Background
The B-MaP-C study aimed to determine alterations to breast cancer (BC) management during the peak transmission period of the UK COVID-19 pandemic and the potential impact of these treatment decisions.
Methods
This was a national cohort study of patients with early BC undergoing multidisciplinary team (MDT)-guided treatment recommendations during the pandemic, designated ‘standard’ or ‘COVID-altered’, in the preoperative, operative and post-operative setting.
Findings
Of 3776 patients (from 64 UK units) in the study, 2246 (59%) had ‘COVID-altered’ management. ‘Bridging’ endocrine therapy was used (n = 951) where theatre capacity was reduced. There was increasing access to COVID-19 low-risk theatres during the study period (59%). In line with national guidance, immediate breast reconstruction was avoided (n = 299). Where adjuvant chemotherapy was omitted (n = 81), the median benefit was only 3% (IQR 2–9%) using ‘NHS Predict’. There was the rapid adoption of new evidence-based hypofractionated radiotherapy (n = 781, from 46 units). Only 14 patients (1%) tested positive for SARS-CoV-2 during their treatment journey.
Conclusions
The majority of ‘COVID-altered’ management decisions were largely in line with pre-COVID evidence-based guidelines, implying that breast cancer survival outcomes are unlikely to be negatively impacted by the pandemic. However, in this study, the potential impact of delays to BC presentation or diagnosis remains unknown.
Purpose
The B-MaP-C study investigated changes to breast cancer care that were necessitated by the COVID-19 pandemic. Here we present a follow-up analysis of those patients commenced on bridging endocrine therapy (BrET), whilst they were awaiting surgery due to reprioritisation of resources.
Methods
This multicentre, multinational cohort study recruited 6045 patients from the UK, Spain and Portugal during the peak pandemic period (Feb–July 2020). Patients on BrET were followed up to investigate the duration of, and response to, BrET. This included changes in tumour size to reflect downstaging potential, and changes in cellular proliferation (Ki67), as a marker of prognosis.
Results
1094 patients were prescribed BrET, over a median period of 53 days (IQR 32–81 days). The majority of patients (95.6%) had strong ER expression (Allred score 7–8/8). Very few patients required expedited surgery, due to lack of response (1.2%) or due to lack of tolerance/compliance (0.8%). There were small reductions in median tumour size after 3 months’ treatment duration; median of 4 mm [IQR − 20, 4]. In a small subset of patients (n = 47), a drop in cellular proliferation (Ki67) occurred in 26 patients (55%), from high (Ki67 ≥ 10%) to low (< 10%), with at least one month’s duration of BrET.
Discussion
This study describes real-world usage of pre-operative endocrine therapy as necessitated by the pandemic. BrET was found to be tolerable and safe. The data support short-term (≤ 3 months) usage of pre-operative endocrine therapy. Longer-term use should be investigated in future trials.
This article provides an overview of the principles and techniques of oncoplastic and reconstructive breast surgery for patients with early-stage breast cancer. Oncoplastic breast surgery (OPBS) with partial breast reconstruction is a natural evolution in the application of breast conserving surgery and permits wide surgical resection of tumours that might otherwise mandate mastectomy and whole breast reconstruction. These reconstructive techniques must be optimally selected and integrated with ablative breast surgery together with non-surgical treatments such as radiotherapy and chemotherapy that may be variably sequenced with each other. A multidisciplinary approach with shared decision-making is essential to ensure optimal clinical and patient-reported outcomes that address oncological, aesthetic, functional and psychosocial domains. Future practice of OPBS must incorporate routine audit and comprehensive evaluation of outcomes.
Background: Skin-sparing mastectomy (SSM) has emerged as a safe oncologic technique for extirpation of breast tissue in the context of immediate breast reconstruction (IBR). Documented rates of local recurrence are comparable for SSM and conventional mastectomy and attention to the plane of dissection is essential with removal of skin overlying the tumor when clinically indicated. The incidence of positive or close margins is greatest for peripheral tumors at the breast boundaries and will influence rates of local recurrence. Management of positive or close margins is inconsistent and this audit aimed to determine the incidence of compromised margins and their impact on local recurrence and overall survival in SSM patients.
Methods: A retrospective analysis was undertaken of breast patients with invasive or non-invasive breast cancer undergoing SSM and IBR at a single tertiary referral centre between January 2006 and December 2009. A total of 150 patients were included and all underwent resection of breast tissue with a peri-areolar incision. Clinical information was extracted from a prospectively maintained database. Data was collected on patient demographics, tumor characteristics, non-surgical treatment and outcome events (recurrence and death). The definition of a negative margin on histology during the study period was tumor ≥2mm from the edge of the specimen with close margins <2mm but no ink on tumor.
Results: The mean age of patients was 51 years (range 24 - 75) and median duration of follow up 140 months (range 10 - 167). Amongst these 150 SSM patients, 25 (17%) had positive or close anterior margins (<2mm) with 125 patients having negative anterior margins (>2mm). None of these patients with close or positive margins underwent re-excision following initial SSM. Twenty-four patients (16%) developed either loco-regional (n=9) or distant recurrence (n=15) with 126 patients (84%) alive at 10 years. Although more patients with positive/close compared with negative margins had recurrence (20% versus 15%), this did not reach statistical significance (p=0.55) Similar proportions of patients in each margin category received post-mastectomy radiotherapy (p=0.66) and adjuvant/neo-adjuvant chemotherapy (p=0.66). There were no statistically significant differences in rates of local recurrence or survival between patients with positive/close and negative margins but the number of events is small and may represent a type II error.
Conclusion: Twenty percent of patients (5/25) with positive or close margins after SSM develop local or distant recurrence with reduction of risk by PMRT of <50%. None of the patients with positive/close margins who developed recurrence survived for 10 years. Close/positive margins after SSM may portend a worse outcome from recurrent disease and further research is required to optimize management of this group of patients in an era of skin-preserving mastectomy.
Citation Format: Primeera Wignarajah, Dorin Dumitru, John R Benson. Outcomes and management of positive and close anterior margins following skin-sparing mastectomy [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS1-36.
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