Introduction: Conflicting reports exist regarding characteristics and outcomes of patients with only invasive lobular carcinoma (ILC) and mixed invasive lobular and ductal carcinoma (ILC/IDC). The purpose of this project is to report experience of 20 year cohort at one institution. Methods: Patients diagnosed with ILC between 1990 and 2010 were divided into two groups: ILC alone and ILC/IDC. Patient demographics, history, diagnosis and treatment modalities, and outcomes were captured. Chi-square, log-rank, and Wilcoxon rank sums tests were utilized for statistical analysis. P < 0.05 was considered significant. Results: In 189 AJCC Stage I-III patients, ILC was identified in 149 (79%) and ILC/IDC in 39 (21%). ILC stage was I, II, III in 46 (31%), 57 (41%), 32 (21%) ILC, and ILC/IDC was 17 (44%), 16 (41%), 4 (10%). Median age (range) at diagnosis was 64 (31-88) for ILC and 64 (35-84) years for ILC/IDC (p = 0.78). Median largest tumor diameter was 22 (range 1-100) in ILC, and 20 (range 2-110) mm in ILC/IDC (p = 0.97). Seventy-eight (52%) and 20 (51%) were diagnosed with ILC and ILC/IDC clinically, and 58 (39%) and 15 (38%) were diagnosed with ILC and ILC/IDC radiographically (p = 0.96). Treatment modalities were mastectomy and breast conservation therapy in 82(55%) and 67(45%) of patients with ILC, 18 (46%) and 21 (54%) of patients with ILC/IDC (p = 0.32). In 136 (91%) ILC and 33 (85%) ILC/IDC patients who had nodal evaluation/excision, 59 (43%) ILC and 12 (36%) ILC/IDC patients presented with positive nodal status. ER, PR, and HER2 status were positive in 132 (89%), 104 (70%), 7 (5%) ILC, and 29 (74%), 26 (67%), 3 (8%) ILC/IDC patients respectively (p = 0.02, p = 0.85, p = 0.17). Median (range) follow-up for ILC was 6.1 (< 1-22.3), and 8.0 (1.72-17.7) years for ILC/IDC (p = 0.03). At the time of analysis, 43(29%) patients with ILC, and 11(28%) patients with ILC/IDC had expired (p = 0.94). Median (range) follow-up for patients who were alive at time of analysis was 6.8 (<1-20.7) years for ILC, and10.1 (2.3-17.7) years for ILC/IDC (p = 0.06). Time to first recurrence was 3.23 (0.8-17.0) years in ILC, and 5.2 (2.9-9.3) years in ILC/IDC (p = 0.20). Recurrence was identified in 33(22%) ILC: 15(46%) locoregional and18 (54%) distant disease. Similarly, recurrence was found in 7 (20%) ILC/IDC patients: 4 locoregional and 3 distant. Most locoregional recurrences, 12/15 (80%), occurred in the ipsilateral breast in ILC, and 3/4 (75%) in ILC/IDC (p = 0.82). Five years disease free survival rates were 76% ILC and 85% for ILC/IDC, and 10 years rates were 63% for ILC and 67% for ILC/IDC (p = 0.4941). Overall survival estimates at 5 years were 84% for ILC and 92% for ILC/IDC, and at 10 years were 65% for ILC and 74% for ILC/IDC (p = 0.52). Conclusion: While basic demographics and survival patterns did not differ statistically between ILC and ILC/IDC, pure ILC histology tends to carry a higher risk of recurrence, as well as worse disease free and overall survival compared to ILC/IDC. ILC histology was more likely to be ER positive, present with advanced stage, and recur in the ipsilateral breast than the contralateral breast. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-06-35.
Purpose/Objective(s): ASTRO Choosing Wisely campaign recommends no more than annual mammography after breast conservation therapy (BCT). HER2+ disease portends increased risk of locoregional recurrence in comparison to Luminal A disease. Our previous institutional practice included surveillance imaging every 6 months for the first 2-3 years after BCT. The purpose of this study is to evaluate surveillance imaging intervals as a means of detecting early locoregional recurrence at one institution. Materials/Methods: Women with HER2+ locoregionally confined invasive breast cancer treated with lumpectomy and radiation as part of breast conservation therapy at one institution were retrospectively identified after IRB approval. Patient demographics, treatment, surveillance, and outcomes data were captured. BRCA+ patients or those without available surveillance follow-up at our institution were excluded. Surveillance period started after the last fraction of radiation was completed. Results: In 86 women treated from 2008-2016, median age at diagnosis was 57, and 69% were Caucasian. Most patients were treated for Stage I-II invasive ductal carcinoma. All but one were treated with chemotherapy, with similar distribution between adjuvant and neoadjuvant regimens. Receptor status was as follows: ER+ 66%, PR+ 59%, ER+/PR+/HER2+ in 58%, ER-/PR-/HER2+ in 33%. Mammography +/- ultrasound was utilized, with infrequent use of magnetic resonance imaging. Median time from end of radiation to first surveillance imaging was 4 months. All women had 1 post-BCT imaging, with 2nd, 3rd, and 4th available in 91%, 85%, 73% respectively. Interval frequency between first 4 images was 6 months. No patients had expired at the time of analysis. Recurrence were identified in 2 women: 1 identified clinically after negative mammography, and 1 identified on mammography at 27 months. Conclusion: While overall events are small, discordant biannual mammography did not identify locoregional recurrences in this biologically higher risk group in the first two years post-treatment. This data supports current guideline recommendations limiting surveillance breast imaging in patients undergoing breast conservation to an annual frequency. Citation Format: Everett A, Wallace AS, De Los Santos JF, Rocgue GB, Parker CS, Keene KS. Choosing wisely: Radiographic surveillance after breast conservation therapy in HER2+ breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-01-02.
Background: Surgical treatment for breast cancer is often a preference sensitive decision. The American Society of Breast Surgeons 2016 Choosing Wisely recommendation discourages routine contralateral prophylactic mastectomy (CPM). The purpose of this abstract is to analyze trends and factors that may be contributing to increasing utilization of CPM in the setting of unilateral breast cancer in the National Cancer Database (NCDB) from 2004-2013. Methods: The NCDB is a national database of the American Cancer Society and the Commission on Cancer comprising approximately 70% of the cancer population in the US. Data from women with AJCC Stage 0-2 breast cancer treated with unilateral mastectomy (UM) vs CPM were abstracted. CPM was the primary outcome variable. Other variables included age, race, geographic region, payer status, income quartile, estrogen/progesterone receptor(ER/PR) status. HER2 status was not evaluated given limited availability of data. Categorical data was compared using Chi square tests. Odds ratios (OR) and Hazard ratios (HR) with confidence intervals (CI) were reported for univariate logistic regression models to evaluate effect of various factors on type of surgical treatment, and cox regression for survival with CPM, respectively. Significance was defined as p<0.01. Results: Median age for UM and CPM were 62.5 (SD 12) and 56.5 (SD 10.7) years respectively. In adjusted analysis, compared to Caucasian women, African American (OR 0.48, CI 0.47-0.50, p<0.01) and Hispanic (OR 0.58, CI 0.56-0.61, p<0.01) women were less likely to undergo CPM. Compared to women without insurance, those with private insurance (OR 1.53, CI 1.43-1.63, p<0.01) or Medicare (OR 1.45, CI 1.37-1.57, p<0.01) were more likely to under CPM. In comparison to women living in metro regions, those in urban (OR 1.08, CI 1.12-1.27, p<0.01) and rural (OR 1.19, CI 1.12-1.27, p<0.01) were more likely to undergo CPM. Women in the lower income quartile (OR 0.85 CI 0.82-0.87, p<0.01) were less likely to undergo CPM compared to women in the highest quartile. In the entire cohort, CPM was performed in 6.9% of ER/PR-, and 5.5% of ER/PR+ women (p<0.01). ER/PR + women were less likely to undergo CPM (HR 0.7, CPM 0.69-0.73,p< 0.01). Despite undergoing fewer CPM, women with ER/PR+ disease had improved overall survival in comparison to women who were ER/PR- There was an increase in utilization of CPM from 3.3% in 2004 to 7.5% in 2013 (p<0.01) Progressive year of diagnosis (HR 1.12, CI 1.12-1.13, p<0.01) was associated with increasing treatment with CPM, but among newly diagnosed women with CPM there was no change in survival over time (HR 1.0). Conclusion: Women with newly diagnosed unilateral breast cancer are increasingly undergoing contralateral prophylactic mastectomy. There is great heterogeneity in socioeconomic factors associated with CPM. Women with ER/PR+ disease are undergoing CPM more often despite good outcomes in comparison to women with hormone negative disease. Given the new AJCC staging emphasis on tumor biology and disease outcomes, further research should consider socioeconomic variables as well as biology to create individualized risk assessment and decision aids to guide surgical decision making. Citation Format: Wallace AS, Threet A, Richman J, Lancaster R, Parker CC. Choosing wisely recommendations against prophylactic bilateral mastectomy: Analysis of the National cancer database [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-22-16.
Intensity modulated proton therapy (IMPT) is a promising radiation therapy (RT) modality for cervical cancer treatment, especially for its potential role in reducing hematologic toxicity. IMPT dose distribution is known to be sensitive to patient anatomical changes during the treatment course. This study quantifies the effect of the anatomical change on IMPT's target coverage for cervical cancer treatment. Materials/Methods: In this IRB-approved study, 3-beam IMPT plans were generated on the planning computed tomography (CT) image for 6 enrolled patients. Three or 4 weekly CT images were obtained for each patient using the same imaging protocol in subsequent weeks after the simulation day, for a total of 21 weekly CT images. CTs of the same patient were rigidly registered to the planning CT by matching bony anatomy. The geometric cervical and nodal target volumes were the same in subsequent CTs as in the planning CT, while major organs-at-risk including bowel, bladder, and rectum were re-contoured on each weekly CT. Patient body weights at the time of each weekly CT scan were also recorded. Dose from the IMPT plan was recomputed on these weekly CTs. Dose received by at least 95% of the cervical and nodal internal target volumes (Cervical D ITV95% and Nodal D ITV95% , respectively) were compared to their planned values. Univariate analysis was performed to discover the correlation between D ITV95% to the relative changes of various anatomical factors, as well as the correlation between the anatomical factors. Results: Body weight increase was found to be significantly correlated to the decrease of both Cervical D ITV95% (Spearman rank correlation coefficient SCCZ-0.653, PZ.001) and Nodal D ITV95% (SCCZ-0.713, P<.001). Bowel volume increase was found to be significantly correlated to the decrease of Nodal D ITV95% only (SCCZ-0.502, PZ.020), but not Cervical D ITV95% (SCC Z-0.260, PZ.256). The correlations between bladder or rectum changes and target coverage were not statistically significant. Yet, there was also a significant correlation between bowel volume and body weight (SCCZ0.576, PZ.006). By deducting the bowel and bladder volume change, body weight increase was still found to be significantly correlated to the decrease of both Cervical D ITV95% (SCCZ0.613, PZ.003) and Nodal D ITV95% (SCCZ-0.646, PZ.002). Conclusion: The decrease of target coverage in IMPT for cervical cancer was found to be significantly correlated to mainly the increase of body weight, although intercorrelations between the changes of bladder, rectum, bowel, and body weight also existed. Multivariate analysis is needed to further uncover the major anatomical factor that impacts IMPT target coverage so that patient surveillance or intervention may be applied to maintain IMPT's superior dose distribution.
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