Society of Surgical Oncology (SSO): Annual Cancer Symposium

BOSTON – With art supplies and “mystery” sutures, a team of investigators has determined that immediate intraoperative inking of lumpectomy specimens appears to be a better method than suture placement for orienting specimens for pathology, a finding that could reduce re-excisions.

“Intraoperative specimen suturing appears to be inaccurate for margin identification, and additional means by the surgeon to improve the accuracy are needed. This could be either immediate inking or routine excision of shave margins, either at the original surgery or when you go back for re-excision, to take all the margins instead of one specific margin,” Dr. Angel Arnaout, a breast surgeon at the University of Ottawa, Ont., said at the annual Society of Surgical Oncology Cancer Symposium.

She presented results of the randomized, blinded SMART (Specimen Margin Assessment Technique) trial comparing suture placement with intraoperative inking within the same surgical specimen.

Positive resection margins during breast-conserving surgery are associated with a twofold increase in the risk of ipsilateral tumor recurrence, and require re-excision or conversion to mastectomy. Re-excisions rates range from 25% to 45%, but in the majority of cases – 53% to 65% – no additional disease is found, Dr. Arnaout said.

In addition to adding to patient distress, re-excisions diminish cosmetic results because they take additional tissue, and delay the start of adjuvant breast cancer therapy, she noted.

Surgeons typically orient specimens for pathologists by placing two or three sutures in the center of the margin surfaces or, less frequently, by intraoperative marking of the margins with ink. But in transit from the OR to the pathology lab, specimens often flatten or “pancake” under their own weight, making it challenging for the pathologist to identify the originally marked margins.

To test whether suturing or inking is better at identifying the extent of tumors during breast-conserving surgery, the investigators devised a strategy using benign breast tissue removed during prophylactic mastectomy or reduction mammoplasty.

The surgeons first performed a sham lumpectomy within the tissue. They then painted the specimen margins in the OR using a phospholuminescent paint obtained from an art supply store. The paint dries clear and colorless, but glows in different colors under black light. By using the paint, carefully selected so as not to interfere with pathology staining, the investigators were able to blind the pathologists to the actual orientation of the margins.

While the tissue was still in the OR, the surgeons then placed two or three orienting sutures in customary locations, plus a third, “mystery” suture at a location known only to the surgeon.

In the pathology lab, the assistant was asked to look at the sutures and outline in black ink the edges of the margins using the sutures for guidance.

The specimen was then examined under black light to determine the degree of discordance between surgeons and pathologist for identification of margins using the suture and painting methods (primary outcome), and to evaluate the discrepancy in the extent of margin surface areas as identified by the surgeons and the pathologists (secondary outcome).

“We asked breast surgeons ‘what would be a clinically significant discordance rate for you?’ and most of them said between 10% and 20%, so we looked for a 15% discordance rate as being clinically significant between the two margin assessment techniques,” Dr. Arnaout said.

They found that the overall discordance in the location of the mystery suture between surgeons and pathologists was similar whether the samples contained two or three location sutures, with discordance rates of 46% (34 of 75 samples) for two sutures, and 47% (41 of 88 samples) for three sutures.

For the secondary outcome of discordance in the extent of margins, they found that pathologists tended to estimate the mean surface of the anterior and posterior margins to be significantly larger than the surgeons did (P less than .01), while significantly underestimating the superior, inferior, and lateral margins (P less than .01 for superior and inferior, and P = .04 for lateral margins).

Examination under black light showed that often two or three additional margins would be included by the surgeon within what the pathologist had identified as the anterior margin.

“This has implications for the surgeon and for the patient,” Dr. Arnaout said. “For most of us that do lumpectomies that go from skin down to chest wall, if an anterior margin or posterior margin is positive, a lot of times we would fight not to go back because we would say there is no further room for re-excision.”

But if the tumor is within what is actually the superior margin but labeled by the pathologist as an anterior margin, the patient may miss an opportunity for successful re-excision, she explained.

The study was limited by the fact that the sham lumpectomy specimens did not contain skin or muscle, which would have allowed for more accurate margin orientation in an actual operative setting; by lack of compression of specimens with small nonpalpable lesions in containers, which further distorts specimens; and by the use of smaller lumpectomy specimens than normally obtained during cancer surgery, which could have resulted in overestimation of the discordance that might occur when larger specimens are taken, Dr. Arnaout said.

“The conclusion of our study is that specimen margin orientation really should be defined by the surgeon who knows the original shape and orientation of the tissue during surgery, and not to rely on the pathology to reorient based on some sutures placed in the centers of the specimens without defining the extent of the surface area of each of the margins,” she said.

The Canadian Cancer Society Research Institute and the Canadian Surgical Research Fund supported the study. Dr. Arnaout and coauthors reported no conflicts of interest.

BOSTON – With art supplies and “mystery” sutures, a team of investigators has determined that immediate intraoperative inking of lumpectomy specimens appears to be a better method than suture placement for orienting specimens for pathology, a finding that could reduce re-excisions.

“Intraoperative specimen suturing appears to be inaccurate for margin identification, and additional means by the surgeon to improve the accuracy are needed. This could be either immediate inking or routine excision of shave margins, either at the original surgery or when you go back for re-excision, to take all the margins instead of one specific margin,” Dr. Angel Arnaout, a breast surgeon at the University of Ottawa, Ont., said at the annual Society of Surgical Oncology Cancer Symposium.

She presented results of the randomized, blinded SMART (Specimen Margin Assessment Technique) trial comparing suture placement with intraoperative inking within the same surgical specimen.

Positive resection margins during breast-conserving surgery are associated with a twofold increase in the risk of ipsilateral tumor recurrence, and require re-excision or conversion to mastectomy. Re-excisions rates range from 25% to 45%, but in the majority of cases – 53% to 65% – no additional disease is found, Dr. Arnaout said.

In addition to adding to patient distress, re-excisions diminish cosmetic results because they take additional tissue, and delay the start of adjuvant breast cancer therapy, she noted.

Surgeons typically orient specimens for pathologists by placing two or three sutures in the center of the margin surfaces or, less frequently, by intraoperative marking of the margins with ink. But in transit from the OR to the pathology lab, specimens often flatten or “pancake” under their own weight, making it challenging for the pathologist to identify the originally marked margins.

To test whether suturing or inking is better at identifying the extent of tumors during breast-conserving surgery, the investigators devised a strategy using benign breast tissue removed during prophylactic mastectomy or reduction mammoplasty.

The surgeons first performed a sham lumpectomy within the tissue. They then painted the specimen margins in the OR using a phospholuminescent paint obtained from an art supply store. The paint dries clear and colorless, but glows in different colors under black light. By using the paint, carefully selected so as not to interfere with pathology staining, the investigators were able to blind the pathologists to the actual orientation of the margins.

While the tissue was still in the OR, the surgeons then placed two or three orienting sutures in customary locations, plus a third, “mystery” suture at a location known only to the surgeon.

In the pathology lab, the assistant was asked to look at the sutures and outline in black ink the edges of the margins using the sutures for guidance.

The specimen was then examined under black light to determine the degree of discordance between surgeons and pathologist for identification of margins using the suture and painting methods (primary outcome), and to evaluate the discrepancy in the extent of margin surface areas as identified by the surgeons and the pathologists (secondary outcome).

“We asked breast surgeons ‘what would be a clinically significant discordance rate for you?’ and most of them said between 10% and 20%, so we looked for a 15% discordance rate as being clinically significant between the two margin assessment techniques,” Dr. Arnaout said.

They found that the overall discordance in the location of the mystery suture between surgeons and pathologists was similar whether the samples contained two or three location sutures, with discordance rates of 46% (34 of 75 samples) for two sutures, and 47% (41 of 88 samples) for three sutures.

For the secondary outcome of discordance in the extent of margins, they found that pathologists tended to estimate the mean surface of the anterior and posterior margins to be significantly larger than the surgeons did (P less than .01), while significantly underestimating the superior, inferior, and lateral margins (P less than .01 for superior and inferior, and P = .04 for lateral margins).

Examination under black light showed that often two or three additional margins would be included by the surgeon within what the pathologist had identified as the anterior margin.

“This has implications for the surgeon and for the patient,” Dr. Arnaout said. “For most of us that do lumpectomies that go from skin down to chest wall, if an anterior margin or posterior margin is positive, a lot of times we would fight not to go back because we would say there is no further room for re-excision.”

But if the tumor is within what is actually the superior margin but labeled by the pathologist as an anterior margin, the patient may miss an opportunity for successful re-excision, she explained.

The study was limited by the fact that the sham lumpectomy specimens did not contain skin or muscle, which would have allowed for more accurate margin orientation in an actual operative setting; by lack of compression of specimens with small nonpalpable lesions in containers, which further distorts specimens; and by the use of smaller lumpectomy specimens than normally obtained during cancer surgery, which could have resulted in overestimation of the discordance that might occur when larger specimens are taken, Dr. Arnaout said.

“The conclusion of our study is that specimen margin orientation really should be defined by the surgeon who knows the original shape and orientation of the tissue during surgery, and not to rely on the pathology to reorient based on some sutures placed in the centers of the specimens without defining the extent of the surface area of each of the margins,” she said.

The Canadian Cancer Society Research Institute and the Canadian Surgical Research Fund supported the study. Dr. Arnaout and coauthors reported no conflicts of interest.

BOSTON – With art supplies and “mystery” sutures, a team of investigators has determined that immediate intraoperative inking of lumpectomy specimens appears to be a better method than suture placement for orienting specimens for pathology, a finding that could reduce re-excisions.

“Intraoperative specimen suturing appears to be inaccurate for margin identification, and additional means by the surgeon to improve the accuracy are needed. This could be either immediate inking or routine excision of shave margins, either at the original surgery or when you go back for re-excision, to take all the margins instead of one specific margin,” Dr. Angel Arnaout, a breast surgeon at the University of Ottawa, Ont., said at the annual Society of Surgical Oncology Cancer Symposium.

She presented results of the randomized, blinded SMART (Specimen Margin Assessment Technique) trial comparing suture placement with intraoperative inking within the same surgical specimen.

Positive resection margins during breast-conserving surgery are associated with a twofold increase in the risk of ipsilateral tumor recurrence, and require re-excision or conversion to mastectomy. Re-excisions rates range from 25% to 45%, but in the majority of cases – 53% to 65% – no additional disease is found, Dr. Arnaout said.

In addition to adding to patient distress, re-excisions diminish cosmetic results because they take additional tissue, and delay the start of adjuvant breast cancer therapy, she noted.

Surgeons typically orient specimens for pathologists by placing two or three sutures in the center of the margin surfaces or, less frequently, by intraoperative marking of the margins with ink. But in transit from the OR to the pathology lab, specimens often flatten or “pancake” under their own weight, making it challenging for the pathologist to identify the originally marked margins.

To test whether suturing or inking is better at identifying the extent of tumors during breast-conserving surgery, the investigators devised a strategy using benign breast tissue removed during prophylactic mastectomy or reduction mammoplasty.

The surgeons first performed a sham lumpectomy within the tissue. They then painted the specimen margins in the OR using a phospholuminescent paint obtained from an art supply store. The paint dries clear and colorless, but glows in different colors under black light. By using the paint, carefully selected so as not to interfere with pathology staining, the investigators were able to blind the pathologists to the actual orientation of the margins.

While the tissue was still in the OR, the surgeons then placed two or three orienting sutures in customary locations, plus a third, “mystery” suture at a location known only to the surgeon.

In the pathology lab, the assistant was asked to look at the sutures and outline in black ink the edges of the margins using the sutures for guidance.

The specimen was then examined under black light to determine the degree of discordance between surgeons and pathologist for identification of margins using the suture and painting methods (primary outcome), and to evaluate the discrepancy in the extent of margin surface areas as identified by the surgeons and the pathologists (secondary outcome).

“We asked breast surgeons ‘what would be a clinically significant discordance rate for you?’ and most of them said between 10% and 20%, so we looked for a 15% discordance rate as being clinically significant between the two margin assessment techniques,” Dr. Arnaout said.

They found that the overall discordance in the location of the mystery suture between surgeons and pathologists was similar whether the samples contained two or three location sutures, with discordance rates of 46% (34 of 75 samples) for two sutures, and 47% (41 of 88 samples) for three sutures.

For the secondary outcome of discordance in the extent of margins, they found that pathologists tended to estimate the mean surface of the anterior and posterior margins to be significantly larger than the surgeons did (P less than .01), while significantly underestimating the superior, inferior, and lateral margins (P less than .01 for superior and inferior, and P = .04 for lateral margins).

Examination under black light showed that often two or three additional margins would be included by the surgeon within what the pathologist had identified as the anterior margin.

“This has implications for the surgeon and for the patient,” Dr. Arnaout said. “For most of us that do lumpectomies that go from skin down to chest wall, if an anterior margin or posterior margin is positive, a lot of times we would fight not to go back because we would say there is no further room for re-excision.”

But if the tumor is within what is actually the superior margin but labeled by the pathologist as an anterior margin, the patient may miss an opportunity for successful re-excision, she explained.

The study was limited by the fact that the sham lumpectomy specimens did not contain skin or muscle, which would have allowed for more accurate margin orientation in an actual operative setting; by lack of compression of specimens with small nonpalpable lesions in containers, which further distorts specimens; and by the use of smaller lumpectomy specimens than normally obtained during cancer surgery, which could have resulted in overestimation of the discordance that might occur when larger specimens are taken, Dr. Arnaout said.

“The conclusion of our study is that specimen margin orientation really should be defined by the surgeon who knows the original shape and orientation of the tissue during surgery, and not to rely on the pathology to reorient based on some sutures placed in the centers of the specimens without defining the extent of the surface area of each of the margins,” she said.

The Canadian Cancer Society Research Institute and the Canadian Surgical Research Fund supported the study. Dr. Arnaout and coauthors reported no conflicts of interest.

BOSTON – Recurrence rates of cancer following breast-conserving surgery for ductal carcinoma in situ differ significantly with patient age, with younger women having a three-fold higher 10-year recurrence rate than older women.

The lower risk for 10-year recurrence among older women was independent of whether they had received adjuvant radiation therapy, reported Dr. Patricia A. Cronin, a surgical fellow at Memorial Sloan Kettering Cancer Center in New York City.

“Women over 80 are at low risk of recurrence, even in the absence of adjuvant therapies, whilst young age is a highly significant risk factor for any recurrence, in particular invasive recurrence, and therefore age is an important factor that should be weighed when considering other treatment options, including surgical options and adjuvant therapy,” she said at the annual Society of Surgical Oncology Cancer Symposium.

Ductal carcinoma in situ (DCIS) now accounts for more than 20% of all breast cancers. It can be treated with breast conserving surgery (BCS) alone or in conjunction with adjuvant therapy, radiation, and endocrine therapy, or by mastectomy.

“All treatment options have excellent survival but there can be markedly different recurrence rates,” Dr. Cronin said.

She noted that age is recognized as a risk factor for recurrence after BCS for DCIS, an observation confirmed in radiotherapy trials, but added that “the full nature of the relationship between age and recurrence and its interaction with other factors is not clear.”

DCIS through the ages

To get a better handle on the effect of age on recurrence, the investigators looked at data on patients who underwent breast-conserving surgery from 1978 through 2010. The women were stratified by age into six categories, beginning with those under age 40 and continuing at 10-year increments to age 80 and older.

Clinical, pathological, and treatment factors included in the analysis were family history, clinical vs. radiologic presentation, nuclear grade, necrosis, number of excision, margin status, radiotherapy, endocrine therapy, and treatment period.

Outcomes included ipsilateral DCIS recurrence, ipsilateral invasive breast cancer, ipsilateral axillary node recurrence, and distant recurrence in the absence of both ipsilateral recurrence and contralateral breast cancer.

A total of 2,996 women were identified, 363 of whom (12%) had local recurrences, either as DCIS in 192 patients, invasive disease in 160, of unknown status in 11.

An analysis of recurrence rates by age showed decreasing risk with each advance in age category, compared with women under age 40, with women aged 40-49 having a hazard ratio (HR) of 0.68 (P = .05), and women age 80 and over having an HR of 0.34 (P = .01), with 10-year recurrence rates ranging from 27% in the youngest cohort to about 8% in the oldest (log rank P less than .0001 for the overall effect of age on recurrence).

Looking at the individual factors associated with age, women under age 40 had a significantly higher proportion of clinical vs. radiologic presentation, with either a mass, nipple discharge, or Paget disease. Younger women also had less endocrine therapy.

Older women less frequently underwent multiple excisions, and more frequently had close or positive surgical margins, as well as lower rates of adjuvant therapy, and less endocrine therapy than women in the middle-age categories.

In a multivariable analysis for recurrence risk by age controlling for presentation, family history, necrosis, excision number, margin status, adjuvant radiation, endocrine therapy, and treatment period, the association between age and risk remained significant beginning in patients aged 50-59 (HR, 0.46; P = .0005) and continuing to dwindle through the decades to those age 80 and older (HR, 0.21; P = .001).

Age was also significantly associated with recurrence both among who received radiation and those who did not.

Women under age 40 were also found to be at greater risk for invasive recurrences, with 15.8% of all patients in this age group having invasive recurrences, and 11.5% having recurrent DCIS. In contrast, among all women aged 80 and older, 3.2% had invasive recurrences, and 3.4% had recurrent DCIS.

Question of mammography

Following Dr. Cronin’s presentation, Dr. Nicholas Tranakas from Broward Health Medical Center in Fort Lauderdale, Fla., asked whether, since the evidence shows that the majority of younger patients do not have indolent disease, they should be screened with mammography at earlier age than current guidelines recommend.

Dr. Cronin noted that although women under 40 don’t routinely undergo screening, “you can see that most patients under 40 present clinically, and therefore it’s hard in this study to make any recommendations in regards to screening.”

Asked how she counsels younger patients, she noted that although the data on recurrence risk in younger women are provocative, overall survival rates are excellent for both breast-conserving procedures and mastectomy, and the decision about which procedure to choose may rely on the patient’s degree of aversion to risk.

“We don’t automatically recommend mastectomy under 40, but I think this data does make us very concerned about recurrence, and particularly invasive recurrence and its potential influence then on distant disease,” she said.

The study funding source was not reported. The authors reported having no disclosures. Dr. Tranakas reported no disclosures.

BOSTON – Recurrence rates of cancer following breast-conserving surgery for ductal carcinoma in situ differ significantly with patient age, with younger women having a three-fold higher 10-year recurrence rate than older women.

The lower risk for 10-year recurrence among older women was independent of whether they had received adjuvant radiation therapy, reported Dr. Patricia A. Cronin, a surgical fellow at Memorial Sloan Kettering Cancer Center in New York City.

“Women over 80 are at low risk of recurrence, even in the absence of adjuvant therapies, whilst young age is a highly significant risk factor for any recurrence, in particular invasive recurrence, and therefore age is an important factor that should be weighed when considering other treatment options, including surgical options and adjuvant therapy,” she said at the annual Society of Surgical Oncology Cancer Symposium.

Ductal carcinoma in situ (DCIS) now accounts for more than 20% of all breast cancers. It can be treated with breast conserving surgery (BCS) alone or in conjunction with adjuvant therapy, radiation, and endocrine therapy, or by mastectomy.

“All treatment options have excellent survival but there can be markedly different recurrence rates,” Dr. Cronin said.

She noted that age is recognized as a risk factor for recurrence after BCS for DCIS, an observation confirmed in radiotherapy trials, but added that “the full nature of the relationship between age and recurrence and its interaction with other factors is not clear.”

DCIS through the ages

To get a better handle on the effect of age on recurrence, the investigators looked at data on patients who underwent breast-conserving surgery from 1978 through 2010. The women were stratified by age into six categories, beginning with those under age 40 and continuing at 10-year increments to age 80 and older.

Clinical, pathological, and treatment factors included in the analysis were family history, clinical vs. radiologic presentation, nuclear grade, necrosis, number of excision, margin status, radiotherapy, endocrine therapy, and treatment period.

Outcomes included ipsilateral DCIS recurrence, ipsilateral invasive breast cancer, ipsilateral axillary node recurrence, and distant recurrence in the absence of both ipsilateral recurrence and contralateral breast cancer.

A total of 2,996 women were identified, 363 of whom (12%) had local recurrences, either as DCIS in 192 patients, invasive disease in 160, of unknown status in 11.

An analysis of recurrence rates by age showed decreasing risk with each advance in age category, compared with women under age 40, with women aged 40-49 having a hazard ratio (HR) of 0.68 (P = .05), and women age 80 and over having an HR of 0.34 (P = .01), with 10-year recurrence rates ranging from 27% in the youngest cohort to about 8% in the oldest (log rank P less than .0001 for the overall effect of age on recurrence).

Looking at the individual factors associated with age, women under age 40 had a significantly higher proportion of clinical vs. radiologic presentation, with either a mass, nipple discharge, or Paget disease. Younger women also had less endocrine therapy.

Older women less frequently underwent multiple excisions, and more frequently had close or positive surgical margins, as well as lower rates of adjuvant therapy, and less endocrine therapy than women in the middle-age categories.

In a multivariable analysis for recurrence risk by age controlling for presentation, family history, necrosis, excision number, margin status, adjuvant radiation, endocrine therapy, and treatment period, the association between age and risk remained significant beginning in patients aged 50-59 (HR, 0.46; P = .0005) and continuing to dwindle through the decades to those age 80 and older (HR, 0.21; P = .001).

Age was also significantly associated with recurrence both among who received radiation and those who did not.

Women under age 40 were also found to be at greater risk for invasive recurrences, with 15.8% of all patients in this age group having invasive recurrences, and 11.5% having recurrent DCIS. In contrast, among all women aged 80 and older, 3.2% had invasive recurrences, and 3.4% had recurrent DCIS.

Question of mammography

Following Dr. Cronin’s presentation, Dr. Nicholas Tranakas from Broward Health Medical Center in Fort Lauderdale, Fla., asked whether, since the evidence shows that the majority of younger patients do not have indolent disease, they should be screened with mammography at earlier age than current guidelines recommend.

Dr. Cronin noted that although women under 40 don’t routinely undergo screening, “you can see that most patients under 40 present clinically, and therefore it’s hard in this study to make any recommendations in regards to screening.”

Asked how she counsels younger patients, she noted that although the data on recurrence risk in younger women are provocative, overall survival rates are excellent for both breast-conserving procedures and mastectomy, and the decision about which procedure to choose may rely on the patient’s degree of aversion to risk.

“We don’t automatically recommend mastectomy under 40, but I think this data does make us very concerned about recurrence, and particularly invasive recurrence and its potential influence then on distant disease,” she said.

The study funding source was not reported. The authors reported having no disclosures. Dr. Tranakas reported no disclosures.

BOSTON – Recurrence rates of cancer following breast-conserving surgery for ductal carcinoma in situ differ significantly with patient age, with younger women having a three-fold higher 10-year recurrence rate than older women.

The lower risk for 10-year recurrence among older women was independent of whether they had received adjuvant radiation therapy, reported Dr. Patricia A. Cronin, a surgical fellow at Memorial Sloan Kettering Cancer Center in New York City.

“Women over 80 are at low risk of recurrence, even in the absence of adjuvant therapies, whilst young age is a highly significant risk factor for any recurrence, in particular invasive recurrence, and therefore age is an important factor that should be weighed when considering other treatment options, including surgical options and adjuvant therapy,” she said at the annual Society of Surgical Oncology Cancer Symposium.

Ductal carcinoma in situ (DCIS) now accounts for more than 20% of all breast cancers. It can be treated with breast conserving surgery (BCS) alone or in conjunction with adjuvant therapy, radiation, and endocrine therapy, or by mastectomy.

“All treatment options have excellent survival but there can be markedly different recurrence rates,” Dr. Cronin said.

She noted that age is recognized as a risk factor for recurrence after BCS for DCIS, an observation confirmed in radiotherapy trials, but added that “the full nature of the relationship between age and recurrence and its interaction with other factors is not clear.”

DCIS through the ages

To get a better handle on the effect of age on recurrence, the investigators looked at data on patients who underwent breast-conserving surgery from 1978 through 2010. The women were stratified by age into six categories, beginning with those under age 40 and continuing at 10-year increments to age 80 and older.

Clinical, pathological, and treatment factors included in the analysis were family history, clinical vs. radiologic presentation, nuclear grade, necrosis, number of excision, margin status, radiotherapy, endocrine therapy, and treatment period.

Outcomes included ipsilateral DCIS recurrence, ipsilateral invasive breast cancer, ipsilateral axillary node recurrence, and distant recurrence in the absence of both ipsilateral recurrence and contralateral breast cancer.

A total of 2,996 women were identified, 363 of whom (12%) had local recurrences, either as DCIS in 192 patients, invasive disease in 160, of unknown status in 11.

An analysis of recurrence rates by age showed decreasing risk with each advance in age category, compared with women under age 40, with women aged 40-49 having a hazard ratio (HR) of 0.68 (P = .05), and women age 80 and over having an HR of 0.34 (P = .01), with 10-year recurrence rates ranging from 27% in the youngest cohort to about 8% in the oldest (log rank P less than .0001 for the overall effect of age on recurrence).

Looking at the individual factors associated with age, women under age 40 had a significantly higher proportion of clinical vs. radiologic presentation, with either a mass, nipple discharge, or Paget disease. Younger women also had less endocrine therapy.

Older women less frequently underwent multiple excisions, and more frequently had close or positive surgical margins, as well as lower rates of adjuvant therapy, and less endocrine therapy than women in the middle-age categories.

In a multivariable analysis for recurrence risk by age controlling for presentation, family history, necrosis, excision number, margin status, adjuvant radiation, endocrine therapy, and treatment period, the association between age and risk remained significant beginning in patients aged 50-59 (HR, 0.46; P = .0005) and continuing to dwindle through the decades to those age 80 and older (HR, 0.21; P = .001).

Age was also significantly associated with recurrence both among who received radiation and those who did not.

Women under age 40 were also found to be at greater risk for invasive recurrences, with 15.8% of all patients in this age group having invasive recurrences, and 11.5% having recurrent DCIS. In contrast, among all women aged 80 and older, 3.2% had invasive recurrences, and 3.4% had recurrent DCIS.

Question of mammography

Following Dr. Cronin’s presentation, Dr. Nicholas Tranakas from Broward Health Medical Center in Fort Lauderdale, Fla., asked whether, since the evidence shows that the majority of younger patients do not have indolent disease, they should be screened with mammography at earlier age than current guidelines recommend.

Dr. Cronin noted that although women under 40 don’t routinely undergo screening, “you can see that most patients under 40 present clinically, and therefore it’s hard in this study to make any recommendations in regards to screening.”

Asked how she counsels younger patients, she noted that although the data on recurrence risk in younger women are provocative, overall survival rates are excellent for both breast-conserving procedures and mastectomy, and the decision about which procedure to choose may rely on the patient’s degree of aversion to risk.

“We don’t automatically recommend mastectomy under 40, but I think this data does make us very concerned about recurrence, and particularly invasive recurrence and its potential influence then on distant disease,” she said.

The study funding source was not reported. The authors reported having no disclosures. Dr. Tranakas reported no disclosures.

BOSTON – Extreme breast density on mammography in women with breast cancer is a strong independent risk factor for in situ or invasive cancer in the contralateral breast, investigators in two studies say.

Among 7,684 women with breast cancer followed by the Breast Cancer Surveillance Consortium, those with extremely dense breasts according to Breast Imaging Reporting and Data System (BI-RADS) criteria had a more than twofold risk for cancer in the contralateral breast, compared with women with fatty breasts, reported Dr. Maureen O’Donnell, a surgeon at Johns Hopkins Hospital in Baltimore.

“Mammographic density may identify women whose lifetime contralateral breast cancer risk is high enough to warrant enhanced surveillance with MRI, and may contribute to individualized contralateral breast cancer risk estimations, and help guide surgical decision making,” she said at the annual Society of Surgical Oncology Cancer Symposium.

The findings of Dr. O’Donnell’s study were supported by a separate, nested case-control study in 680 patients showing that patients with extremely dense or heterogeneously dense breasts had a nearly twofold risk for developing a contralateral breast cancer, compared with those with fatty breasts.

“The hormonal receptor status of the contralateral breast cancer was independent of breast density,” noted Dr. Akshara Raghavendra of the University of Texas MD Anderson Cancer Center in Houston.

Breast density is a known risk factor for primary breast cancer. Breasts with greater than 75% density are associated with a fivefold greater risk for cancers than breasts with no dense tissues, according to the Boyd Classification of Breast Density.

To assess whether mammographic density modifies the risk of contralateral in situ or invasive breast cancer after an initial diagnosis, Dr. O’Donnell and colleagues looked at records on 7,684 patients with a screening mammography and diagnosis of breast cancer from 1998 through 2009. In this group, invasive cancers were diagnosed in 70% of patients, ductal carcinoma in situ (DCIS) in 24%, and mixed DCIS/invasive in 6%.

Of these patients, 1,921 developed cancer in the contralateral breast, with a median time from the diagnosis of the primary cancer of 4.8 years. The distribution of contralateral cancers was similar to that of the primary cancers, with more than two-thirds of patients having invasive tumors.

The patients with contralateral cancers were retrospectively matched with three controls each for year of diagnosis of the primary cancer, race, and follow-up time.

In univariate analysis, factors significantly associated with increased risk for contralateral breast cancer were heterogeneous mammographic density (odds ratio, 1.77; P = .016), extreme density (OR, 2.13; P = .004), age 30-40 at diagnosis (OR, 1.38; P = .005), age younger than 30 at diagnosis (OR, 2.27; P = .009), and estrogen receptor–negative status (OR, 1.23; P = .006).

In multivariate analysis controlling for age and antiestrogen therapy, factors associated with increased risk, compared with fatty breasts, were heterogeneous density (OR, 1.78; P = .015), and extreme density (OR, 2.34; P = .004). Women with breasts with scattered fibroglandular density had a borderline but nonsignificantly increased risk.

In the second study, Dr. Raghavendra and colleagues performed a retrospective nested case-control study in which every patient with breast cancer was matched with two controls by year of diagnosis of the primary cancer and by hormone receptor status of the primary tumor.

In multivariate analysis controlling for body mass index, tumor histology, chemotherapy, endocrine therapy, and radiation, they saw that, compared with women with predominantly fatty breasts, women with dense breasts (extreme and heterogeneous densities combined) had a nearly twofold increased risk for contralateral breast cancer (OR, 1.80; P = .03).

Because hormonal therapy is known to influence breast density, the investigators examined the relationship between hormone receptor subtypes of contralateral breast cancers and density, and found that there was no difference between hormone receptor negative or positive cancers as a function of density.

The study by Dr. O’Donnell and her colleagues was supported by the Breast Cancer Surveillance Consortium and by a grant from the National Cancer Institute. Dr. Raghavendra did not disclose a funding source. Both investigators reported having no conflicts of interest.

BOSTON – Extreme breast density on mammography in women with breast cancer is a strong independent risk factor for in situ or invasive cancer in the contralateral breast, investigators in two studies say.

Among 7,684 women with breast cancer followed by the Breast Cancer Surveillance Consortium, those with extremely dense breasts according to Breast Imaging Reporting and Data System (BI-RADS) criteria had a more than twofold risk for cancer in the contralateral breast, compared with women with fatty breasts, reported Dr. Maureen O’Donnell, a surgeon at Johns Hopkins Hospital in Baltimore.

“Mammographic density may identify women whose lifetime contralateral breast cancer risk is high enough to warrant enhanced surveillance with MRI, and may contribute to individualized contralateral breast cancer risk estimations, and help guide surgical decision making,” she said at the annual Society of Surgical Oncology Cancer Symposium.

The findings of Dr. O’Donnell’s study were supported by a separate, nested case-control study in 680 patients showing that patients with extremely dense or heterogeneously dense breasts had a nearly twofold risk for developing a contralateral breast cancer, compared with those with fatty breasts.

“The hormonal receptor status of the contralateral breast cancer was independent of breast density,” noted Dr. Akshara Raghavendra of the University of Texas MD Anderson Cancer Center in Houston.

Breast density is a known risk factor for primary breast cancer. Breasts with greater than 75% density are associated with a fivefold greater risk for cancers than breasts with no dense tissues, according to the Boyd Classification of Breast Density.

To assess whether mammographic density modifies the risk of contralateral in situ or invasive breast cancer after an initial diagnosis, Dr. O’Donnell and colleagues looked at records on 7,684 patients with a screening mammography and diagnosis of breast cancer from 1998 through 2009. In this group, invasive cancers were diagnosed in 70% of patients, ductal carcinoma in situ (DCIS) in 24%, and mixed DCIS/invasive in 6%.

Of these patients, 1,921 developed cancer in the contralateral breast, with a median time from the diagnosis of the primary cancer of 4.8 years. The distribution of contralateral cancers was similar to that of the primary cancers, with more than two-thirds of patients having invasive tumors.

The patients with contralateral cancers were retrospectively matched with three controls each for year of diagnosis of the primary cancer, race, and follow-up time.

In univariate analysis, factors significantly associated with increased risk for contralateral breast cancer were heterogeneous mammographic density (odds ratio, 1.77; P = .016), extreme density (OR, 2.13; P = .004), age 30-40 at diagnosis (OR, 1.38; P = .005), age younger than 30 at diagnosis (OR, 2.27; P = .009), and estrogen receptor–negative status (OR, 1.23; P = .006).

In multivariate analysis controlling for age and antiestrogen therapy, factors associated with increased risk, compared with fatty breasts, were heterogeneous density (OR, 1.78; P = .015), and extreme density (OR, 2.34; P = .004). Women with breasts with scattered fibroglandular density had a borderline but nonsignificantly increased risk.

In the second study, Dr. Raghavendra and colleagues performed a retrospective nested case-control study in which every patient with breast cancer was matched with two controls by year of diagnosis of the primary cancer and by hormone receptor status of the primary tumor.

In multivariate analysis controlling for body mass index, tumor histology, chemotherapy, endocrine therapy, and radiation, they saw that, compared with women with predominantly fatty breasts, women with dense breasts (extreme and heterogeneous densities combined) had a nearly twofold increased risk for contralateral breast cancer (OR, 1.80; P = .03).

Because hormonal therapy is known to influence breast density, the investigators examined the relationship between hormone receptor subtypes of contralateral breast cancers and density, and found that there was no difference between hormone receptor negative or positive cancers as a function of density.

The study by Dr. O’Donnell and her colleagues was supported by the Breast Cancer Surveillance Consortium and by a grant from the National Cancer Institute. Dr. Raghavendra did not disclose a funding source. Both investigators reported having no conflicts of interest.

BOSTON – Extreme breast density on mammography in women with breast cancer is a strong independent risk factor for in situ or invasive cancer in the contralateral breast, investigators in two studies say.

Among 7,684 women with breast cancer followed by the Breast Cancer Surveillance Consortium, those with extremely dense breasts according to Breast Imaging Reporting and Data System (BI-RADS) criteria had a more than twofold risk for cancer in the contralateral breast, compared with women with fatty breasts, reported Dr. Maureen O’Donnell, a surgeon at Johns Hopkins Hospital in Baltimore.

“Mammographic density may identify women whose lifetime contralateral breast cancer risk is high enough to warrant enhanced surveillance with MRI, and may contribute to individualized contralateral breast cancer risk estimations, and help guide surgical decision making,” she said at the annual Society of Surgical Oncology Cancer Symposium.

The findings of Dr. O’Donnell’s study were supported by a separate, nested case-control study in 680 patients showing that patients with extremely dense or heterogeneously dense breasts had a nearly twofold risk for developing a contralateral breast cancer, compared with those with fatty breasts.

“The hormonal receptor status of the contralateral breast cancer was independent of breast density,” noted Dr. Akshara Raghavendra of the University of Texas MD Anderson Cancer Center in Houston.

Breast density is a known risk factor for primary breast cancer. Breasts with greater than 75% density are associated with a fivefold greater risk for cancers than breasts with no dense tissues, according to the Boyd Classification of Breast Density.

To assess whether mammographic density modifies the risk of contralateral in situ or invasive breast cancer after an initial diagnosis, Dr. O’Donnell and colleagues looked at records on 7,684 patients with a screening mammography and diagnosis of breast cancer from 1998 through 2009. In this group, invasive cancers were diagnosed in 70% of patients, ductal carcinoma in situ (DCIS) in 24%, and mixed DCIS/invasive in 6%.

Of these patients, 1,921 developed cancer in the contralateral breast, with a median time from the diagnosis of the primary cancer of 4.8 years. The distribution of contralateral cancers was similar to that of the primary cancers, with more than two-thirds of patients having invasive tumors.

The patients with contralateral cancers were retrospectively matched with three controls each for year of diagnosis of the primary cancer, race, and follow-up time.

In univariate analysis, factors significantly associated with increased risk for contralateral breast cancer were heterogeneous mammographic density (odds ratio, 1.77; P = .016), extreme density (OR, 2.13; P = .004), age 30-40 at diagnosis (OR, 1.38; P = .005), age younger than 30 at diagnosis (OR, 2.27; P = .009), and estrogen receptor–negative status (OR, 1.23; P = .006).

In multivariate analysis controlling for age and antiestrogen therapy, factors associated with increased risk, compared with fatty breasts, were heterogeneous density (OR, 1.78; P = .015), and extreme density (OR, 2.34; P = .004). Women with breasts with scattered fibroglandular density had a borderline but nonsignificantly increased risk.

In the second study, Dr. Raghavendra and colleagues performed a retrospective nested case-control study in which every patient with breast cancer was matched with two controls by year of diagnosis of the primary cancer and by hormone receptor status of the primary tumor.

In multivariate analysis controlling for body mass index, tumor histology, chemotherapy, endocrine therapy, and radiation, they saw that, compared with women with predominantly fatty breasts, women with dense breasts (extreme and heterogeneous densities combined) had a nearly twofold increased risk for contralateral breast cancer (OR, 1.80; P = .03).

Because hormonal therapy is known to influence breast density, the investigators examined the relationship between hormone receptor subtypes of contralateral breast cancers and density, and found that there was no difference between hormone receptor negative or positive cancers as a function of density.

The study by Dr. O’Donnell and her colleagues was supported by the Breast Cancer Surveillance Consortium and by a grant from the National Cancer Institute. Dr. Raghavendra did not disclose a funding source. Both investigators reported having no conflicts of interest.

BOSTON – Phosphate levels following colorectal surgery are predictive of risk for intra-abdominal infections, and can be helpful in identifying low-risk patients who may be suitable for early discharge after surgery, investigators say.

“The association between hypophosphatemia and intra-abdominal infections after colorectal resection is a novel finding,” said Dr. Eran Sadot, a visiting surgical oncology fellow at Memorial Sloan Kettering Cancer Center in New York City.

©CDC/Janice Haney Carr

He described an intra-abdominal infection (IAI) risk-prediction tool at the annual Society of Surgical Oncology Cancer Symposium.

An estimated 5%-15% of patients who undergo colorectal surgery develop an IAI, largely from anastomotic leak, fistula, or intra-abdominal abscess. IAIs are associated with prolonged length of stay and higher costs, as well as an estimated 20% increase in short-term mortality, and reduced long-term survival, he said.

“These complications typically become clinically evident beyond postop day 5, and early identification of intra-abdominal infections can potentially lead to early intervention and limit sepsis, “ he said.

Several studies have shown that hypophosphatemia is associated with poor outcomes in various clinical settings – among hospitalized patients in general, in surgical and cardiac intensive care units, following open heart surgery, and after hepatic resections, he noted.

The investigators hypothesized that patients who develop IAIs have an intense acute-phase response accompanied by hypophosphatemia, and that early measurement of postoperative phosphate levels could serve as a marker for systemic response and early IAI. They conducted a retrospective study of data on patients who underwent first colorectal resection at their center from 2005 through 2015. They looked at postoperative hypophosphatemia, defined as serum levels less than 2.5 mg/dL, and they used logistic regression to create a risk model.

The sample included 7,423 patients with a median age of 61 years, including 42% who underwent resection for colon cancer, 26% for rectal cancer, and the remainder for various diagnoses.

In all, 399 patients (5%) developed IAIs, and two of these patients (0.5%) died.

The authors looked at the course of perioperative serum phosphate levels and saw that all patients had a slight rise in phosphate levels on the day of surgery, which then dropped rapidly to a nadir on postoperative day, and began to recover on day 3. They found that patients who did not have IAIs had more rapid recovery of phosphate levels than did patients who developed infections. In addition, they found that hypophosphatemia on postoperative day 3 was associated with a 50% increased risk of IAI (P = .001).

In a multivariable model of the cohort characteristics stratified by IAI, the researchers saw that risk factors independently associated with IAI included body mass index greater than 30 kg.m² (odds ratio [OR] 1.4, P = .04), combined liver resection (OR 1.9, P less than .001), estimated blood loss greater than 400 mL (OR 1.7, P = .01), hypophosphatemia on postoperative day 3 (OR 1.4, P = .03), and abnormal white blood cell count on postoperative day 3 (OR 1.9, P less than .001).

They then created an IAI risk score assigning 1 point each to the risk factors just mentioned and tested it as a risk prediction tool. A score of 0 or 1 was associated with a low, 5% predicted risk of IAI, giving the score a negative predictive value of 95%. Scores of 2-3 were associated with moderate risk of IAI (9%-15%), and scores of 4 or 5 were associated with high risk (17%-21%) of infection.

The area under the receiver operating characteristic curve was 0.66 (95% confidence interval 0.61-0.7), indicating a test with a good mix of sensitivity and specificity.

“This model may be used in conjunction with the recently developed enhanced recovery or ERAS pathways to safely reduce the hospital stay,” Dr. Sadot concluded.

The study was internally supported. Dr. Sadot and colleagues reported no conflicts of interest.

BOSTON – Phosphate levels following colorectal surgery are predictive of risk for intra-abdominal infections, and can be helpful in identifying low-risk patients who may be suitable for early discharge after surgery, investigators say.

“The association between hypophosphatemia and intra-abdominal infections after colorectal resection is a novel finding,” said Dr. Eran Sadot, a visiting surgical oncology fellow at Memorial Sloan Kettering Cancer Center in New York City.

©CDC/Janice Haney Carr

He described an intra-abdominal infection (IAI) risk-prediction tool at the annual Society of Surgical Oncology Cancer Symposium.

An estimated 5%-15% of patients who undergo colorectal surgery develop an IAI, largely from anastomotic leak, fistula, or intra-abdominal abscess. IAIs are associated with prolonged length of stay and higher costs, as well as an estimated 20% increase in short-term mortality, and reduced long-term survival, he said.

“These complications typically become clinically evident beyond postop day 5, and early identification of intra-abdominal infections can potentially lead to early intervention and limit sepsis, “ he said.

Several studies have shown that hypophosphatemia is associated with poor outcomes in various clinical settings – among hospitalized patients in general, in surgical and cardiac intensive care units, following open heart surgery, and after hepatic resections, he noted.

The investigators hypothesized that patients who develop IAIs have an intense acute-phase response accompanied by hypophosphatemia, and that early measurement of postoperative phosphate levels could serve as a marker for systemic response and early IAI. They conducted a retrospective study of data on patients who underwent first colorectal resection at their center from 2005 through 2015. They looked at postoperative hypophosphatemia, defined as serum levels less than 2.5 mg/dL, and they used logistic regression to create a risk model.

The sample included 7,423 patients with a median age of 61 years, including 42% who underwent resection for colon cancer, 26% for rectal cancer, and the remainder for various diagnoses.

In all, 399 patients (5%) developed IAIs, and two of these patients (0.5%) died.

The authors looked at the course of perioperative serum phosphate levels and saw that all patients had a slight rise in phosphate levels on the day of surgery, which then dropped rapidly to a nadir on postoperative day, and began to recover on day 3. They found that patients who did not have IAIs had more rapid recovery of phosphate levels than did patients who developed infections. In addition, they found that hypophosphatemia on postoperative day 3 was associated with a 50% increased risk of IAI (P = .001).

In a multivariable model of the cohort characteristics stratified by IAI, the researchers saw that risk factors independently associated with IAI included body mass index greater than 30 kg.m² (odds ratio [OR] 1.4, P = .04), combined liver resection (OR 1.9, P less than .001), estimated blood loss greater than 400 mL (OR 1.7, P = .01), hypophosphatemia on postoperative day 3 (OR 1.4, P = .03), and abnormal white blood cell count on postoperative day 3 (OR 1.9, P less than .001).

They then created an IAI risk score assigning 1 point each to the risk factors just mentioned and tested it as a risk prediction tool. A score of 0 or 1 was associated with a low, 5% predicted risk of IAI, giving the score a negative predictive value of 95%. Scores of 2-3 were associated with moderate risk of IAI (9%-15%), and scores of 4 or 5 were associated with high risk (17%-21%) of infection.

The area under the receiver operating characteristic curve was 0.66 (95% confidence interval 0.61-0.7), indicating a test with a good mix of sensitivity and specificity.

“This model may be used in conjunction with the recently developed enhanced recovery or ERAS pathways to safely reduce the hospital stay,” Dr. Sadot concluded.

The study was internally supported. Dr. Sadot and colleagues reported no conflicts of interest.

BOSTON – Phosphate levels following colorectal surgery are predictive of risk for intra-abdominal infections, and can be helpful in identifying low-risk patients who may be suitable for early discharge after surgery, investigators say.

“The association between hypophosphatemia and intra-abdominal infections after colorectal resection is a novel finding,” said Dr. Eran Sadot, a visiting surgical oncology fellow at Memorial Sloan Kettering Cancer Center in New York City.

©CDC/Janice Haney Carr

He described an intra-abdominal infection (IAI) risk-prediction tool at the annual Society of Surgical Oncology Cancer Symposium.

An estimated 5%-15% of patients who undergo colorectal surgery develop an IAI, largely from anastomotic leak, fistula, or intra-abdominal abscess. IAIs are associated with prolonged length of stay and higher costs, as well as an estimated 20% increase in short-term mortality, and reduced long-term survival, he said.

“These complications typically become clinically evident beyond postop day 5, and early identification of intra-abdominal infections can potentially lead to early intervention and limit sepsis, “ he said.

Several studies have shown that hypophosphatemia is associated with poor outcomes in various clinical settings – among hospitalized patients in general, in surgical and cardiac intensive care units, following open heart surgery, and after hepatic resections, he noted.

The investigators hypothesized that patients who develop IAIs have an intense acute-phase response accompanied by hypophosphatemia, and that early measurement of postoperative phosphate levels could serve as a marker for systemic response and early IAI. They conducted a retrospective study of data on patients who underwent first colorectal resection at their center from 2005 through 2015. They looked at postoperative hypophosphatemia, defined as serum levels less than 2.5 mg/dL, and they used logistic regression to create a risk model.

The sample included 7,423 patients with a median age of 61 years, including 42% who underwent resection for colon cancer, 26% for rectal cancer, and the remainder for various diagnoses.

In all, 399 patients (5%) developed IAIs, and two of these patients (0.5%) died.

The authors looked at the course of perioperative serum phosphate levels and saw that all patients had a slight rise in phosphate levels on the day of surgery, which then dropped rapidly to a nadir on postoperative day, and began to recover on day 3. They found that patients who did not have IAIs had more rapid recovery of phosphate levels than did patients who developed infections. In addition, they found that hypophosphatemia on postoperative day 3 was associated with a 50% increased risk of IAI (P = .001).

In a multivariable model of the cohort characteristics stratified by IAI, the researchers saw that risk factors independently associated with IAI included body mass index greater than 30 kg.m² (odds ratio [OR] 1.4, P = .04), combined liver resection (OR 1.9, P less than .001), estimated blood loss greater than 400 mL (OR 1.7, P = .01), hypophosphatemia on postoperative day 3 (OR 1.4, P = .03), and abnormal white blood cell count on postoperative day 3 (OR 1.9, P less than .001).

They then created an IAI risk score assigning 1 point each to the risk factors just mentioned and tested it as a risk prediction tool. A score of 0 or 1 was associated with a low, 5% predicted risk of IAI, giving the score a negative predictive value of 95%. Scores of 2-3 were associated with moderate risk of IAI (9%-15%), and scores of 4 or 5 were associated with high risk (17%-21%) of infection.

The area under the receiver operating characteristic curve was 0.66 (95% confidence interval 0.61-0.7), indicating a test with a good mix of sensitivity and specificity.

“This model may be used in conjunction with the recently developed enhanced recovery or ERAS pathways to safely reduce the hospital stay,” Dr. Sadot concluded.

The study was internally supported. Dr. Sadot and colleagues reported no conflicts of interest.

BOSTON – The majority of patients with hormone receptor–negative breast cancer in the United States get chemotherapy in the adjuvant setting, but neoadjuvant chemotherapy is gaining in use, and is associated with a higher likelihood of breast-conserving surgery for some women with advanced disease, as well as less extensive axillary node dissection.

A review of data on more than 130,000 patients with breast tumors negative for both estrogen and progesterone receptors (ER–/PR–) showed that among patients with clinical stage T3 disease, 26% of those who had received neoadjuvant chemotherapy were able to have breast-conserving surgery, compared with 20% of patients who had received adjuvant chemotherapy, reported Dr. Carlos A. Puig and his colleagues from the Mayo Clinic in Rochester, Minn.

“Patients treated with neoadjuvant chemotherapy have less extensive axillary surgery and a lower rate of nodal positivity,” he added at the annual Society of Surgical Oncology Cancer Symposium.

The data showed that nearly a third of all patients with clinically node-positive disease (cN1-3) who received neoadjuvant chemotherapy had pathologically node-negative disease at the end of therapy.

The aggressive biology of ER–/PR– tumors makes them suitable targets for chemotherapy in the neoadjuvant setting, Dr. Puig said. Overall survival among patients with ER–/PR– who receive neoadjuvant chemotherapy is comparable to that of patients who receive chemotherapy in the adjuvant setting. Neoadjuvant regimens can also downstage tumors before surgery, and a pathologic complete response to chemotherapy delivered prior to surgery is prognostic for outcomes.

Trends in chemotherapy

Dr. Puig and his colleagues combed through the National Cancer Data Base, looking for trends in national practice patterns of use of neoadjuvant chemotherapy in ER–/PR– breast cancer from 2004 through 2012.

They identified a total of 108,128 patients with invasive ER–/PR– breast cancer who received adjuvant chemotherapy, and 24,848 who received neoadjuvant chemo; an additional 43,969 patients who did not receive chemotherapy were excluded from the analysis.

Factors significantly associated with the choice to administer neoadjuvant chemotherapy included age younger than 50, no comorbidities vs. one or two comorbidities on the Charlson/Deyo index, academic/research center vs. community cancer program, higher clinical T stage, and higher clinical N stage.

There was a gradual increase in the use of neoadjuvant chemotherapy over time, from 14.2% in 2004 to 22.3% of all patients in 2012 (P less than .001).

The overall breast-conserving surgery rates were lower among patients who had chemotherapy in the neoadjuvant setting – 33.2% vs. 54.7% (P less than .001). The rates of conservative surgery increased over time, from 32% in 2004 to 36% in 2012 (P less than .001), but decreased over the same period in patients who had adjuvant chemotherapy, from 58% to 51%, respectively.

In a breakdown of surgery type by clinical T stage, mastectomy was more frequently performed in patients who had undergone neoadjuvant treatment, compared with adjuvant therapy, except for stage T3 disease. A higher percentage of those with T3 tumors who had neoadjuvant therapy had breast-conserving surgery in comparison with women who had T3 tumors and adjuvant therapy (26.2% vs. 20.2%, respectively; P less than .001).

To identify the extent of axillary surgery, the authors considered one to five nodes removed to be a surrogate for sentinel lymph node biopsy, and six or more nodes as a surrogate for axillary lymph node dissection.

They found that among patients with clinical stage N1 through N3 who received neoadjuvant chemotherapy, 31.8% converted to pathologically node-negative status.

Dr. Puig noted that the study was limited by the retrospective design and the lack of data on HER2 receptor status, making it impossible to distinguish between ER–/PR– and triple-negative tumors. In addition, they did not have data on genetic testing that could affect surgical choices, such as the presence of BRCA1 or BRCA2.

Following Dr. Puig’s presentation, Dr. Monica Morrow, chief of breast surgery at Memorial Sloan-Kettering Cancer Center, New York, commented that the study put together “patients in whom we would consider there to be an absolute indication for neoadjuvant chemotherapy – meaning T4, N2-N3 – and patients where it’s optional.” The study results suggested that not all patients who should receive neoadjuvant therapy were getting it “which is a little disturbing,” Dr. Morrow said.

She also noted that the decrease in the use of axillary lymph node dissection began prior to publication of studies suggesting that it might be safe to do so.

Dr. Puig and Dr. Morrow had no relevant disclosures.

BOSTON – The majority of patients with hormone receptor–negative breast cancer in the United States get chemotherapy in the adjuvant setting, but neoadjuvant chemotherapy is gaining in use, and is associated with a higher likelihood of breast-conserving surgery for some women with advanced disease, as well as less extensive axillary node dissection.

A review of data on more than 130,000 patients with breast tumors negative for both estrogen and progesterone receptors (ER–/PR–) showed that among patients with clinical stage T3 disease, 26% of those who had received neoadjuvant chemotherapy were able to have breast-conserving surgery, compared with 20% of patients who had received adjuvant chemotherapy, reported Dr. Carlos A. Puig and his colleagues from the Mayo Clinic in Rochester, Minn.

“Patients treated with neoadjuvant chemotherapy have less extensive axillary surgery and a lower rate of nodal positivity,” he added at the annual Society of Surgical Oncology Cancer Symposium.

The data showed that nearly a third of all patients with clinically node-positive disease (cN1-3) who received neoadjuvant chemotherapy had pathologically node-negative disease at the end of therapy.

The aggressive biology of ER–/PR– tumors makes them suitable targets for chemotherapy in the neoadjuvant setting, Dr. Puig said. Overall survival among patients with ER–/PR– who receive neoadjuvant chemotherapy is comparable to that of patients who receive chemotherapy in the adjuvant setting. Neoadjuvant regimens can also downstage tumors before surgery, and a pathologic complete response to chemotherapy delivered prior to surgery is prognostic for outcomes.

Trends in chemotherapy

Dr. Puig and his colleagues combed through the National Cancer Data Base, looking for trends in national practice patterns of use of neoadjuvant chemotherapy in ER–/PR– breast cancer from 2004 through 2012.

They identified a total of 108,128 patients with invasive ER–/PR– breast cancer who received adjuvant chemotherapy, and 24,848 who received neoadjuvant chemo; an additional 43,969 patients who did not receive chemotherapy were excluded from the analysis.

Factors significantly associated with the choice to administer neoadjuvant chemotherapy included age younger than 50, no comorbidities vs. one or two comorbidities on the Charlson/Deyo index, academic/research center vs. community cancer program, higher clinical T stage, and higher clinical N stage.

There was a gradual increase in the use of neoadjuvant chemotherapy over time, from 14.2% in 2004 to 22.3% of all patients in 2012 (P less than .001).

The overall breast-conserving surgery rates were lower among patients who had chemotherapy in the neoadjuvant setting – 33.2% vs. 54.7% (P less than .001). The rates of conservative surgery increased over time, from 32% in 2004 to 36% in 2012 (P less than .001), but decreased over the same period in patients who had adjuvant chemotherapy, from 58% to 51%, respectively.

In a breakdown of surgery type by clinical T stage, mastectomy was more frequently performed in patients who had undergone neoadjuvant treatment, compared with adjuvant therapy, except for stage T3 disease. A higher percentage of those with T3 tumors who had neoadjuvant therapy had breast-conserving surgery in comparison with women who had T3 tumors and adjuvant therapy (26.2% vs. 20.2%, respectively; P less than .001).

To identify the extent of axillary surgery, the authors considered one to five nodes removed to be a surrogate for sentinel lymph node biopsy, and six or more nodes as a surrogate for axillary lymph node dissection.

They found that among patients with clinical stage N1 through N3 who received neoadjuvant chemotherapy, 31.8% converted to pathologically node-negative status.

Dr. Puig noted that the study was limited by the retrospective design and the lack of data on HER2 receptor status, making it impossible to distinguish between ER–/PR– and triple-negative tumors. In addition, they did not have data on genetic testing that could affect surgical choices, such as the presence of BRCA1 or BRCA2.

Following Dr. Puig’s presentation, Dr. Monica Morrow, chief of breast surgery at Memorial Sloan-Kettering Cancer Center, New York, commented that the study put together “patients in whom we would consider there to be an absolute indication for neoadjuvant chemotherapy – meaning T4, N2-N3 – and patients where it’s optional.” The study results suggested that not all patients who should receive neoadjuvant therapy were getting it “which is a little disturbing,” Dr. Morrow said.

She also noted that the decrease in the use of axillary lymph node dissection began prior to publication of studies suggesting that it might be safe to do so.

Dr. Puig and Dr. Morrow had no relevant disclosures.

BOSTON – The majority of patients with hormone receptor–negative breast cancer in the United States get chemotherapy in the adjuvant setting, but neoadjuvant chemotherapy is gaining in use, and is associated with a higher likelihood of breast-conserving surgery for some women with advanced disease, as well as less extensive axillary node dissection.

A review of data on more than 130,000 patients with breast tumors negative for both estrogen and progesterone receptors (ER–/PR–) showed that among patients with clinical stage T3 disease, 26% of those who had received neoadjuvant chemotherapy were able to have breast-conserving surgery, compared with 20% of patients who had received adjuvant chemotherapy, reported Dr. Carlos A. Puig and his colleagues from the Mayo Clinic in Rochester, Minn.

“Patients treated with neoadjuvant chemotherapy have less extensive axillary surgery and a lower rate of nodal positivity,” he added at the annual Society of Surgical Oncology Cancer Symposium.

The data showed that nearly a third of all patients with clinically node-positive disease (cN1-3) who received neoadjuvant chemotherapy had pathologically node-negative disease at the end of therapy.

The aggressive biology of ER–/PR– tumors makes them suitable targets for chemotherapy in the neoadjuvant setting, Dr. Puig said. Overall survival among patients with ER–/PR– who receive neoadjuvant chemotherapy is comparable to that of patients who receive chemotherapy in the adjuvant setting. Neoadjuvant regimens can also downstage tumors before surgery, and a pathologic complete response to chemotherapy delivered prior to surgery is prognostic for outcomes.

Trends in chemotherapy

Dr. Puig and his colleagues combed through the National Cancer Data Base, looking for trends in national practice patterns of use of neoadjuvant chemotherapy in ER–/PR– breast cancer from 2004 through 2012.

They identified a total of 108,128 patients with invasive ER–/PR– breast cancer who received adjuvant chemotherapy, and 24,848 who received neoadjuvant chemo; an additional 43,969 patients who did not receive chemotherapy were excluded from the analysis.

Factors significantly associated with the choice to administer neoadjuvant chemotherapy included age younger than 50, no comorbidities vs. one or two comorbidities on the Charlson/Deyo index, academic/research center vs. community cancer program, higher clinical T stage, and higher clinical N stage.

There was a gradual increase in the use of neoadjuvant chemotherapy over time, from 14.2% in 2004 to 22.3% of all patients in 2012 (P less than .001).

The overall breast-conserving surgery rates were lower among patients who had chemotherapy in the neoadjuvant setting – 33.2% vs. 54.7% (P less than .001). The rates of conservative surgery increased over time, from 32% in 2004 to 36% in 2012 (P less than .001), but decreased over the same period in patients who had adjuvant chemotherapy, from 58% to 51%, respectively.

In a breakdown of surgery type by clinical T stage, mastectomy was more frequently performed in patients who had undergone neoadjuvant treatment, compared with adjuvant therapy, except for stage T3 disease. A higher percentage of those with T3 tumors who had neoadjuvant therapy had breast-conserving surgery in comparison with women who had T3 tumors and adjuvant therapy (26.2% vs. 20.2%, respectively; P less than .001).

To identify the extent of axillary surgery, the authors considered one to five nodes removed to be a surrogate for sentinel lymph node biopsy, and six or more nodes as a surrogate for axillary lymph node dissection.

They found that among patients with clinical stage N1 through N3 who received neoadjuvant chemotherapy, 31.8% converted to pathologically node-negative status.

Dr. Puig noted that the study was limited by the retrospective design and the lack of data on HER2 receptor status, making it impossible to distinguish between ER–/PR– and triple-negative tumors. In addition, they did not have data on genetic testing that could affect surgical choices, such as the presence of BRCA1 or BRCA2.

Following Dr. Puig’s presentation, Dr. Monica Morrow, chief of breast surgery at Memorial Sloan-Kettering Cancer Center, New York, commented that the study put together “patients in whom we would consider there to be an absolute indication for neoadjuvant chemotherapy – meaning T4, N2-N3 – and patients where it’s optional.” The study results suggested that not all patients who should receive neoadjuvant therapy were getting it “which is a little disturbing,” Dr. Morrow said.

She also noted that the decrease in the use of axillary lymph node dissection began prior to publication of studies suggesting that it might be safe to do so.

Dr. Puig and Dr. Morrow had no relevant disclosures.