Invasive Ductal Carcinoma of the Breast in a Transgender Man: A Case Report.

There is limited literature about breast cancer in the transgender population. Very little is known about how gender-affirming hormone therapy affects their breast cancer risk. On the other end, for those diagnosed with breast cancer, there are no clinical guidelines to manage their breast cancer, specifically, how to manage their gender-affirming hormone therapy during breast cancer treatment. Here, we report a 52-year-old transman diagnosed with a grade 2 invasive ductal carcinoma (ER+/PR+/HER2-), and ductal carcinoma in situ (DCIS) of intermediate grade. We discussed his risk factors as well as treatment options.

Malpractice Cases in Breast Surgery: An Assessment of Litigation Involving Surgeons.

INTRODUCTION: Improving patient safety and quality are priorities in health care. The study of malpractice cases provides an opportunity to identify areas for quality improvement. While the issues surrounding malpractice cases in breast cancer are often multifactorial, there are few studies providing insight into malpractice cases specifically related to common breast cancer surgical procedures. We sought to characterize the factors in liability cases involving breast cancer surgery. METHODS: Closed cases from 2008 to 2019 involving a breast cancer diagnosis, a primary responsible service of general surgery, surgical oncology, or plastic surgery, and a breast cancer procedure were reviewed using data from the Controlled Risk Insurance Company (CRICO) Strategies Comparative Benchmarking System database, a national repository of professional liability data. RESULTS: A total of 174 malpractice cases were reviewed, of which 41 cases were closed with payment. Plastic surgeons were most commonly named (64%, 111/174), followed by general surgeons (30%, 53/174), and surgical oncologists (6%, 10/174). The most common allegation was error in surgical treatment (87%, 152/174), and infection, cosmetic injury, emotional trauma, foreign body, and nosocomial infections represented the top five injury descriptions. On average, indemnity payments were larger for high clinical severity cases. Technical skills, followed by clinical judgment, were the most commonly named contributing factors. The average payment per case was $130,422. CONCLUSION: Malpractice cases predominantly involve technical complications related to plastic surgery procedures. Better understanding of the malpractice environment involving surgical procedures performed for breast cancer may provide practical insight to guide initiatives aimed at improving patient outcomes.

Evaluation of online Spanish and English health materials for preventive mastectomy. are we providing adequate information?

PURPOSE: Breast cancer remains the leading cause of cancer-related death in US Hispanic women. When present, lower health literacy levels potentially within this patient population require tailored materials to address health disparities. We aim to evaluate and compare Spanish and English online health care informative resources on preventive mastectomy. METHODS: A Google web search using "preventive mastectomy" and "mastectomía preventiva" was conducted. The first ten institutional/organizational websites in each language were selected. Assessment of mean reading grade level, cultural sensitivity, understandability, and actionability was carried out utilizing validated tools. RESULTS: The mean reading grade level for English materials was 14.69 compared with 11.3 for Spanish, both exceeding the recommended grade level established by the AMA and NIH. The mean cultural sensitivity score for English information was 2.20 compared with 1.88 for Spanish information, both below the acceptability benchmark of 2.5. English webpages scored 65% and 35% for understandability and actionability, respectively, while Spanish webpages scored 47% and 18%. CONCLUSIONS: Online English and Spanish preventive mastectomy materials were written at an elevated reading level and lacked cultural sensitivity. Spanish language information demonstrated inferior understandability, actionability, and cultural sensitivity. Addressing these issues provides an opportunity to help resolve health literature disparities regarding preventive mastectomy for US Hispanic women.

The Role of Oncotype DX® Recurrence Score in Predicting Axillary Response After Neoadjuvant Chemotherapy in Breast Cancer.

INTRODUCTION: Oncotype DX® recurrence score (RS) is well-recognized for guiding decision making in adjuvant chemotherapy; however, the predictive capability of this genomic assay in determining axillary response to neoadjuvant chemotherapy (NCT) has not been established. METHODS: Using the National Cancer Data Base (NCDB), we identified patients diagnosed with T1-T2, clinically N1/N2, estrogen receptor-positive/human epidermal growth factor receptor 2-negative (ER +/HER2 -) invasive ductal carcinoma of the breast between 2010 and 2015. Patients with an Oncotype DX® RS who received NCT were included. RS was defined as low (< 18), intermediate (18-30), or high (> 30). Unadjusted and adjusted analyses were performed to determine the association between axillary pathologic complete response (pCR) and RS. RESULTS: This study included a total of 158 women. RS was low in 56 (35.4%) patients, intermediate in 62 (39.2%) patients, and high in 40 (25.3%) patients. The majority of patients presented with clinical N1 disease (89.2%). Axillary pCR was achieved in 23 (14.6%) patients. When stratifying patients with axillary pCR by RS, 11 (47.8%) patients had a high RS, 6 (26.1%) patients had an intermediate RS, and 6 (26.1%) patients had a low RS. Comparing cohorts by RS, 27.5% of patients with high RS tumors had an axillary pCR, compared with only 9.7% in the intermediate RS group, and 10.7% in the low RS group (p = 0.0268). CONCLUSION: Our findings demonstrate that Oncotype DX® RS is an independent predictor of axillary pCR in patients with ER +/HER2 - breast cancers receiving NCT. A greater proportion of patients with a high RS achieved axillary pCR. These results support Oncotype DX® as a tool to improve clinical decision making in axillary management.

The Tyrer-Cuzick Model Inaccurately Predicts Invasive Breast Cancer Risk in Women With LCIS.

BACKGROUND: The Tyrer-Cuzick model has been shown to overestimate risk in women with atypical hyperplasia, although its accuracy among women with lobular carcinoma in situ (LCIS) is unknown. We evaluated the accuracy of the Tyrer-Cuzick model for predicting invasive breast cancer (IBC) development among women with LCIS. METHODS: Women with LCIS participating in surveillance from 1987 to 2017 were identified from a prospectively maintained database. Tyrer-Cuzick score (version 7) was calculated near the time of LCIS diagnosis. Patients with prior or concurrent breast cancer, a BRCA mutation, receiving chemoprevention, or with pleomorphic LCIS were excluded. Invasive cancer-free probability was estimated using the Kaplan-Meier method. RESULTS: A total of 1192 women with a median follow-up of 6 years (interquartile range [IQR] 2.5-9.9) were included. Median age at LCIS diagnosis was 49 years (IQR 45-55), 88% were white; 37% were postmenopausal, 28% had ≥ 1 first-degree family member with breast cancer, and 13% had ≥ 2 second-degree family members with breast cancer. In total, 128 patients developed an IBC; median age at diagnosis was 54 years (IQR 49-61). Five- and 10-year cumulative incidences of invasive cancer were 8% (95% confidence interval [CI] 6-9%) and 14% (95% CI 12-17%), respectively. The median Tyrer-Cuzick 10-year risk score was 20.1 (IQR 17.4-24.3). Discrimination measured by the C-index was 0.493, confirming that the Tyrer-Cuzick model is not well calibrated in this patient population. CONCLUSIONS: The Tyrer-Cuzick model is not accurate and may overpredict IBC risk for women with LCIS, and therefore should not be used for breast cancer risk assessment in this high-risk population.

Bilateral mastectomy operations and the role for the cosurgeon technique: A Nationwide analysis of surgical practice patterns.

Traditionally, bilateral mastectomy (BM) operations are performed by a single surgeon but a two-attending co-surgeon technique (CST) has been described. A questionnaire was sent to members of the American Society of Breast Surgeons to assess national BM practices and analyze utilization and perceived benefits of the CST. Among surgeons responding, most continue to use the single-surgeon approach for BMs; however, 14.1% utilize the CST and up to 31% are interested in future CST use. Time savings, mentorship, cost savings, and opportunity to learn new techniques were identified as perceived CST advantages.

Increase in Utilization of Nipple-Sparing Mastectomy for Breast Cancer: Indications, Complications, and Oncologic Outcomes.

BACKGROUND: Nipple-sparing mastectomy (NSM) is increasingly performed for invasive breast cancer. Growing evidence supporting the oncologic safety of NSM has led to its widespread use and broadened indications. In this study, we examine the indications, complications, and long-term outcomes of therapeutic NSM. METHODS: From 2003 to 2016, women undergoing NSM for invasive cancer or ductal carcinoma in situ (DCIS) were identified from a prospectively maintained database. Patient and disease characteristics were compared by procedure year, while complications were compared by procedure year using generalized mixed-effects models accounting for a random surgeon effect. Overall survival and time to recurrence were examined. RESULTS: Of the 467 therapeutic NSMs, 337 (72%) were invasive cancer, 126 (27%) were DCIS, and 4 (1%) were phyllodes tumors. Median age was 45 years (range 24-75) and median follow-up among survivors was 39.4 months. Three hundred and fifty-seven (76.4%) cases were performed in 2011 or after. When comparing NSMs performed before and after 2011, there was a significant increase in NSMs performed for invasive tumors (58% vs. 77%; p < 0.001). There was no difference in family history, genetic mutations, smoking status, neoadjuvant chemotherapy, prior radiation, nodal involvement, or tumor subtype. Twenty-one (4.5%) nipple excisions were performed, of which 14 were performed for cancer at the nipple margin. Forty-four breasts (9.4%) had complications that required re-operation. Fifteen patients had locoregional recurrence or distant metastasis. CONCLUSIONS: NSM use for invasive carcinoma has doubled at our institution since 2011, while postoperative complications and recurrence rates remain low. Our experience supports the selective use of NSM in the malignant setting with careful patient selection.

Surgeon Variability and Factors Predicting for Reoperation Following Breast-Conserving Surgery.

BACKGROUND: Reoperation after breast-conserving surgery (BCS) is common and has been partially associated with the lack of consensus on margin definition. We sought to investigate factors associated with reoperations and variation in reoperation rates across breast surgeons at our cancer center. METHODS: Retrospective analyses of patients with clinical stage I-II breast cancer who underwent BCS between January and December 2014 were conducted prior to the recommendation of 'no ink on tumor' margin. Patient demographics and tumor and surgical data were extracted from medical records. A multivariate regression model was used to identify factors associated with reoperation. RESULTS: Overall, 490 patients with stage I (n  = 408) and stage II (n  = 89) breast cancer underwent BCS; seven patients had bilateral breast cancer and underwent bilateral BCS procedures. Median invasive tumor size was 1.1 cm, reoperation rate was 22.9% (n  = 114) and varied among surgeons (range 15-40%), and, in 100 (88%) patients, the second procedure was re-excision, followed by unilateral mastectomy (n  = 7, 6%) and bilateral mastectomy (n  = 7, 6%). Intraoperative margin techniques (global cavity or targeted shaves) were utilized in 50.1% of cases, while no specific margin technique was utilized in 49.9% of cases. Median total specimen size was 65.8 cm3 (range 24.5-156.0). In the adjusted model, patients with multifocal disease were more likely to undergo reoperation [odds ratio (OR) 5.78, 95% confidence interval (CI) 2.17-15.42]. In addition, two surgeons were found to have significantly higher reoperation rates (OR 6.41, 95% CI 1.94-21.22; OR 3.41, 95% CI 1.07-10.85). CONCLUSIONS: Examination of BCS demonstrated variability in reoperation rates and margin practices among our breast surgeons. Future trials should look at surgeon-specific factors that may predict for reoperations.

Management of the Axilla in Early Breast Cancer.

Management of the axilla in early breast cancer patients has significantly evolved in the last several decades. With the arrival of the sentinel lymph node biopsy, surgical practice for axillary staging in patients with early breast cancer has become gradually less invasive and formal axillary lymph node dissection has been confined to selected patients. Over the last two decades, evidence from randomized clinical trials have allowed for the de-escalation of axillary surgery in the management of early stage breast cancer. Advances in the staging and treatment of the axilla constitute a key component in determining initial surgical planning and therapeutic strategies in the treatment of early breast cancer. This chapter provides an updated review on the history, evolution, and current practices for axillary management in patients with early breast cancer, with particular attention to the surgical recommendations and controversial scenarios of the evolving management of the axilla.

Intraoperative digital specimen mammography: a significant improvement in operative efficiency.

BACKGROUND: The goal of this study was to determine the length of operative time and its effect on surgeon productivity with the use of intraoperative digital specimen mammography (IDSM) compared to standard specimen mammography (SSM). METHODS: A retrospective chart review was performed on 344 consecutive patients from a single breast surgeon from 2003 to 2010. Operative time was compared between procedures using SSM vs IDSM. Surgeon productivity was evaluated by the number of wire-localized excisions performed prior to and after implementation of IDSM. RESULTS: Two hundred thirty patients underwent SSM and 114 underwent IDSM. Average operative time in the SSM group was 78 minutes vs 68 minutes in the IDSM group (P < .0001). In the first 2 years after implementation of IDSM, the number of wire-localized excisions performed increased by 20%. CONCLUSIONS: Operative times were significantly shorter with the use of IDSM vs SSM, and this was associated with an increase in surgeon productivity.