using multivariable logistic regression. RESULTS: A total of 202 934 patients were included, 82 200 treated in 1989-2002 and 120 734 in 2003-2015. During 1989-2002, the mean rate of BCS was 50·6 per cent, varying significantly from 39·0 to 71·7 per cent between the nine regions. For most regions, a marked rise in BCS was observed between 2002 and 2003. During 2003-2015, the mean rate of BCS increased to 67·4 per cent, but still varied significantly between regions from 58·5 to 75·5 per cent. A significant variation remained after case-mix correction. CONCLUSION: This large nationwide study showed that the use of BCS increased from 1989 to 2015 in the Netherlands. After adjustment for explanatory variables, a large variation still existed between the nine regions. This regional variation underlines the need for implementation of a uniform treatment and decision-making strategy.

Resection of primary lesion for patients with metastatic breast cancer: where are we now?

It is largely unclear that whether or not surgical resection of the primary tumors could confer survival benefit among patients with metastatic breast cancer at initial presentation. We thoroughly reviewed the up-to-date evidence on surgical resection of the primary lesion in metastatic breast cancer, including comparative studies (of particular interest in risk modifiers, the type, and timing of surgical procedures), Chinese and international guidelines, as well as the progress of clinical trials. Partial modified radical mastectomy and breast-conserving surgery are by far the most common choices for patients with metastatic breast cancer. Patients with certain characteristics, for example, younger than 45 years of age or with oligo-metastasis, might benefit from the surgery. The type and timing of surgical procedures are still in debate according to the guidelines from different countries. Forthcoming evidence from the ongoing clinical trials might help close the knowledge gaps in surgical treatment for patients with metastatic breast cancer and aid the decision-making in clinical practice.

Present and changing trends in surgical modalities and neoadjuvant chemotherapy administration for female breast cancer in Beijing, China: A 10-year (2006-2015) retrospective hospitalization summary report-based study.

BACKGROUND: This study was conducted to describe present and changing trends in surgical modalities and neoadjuvant chemotherapy (NACT) in female breast cancer patients in China from 2006 to 2015. METHODS: Data of 44 299 female breast cancer patients from 15 tertiary hospitals in Beijing were extracted from hospitalization summary reports. Surgeries were categorized into five modalities: breast-conserving surgery (BCS), simple mastectomy (SM), modified radical mastectomy (MRM), radical mastectomy (RM), and extensive radical mastectomy (ERM). RESULTS: In total, 38 471 (86.84%) breast cancer patients underwent surgery: 22.64% BCS, 8.22% SM, 63.97% MRM, 4.24% RM, and 0.93% ERM. Older patients (> 60) underwent surgery more frequently than younger patients (< 60). The proportion of patients who underwent BCS was highest in the age ≥ 80 (39.24%) and < 40 (28.69%) subgroups and in patients with papillary carcinoma (35.48%), and lowest in the age 60- subgroup (18.17%) and in patients with Paget's disease (19.05%). SM was most frequently performed in patients with Paget's disease (29.00%), and MRM for ductal (64.99%), and lobular (63.78%) carcinomas. During the study period, the proportion of patients who underwent MRM dropped by 29.04%, SM and BCS increased from 15.78% and 30.83%, respectively, and NACT increased in all subgroups, particularly in patients with lymph node involvement (26.72%). CONCLUSIONS: Surgical modalities varied significantly by age and histologic group. The use of BCS and SM increased dramatically, while MRM declined significantly. The proportion of patients treated with NACT has increased significantly, especially in patients with lymph node involvement.

Mastectomy patterns, but not rates, are changing in the treatment of early breast cancer. Experience of a single European institution on 2315 consecutive patients.

BACKGROUND: Recent literature reports that rates of mastectomy are increasing in early breast cancer. However, data from European institutions are limited and revealed conflicting results. We report on 15-year trends of mastectomy, mastectomy plus immediate reconstruction and contralateral prophylactic mastectomy (CPM) at an academic institution. METHODS: We identified women diagnosed with unilateral early breast cancer at stage 0-IIa, with tumour size ≤ 4 cm, between 2002 and 2016. Trends were assessed using the Cochrane-Armitage test. Multivariable logistic regression was used to identify factors associated with receipt of mastectomy plus immediate reconstruction. RESULTS: A total of 2315 patients were identified. Of them, 65.7% underwent breast conserving surgery (BCS), while 34.3% underwent mastectomy as upfront surgery. Two point four per cent also received CPM. Immediate reconstruction was performed in 36.0% of patients receiving mastectomy. There was no change in trends of mastectomy over the 15 years studied (p = 0.69), as well as in trends of patients undergoing CPM (p = 0.44). In contrast, rates of immediate reconstruction rose significantly over the study period (from 12.2% in 2002 to 62.7% in 2016, p < 0.0001). Women were more likely to receive mastectomy plus immediate reconstruction if they were aged 50 years or younger, or had tumours larger than 2 cm, or had non-invasive carcinoma. CONCLUSIONS: Our study suggests that rates of both mastectomy and CPM in early breast cancer are not increasing, while use of immediate reconstruction is on the rise.

The Shifting Paradigm for Breast Cancer Surgery in Patients Undergoing Neoadjuvant Chemotherapy.

INTRODUCTION: Surgical therapy for newly diagnosed breast cancer has changed over the past decade, but these trends have not been well documented in patients undergoing neoadjuvant therapy (NAC). METHODS: In a retrospective cohort study of the National Cancer Database (NCDB), we selected 285,514 women with clinical stage I-III breast cancer who underwent NAC or adjuvant therapy (AC) from 2006 to 2014. Breast-conserving surgery (BCS), unilateral mastectomy (UM), and bilateral mastectomy (BM) rates were compared between patients undergoing NAC and AC. RESULTS: Of 285,514 women, 68,850 (24.1%) underwent NAC. Of NAC patients, 18,158 (26.4%) underwent BM and 27,349 (39.7%) BCS compared with 31,886 (14.7%) and 120,626 (55.7%) AC patients, respectively. From 2006 to 2014, BM increased from 16.1 to 28.8% (p < 0.001) for NAC and from 7.4 to 17.5% (p < 0.001) for AC. After adjusting for patient, tumor, and facility factors, NAC patients were 1.50 times [odds ratio (OR) 1.50, confidence interval (CI) 1.42-1.51] more likely to undergo BM then AC patients. The difference in BM rates between patients receiving NAC versus AC varied significantly by cT classification. This difference was the greatest among cT1 tumors between NAC and AC (31.7 vs. 13.0%, p < 0.001), followed by cT2 tumors (24.1 vs. 16.6%, p < 0.001) and cT3 tumors (24.3 vs. 22.3%). CONCLUSIONS AND RELEVANCE: More NAC patients are undergoing BM while fewer are undergoing BCS compared with patients undergoing AC. This trend is particularly striking for those patients with smaller tumors who would otherwise be candidates for BCS.

Localization for Breast Surgery: The Next Generation.

CONTEXT: - Preoperative localization of nonpalpable breast lesions using image-guided wire placement has been a standard of breast imaging, diagnosis, and treatment since its development in the 1970s. With this technique, coordinated, same-day wire placement by the radiologist and surgery are required, which can lead to significant inefficiencies in workflow. Other disadvantages of wire localization (WL) include limitations in surgical incision and dissection route and protruding wires that can be both bothersome for the patient and have risk of displacement. OBJECTIVE: - To outline several recently developed techniques that could replace traditional WL and eliminate its disadvantages. The first developed was radioactive seed localization (RSL) using I-125, a technique adopted by many institutions during the last few years. The challenge to this method, however, is the strict nuclear regulatory requirements, which can be a significant burden and limitation. The disadvantages of WL and RSL have provided incentive for the development of other types of preoperative localization procedures. Two of these are recently US Food and Drug Administration-cleared, nonradioactive, non-wire location technologies emerging as alternatives to WL and RSL; SAVI SCOUT (Cianna Medical Inc, Aliso Viejo, California), which uses infrared light and a microimpulse radar reflector, and Magseed (Endomagnetics Inc, Austin, Texas), which uses a magnetic seed for localization. DATA SOURCES: - We review the published literature on non-wire location technologies for breast tissue resection. CONCLUSIONS: - Non-wire location techniques are beneficial, allowing image-guided placement before the day of surgery and resulting in improved workflows. These techniques also eliminate bothersome protruding wires, risk of dislodging, and allow the incision site to be independent from the localization site.

Decision Making in the Surgical Management of Invasive Breast Cancer-Part 2: Expanded Applications for Breast-Conserving Surgery.

Treatment of early-stage invasive breast cancer with breast-conserving surgery plus radiation therapy (RT) yields overall survival outcomes equivalent to those achieved with mastectomy. Further, breast-conserving surgery is endorsed by the National Comprehensive Cancer Network as being supported by the highest-level, category 1 evidence. Advances in pathologic evaluation, management of multiple tumors, oncoplastic lumpectomy techniques, neoadjuvant chemotherapy, and hypofractionated RT can expand the pool of patients eligible for breast-conserving surgery. Selected patients (for example, patients older than 70 years of age with hormone receptor-positive T1 tumors who are willing to commit to receiving adjuvant endocrine therapy) may be able to forgo RT completely. This article will detail current management approaches to achieving breast conservation in patients with invasive breast cancer, including cases of bulky tumors and/or multiple tumors.