BACKGROUNDAt present, there is no consensus regarding how frequently BRCA mutation carriers should be screened for malignancies using breast imaging techniques. An interval malignancy is defined as a malignancy that becomes evident during the period between annual screening mammography scans; the finding of such a malignancy indicates that the malignancy either went undetected by the last breast imaging scan or developed during the interval since that last scan.METHODSThe authors retrospectively reviewed the medical charts of all BRCA mutation carriers who were followed by the genetic counselor at the Columbia‐Presbyterian Comprehensive Breast Center (New York, NY) between September 1995 and September 2002.RESULTSThirteen BRCA mutation carriers elected to undergo close surveillance and thus were followed at our institution. Three of these 13 patients (23%) did not develop breast carcinoma, 4 (31%) developed breast carcinoma that was detected at the time of annual screening, and 6 (46%) developed palpable interval malignancies in less than 12 months. Among the six patients who developed interval malignancies, the mean time between the last screening mammogram and disease presentation was 5.1 months (range, 2–9 months); the average tumor size in this patient subgroup was 1.7 cm (range, 0.8–3 cm). Two of these six patients had ductal carcinoma in situ, whereas the remaining four had invasive breast carcinoma; three patients had positive lymph nodes at presentation. All six patients who developed interval disease exhibited dense breast tissue on the previous mammogram. Focused breast ultrasonography was able to identify the tumor mass in 3 of 4 patients (75%).CONCLUSIONSNearly half of all BRCA‐positive women who chose to undergo close surveillance in the current study developed malignant disease less than a year after exhibiting normal findings on screening mammography. Half of these interval malignancies were positive for lymph node involvement. These results suggest that strong consideration should be given to screening BRCA‐positive women at more frequent intervals and to using additional imaging techniques, such as breast ultrasonography and/or breast magnetic resonance imaging, as a part of this screening. Cancer 2004. © 2004 American Cancer Society.

Background Most women with localized breast cancer (BC) have a choice between mastectomy and breast conserving surgery (BCS). Aside from clinical factors, this decision may be associated with surgeon and patient characteristics. We investigated the effect of surgeon characteristics on the BCS rate. Methods We used the SEER-Medicare database to identify women >65 years, diagnosed with stages I-II BC, between 1991–2002, and used the Physician Unique Identification Number linked to the American Medical Association Masterfile to obtain information on surgeons. We investigated the association of patient demographic, tumor, and surgeon-related factors with receipt of BCS, using Generalized Estimating Equations to control for clustering. Results Of 56,768 women with BC, 30,006 (53%) underwent BCS while 26,762 (47%) underwent mastectomy. From 1991 to 2002, the proportion of patients undergoing BCS increased from 35% to 60%. In a multivariate analysis, patients who received BCS were younger, of higher SES, and had more favorable tumor characteristics. They were also more likely to be black and live in metropolitan areas. Women who underwent BCS were more likely to have surgeons who were female (OR=1.40; 95%CI 1.25–1.55), US-trained (OR=1.12; 95%CI 1.02–1.22), with a larger patient panel (OR=1.29; 95%CI 1.21–1.39), and completed training after 1975 (OR=1.16; 95%CI 1.08–1.25), than surgeons of patients who underwent mastectomy. Conclusions Surgeon characteristics, such as gender, training, year of graduation and volume, are small but significant independent predictor of BCS. Efforts to differentiate whether these associations reflect patients’ preferences, quality of physician training, surgeon attitudes, physician-patient communication, or other effects on decision-making are warranted.

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Surgeon characteristics were associated with patients' receipt of adjuvant radiotherapy after BCS after controlling for patient and tumor characteristics, although the individual effect sizes were small for surgeon sex, location of training, and type of medical degree. More research is warranted to confirm the associations to determine whether they reflect surgeon behavior, patient response, or physician-patient interactions.

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