Limits of resection for ductal carcinoma in situ.
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Breast Neoplasms↗
Biomedical subjects
R T Osteen
Publications and source records attributed to R T Osteen.
The National Cancer Data Base report on breast carcinoma characteristics and outcome in relation to age.
BACKGROUND: Previous data from the National Cancer Data Base have examined time trends in stage of disease, treatment patterns, and survival for selected cancers. The most current (1993) data for breast carcinoma are described here. METHODS: Five Calls for Data have yielded a total of 508,724 breast cancer cases diagnosed from 1985 to 1993, from hospital cancer registries throughout the U.S. RESULTS: Women younger than age 35 had a lower rate of ductal carcinoma in situ, higher grade primary tumors, more advanced American Joint Committee on Cancer stage disease, and poorer 5-year relative survival than older premenopausal women. African American women were more likely to have advanced disease than non-Hispanic whites in all three age groups analyzed. Improved time trends of early detection of breast carcinoma and use of breast conservation treatment are reported. The overall prognosis for breast carcinoma remains relatively good for all age groups when compared with other cancers. CONCLUSIONS: These data are consistent with the hypothesis that younger women are at increased risk for biologically more aggressive breast carcinoma.
Adult↗
Patterns of breast cancer care in the elderly.
BACKGROUND: The elderly represent a large proportion of the women with breast cancer. However, there is a lack of information regarding breast cancer care in the elderly. METHODS: A patient care evaluation survey for breast carcinoma was conducted by the Commission on Cancer of the American College of Surgeons for 1983 and 1990. Data were obtained from hospital tumor registries from all 50 states, Puerto Rico, and Canada. Information regarding presentation, diagnostics, staging, treatment, recurrence, and survival were analyzed. Comparisons were made between women 75 years and older and those younger than 75 years. RESULTS: Included were 17,029 diagnosed with breast carcinoma during 1983 and 24,004 diagnosed during 1990. In 1983 and 1990, 20.4% and 23.4% of women, respectively, were 75 years or older. Fewer cancers were detected mammographically and needle localized biopsies were performed less often in the elderly. There was no difference in tumor location or histology. Stage at diagnosis appeared more advanced in the elderly. Most women regardless of age, underwent modified radical mastectomy. Of the elderly who did undergo breast conserving surgery in 1983 and 1990, 72% and 39%, respectively, did not receive radiation therapy. No difference was found in the local recurrence rates between the elderly and younger groups. In the elderly, 20% of deaths occurred from causes other than breast cancer. Overall disease specific survival was worse in the elderly but, when analyzed by stage, was significantly different for only certain stages. CONCLUSIONS: There are several differences in the detection, diagnostic methods, stage at diagnosis, treatment approaches, and outcome of breast cancer in elderly women compared with younger women.
Age Factors↗
A prospective study of conservative surgery alone in the treatment of selected patients with stage I breast cancer.
BACKGROUND: Randomized clinical trials have clearly demonstrated that the use of radiation therapy (RT) following breast-conserving surgery (CS) substantially reduces the risk of local recurrence. However, the low rate of local recurrence after CS and RT for patients without known risk factors, and the recent increase in the detection of smaller cancers due to mammographic screening have led to the speculation that a subgroup of patients who have a low risk of local recurrence without RT might be identified. In 1986, we initiated a one-arm, prospective clinical trial of CS alone for treatment of highly selected breast cancer patients without known risk factors for local recurrence. METHODS: The study had a sequential design with a planned accrual of 90 patients. Criteria for entry into the trial were: a unicentric, clinical TI infiltrating ductal, mucinous or tubular carcinoma without an extensive intraductal component or lymphatic vessel invasion; a wide excision with a pathologically-documented negative margin of at least 1 cm; and histologically negative axillary lymph nodes. No adjuvant RT or systemic therapy was administered. Seventy-six per cent of the lesions were detected by mammography alone. The median gross pathologic tumor size was 0.9 cm. The median patient age was 67 years. RESULTS: Eighty-seven patients were enrolled in the trial before it closed prematurely in 1992 because the predefined stopping boundary was crossed (i.e., the sixth local recurrence was observed). At that time, the average annual local recurrence rate was 4.2%. With a median follow-up of 56 months, there are now 14 patients (16%) with local recurrence as their site of first failure (average annual local recurrence rate: 3.6%). Four patients without local recurrence developed distant metastases. Three patients have died, one of metastatic breast cancer and two of unrelated causes. CONCLUSIONS: Even in a highly selected group of patients with early-stage breast cancer, there is a substantial risk of early local recurrence for those treated with wide excision alone.
Adenocarcinoma, Mucinous↗
The presence of membrane-bound stem cell factor on highly immature nonmetachromatic mast cells in the peripheral blood of a patient with aggressive systemic mastocytosis.
BACKGROUND: Systemic mastocytosis is characterized by mast cell infiltration of bone marrow and tissues in the absence of identified circulating bone marrow-derived progenitors. A 58-year-old man was first seen with aggressive systemic mastocytosis manifested by urticaria pigmentosa, hepatosplenomegaly, generalized bone lesions, anemia, thrombocytopenia, monoclonal gammopathy, and increased urine histamine levels. OBJECTIVES AND METHODS: A rapidly progressive anemia and thrombocytopenia dictated a splenectomy. We sought to identify the mast cell progenitors in the peripheral blood and to provide evidence of their maturation in tissues with immunohistochemical and ultrastructural analyses. RESULTS: The peripheral blood contained 1% to 3% nonmetachromatic mononuclear cells with eccentric nuclei that expressed the mast cell proteases, tryptase and carboxypeptidase A, along with c-kit, stem cell factor (SCF), and high-affinity IgE receptor (Fc epsilon RI), but not chymase. Similar mononuclear cells colocalized in the spleen and lymph nodes with mature, metachromatic mast cells that expressed tryptase, chymase, carboxypeptidase A, c-kit, SCF, and Fc epsilon RI. Electron microscopy disclosed, at each site, a mature mast cell population with electron-dense, scroll-poor granules. CONCLUSIONS: The peripheral blood of a patient with aggressive systemic mastocytosis contained immature mononuclear cells of the mast cell lineage that express c-kit, SCF, tryptase, carboxypeptidase A, and Fc epsilon RI. These cells were also found in the skin, spleen, and lymph nodes where they presumably expand, differentiate, and mature, assuming the mast cell phenotype for those tissues characterized by metachromasia, expression of a full range of mast cell-related secretory granule proteases, and ultrastructural appearance. The presence of SCF on the surface membrane of the circulating, highly immature mast cells suggests an autocrine regulation of the c-kit-SCF interaction.
Cell Differentiation↗
Reconstruction after mastectomy.
Although reconstruction after mastectomy offers an opportunity for cosmetic rehabilitation that should make mastectomy more acceptable and contribute to overall rehabilitation, the procedure is relatively underutilized. The best cosmetic results usually come from breast conservation rather than from mastectomy and subsequent reconstruction, and most small (T0-T2) cancers can be treated by means of breast-conserving measures. The surgeon who is performing the mastectomy plays a key role in explaining reconstruction to the patient and encouraging her to consider the process. Surgeon- and patient-related factors contribute to under-utilization. Physician assessment of the results of reconstruction, particularly with use of implants, tends to be less favorable than that of the patient. Surgeons may overemphasize the inadequacies of the results and patients may be overwhelmed by the diagnosis and array of decisions that must be made. Immediate reconstruction poses little risk of treatment delay or limitation. Reconstruction after mastectomy does not interfere with follow-up for recurrence. Choices for reconstruction have been limited by the withdrawal of silicone implants from the market. The availability of reconstruction has encouraged the inappropriate use of mastectomy for low risk disease. Prophylactic mastectomies and reconstruction should be performed for appropriate indications. To be effective, prophylactic mastectomy must include the nipple areolar complex. The availability of genetic testing to define very high risk groups brings into question the adequacy of protection offered by this procedure. Whereas prophylaxis in humans for premalignant mastopathy appears to be nearly complete, mastectomy appears to offer little protection in a rodent carcinogen model. The effectiveness of mastectomy for prophylaxis in a genetically high risk human population is unknown.
Breast Implants↗
Strategies for breast-conserving surgery. An unresolved dilemma.
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Breast Neoplasms↗
A national quality improvement effort: cancer registry data.
Cancer registries are sources of epidemiological, patterns-of-care, and outcome data for local, regional, state, and national studies of patients with cancer. Since 1976, these registries have formed a voluntary network of contributors to annual patient care studies under the aegis of the National Cancer Data Committee of the Commission on Cancer. These annual studies provide timely clinical information that is widely disseminated to physicians, allied health personnel, administrators, health care planners, and public and private agencies. The use of the data has grown exponentially and has been the basis for more than 90 publications. Merging this activity with the National Cancer Data Base has further expanded the demand and use of registry data. This study was undertaken to respond to inquiries as to the validity of the data and the qualifications and competency of cancer registrars. It provides the baseline for cancer registry data quality and serves as a quality management tool to identify opportunities to enhance data quality.
Databases, Factual↗
Treatment trends for ductal carcinoma in situ of the breast.
BACKGROUND: As a result of clinical trial publications, breast conservation treatment has been increasingly used for invasive breast cancer. The patterns of care for ductal carcinoma in situ (DCIS) were analyzed for the years 1985, 1986, 1988, 1990, and 1991 to determine whether the same treatment principles had been applied to patients with non-invasive disease. METHODS: Data submitted on 20,556 patients with DCIS during the 5 study years were analyzed with regard to basic demographics and treatment trends. RESULTS: Breast-conserving surgery for DCIS increased from 20.9% in 1985 to 35.4% in 1991. Modified radical mastectomy remained constant at 42%. Axillary node surgery increased from 52% in 1985 to 58.5% in 1991. The use of radiation therapy for patients with partial mastectomy and no lymph node dissection ranges from 24.2% in 1990 to 37.7% in 1985, with 31.1% receiving radiation therapy in 1991. Patients undergoing lymph node dissection with partial mastectomy were more than twice as likely to receive postoperative radiation therapy than were patients without lymph node dissection. CONCLUSIONS: Modified radical mastectomy remains the most common surgical procedure, despite the eligibility of many women for breast conservation treatment. As of 1991 the majority of women were still undergoing axillary lymph node surgery despite a node positivity rate of approximately 1%. Radiation therapy is significantly underused in patients with partial mastectomy, especially when no nodes were removed. Clinical trial results and professional education for DCIS treatment should change these trends.
Adult↗
Selection of patients for breast conserving surgery.
The majority of patients with breast cancer can be treated by partial mastectomy and radiation therapy. Ineligibility for breast conservation usually is related to previous radiation or the inability to receive radiation for other reasons. For patients who can receive radiation, selection for breast conservation involves the estimation of the risk for in-breast recurrence and the ability to achieve a satisfactory cosmetic result. Multiple sites of cancer within the breast and the inability to attain negative pathologic margins on the excised breast specimen are predictive for an increased risk of recurrence. The cosmetic result is compromised by excision of large volumes of breast tissue. Although the size of the tumor is not an important consideration for in-breast recurrence, the relation of the size of the tumor, and hence the volume of tissue excised, to the size of the breast is an important cosmetic consideration. Compared to invasive ductal carcinoma, an extensive intraductal component or invasive lobular carcinoma tends to be more difficult to define within the breast and may require excision of a large volume of tissue to obtain negative pathologic margins.
Breast Neoplasms↗
The National Cancer Data Base report on breast cancer.
BACKGROUND: Previous National Cancer Data Base data have been used to examine time trends in stage of disease and treatment patterns for breast cancer. The most current (1990) data are described here. METHODS: Two calls for data have yielded a total of 143,051 breast cancer cases for 1985, 1988, and 1990 from hospital cancer registries across the United States. RESULTS: The percentage of in situ cancers increased between 1985 and 1988 but was essentially constant between 1988 and 1990. The use of breast-conserving partial mastectomy across the country increased between 1988 and 1990. Some interesting regional differences appeared in the use of multimodality treatment. CONCLUSIONS: These data suggest a plateau in the use of mammographic screening.
Adult↗
Insurance coverage of patients with breast cancer in the 1991 commission on cancer patient care evaluation study.
BACKGROUND: Trends in the care of patients with cancer are monitored annually by the Commission on Cancer of the American College of Surgeons. In 1991 a patient care evaluation study of breast cancer was conducted, which among other questions examined the correlation of health insurance with type or quality of care delivered for breast cancer on a national basis. METHODS: The tumor registry system of the American College of Surgeons was used to obtain data on patients with breast cancer diagnosed in 1983 and 1990. Trends in diagnosis and treatment were correlated with the type of insurance or lack of insurance. RESULTS: Data were obtained from hospitals in 50 states on a total of 41,651 patients. The largest number of patients were covered by Medicare. Fewer than 5% were considered medically indigent. Medically indigent patients presented with higher stage disease and did not participate in a trend toward downstaging, which occurred between the two study years. The treatment of medically indigent patients appeared to be appropriate and comparable with better insured patients. Insurance type (health maintenance organization vs. private) did not affect stage, treatment, or outcome. Decisions to use controversial therapies, such as chemotherapy for stage I disease, did not appear to be financially driven. CONCLUSION: A nationwide pattern of care study for breast cancer indicates that medically indigent patients present with more advanced disease compared with better insured patients, but once the diagnosis is made, treatment and outcome have little to do with insurance type.
Antineoplastic Combined Chemotherapy Protocols↗
Patterns of care for younger women with breast cancer.
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Adult↗
1991 national survey of carcinoma of the breast by the Commission on Cancer.
A nationwide survey of patterns of care for carcinoma of the breast was conducted by the Commission on Cancer of the American College of Surgeons. Information regarding patient history, diagnostic tests, treatment, survival and disease status was obtained for 17,295 patients treated during 1983 and 24,356 patients treated during 1990. The results indicate that patients diagnosed in recent years (1990) are being treated at an earlier stage of the disease compared with the 1983 survey and the findings of earlier years, probably because of the use of mammography. Surgical treatment for conservation of the breast is being used more frequently, but modified radical mastectomy remains the most commonly used surgical treatment.
Aged↗
Preoperative irradiation for unresectable carcinoma of the rectum.
The records of 20 patients with unresectable carcinoma of the rectum who received preoperative radiation therapy (4,300 to 5,580 cGy) in an attempt to facilitate resection were reviewed. Patients were stratified as unequivocally unresectable at the time of diagnosis or borderline resectable. Thirteen of the 20 patients were able to undergo resection with curative intent after radiotherapy. Patients had follow-up examinations for a minimum of five years, and median survival period for all patients was 43 months with a five year survival rate of 40 percent. Patients stratified to unequivocally resectable survived for a median of only 17 months. Three of the 13 patients who underwent a curative resection had a local recurrence in the pelvic area. Sixteen complications occurred in nine of the 17 patients who underwent any sort of resection, with infectious and wound healing complications being most prevalent. The incidence of complications in similar series is discussed and the need for better selection of patients is addressed.
Adult↗
Recurrence in the breast following conservative surgery and radiation therapy for early-stage breast cancer.
This report summarizes the experience of the Joint Center for Radiation Therapy (JCRT) in treating patients with clinical stage I and II breast cancer with conservative surgery and radiation therapy. The study population consisted of 1396 patients treated between 1968 and 1985. All patients underwent a gross excision of the tumor and received breast irradiation (with or without nodal irradiation) including a "boost" to bring the primary tumor site to a total dose of at least 60 Gy. The method of treatment evolved over the study-time period. During the interval from 1968 to 1982, patients typically underwent a limited gross excision of the tumor without regard to the microscopic margins of resection. During the period 1983 to 1985, film-screen mammography, inking of specimen margins, and reexcisions for inevaluable or involved margins were more commonly performed. With a median follow-up of 80 months, the 5-year crude rate of failure in the breast (as the first site of failure) was 8% (106/1396) and the crude rate of regional nodal/distant failure (as the first site of failure) was 16% (228/1396). The time-course of failures in the breast was protracted, occurring at a fairly constant rate over the first 7 years after treatment, but still seen beyond that point. Most recurrences in the breast (75%) developed at or near the original tumor site. The most important risk factor for developing a breast recurrence was the presence of an extensive intraductal component in the tumor. The cosmetic results following treatment were excellent or good in the majority of patients (87%) and were most adversely affected by extensive surgery.(ABSTRACT TRUNCATED AT 250 WORDS)
Breast Neoplasms↗
Results of treating ductal carcinoma in situ of the breast with conservative surgery and radiation therapy.
To determine the frequency, pattern, and time course of tumor recurrence in the breast, the outcome of 38 women with ductal carcinoma in situ (DCIS) treated with conservative surgery and radiation therapy between 1976 and 1985 was studied. Surgery typically consisted of local excision without evaluation of the microscopic margins of resection. The median radiation dose to the tumor site was 6400 cGy. With a median follow-up time of 81 months, eight patients (21%) have experienced a recurrence in the breast. The time course to recurrence was protracted in some cases, with failures occurring at 17, 27, 43, 63, 71, 83, 92, and 104 months. The 5-year and 8-year actuarial rates of tumor recurrence in the breast were 8% and 27%, respectively. Seven patients had a recurrence at or near the primary tumor site, four with invasive carcinoma, and one had an invasive recurrence at a site elsewhere in the breast. No clinical or pathologic factor was significantly associated with an increased risk of recurrence, but the number of patients in the study population was small. The authors reached the following conclusions for patients with DCIS treated with conservative surgery and radiation therapy without careful mammographic and pathologic evaluation: (1) recurrence in the breast may be seen in at least one fifth of the patients; (2) recurrence typically occurs at or near the primary site; and (3) recurrence can occur long after treatment. Careful mammographic and pathologic assessment may be useful in reducing the local recurrence rate and should be considered essential if patients are considered for conservative surgery and radiation therapy.
Adult↗
Regional nodal failure after conservative surgery and radiotherapy for early-stage breast carcinoma.
We retrospectively analyzed the likelihood of regional nodal failure (RNF) for 1,624 patients with stage I or II invasive breast carcinoma treated with conservative surgery and radiotherapy (RT) at the Joint Center for Radiation Therapy (JCRT) between 1968 and 1985. The median follow-up time was 77 months. RNF was the first site of failure for 38 of the 1,624 patients (2.3%). The incidence of axillary failure for patients undergoing axillary dissection (AXD) who were irradiated to the breast only was 2.1% (nine of 420) for patients with negative nodes and 2.1% (one of 47) for patients with one to three positive nodes. The incidence of supraclavicular failure in these two groups was 1.9% (eight of 420) and 0% (zero of 47), respectively. The incidences of axillary and supraclavicular failure in patients without clinically suspicious axillary involvement who did not have AXD but were treated with RT were 0.8% (three of 355) and 0.3% (one of 364), respectively. Despite various combinations of salvage surgery, RT, and systemic therapy, only 47% of patients (18 of 38) achieved complete regional control after nodal relapse. We conclude that RNF is uncommon in patients treated to the breast alone following an adequate AXD when the axillary nodes are negative or when one to three nodes are positive. RNF is also uncommon in patients with a clinically uninvolved axilla treated with nodal RT without AXD. Symptoms of RNF can be controlled in most but not all patients. Further study is needed to determine if the benefits of RT in preventing a small number of symptomatic RNF outweigh the potential toxicity for any subgroup of patients.
Adult↗