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Consider invasive mediastinal staging in higher risk NSCLC patients, despite guidelines
Endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) appears to be cost effective for use in non–small cell lung cancer (NSCLC) staging if the prevalence of mediastinal lymph node metastasis (MLNM) is greater than or equal to 2.5%, according to the results of single institution modeling study. In addition, the study found that confirmatory mediastinoscopy should be performed in high-risk patients in cases of negative EBUS-TBNA.
Katarzyna Czarnecka-Kujawa, MD, of the University of Toronto and Toronto General Hospital, and her colleagues performed a decision analysis to compare health outcomes and costs of four mediastinal staging strategies. They assessed the following: no invasive staging, endobronchial ultrasound-guided transbronchial need aspiration (EBUS-TBNA), mediastinoscopy, and EBUS-TBNA followed by mediastinoscopy if EBUS-TBNA results were negative. They determined incremental cost-effectiveness ratios (ICER) for all strategies and performed comprehensive sensitivity analyses using a willingness to pay threshold of $80,000 [Canadian]/quality adjusted life-year (QALY).
They used data obtained for staging, outcomes, and costs from the patients in the lung cancer program at the Toronto General Hospital from Jan. 1, 2005 to Dec. 31, 2014, as detailed in a report published in the June issue of the Journal of Thoracic and Cardiovascular Surgery (2017. doi: 10.1016/j.jtcvs.2016.12.048).
After exclusions, they utilized a final case count of 499 cases for developing their surgical and procedure cost analysis, and a total of 750 cases in their endoscopy database for endoscopy analysis. For the base-case analysis, they assumed a prevalence of mediastinal metastasis of 9%, and obtained the prevalence of a pathologic lymph nodal stage disease following EBUS-TBNA from their institutional data.
Their results showed that EBUS-TBNA followed by mediastinoscopy was the strategy that resulted in the highest QALYs, but that it had a prohibitive ICER of greater than $1.4 million/QALY. Accordingly, it may not be justifiable to use mediastinoscopy after negative EBUS-TBNA in all patients, the researchers noted. However, the researchers’ data suggest that invasive screening may be justified in a very-low-risk population (MLNM above 2.5%).
In addition, the researchers stated that “[the] benefit conveyed by detecting mediastinal metastatic disease becomes more apparent as the prevalence of MLNM increases, with confirmatory mediastinoscopy becoming cost effective in cases of negative EBUS-TBNA in patients with moderate to high probability of MLNM” (greater than 57%).
Our model points out that there is a well-defined role for the use of different modalities, including mediastinoscopy. This stresses the need for ongoing focus on maintenance of competency and skill acquisition in mediastinoscopy and EBUS-TBNA by currently practicing and future thoracic surgeons respectively,” the researchers concluded.
Dr. Czarnecka-Kujawa disclosed that she is a research consultant with Olympus America. The study was funded in part by agencies of the Austrian government.
The authors make a compelling argument for invasive mediastinal staging in patients with clinical stage I non–small cell lung cancer and acknowledge that this conflicts with current guidelines, according to Biniam Kidane, MD, of the University of Manitoba, Winnipeg, in his invited comments on the study in the Journal of Thoracic and Cardiovascular Surgery (2017 Mar 10. doi: 10.1016/j.jtcvs.2017.02.051).
Their single-payer system is likely to have a different willingness-to-pay threshold, compared with those in other countries, especially the United States, where the EBUS-TBNA strategy without invasive staging is likely to remain the cost-effective choice.
“Cost-economic analyses such as these provide a window into the factors necessary to bridge guidelines from the realm of the abstract to the realm of local reality. When interpreting these findings, clinicians should consider: 1) What EBUS resources are available? (2) What is your local EBUS sensitivity? 3) What is the prevalence of MLNM?” Dr. Kidane concluded, with the caveat that such studies are not infallible and models are based on assumptions and must be treated with care.
Dr. Kidane reported no disclosures with regard to commercial support.
The authors make a compelling argument for invasive mediastinal staging in patients with clinical stage I non–small cell lung cancer and acknowledge that this conflicts with current guidelines, according to Biniam Kidane, MD, of the University of Manitoba, Winnipeg, in his invited comments on the study in the Journal of Thoracic and Cardiovascular Surgery (2017 Mar 10. doi: 10.1016/j.jtcvs.2017.02.051).
Their single-payer system is likely to have a different willingness-to-pay threshold, compared with those in other countries, especially the United States, where the EBUS-TBNA strategy without invasive staging is likely to remain the cost-effective choice.
“Cost-economic analyses such as these provide a window into the factors necessary to bridge guidelines from the realm of the abstract to the realm of local reality. When interpreting these findings, clinicians should consider: 1) What EBUS resources are available? (2) What is your local EBUS sensitivity? 3) What is the prevalence of MLNM?” Dr. Kidane concluded, with the caveat that such studies are not infallible and models are based on assumptions and must be treated with care.
Dr. Kidane reported no disclosures with regard to commercial support.
The authors make a compelling argument for invasive mediastinal staging in patients with clinical stage I non–small cell lung cancer and acknowledge that this conflicts with current guidelines, according to Biniam Kidane, MD, of the University of Manitoba, Winnipeg, in his invited comments on the study in the Journal of Thoracic and Cardiovascular Surgery (2017 Mar 10. doi: 10.1016/j.jtcvs.2017.02.051).
Their single-payer system is likely to have a different willingness-to-pay threshold, compared with those in other countries, especially the United States, where the EBUS-TBNA strategy without invasive staging is likely to remain the cost-effective choice.
“Cost-economic analyses such as these provide a window into the factors necessary to bridge guidelines from the realm of the abstract to the realm of local reality. When interpreting these findings, clinicians should consider: 1) What EBUS resources are available? (2) What is your local EBUS sensitivity? 3) What is the prevalence of MLNM?” Dr. Kidane concluded, with the caveat that such studies are not infallible and models are based on assumptions and must be treated with care.
Dr. Kidane reported no disclosures with regard to commercial support.
Endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) appears to be cost effective for use in non–small cell lung cancer (NSCLC) staging if the prevalence of mediastinal lymph node metastasis (MLNM) is greater than or equal to 2.5%, according to the results of single institution modeling study. In addition, the study found that confirmatory mediastinoscopy should be performed in high-risk patients in cases of negative EBUS-TBNA.
Katarzyna Czarnecka-Kujawa, MD, of the University of Toronto and Toronto General Hospital, and her colleagues performed a decision analysis to compare health outcomes and costs of four mediastinal staging strategies. They assessed the following: no invasive staging, endobronchial ultrasound-guided transbronchial need aspiration (EBUS-TBNA), mediastinoscopy, and EBUS-TBNA followed by mediastinoscopy if EBUS-TBNA results were negative. They determined incremental cost-effectiveness ratios (ICER) for all strategies and performed comprehensive sensitivity analyses using a willingness to pay threshold of $80,000 [Canadian]/quality adjusted life-year (QALY).
They used data obtained for staging, outcomes, and costs from the patients in the lung cancer program at the Toronto General Hospital from Jan. 1, 2005 to Dec. 31, 2014, as detailed in a report published in the June issue of the Journal of Thoracic and Cardiovascular Surgery (2017. doi: 10.1016/j.jtcvs.2016.12.048).
After exclusions, they utilized a final case count of 499 cases for developing their surgical and procedure cost analysis, and a total of 750 cases in their endoscopy database for endoscopy analysis. For the base-case analysis, they assumed a prevalence of mediastinal metastasis of 9%, and obtained the prevalence of a pathologic lymph nodal stage disease following EBUS-TBNA from their institutional data.
Their results showed that EBUS-TBNA followed by mediastinoscopy was the strategy that resulted in the highest QALYs, but that it had a prohibitive ICER of greater than $1.4 million/QALY. Accordingly, it may not be justifiable to use mediastinoscopy after negative EBUS-TBNA in all patients, the researchers noted. However, the researchers’ data suggest that invasive screening may be justified in a very-low-risk population (MLNM above 2.5%).
In addition, the researchers stated that “[the] benefit conveyed by detecting mediastinal metastatic disease becomes more apparent as the prevalence of MLNM increases, with confirmatory mediastinoscopy becoming cost effective in cases of negative EBUS-TBNA in patients with moderate to high probability of MLNM” (greater than 57%).
Our model points out that there is a well-defined role for the use of different modalities, including mediastinoscopy. This stresses the need for ongoing focus on maintenance of competency and skill acquisition in mediastinoscopy and EBUS-TBNA by currently practicing and future thoracic surgeons respectively,” the researchers concluded.
Dr. Czarnecka-Kujawa disclosed that she is a research consultant with Olympus America. The study was funded in part by agencies of the Austrian government.
Endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) appears to be cost effective for use in non–small cell lung cancer (NSCLC) staging if the prevalence of mediastinal lymph node metastasis (MLNM) is greater than or equal to 2.5%, according to the results of single institution modeling study. In addition, the study found that confirmatory mediastinoscopy should be performed in high-risk patients in cases of negative EBUS-TBNA.
Katarzyna Czarnecka-Kujawa, MD, of the University of Toronto and Toronto General Hospital, and her colleagues performed a decision analysis to compare health outcomes and costs of four mediastinal staging strategies. They assessed the following: no invasive staging, endobronchial ultrasound-guided transbronchial need aspiration (EBUS-TBNA), mediastinoscopy, and EBUS-TBNA followed by mediastinoscopy if EBUS-TBNA results were negative. They determined incremental cost-effectiveness ratios (ICER) for all strategies and performed comprehensive sensitivity analyses using a willingness to pay threshold of $80,000 [Canadian]/quality adjusted life-year (QALY).
They used data obtained for staging, outcomes, and costs from the patients in the lung cancer program at the Toronto General Hospital from Jan. 1, 2005 to Dec. 31, 2014, as detailed in a report published in the June issue of the Journal of Thoracic and Cardiovascular Surgery (2017. doi: 10.1016/j.jtcvs.2016.12.048).
After exclusions, they utilized a final case count of 499 cases for developing their surgical and procedure cost analysis, and a total of 750 cases in their endoscopy database for endoscopy analysis. For the base-case analysis, they assumed a prevalence of mediastinal metastasis of 9%, and obtained the prevalence of a pathologic lymph nodal stage disease following EBUS-TBNA from their institutional data.
Their results showed that EBUS-TBNA followed by mediastinoscopy was the strategy that resulted in the highest QALYs, but that it had a prohibitive ICER of greater than $1.4 million/QALY. Accordingly, it may not be justifiable to use mediastinoscopy after negative EBUS-TBNA in all patients, the researchers noted. However, the researchers’ data suggest that invasive screening may be justified in a very-low-risk population (MLNM above 2.5%).
In addition, the researchers stated that “[the] benefit conveyed by detecting mediastinal metastatic disease becomes more apparent as the prevalence of MLNM increases, with confirmatory mediastinoscopy becoming cost effective in cases of negative EBUS-TBNA in patients with moderate to high probability of MLNM” (greater than 57%).
Our model points out that there is a well-defined role for the use of different modalities, including mediastinoscopy. This stresses the need for ongoing focus on maintenance of competency and skill acquisition in mediastinoscopy and EBUS-TBNA by currently practicing and future thoracic surgeons respectively,” the researchers concluded.
Dr. Czarnecka-Kujawa disclosed that she is a research consultant with Olympus America. The study was funded in part by agencies of the Austrian government.
FROM THE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY
Key clinical point:
Major finding: Once the pathologic lymph nodal stage reaches 57%, EBUS-TBNA followed by mediastinoscopy is cost effective.
Data source: A model of health care outcomes and costs was developed from data obtained from patients treated over a 10-year period at a single institution.
Disclosures: Dr. Czarnecka-Kujawa disclosed that she is a research consultant with Olympus America. The study was funded in part by agencies of the Austrian government.
Decision to remove breast cancer metastases depends on location of lesions
LAS VEGAS – Determination of whether excision of persistent breast cancer metastases can benefit the patient and even prolong survival depends on the location of the metastatic lesions, an investigator said at the annual meeting of the American Society of Breast Surgeons.
Before making the decision, it’s important to restage the patient’s disease and to recheck the receptor status if a biopsy is accessible, said Roshni Rao, MD, of the University of Texas Southwestern Medical Center.
Brain
Survival is worse when there are concurrent extracranial metastases or when brain metastases are greater than 5 cm, in patients with triple negative tumors, and in patients with a Karnofsky score of 70 or less, Dr. Rao said.
Surgery has the greatest benefit in patients with a single metastasis, with no extracranial disease, and who are able to undergo adjuvant whole brain radiation. In these cases, surgery improves survival, lowers recurrence rates, and reduces the risk of death neurological causes, she said.
Long-term survival is most common with continuous adjuvant therapy, either trastuzumab or hormonal, and in patients with a longer time interval to development of metastases. One series showed a 20-month survival increase.
Liver
Approximately 15% of patients with synchronous metastases will have liver metastases, and about half of stage IV patients will experience liver metastases at some point during treatment.
There is evidence from colorectal cancer that removing liver metastases is beneficial, and that has prompted interest in a similar approach in breast cancer. Liver resection has also become safer with new advances.
Dr. Rao discussed a single-institution study which took an aggressive approach to liver resection in 85 patients (Ann Surg. 2006;244:897-907). The researchers found that increased survival was associated with a good response to adjuvant chemotherapy, an r0 or r1 resection, and in patients who had a previous liver resection and were healthy enough to undergo another resection.
Overall, existing studies support liver resection if there are one to three lesions, if negative margins can be achieved, if the tumors are hormone receptor positive, and if the cancer is hormone positive and has good response to chemotherapy.
Dr. Rao emphasized that liver resections should be performed with a multidisciplinary team and should only be attempted at centers with low morbidity and where the doctors are experienced with liver resection.
When it’s possible, liver resection is beneficial. “There have been multiple reports of long-term survivors with no evidence of disease. There is likely a survival benefit with careful selection of these patients,” Dr. Rao said.
Lung
Lung surgeries are becoming safer, especially with the availability of video-assisted techniques, and pulmonary metastases are increasingly being spotted using more sensitive techniques such as higher resolution computed tomography.
A lung metastasis registry analysis showed three factors improved survival: prolonged disease-free survival, especially longer than 36 months; a complete resection; and a small number of metastases and success in resecting them all (Eur J Cardiothorac Surg. 2002;22:335-44). A more recent meta-analysis showed the same results (J Thorac Dis. 2015;7:1441-51).
Bone
Bone metastases remain rare choices for surgical treatment. Most of the time, morbidity will be too high, and there are good options for systemic treatment. That leaves surgery reserved mostly for stabilization or the treatment of fractures.
However, there are a couple of exceptions, according to Dr. Rao. One multi-institutional randomized trial looked at metastatic epidural spinal cord compression. Subjects either underwent decompressive surgery with stabilization and radiation or radiation alone. Patients in the surgical group had a longer ambulatory period and had a lower usage rate of steroids and opioids. Morbidity outcomes were similar in both groups. Patients whose primary tumor was in the breast seemed to benefit the most with respect to ambulatory time (Lancet. 2005;9486:643-8; J Neurosurg Spine. 2008;8:271-8).
Sternal metastases represent another special case. 70% of the time, patients with sternal metastases have it as their only metastatic site. A French series of 33 patients who underwent aggressive chest wall and rib resection reported a 36% complication rate, while another study of 28 patients showed a 21% complication rate. Those complications are a problem, “but if you’re able to perform this in a resected tumor, there are long term survivors. As usual, triple negative breast cancers predicted a worse prognosis,” said Dr. Rao.
Dr. Rao concluded that resection of metastatic sites has a role. “I think it’s our responsibility as breast surgeons who are many times continuously following these patients to consider appropriate operations,” said Dr. Rao.
However, she did sound one note of caution. Surgery can interrupt therapy that is helping a patient. “Let’s say you have someone get a big liver resection, and then they have a tough time with recovery. There could be a long period of time they can’t get the therapy that was keeping them alive. That’s the real concern,” she said.
LAS VEGAS – Determination of whether excision of persistent breast cancer metastases can benefit the patient and even prolong survival depends on the location of the metastatic lesions, an investigator said at the annual meeting of the American Society of Breast Surgeons.
Before making the decision, it’s important to restage the patient’s disease and to recheck the receptor status if a biopsy is accessible, said Roshni Rao, MD, of the University of Texas Southwestern Medical Center.
Brain
Survival is worse when there are concurrent extracranial metastases or when brain metastases are greater than 5 cm, in patients with triple negative tumors, and in patients with a Karnofsky score of 70 or less, Dr. Rao said.
Surgery has the greatest benefit in patients with a single metastasis, with no extracranial disease, and who are able to undergo adjuvant whole brain radiation. In these cases, surgery improves survival, lowers recurrence rates, and reduces the risk of death neurological causes, she said.
Long-term survival is most common with continuous adjuvant therapy, either trastuzumab or hormonal, and in patients with a longer time interval to development of metastases. One series showed a 20-month survival increase.
Liver
Approximately 15% of patients with synchronous metastases will have liver metastases, and about half of stage IV patients will experience liver metastases at some point during treatment.
There is evidence from colorectal cancer that removing liver metastases is beneficial, and that has prompted interest in a similar approach in breast cancer. Liver resection has also become safer with new advances.
Dr. Rao discussed a single-institution study which took an aggressive approach to liver resection in 85 patients (Ann Surg. 2006;244:897-907). The researchers found that increased survival was associated with a good response to adjuvant chemotherapy, an r0 or r1 resection, and in patients who had a previous liver resection and were healthy enough to undergo another resection.
Overall, existing studies support liver resection if there are one to three lesions, if negative margins can be achieved, if the tumors are hormone receptor positive, and if the cancer is hormone positive and has good response to chemotherapy.
Dr. Rao emphasized that liver resections should be performed with a multidisciplinary team and should only be attempted at centers with low morbidity and where the doctors are experienced with liver resection.
When it’s possible, liver resection is beneficial. “There have been multiple reports of long-term survivors with no evidence of disease. There is likely a survival benefit with careful selection of these patients,” Dr. Rao said.
Lung
Lung surgeries are becoming safer, especially with the availability of video-assisted techniques, and pulmonary metastases are increasingly being spotted using more sensitive techniques such as higher resolution computed tomography.
A lung metastasis registry analysis showed three factors improved survival: prolonged disease-free survival, especially longer than 36 months; a complete resection; and a small number of metastases and success in resecting them all (Eur J Cardiothorac Surg. 2002;22:335-44). A more recent meta-analysis showed the same results (J Thorac Dis. 2015;7:1441-51).
Bone
Bone metastases remain rare choices for surgical treatment. Most of the time, morbidity will be too high, and there are good options for systemic treatment. That leaves surgery reserved mostly for stabilization or the treatment of fractures.
However, there are a couple of exceptions, according to Dr. Rao. One multi-institutional randomized trial looked at metastatic epidural spinal cord compression. Subjects either underwent decompressive surgery with stabilization and radiation or radiation alone. Patients in the surgical group had a longer ambulatory period and had a lower usage rate of steroids and opioids. Morbidity outcomes were similar in both groups. Patients whose primary tumor was in the breast seemed to benefit the most with respect to ambulatory time (Lancet. 2005;9486:643-8; J Neurosurg Spine. 2008;8:271-8).
Sternal metastases represent another special case. 70% of the time, patients with sternal metastases have it as their only metastatic site. A French series of 33 patients who underwent aggressive chest wall and rib resection reported a 36% complication rate, while another study of 28 patients showed a 21% complication rate. Those complications are a problem, “but if you’re able to perform this in a resected tumor, there are long term survivors. As usual, triple negative breast cancers predicted a worse prognosis,” said Dr. Rao.
Dr. Rao concluded that resection of metastatic sites has a role. “I think it’s our responsibility as breast surgeons who are many times continuously following these patients to consider appropriate operations,” said Dr. Rao.
However, she did sound one note of caution. Surgery can interrupt therapy that is helping a patient. “Let’s say you have someone get a big liver resection, and then they have a tough time with recovery. There could be a long period of time they can’t get the therapy that was keeping them alive. That’s the real concern,” she said.
LAS VEGAS – Determination of whether excision of persistent breast cancer metastases can benefit the patient and even prolong survival depends on the location of the metastatic lesions, an investigator said at the annual meeting of the American Society of Breast Surgeons.
Before making the decision, it’s important to restage the patient’s disease and to recheck the receptor status if a biopsy is accessible, said Roshni Rao, MD, of the University of Texas Southwestern Medical Center.
Brain
Survival is worse when there are concurrent extracranial metastases or when brain metastases are greater than 5 cm, in patients with triple negative tumors, and in patients with a Karnofsky score of 70 or less, Dr. Rao said.
Surgery has the greatest benefit in patients with a single metastasis, with no extracranial disease, and who are able to undergo adjuvant whole brain radiation. In these cases, surgery improves survival, lowers recurrence rates, and reduces the risk of death neurological causes, she said.
Long-term survival is most common with continuous adjuvant therapy, either trastuzumab or hormonal, and in patients with a longer time interval to development of metastases. One series showed a 20-month survival increase.
Liver
Approximately 15% of patients with synchronous metastases will have liver metastases, and about half of stage IV patients will experience liver metastases at some point during treatment.
There is evidence from colorectal cancer that removing liver metastases is beneficial, and that has prompted interest in a similar approach in breast cancer. Liver resection has also become safer with new advances.
Dr. Rao discussed a single-institution study which took an aggressive approach to liver resection in 85 patients (Ann Surg. 2006;244:897-907). The researchers found that increased survival was associated with a good response to adjuvant chemotherapy, an r0 or r1 resection, and in patients who had a previous liver resection and were healthy enough to undergo another resection.
Overall, existing studies support liver resection if there are one to three lesions, if negative margins can be achieved, if the tumors are hormone receptor positive, and if the cancer is hormone positive and has good response to chemotherapy.
Dr. Rao emphasized that liver resections should be performed with a multidisciplinary team and should only be attempted at centers with low morbidity and where the doctors are experienced with liver resection.
When it’s possible, liver resection is beneficial. “There have been multiple reports of long-term survivors with no evidence of disease. There is likely a survival benefit with careful selection of these patients,” Dr. Rao said.
Lung
Lung surgeries are becoming safer, especially with the availability of video-assisted techniques, and pulmonary metastases are increasingly being spotted using more sensitive techniques such as higher resolution computed tomography.
A lung metastasis registry analysis showed three factors improved survival: prolonged disease-free survival, especially longer than 36 months; a complete resection; and a small number of metastases and success in resecting them all (Eur J Cardiothorac Surg. 2002;22:335-44). A more recent meta-analysis showed the same results (J Thorac Dis. 2015;7:1441-51).
Bone
Bone metastases remain rare choices for surgical treatment. Most of the time, morbidity will be too high, and there are good options for systemic treatment. That leaves surgery reserved mostly for stabilization or the treatment of fractures.
However, there are a couple of exceptions, according to Dr. Rao. One multi-institutional randomized trial looked at metastatic epidural spinal cord compression. Subjects either underwent decompressive surgery with stabilization and radiation or radiation alone. Patients in the surgical group had a longer ambulatory period and had a lower usage rate of steroids and opioids. Morbidity outcomes were similar in both groups. Patients whose primary tumor was in the breast seemed to benefit the most with respect to ambulatory time (Lancet. 2005;9486:643-8; J Neurosurg Spine. 2008;8:271-8).
Sternal metastases represent another special case. 70% of the time, patients with sternal metastases have it as their only metastatic site. A French series of 33 patients who underwent aggressive chest wall and rib resection reported a 36% complication rate, while another study of 28 patients showed a 21% complication rate. Those complications are a problem, “but if you’re able to perform this in a resected tumor, there are long term survivors. As usual, triple negative breast cancers predicted a worse prognosis,” said Dr. Rao.
Dr. Rao concluded that resection of metastatic sites has a role. “I think it’s our responsibility as breast surgeons who are many times continuously following these patients to consider appropriate operations,” said Dr. Rao.
However, she did sound one note of caution. Surgery can interrupt therapy that is helping a patient. “Let’s say you have someone get a big liver resection, and then they have a tough time with recovery. There could be a long period of time they can’t get the therapy that was keeping them alive. That’s the real concern,” she said.
EXPERT ANALYSIS FROM ASBS 2017
Androgen receptor screening not ready for triple-negative breast cancer
LAS VEGAS – Despite the early promise of antiandrogen therapy, it’s not time yet to routinely screen women with triple-negative breast cancer for androgen receptors, according to Tiffany A. Traina, MD, the head of research into the disease at Memorial Sloan Kettering Cancer Center, New York.
There’s no standardized test for androgen receptors in breast cancer, so people “are doing different kinds of testing.” In the literature, “the range of AR positivity is anywhere from 12% to 79%, which reflects how we are all over the map in methodology; you might just as well throw a dart at the board. I would encourage screening in the context of the ongoing trials,” Dr. Traina said.
More than a decade ago, Memorial Sloan Kettering found a subset of TNBC that had ARs, which was peculiar because the tumors weren’t otherwise responsive to hormones. Androgen exposure increased growth, but the AR antagonist flutamide (Eulexin)blocked it. “It was thought provoking. There are a lot of drugs in the prostate cancer world” such as flutamide that shut down androgens, she said (Oncogene. 2006 Jun 29;25[28]:3994-4008).
Several have been tried, and investigations are ongoing. The work matters because TNBC is a particularly bad diagnosis. Blocking androgens seems to give some women a few more months of life.
Dr. Traina was the senior author in an early proof-of-concept study for AR blockade that involved 26 women with metastatic TNBC who had been through up to eight prior chemotherapy regimens. The women received 150 mg daily of the prostate cancer AR antagonist bicalutamide (Casodex). Disease remained stable in five (19%) for more than 6 months. Median progression-free survival was 12 weeks, which was “not that far off from what you get with [standard] chemotherapies. This was encouraging, and it led to multiple other trials looking at targeted therapies,” she said (Clin Cancer Res. 2013 Oct 1; 19[19]: 5505-12).
Dr. Traina led a phase II investigation of the prostate cancer AR antagonist enzalutamide (Xtandi) in 118 women with advanced AR-positive TNBC. Her team created an androgen-driven gene signature as a potential biomarker of response. Median progression-free survival was 32 weeks in the 56 women (47%) who were positive for the gene signature, but 9 weeks in those who were not. There were two complete responses and five partial responses with enzalutamide. Currently, “we are looking at using enzalutamide for patients with AR-positive TNBC in the early stage after failure of standard therapies,” she said.
French investigators recently reported a 6-month clinical benefit – including one complete response – in 7 (21%) of 34 women with locally advanced or metastatic TNBC who were treated with 1,000 mg daily of abiraterone acetate (Zytiga), an androgen biosynthesis inhibitor approved for prostate cancer (Ann Oncol. 2016 May;27[5]:812-8).
“We still have a ways to go” before AR treatment reaches the clinic for routine breast cancer treatment, “but there’s reason for hope,” Dr. Traina said.
Dr. Traina reported funding, honoraria, and steering committing payments from a number of companies working on or marketing TNBC AR drugs, including Pfizer, Astellas, Innocrin, AstraZeneca, Eisai, and Merck.
LAS VEGAS – Despite the early promise of antiandrogen therapy, it’s not time yet to routinely screen women with triple-negative breast cancer for androgen receptors, according to Tiffany A. Traina, MD, the head of research into the disease at Memorial Sloan Kettering Cancer Center, New York.
There’s no standardized test for androgen receptors in breast cancer, so people “are doing different kinds of testing.” In the literature, “the range of AR positivity is anywhere from 12% to 79%, which reflects how we are all over the map in methodology; you might just as well throw a dart at the board. I would encourage screening in the context of the ongoing trials,” Dr. Traina said.
More than a decade ago, Memorial Sloan Kettering found a subset of TNBC that had ARs, which was peculiar because the tumors weren’t otherwise responsive to hormones. Androgen exposure increased growth, but the AR antagonist flutamide (Eulexin)blocked it. “It was thought provoking. There are a lot of drugs in the prostate cancer world” such as flutamide that shut down androgens, she said (Oncogene. 2006 Jun 29;25[28]:3994-4008).
Several have been tried, and investigations are ongoing. The work matters because TNBC is a particularly bad diagnosis. Blocking androgens seems to give some women a few more months of life.
Dr. Traina was the senior author in an early proof-of-concept study for AR blockade that involved 26 women with metastatic TNBC who had been through up to eight prior chemotherapy regimens. The women received 150 mg daily of the prostate cancer AR antagonist bicalutamide (Casodex). Disease remained stable in five (19%) for more than 6 months. Median progression-free survival was 12 weeks, which was “not that far off from what you get with [standard] chemotherapies. This was encouraging, and it led to multiple other trials looking at targeted therapies,” she said (Clin Cancer Res. 2013 Oct 1; 19[19]: 5505-12).
Dr. Traina led a phase II investigation of the prostate cancer AR antagonist enzalutamide (Xtandi) in 118 women with advanced AR-positive TNBC. Her team created an androgen-driven gene signature as a potential biomarker of response. Median progression-free survival was 32 weeks in the 56 women (47%) who were positive for the gene signature, but 9 weeks in those who were not. There were two complete responses and five partial responses with enzalutamide. Currently, “we are looking at using enzalutamide for patients with AR-positive TNBC in the early stage after failure of standard therapies,” she said.
French investigators recently reported a 6-month clinical benefit – including one complete response – in 7 (21%) of 34 women with locally advanced or metastatic TNBC who were treated with 1,000 mg daily of abiraterone acetate (Zytiga), an androgen biosynthesis inhibitor approved for prostate cancer (Ann Oncol. 2016 May;27[5]:812-8).
“We still have a ways to go” before AR treatment reaches the clinic for routine breast cancer treatment, “but there’s reason for hope,” Dr. Traina said.
Dr. Traina reported funding, honoraria, and steering committing payments from a number of companies working on or marketing TNBC AR drugs, including Pfizer, Astellas, Innocrin, AstraZeneca, Eisai, and Merck.
LAS VEGAS – Despite the early promise of antiandrogen therapy, it’s not time yet to routinely screen women with triple-negative breast cancer for androgen receptors, according to Tiffany A. Traina, MD, the head of research into the disease at Memorial Sloan Kettering Cancer Center, New York.
There’s no standardized test for androgen receptors in breast cancer, so people “are doing different kinds of testing.” In the literature, “the range of AR positivity is anywhere from 12% to 79%, which reflects how we are all over the map in methodology; you might just as well throw a dart at the board. I would encourage screening in the context of the ongoing trials,” Dr. Traina said.
More than a decade ago, Memorial Sloan Kettering found a subset of TNBC that had ARs, which was peculiar because the tumors weren’t otherwise responsive to hormones. Androgen exposure increased growth, but the AR antagonist flutamide (Eulexin)blocked it. “It was thought provoking. There are a lot of drugs in the prostate cancer world” such as flutamide that shut down androgens, she said (Oncogene. 2006 Jun 29;25[28]:3994-4008).
Several have been tried, and investigations are ongoing. The work matters because TNBC is a particularly bad diagnosis. Blocking androgens seems to give some women a few more months of life.
Dr. Traina was the senior author in an early proof-of-concept study for AR blockade that involved 26 women with metastatic TNBC who had been through up to eight prior chemotherapy regimens. The women received 150 mg daily of the prostate cancer AR antagonist bicalutamide (Casodex). Disease remained stable in five (19%) for more than 6 months. Median progression-free survival was 12 weeks, which was “not that far off from what you get with [standard] chemotherapies. This was encouraging, and it led to multiple other trials looking at targeted therapies,” she said (Clin Cancer Res. 2013 Oct 1; 19[19]: 5505-12).
Dr. Traina led a phase II investigation of the prostate cancer AR antagonist enzalutamide (Xtandi) in 118 women with advanced AR-positive TNBC. Her team created an androgen-driven gene signature as a potential biomarker of response. Median progression-free survival was 32 weeks in the 56 women (47%) who were positive for the gene signature, but 9 weeks in those who were not. There were two complete responses and five partial responses with enzalutamide. Currently, “we are looking at using enzalutamide for patients with AR-positive TNBC in the early stage after failure of standard therapies,” she said.
French investigators recently reported a 6-month clinical benefit – including one complete response – in 7 (21%) of 34 women with locally advanced or metastatic TNBC who were treated with 1,000 mg daily of abiraterone acetate (Zytiga), an androgen biosynthesis inhibitor approved for prostate cancer (Ann Oncol. 2016 May;27[5]:812-8).
“We still have a ways to go” before AR treatment reaches the clinic for routine breast cancer treatment, “but there’s reason for hope,” Dr. Traina said.
Dr. Traina reported funding, honoraria, and steering committing payments from a number of companies working on or marketing TNBC AR drugs, including Pfizer, Astellas, Innocrin, AstraZeneca, Eisai, and Merck.
EXPERT ANALYSIS FROM ASBS 2017
Breast density is no reason to perform MRI
LAS VEGAS – In women with higher density (HD) breasts, preoperative MRI revealed more abnormalities than were seen in women with lower density (LD) breasts, but there was no difference in the number of secondary cancers detected or long-term recurrence rates.
Breast density is often cited by radiologists as a reason to conduct a preoperative MRI, but the study suggests that it should not be a driving factor. “It’s a real challenge when our radiologists provide us reports that say, ‘Due to increased density, we recommend MRI,’ because it’s really hard to then disregard that. I think this is very important data,” said Judy Boughey, MD, professor of surgery at the Mayo Clinic, Rochester, MN, who moderated the session at the annual meeting of the American Society of Breast Surgeons where the research was presented.
“MRI is a valuable tool, and we’re still trying to figure out who it should be performed in,” said lead author Sarah McLaughlin, MD, of the Mayo Clinic, Jacksonville, FL, in an interview.
The researchers retrospectively analyzed data from 683 women at their institution who underwent preoperative MRI between 2007 and 2011. They grouped them by mammography results into LD (33%; Breast Imaging–Reporting and Data System density, 1 and 2) and HD (67%; BI-RADS density, 3 and 4).
Patients in the HD group more often had ipsilateral MRI findings (42% vs. 31%; P = .005), but ,of those with MRI findings, a similar number of patients in each group needed a second site biopsy (HD 65% vs. LD 67%; P = .78).
In all patients who had an additional MRI finding, the odds of detecting an additional ipsilateral cancer were not statistically significant between HD (32%) and LD (23%; P = .15) patients.
HD patients were also more likely to have abnormalities in the contralateral breast (25% vs. 14%; P = .009), but there were no statistically significant differences in rates of second-site biopsy recommendations or in the percentages of abnormalities that turned out to be cancerous (HD 6% vs. LD 3%; P = 1.0).
Following MRI, 70% of LD patients expressed a preference for breast-conserving surgery, compared with 53% of HD patients (P = .0001).
Over a median 7 years of follow-up, there was no difference in freedom from recurrence rates between the two groups (91% in LD vs. 90% in HD; P = .57).
“To me, it says that you don’t have to order an MRI just because they have cancer in a high density breast. You can feel reassured by your surgical plan and treatment recommendations based on conventional imaging,” said Dr. McLaughlin.
The researchers can’t determine if having an MRI done increased patient worry and potentially led to the higher rate of mastectomies chosen by women in the HD group. “Is that a result of the MRI? I don’t think we can say that, but there’s this whole other discussion piece that goes into it. You definitely see patients who say, ‘But it found these other things, and I’m going to have a mastectomy.’ So, there’s that patient preference and worry piece,” said Dr. McLaughlin.
The study results should offer some reassurance to patients. “There were no differences in local recurrence rates according to density. Maybe the next angle is allaying some of that fear, because the outcomes were the same. It’s really driven more by tumor biology and multimodality therapy,” said Dr. McLaughlin.
The study doesn’t provide the final word on breast density and MRI, according to Dr. Boughey. “I think this is an area that needs to be studied more with a clinical trial. There are several going on in different countries, and this is an area where we need level 1 data. This study does fit with what many other studies have shown, which is that MRI probably doesn’t have as much benefit as patients believe it does, so our role really is to try to help educate patients.”
LAS VEGAS – In women with higher density (HD) breasts, preoperative MRI revealed more abnormalities than were seen in women with lower density (LD) breasts, but there was no difference in the number of secondary cancers detected or long-term recurrence rates.
Breast density is often cited by radiologists as a reason to conduct a preoperative MRI, but the study suggests that it should not be a driving factor. “It’s a real challenge when our radiologists provide us reports that say, ‘Due to increased density, we recommend MRI,’ because it’s really hard to then disregard that. I think this is very important data,” said Judy Boughey, MD, professor of surgery at the Mayo Clinic, Rochester, MN, who moderated the session at the annual meeting of the American Society of Breast Surgeons where the research was presented.
“MRI is a valuable tool, and we’re still trying to figure out who it should be performed in,” said lead author Sarah McLaughlin, MD, of the Mayo Clinic, Jacksonville, FL, in an interview.
The researchers retrospectively analyzed data from 683 women at their institution who underwent preoperative MRI between 2007 and 2011. They grouped them by mammography results into LD (33%; Breast Imaging–Reporting and Data System density, 1 and 2) and HD (67%; BI-RADS density, 3 and 4).
Patients in the HD group more often had ipsilateral MRI findings (42% vs. 31%; P = .005), but ,of those with MRI findings, a similar number of patients in each group needed a second site biopsy (HD 65% vs. LD 67%; P = .78).
In all patients who had an additional MRI finding, the odds of detecting an additional ipsilateral cancer were not statistically significant between HD (32%) and LD (23%; P = .15) patients.
HD patients were also more likely to have abnormalities in the contralateral breast (25% vs. 14%; P = .009), but there were no statistically significant differences in rates of second-site biopsy recommendations or in the percentages of abnormalities that turned out to be cancerous (HD 6% vs. LD 3%; P = 1.0).
Following MRI, 70% of LD patients expressed a preference for breast-conserving surgery, compared with 53% of HD patients (P = .0001).
Over a median 7 years of follow-up, there was no difference in freedom from recurrence rates between the two groups (91% in LD vs. 90% in HD; P = .57).
“To me, it says that you don’t have to order an MRI just because they have cancer in a high density breast. You can feel reassured by your surgical plan and treatment recommendations based on conventional imaging,” said Dr. McLaughlin.
The researchers can’t determine if having an MRI done increased patient worry and potentially led to the higher rate of mastectomies chosen by women in the HD group. “Is that a result of the MRI? I don’t think we can say that, but there’s this whole other discussion piece that goes into it. You definitely see patients who say, ‘But it found these other things, and I’m going to have a mastectomy.’ So, there’s that patient preference and worry piece,” said Dr. McLaughlin.
The study results should offer some reassurance to patients. “There were no differences in local recurrence rates according to density. Maybe the next angle is allaying some of that fear, because the outcomes were the same. It’s really driven more by tumor biology and multimodality therapy,” said Dr. McLaughlin.
The study doesn’t provide the final word on breast density and MRI, according to Dr. Boughey. “I think this is an area that needs to be studied more with a clinical trial. There are several going on in different countries, and this is an area where we need level 1 data. This study does fit with what many other studies have shown, which is that MRI probably doesn’t have as much benefit as patients believe it does, so our role really is to try to help educate patients.”
LAS VEGAS – In women with higher density (HD) breasts, preoperative MRI revealed more abnormalities than were seen in women with lower density (LD) breasts, but there was no difference in the number of secondary cancers detected or long-term recurrence rates.
Breast density is often cited by radiologists as a reason to conduct a preoperative MRI, but the study suggests that it should not be a driving factor. “It’s a real challenge when our radiologists provide us reports that say, ‘Due to increased density, we recommend MRI,’ because it’s really hard to then disregard that. I think this is very important data,” said Judy Boughey, MD, professor of surgery at the Mayo Clinic, Rochester, MN, who moderated the session at the annual meeting of the American Society of Breast Surgeons where the research was presented.
“MRI is a valuable tool, and we’re still trying to figure out who it should be performed in,” said lead author Sarah McLaughlin, MD, of the Mayo Clinic, Jacksonville, FL, in an interview.
The researchers retrospectively analyzed data from 683 women at their institution who underwent preoperative MRI between 2007 and 2011. They grouped them by mammography results into LD (33%; Breast Imaging–Reporting and Data System density, 1 and 2) and HD (67%; BI-RADS density, 3 and 4).
Patients in the HD group more often had ipsilateral MRI findings (42% vs. 31%; P = .005), but ,of those with MRI findings, a similar number of patients in each group needed a second site biopsy (HD 65% vs. LD 67%; P = .78).
In all patients who had an additional MRI finding, the odds of detecting an additional ipsilateral cancer were not statistically significant between HD (32%) and LD (23%; P = .15) patients.
HD patients were also more likely to have abnormalities in the contralateral breast (25% vs. 14%; P = .009), but there were no statistically significant differences in rates of second-site biopsy recommendations or in the percentages of abnormalities that turned out to be cancerous (HD 6% vs. LD 3%; P = 1.0).
Following MRI, 70% of LD patients expressed a preference for breast-conserving surgery, compared with 53% of HD patients (P = .0001).
Over a median 7 years of follow-up, there was no difference in freedom from recurrence rates between the two groups (91% in LD vs. 90% in HD; P = .57).
“To me, it says that you don’t have to order an MRI just because they have cancer in a high density breast. You can feel reassured by your surgical plan and treatment recommendations based on conventional imaging,” said Dr. McLaughlin.
The researchers can’t determine if having an MRI done increased patient worry and potentially led to the higher rate of mastectomies chosen by women in the HD group. “Is that a result of the MRI? I don’t think we can say that, but there’s this whole other discussion piece that goes into it. You definitely see patients who say, ‘But it found these other things, and I’m going to have a mastectomy.’ So, there’s that patient preference and worry piece,” said Dr. McLaughlin.
The study results should offer some reassurance to patients. “There were no differences in local recurrence rates according to density. Maybe the next angle is allaying some of that fear, because the outcomes were the same. It’s really driven more by tumor biology and multimodality therapy,” said Dr. McLaughlin.
The study doesn’t provide the final word on breast density and MRI, according to Dr. Boughey. “I think this is an area that needs to be studied more with a clinical trial. There are several going on in different countries, and this is an area where we need level 1 data. This study does fit with what many other studies have shown, which is that MRI probably doesn’t have as much benefit as patients believe it does, so our role really is to try to help educate patients.”
AT ASBS 2017
Key clinical point: High breast density is probably not cause enough to order preoperative MRI.
Major finding: Freedom from recurrence rates were 90% in high density and 91% in low.
Data source: Retrospective analysis of 683 women at a single institution.
Disclosures: The study was funded internally. Dr. McLaughlin and Dr. Boughey reported having no relevant financial relationships.
Radiation bests mastectomy for occult breast cancer
LAS VEGAS – Overall survival was better when women with occult breast cancer had axillary lymph node dissection and radiation, instead of mastectomy, in a database review of 934 cases by the University of Maryland Medical Center, Baltimore, the largest review to date of how best to handle the problem.
Five- and 10-year overall survival was 90.8% and 84.8%, respectively, among the 342 women treated with axillary lymph node dissection (ALND) plus adjuvant radiation, versus 80.0% and 69.8% among the 592 who had ALND and mastectomies, plus or minus radiation, according to an analysis of the National Cancer Database from 2004-2013. The results were presented at the annual meeting of the American Society of Breast Surgeons.
ALND plus radiation was independently associated with overall survival on multivariate analysis (HR 0.51, 95% CI 0.32-0.81, P = .004), and was associated with fewer comorbidities, use of chemotherapy, number of positive nodes, and number of nodes examined, compared with mastectomy.
Women treated with ALND plus radiation “had significantly better overall survival than those treated with mastectomy, even after adjusting for other covariates. We believe the study supports overall use of this treatment approach in patients with occult breast cancer,” said lead investigator, Lindsay Hessler, MD, of University of Maryland, Baltimore.
Occult breast cancer – axillary lymph node metastases without clinical or radiologic evidence of a primary breast tumor – is rare and accounted for less than 0.1% of the 2.03 million breast cancer cases in the database. It’s been unclear how best to treat it; most of the previous investigations were small single-center series and case reports.
The only other significant review was smaller, with 750 women in the Surveillance, Epidemiology, and End Results database treated from 1983 to 2006, the “vast majority” before routine use of breast MRI. It showed that “definitive locoregional treatment with either mastectomy or [radiation therapy] improves [overall survival] in patients with occult breast cancer and axillary metastasis who undergo ALND,” but it didn’t suggest which option is best. The National Comprehensive Cancer Network recommends either approach (Cancer. 2010 Sep 1;116[17]:4000-6).
The new University of Maryland findings “confirm that women do not need to have a mastectomy if you can’t find the cancer in their breast. Women do better if you radiate the breast instead of removing it. A lot of academic centers are doing this now, but some people don’t know about it. This needs to be implemented in a more widespread fashion,” said Shelley Hwang, MD, a surgical oncologist at Duke University, Durham, N.C., who moderated Dr. Hessler’s presentation.
Indeed, patients were most likely to be treated with radiation and ALND at an academic center (OR 2.03, 95% CI 1.5-2.74, P less than .001), the only factor on multivariate analysis related to treatment choice.
The review excluded women with only internal mammary lymph node involvement, those with lumpectomies, and women who had less than four nodes recovered on ALND. Mastectomy and radiation patients were similar in nodal stage, race, income, insurance, estrogen receptor status, comorbidities, and year of diagnosis. On pathology, a tumor was found in about a third of the patients who had mastectomies. MRI use and recurrence rates were unavailable in the National Cancer Database.
The findings are subject to all the limits of database reviews, including the possible confounder that women treated at university hospitals might also have had more optimal systemic therapy, as an audience member noted.
The investigators said they had no financial disclosures.
LAS VEGAS – Overall survival was better when women with occult breast cancer had axillary lymph node dissection and radiation, instead of mastectomy, in a database review of 934 cases by the University of Maryland Medical Center, Baltimore, the largest review to date of how best to handle the problem.
Five- and 10-year overall survival was 90.8% and 84.8%, respectively, among the 342 women treated with axillary lymph node dissection (ALND) plus adjuvant radiation, versus 80.0% and 69.8% among the 592 who had ALND and mastectomies, plus or minus radiation, according to an analysis of the National Cancer Database from 2004-2013. The results were presented at the annual meeting of the American Society of Breast Surgeons.
ALND plus radiation was independently associated with overall survival on multivariate analysis (HR 0.51, 95% CI 0.32-0.81, P = .004), and was associated with fewer comorbidities, use of chemotherapy, number of positive nodes, and number of nodes examined, compared with mastectomy.
Women treated with ALND plus radiation “had significantly better overall survival than those treated with mastectomy, even after adjusting for other covariates. We believe the study supports overall use of this treatment approach in patients with occult breast cancer,” said lead investigator, Lindsay Hessler, MD, of University of Maryland, Baltimore.
Occult breast cancer – axillary lymph node metastases without clinical or radiologic evidence of a primary breast tumor – is rare and accounted for less than 0.1% of the 2.03 million breast cancer cases in the database. It’s been unclear how best to treat it; most of the previous investigations were small single-center series and case reports.
The only other significant review was smaller, with 750 women in the Surveillance, Epidemiology, and End Results database treated from 1983 to 2006, the “vast majority” before routine use of breast MRI. It showed that “definitive locoregional treatment with either mastectomy or [radiation therapy] improves [overall survival] in patients with occult breast cancer and axillary metastasis who undergo ALND,” but it didn’t suggest which option is best. The National Comprehensive Cancer Network recommends either approach (Cancer. 2010 Sep 1;116[17]:4000-6).
The new University of Maryland findings “confirm that women do not need to have a mastectomy if you can’t find the cancer in their breast. Women do better if you radiate the breast instead of removing it. A lot of academic centers are doing this now, but some people don’t know about it. This needs to be implemented in a more widespread fashion,” said Shelley Hwang, MD, a surgical oncologist at Duke University, Durham, N.C., who moderated Dr. Hessler’s presentation.
Indeed, patients were most likely to be treated with radiation and ALND at an academic center (OR 2.03, 95% CI 1.5-2.74, P less than .001), the only factor on multivariate analysis related to treatment choice.
The review excluded women with only internal mammary lymph node involvement, those with lumpectomies, and women who had less than four nodes recovered on ALND. Mastectomy and radiation patients were similar in nodal stage, race, income, insurance, estrogen receptor status, comorbidities, and year of diagnosis. On pathology, a tumor was found in about a third of the patients who had mastectomies. MRI use and recurrence rates were unavailable in the National Cancer Database.
The findings are subject to all the limits of database reviews, including the possible confounder that women treated at university hospitals might also have had more optimal systemic therapy, as an audience member noted.
The investigators said they had no financial disclosures.
LAS VEGAS – Overall survival was better when women with occult breast cancer had axillary lymph node dissection and radiation, instead of mastectomy, in a database review of 934 cases by the University of Maryland Medical Center, Baltimore, the largest review to date of how best to handle the problem.
Five- and 10-year overall survival was 90.8% and 84.8%, respectively, among the 342 women treated with axillary lymph node dissection (ALND) plus adjuvant radiation, versus 80.0% and 69.8% among the 592 who had ALND and mastectomies, plus or minus radiation, according to an analysis of the National Cancer Database from 2004-2013. The results were presented at the annual meeting of the American Society of Breast Surgeons.
ALND plus radiation was independently associated with overall survival on multivariate analysis (HR 0.51, 95% CI 0.32-0.81, P = .004), and was associated with fewer comorbidities, use of chemotherapy, number of positive nodes, and number of nodes examined, compared with mastectomy.
Women treated with ALND plus radiation “had significantly better overall survival than those treated with mastectomy, even after adjusting for other covariates. We believe the study supports overall use of this treatment approach in patients with occult breast cancer,” said lead investigator, Lindsay Hessler, MD, of University of Maryland, Baltimore.
Occult breast cancer – axillary lymph node metastases without clinical or radiologic evidence of a primary breast tumor – is rare and accounted for less than 0.1% of the 2.03 million breast cancer cases in the database. It’s been unclear how best to treat it; most of the previous investigations were small single-center series and case reports.
The only other significant review was smaller, with 750 women in the Surveillance, Epidemiology, and End Results database treated from 1983 to 2006, the “vast majority” before routine use of breast MRI. It showed that “definitive locoregional treatment with either mastectomy or [radiation therapy] improves [overall survival] in patients with occult breast cancer and axillary metastasis who undergo ALND,” but it didn’t suggest which option is best. The National Comprehensive Cancer Network recommends either approach (Cancer. 2010 Sep 1;116[17]:4000-6).
The new University of Maryland findings “confirm that women do not need to have a mastectomy if you can’t find the cancer in their breast. Women do better if you radiate the breast instead of removing it. A lot of academic centers are doing this now, but some people don’t know about it. This needs to be implemented in a more widespread fashion,” said Shelley Hwang, MD, a surgical oncologist at Duke University, Durham, N.C., who moderated Dr. Hessler’s presentation.
Indeed, patients were most likely to be treated with radiation and ALND at an academic center (OR 2.03, 95% CI 1.5-2.74, P less than .001), the only factor on multivariate analysis related to treatment choice.
The review excluded women with only internal mammary lymph node involvement, those with lumpectomies, and women who had less than four nodes recovered on ALND. Mastectomy and radiation patients were similar in nodal stage, race, income, insurance, estrogen receptor status, comorbidities, and year of diagnosis. On pathology, a tumor was found in about a third of the patients who had mastectomies. MRI use and recurrence rates were unavailable in the National Cancer Database.
The findings are subject to all the limits of database reviews, including the possible confounder that women treated at university hospitals might also have had more optimal systemic therapy, as an audience member noted.
The investigators said they had no financial disclosures.
AT ASBS 2017
Key clinical point:
Major finding: Five- and 10-year overall survival was 90.8% and 84.8%, respectively, among the 342 women treated with axillary lymph node dissection (ALND) plus adjuvant radiation, versus 80.0% and 69.8% among the 592 who had ALND and mastectomies, plus or minus radiation.
Data source: Review of 934 cases in the National Cancer Database.
Disclosures: The investigators said they had no financial disclosures.
Mastectomy unnecessary for some breast cancer recurrences
LAS VEGAS – Although mastectomy is the standard of care for tumor recurrence following lumpectomy and whole breast irradiation, a second lumpectomy with partial breast irradiation is a sound alternative under certain circumstances, according to Manjeet Chadha, MD, professor of radiation oncology and director of the department of radiation oncology at Icahn School of Medicine at Mount Sinai, New York.
It depends on whether the new lesion is a true recurrence, or simply another primary tumor. In the absence of a genetic footprint to compare the two, Dr. Chadha and her colleagues use several of what she called “soft criteria” to make the call and counsel women.
True ipsilateral recurrence of an aggressive tumor tends to happen early, and in the same quadrant. However, if breast cancer recurs more than 3 years after treatment of the primary tumor and in a different quadrant, and if the patient is negative for BRCA mutation, and if the new growth is small, localized on MRI, histologically different from the primary tumor, and likely to be resected with clean margins, Dr. Chadha said she is comfortable offering a second lumpectomy and partial breast radiation – usually multicatheter brachytherapy – to women who do not want a mastectomy.
“Second cancer in a previously irradiated breast is not an uncommon clinical entity. Based on patient preference, the option of repeat breast conservation and reirradiation may be offered selectively as an alternative to mastectomy,” followed by systemic therapy, she said at the annual meeting of the American Society of Breast Surgeons.
“I think all of us across the country are discussing presentations like this in tumor boards,” but it’s not always offered as an option. Sometimes, “the mindset of the treating surgeon is ‘oh, this breast has had radiation; I can’t give radiation again.’ Clearly, whole breast reirradiation is not recommended,” but it seems possible based on a growing body of literature to differentiate new primaries with new biology from true recurrences, and to treat them safely with breast conserving surgery and partial irradiation, she said.
The largest series to date of salvage lumpectomy with multicatheter brachytherapy followed 217 women for a median of 3.9 years. Median tumor size was 1.2 cm. The 5-year local control rate – effectively, the mastectomy-free survival – was 94.4%, and the overall survival was 88.7%, which mirrors the success of first-time lumpectomy with whole breast irradiation, and lends support to the notion that some recurrences are, in fact, entirely new disease. The European team reported excellent or good cosmetic results in 85% of women (Radiother Oncol. 2013 Aug;108[2]:226-31).
The series used high-dose radiation. Dr. Chadha said she and her colleagues have had similar success with low-dose multicatheter brachytherapy, with similarly good aesthetic results. To avoid cosmetic impact, however, she noted it’s important to work with radiation oncologists “mindful of the nuances of what’s needed,” including how far to separate the skin from the radiation.
Brachytherapy has the most support in the literature, but external beam therapy is also an option. “Whatever technique you use, the delineation of the target and the geometric coverage of the lumpectomy cavity [must be] complete in all cases,” she said.
Dr. Chadha had no financial conflicts of interest.
LAS VEGAS – Although mastectomy is the standard of care for tumor recurrence following lumpectomy and whole breast irradiation, a second lumpectomy with partial breast irradiation is a sound alternative under certain circumstances, according to Manjeet Chadha, MD, professor of radiation oncology and director of the department of radiation oncology at Icahn School of Medicine at Mount Sinai, New York.
It depends on whether the new lesion is a true recurrence, or simply another primary tumor. In the absence of a genetic footprint to compare the two, Dr. Chadha and her colleagues use several of what she called “soft criteria” to make the call and counsel women.
True ipsilateral recurrence of an aggressive tumor tends to happen early, and in the same quadrant. However, if breast cancer recurs more than 3 years after treatment of the primary tumor and in a different quadrant, and if the patient is negative for BRCA mutation, and if the new growth is small, localized on MRI, histologically different from the primary tumor, and likely to be resected with clean margins, Dr. Chadha said she is comfortable offering a second lumpectomy and partial breast radiation – usually multicatheter brachytherapy – to women who do not want a mastectomy.
“Second cancer in a previously irradiated breast is not an uncommon clinical entity. Based on patient preference, the option of repeat breast conservation and reirradiation may be offered selectively as an alternative to mastectomy,” followed by systemic therapy, she said at the annual meeting of the American Society of Breast Surgeons.
“I think all of us across the country are discussing presentations like this in tumor boards,” but it’s not always offered as an option. Sometimes, “the mindset of the treating surgeon is ‘oh, this breast has had radiation; I can’t give radiation again.’ Clearly, whole breast reirradiation is not recommended,” but it seems possible based on a growing body of literature to differentiate new primaries with new biology from true recurrences, and to treat them safely with breast conserving surgery and partial irradiation, she said.
The largest series to date of salvage lumpectomy with multicatheter brachytherapy followed 217 women for a median of 3.9 years. Median tumor size was 1.2 cm. The 5-year local control rate – effectively, the mastectomy-free survival – was 94.4%, and the overall survival was 88.7%, which mirrors the success of first-time lumpectomy with whole breast irradiation, and lends support to the notion that some recurrences are, in fact, entirely new disease. The European team reported excellent or good cosmetic results in 85% of women (Radiother Oncol. 2013 Aug;108[2]:226-31).
The series used high-dose radiation. Dr. Chadha said she and her colleagues have had similar success with low-dose multicatheter brachytherapy, with similarly good aesthetic results. To avoid cosmetic impact, however, she noted it’s important to work with radiation oncologists “mindful of the nuances of what’s needed,” including how far to separate the skin from the radiation.
Brachytherapy has the most support in the literature, but external beam therapy is also an option. “Whatever technique you use, the delineation of the target and the geometric coverage of the lumpectomy cavity [must be] complete in all cases,” she said.
Dr. Chadha had no financial conflicts of interest.
LAS VEGAS – Although mastectomy is the standard of care for tumor recurrence following lumpectomy and whole breast irradiation, a second lumpectomy with partial breast irradiation is a sound alternative under certain circumstances, according to Manjeet Chadha, MD, professor of radiation oncology and director of the department of radiation oncology at Icahn School of Medicine at Mount Sinai, New York.
It depends on whether the new lesion is a true recurrence, or simply another primary tumor. In the absence of a genetic footprint to compare the two, Dr. Chadha and her colleagues use several of what she called “soft criteria” to make the call and counsel women.
True ipsilateral recurrence of an aggressive tumor tends to happen early, and in the same quadrant. However, if breast cancer recurs more than 3 years after treatment of the primary tumor and in a different quadrant, and if the patient is negative for BRCA mutation, and if the new growth is small, localized on MRI, histologically different from the primary tumor, and likely to be resected with clean margins, Dr. Chadha said she is comfortable offering a second lumpectomy and partial breast radiation – usually multicatheter brachytherapy – to women who do not want a mastectomy.
“Second cancer in a previously irradiated breast is not an uncommon clinical entity. Based on patient preference, the option of repeat breast conservation and reirradiation may be offered selectively as an alternative to mastectomy,” followed by systemic therapy, she said at the annual meeting of the American Society of Breast Surgeons.
“I think all of us across the country are discussing presentations like this in tumor boards,” but it’s not always offered as an option. Sometimes, “the mindset of the treating surgeon is ‘oh, this breast has had radiation; I can’t give radiation again.’ Clearly, whole breast reirradiation is not recommended,” but it seems possible based on a growing body of literature to differentiate new primaries with new biology from true recurrences, and to treat them safely with breast conserving surgery and partial irradiation, she said.
The largest series to date of salvage lumpectomy with multicatheter brachytherapy followed 217 women for a median of 3.9 years. Median tumor size was 1.2 cm. The 5-year local control rate – effectively, the mastectomy-free survival – was 94.4%, and the overall survival was 88.7%, which mirrors the success of first-time lumpectomy with whole breast irradiation, and lends support to the notion that some recurrences are, in fact, entirely new disease. The European team reported excellent or good cosmetic results in 85% of women (Radiother Oncol. 2013 Aug;108[2]:226-31).
The series used high-dose radiation. Dr. Chadha said she and her colleagues have had similar success with low-dose multicatheter brachytherapy, with similarly good aesthetic results. To avoid cosmetic impact, however, she noted it’s important to work with radiation oncologists “mindful of the nuances of what’s needed,” including how far to separate the skin from the radiation.
Brachytherapy has the most support in the literature, but external beam therapy is also an option. “Whatever technique you use, the delineation of the target and the geometric coverage of the lumpectomy cavity [must be] complete in all cases,” she said.
Dr. Chadha had no financial conflicts of interest.
EXPERT ANALYSIS FROM ASBS 2017
Sutureless, guided lumpectomy produced clean margins in majority
LAS VEGAS – An automated, minimally invasive, stereotactic-guided lumpectomy performed well in an outpatient setting, with no sutures required, potentially decreasing patient morbidity, according to Pat Whitworth, MD.
Pain scores were low, and all high-risk lesions were successfully removed.
The new technology is part of the natural progression of cancer resection, said Dr. Whitworth, director of the Nashville (Tenn.) Breast Center, at the annual meeting of the American Society of Breast Surgeons.
“We went from radical mastectomy, to modified radical mastectomy, to lumpectomy. This is just part of that progression where we match what we do to what the patient really needs,” he said.
Dr. Whitworth said he believes that radiologists will soon be using such technology to treat breast cancer, which puts the onus on breast cancer surgeons to adopt it themselves. “I think it’s important for breast surgeons to acquire the necessary skill and techniques to use the same tools and work collaboratively with radiologists, because this is coming,” he said.
To see if it were possible to achieve results similar to those with lumpectomy, Dr. Whitworth analyzed data from 279 women who had a small ductal carcinoma in situ (DCIS), invasive carcinoma, or high-risk lesion removed using a 15- or 20-mm radiofrequency basket capture with imaging guidance (lumpectomy). Patients who received a cancer diagnosis underwent a second, 20-mm basket capture to obtain shaved margins.
The procedure was conducted under local anesthesia and sedation, and the incisions were closed using Steri-Strip skin closures. The average pain score was 1.55 out of 10 (range, 0-7).
Of 125 patients found to have DCIS (n = 52) and invasive lesions (n = 73), the first capture achieved clear margins in 69 cases, and the shaved margin capture achieved clean margins in another 33 cases.
The remaining 23 patients (18%) had a positive margin by histologic standards following lumpectomy and shaved margin. Of the 22 with reported results, 17 (77%) had no residual lesion following open surgery.
The results convinced Dr. Wentworth of the technique’s utility, particularly in patients who may have a heightened surgical risk, he said. “We think this can replace open lumpectomy in selected patients, with favorable margin clearance.”
The approach is fairly simple, but Dr. Wentworth recommended beginning with stereotactic-guided technology before attempting the ultrasound-guided version, which requires a little more skill. “The biggest challenge is learning that you have to use a lot more local anesthetic. When this technology first came out, people tried to use the same amount of local anesthetic that they used for standard vacuum-assisted core biopsy, and it’s very painful unless you put 30 or 40 cc of dilute anesthetic in there,” said Dr. Wentworth.
The study was funded by Medtronic, which markets the technology. Dr. Whitworth is a principal at Targeted Medical Education, which receives funding from Medtronic.
LAS VEGAS – An automated, minimally invasive, stereotactic-guided lumpectomy performed well in an outpatient setting, with no sutures required, potentially decreasing patient morbidity, according to Pat Whitworth, MD.
Pain scores were low, and all high-risk lesions were successfully removed.
The new technology is part of the natural progression of cancer resection, said Dr. Whitworth, director of the Nashville (Tenn.) Breast Center, at the annual meeting of the American Society of Breast Surgeons.
“We went from radical mastectomy, to modified radical mastectomy, to lumpectomy. This is just part of that progression where we match what we do to what the patient really needs,” he said.
Dr. Whitworth said he believes that radiologists will soon be using such technology to treat breast cancer, which puts the onus on breast cancer surgeons to adopt it themselves. “I think it’s important for breast surgeons to acquire the necessary skill and techniques to use the same tools and work collaboratively with radiologists, because this is coming,” he said.
To see if it were possible to achieve results similar to those with lumpectomy, Dr. Whitworth analyzed data from 279 women who had a small ductal carcinoma in situ (DCIS), invasive carcinoma, or high-risk lesion removed using a 15- or 20-mm radiofrequency basket capture with imaging guidance (lumpectomy). Patients who received a cancer diagnosis underwent a second, 20-mm basket capture to obtain shaved margins.
The procedure was conducted under local anesthesia and sedation, and the incisions were closed using Steri-Strip skin closures. The average pain score was 1.55 out of 10 (range, 0-7).
Of 125 patients found to have DCIS (n = 52) and invasive lesions (n = 73), the first capture achieved clear margins in 69 cases, and the shaved margin capture achieved clean margins in another 33 cases.
The remaining 23 patients (18%) had a positive margin by histologic standards following lumpectomy and shaved margin. Of the 22 with reported results, 17 (77%) had no residual lesion following open surgery.
The results convinced Dr. Wentworth of the technique’s utility, particularly in patients who may have a heightened surgical risk, he said. “We think this can replace open lumpectomy in selected patients, with favorable margin clearance.”
The approach is fairly simple, but Dr. Wentworth recommended beginning with stereotactic-guided technology before attempting the ultrasound-guided version, which requires a little more skill. “The biggest challenge is learning that you have to use a lot more local anesthetic. When this technology first came out, people tried to use the same amount of local anesthetic that they used for standard vacuum-assisted core biopsy, and it’s very painful unless you put 30 or 40 cc of dilute anesthetic in there,” said Dr. Wentworth.
The study was funded by Medtronic, which markets the technology. Dr. Whitworth is a principal at Targeted Medical Education, which receives funding from Medtronic.
LAS VEGAS – An automated, minimally invasive, stereotactic-guided lumpectomy performed well in an outpatient setting, with no sutures required, potentially decreasing patient morbidity, according to Pat Whitworth, MD.
Pain scores were low, and all high-risk lesions were successfully removed.
The new technology is part of the natural progression of cancer resection, said Dr. Whitworth, director of the Nashville (Tenn.) Breast Center, at the annual meeting of the American Society of Breast Surgeons.
“We went from radical mastectomy, to modified radical mastectomy, to lumpectomy. This is just part of that progression where we match what we do to what the patient really needs,” he said.
Dr. Whitworth said he believes that radiologists will soon be using such technology to treat breast cancer, which puts the onus on breast cancer surgeons to adopt it themselves. “I think it’s important for breast surgeons to acquire the necessary skill and techniques to use the same tools and work collaboratively with radiologists, because this is coming,” he said.
To see if it were possible to achieve results similar to those with lumpectomy, Dr. Whitworth analyzed data from 279 women who had a small ductal carcinoma in situ (DCIS), invasive carcinoma, or high-risk lesion removed using a 15- or 20-mm radiofrequency basket capture with imaging guidance (lumpectomy). Patients who received a cancer diagnosis underwent a second, 20-mm basket capture to obtain shaved margins.
The procedure was conducted under local anesthesia and sedation, and the incisions were closed using Steri-Strip skin closures. The average pain score was 1.55 out of 10 (range, 0-7).
Of 125 patients found to have DCIS (n = 52) and invasive lesions (n = 73), the first capture achieved clear margins in 69 cases, and the shaved margin capture achieved clean margins in another 33 cases.
The remaining 23 patients (18%) had a positive margin by histologic standards following lumpectomy and shaved margin. Of the 22 with reported results, 17 (77%) had no residual lesion following open surgery.
The results convinced Dr. Wentworth of the technique’s utility, particularly in patients who may have a heightened surgical risk, he said. “We think this can replace open lumpectomy in selected patients, with favorable margin clearance.”
The approach is fairly simple, but Dr. Wentworth recommended beginning with stereotactic-guided technology before attempting the ultrasound-guided version, which requires a little more skill. “The biggest challenge is learning that you have to use a lot more local anesthetic. When this technology first came out, people tried to use the same amount of local anesthetic that they used for standard vacuum-assisted core biopsy, and it’s very painful unless you put 30 or 40 cc of dilute anesthetic in there,” said Dr. Wentworth.
The study was funded by Medtronic, which markets the technology. Dr. Whitworth is a principal at Targeted Medical Education, which receives funding from Medtronic.
AT ASBS 2017
Key clinical point: The technique could replace standard lumpectomy in patients at high surgical risk.
Major finding: Clean margins were obtained in 102 of 125 women with diagnosed cancer.
Data source: A retrospective analysis of 279 patients.
Disclosures: The study was funded by Medtronic, which markets the technology. Dr. Whitworth is a principal at Targeted Medical Education, which receives funding from Medtronic.
VIDEO: Dr. Lisa Newman on triple negative breast cancer in African American women
LAS VEGAS – The heavy burden of triple negative and other aggressive breast cancers among African American women cannot be simplified to socioeconomic factors alone.
International investigations by Lisa Newman, MD, director of the Breast Oncology Program at the Henry Ford Health System, Detroit, and other researchers are making it clear that genetic factors play a significant role.
She explained the latest findings and what they mean for screening, genetic referral, and treatment in an interview at the American Society of Breast Surgeons annual meeting.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
LAS VEGAS – The heavy burden of triple negative and other aggressive breast cancers among African American women cannot be simplified to socioeconomic factors alone.
International investigations by Lisa Newman, MD, director of the Breast Oncology Program at the Henry Ford Health System, Detroit, and other researchers are making it clear that genetic factors play a significant role.
She explained the latest findings and what they mean for screening, genetic referral, and treatment in an interview at the American Society of Breast Surgeons annual meeting.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
LAS VEGAS – The heavy burden of triple negative and other aggressive breast cancers among African American women cannot be simplified to socioeconomic factors alone.
International investigations by Lisa Newman, MD, director of the Breast Oncology Program at the Henry Ford Health System, Detroit, and other researchers are making it clear that genetic factors play a significant role.
She explained the latest findings and what they mean for screening, genetic referral, and treatment in an interview at the American Society of Breast Surgeons annual meeting.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
AT ASBS 2017
DCIS tool IDs axillary node biopsy candidates
LAS VEGAS – A new tool identifies patients with ductal carcinoma in situ (DCIS) who are at high risk for being upstaged as a result of the pathology report. The screen could encourage patients to undergo axillary nodal staging during the core needle biopsy (CNB), thus avoiding a second procedure.
“The risk factors have been well described, but they haven’t helped give individual risk or individual percentages. Our goal was to try to individualize that risk so that we could counsel patients,” said lead researcher James Jakub, MD, chair of the division of breast endocrine and metabolic surgery at Mayo Clinic Rochester, at the annual meeting of the American Society of Breast Surgeons.
The researchers found that grade on CNB, mass lesion on imaging, multifocal/centric disease, and linear dimension combined to predict the likelihood of being upstaged to invasive disease (C statistic, 0.71; 95% confidence interval, 0.66-0.77).
They then combined those characteristics to create a nomogram and tested it against the validation set. In that group, 11% of patients were upstaged to invasive disease. The nomogram performed almost identically in the external validation set (C statistic, 0.71; 95% CI, 0.63-0.79). The model predicted 56 upstages, and 46 occurred.
This wasn’t the first attempt to create a nomogram to predict upstaging in DCIS patients, but others were not tested against external datasets. “That’s a weakness with other studies. Unless it’s validated externally, you don’t really know if you can apply it to your population. That was a very large plus: having colleagues who were willing to collaborate to validate it,” said Dr. Jakub.
The team is working on posting the nomogram online for widespread use.
It remains to be seen whether the availability of the nomogram will, in fact, change patients’ decision-making and result in more axillary nodal biopsies during CNB procedures in high risk patients.
“We haven’t looked into that. It will be interesting to see how it influences [sentinel lymph node] biopsy rate at our institution, and we’d love to hear from institutions who apply it. My sense is that patients who are at high risk are going to be interested in doing that. I think it will definitely change their management,” said Dr. Jakub.
LAS VEGAS – A new tool identifies patients with ductal carcinoma in situ (DCIS) who are at high risk for being upstaged as a result of the pathology report. The screen could encourage patients to undergo axillary nodal staging during the core needle biopsy (CNB), thus avoiding a second procedure.
“The risk factors have been well described, but they haven’t helped give individual risk or individual percentages. Our goal was to try to individualize that risk so that we could counsel patients,” said lead researcher James Jakub, MD, chair of the division of breast endocrine and metabolic surgery at Mayo Clinic Rochester, at the annual meeting of the American Society of Breast Surgeons.
The researchers found that grade on CNB, mass lesion on imaging, multifocal/centric disease, and linear dimension combined to predict the likelihood of being upstaged to invasive disease (C statistic, 0.71; 95% confidence interval, 0.66-0.77).
They then combined those characteristics to create a nomogram and tested it against the validation set. In that group, 11% of patients were upstaged to invasive disease. The nomogram performed almost identically in the external validation set (C statistic, 0.71; 95% CI, 0.63-0.79). The model predicted 56 upstages, and 46 occurred.
This wasn’t the first attempt to create a nomogram to predict upstaging in DCIS patients, but others were not tested against external datasets. “That’s a weakness with other studies. Unless it’s validated externally, you don’t really know if you can apply it to your population. That was a very large plus: having colleagues who were willing to collaborate to validate it,” said Dr. Jakub.
The team is working on posting the nomogram online for widespread use.
It remains to be seen whether the availability of the nomogram will, in fact, change patients’ decision-making and result in more axillary nodal biopsies during CNB procedures in high risk patients.
“We haven’t looked into that. It will be interesting to see how it influences [sentinel lymph node] biopsy rate at our institution, and we’d love to hear from institutions who apply it. My sense is that patients who are at high risk are going to be interested in doing that. I think it will definitely change their management,” said Dr. Jakub.
LAS VEGAS – A new tool identifies patients with ductal carcinoma in situ (DCIS) who are at high risk for being upstaged as a result of the pathology report. The screen could encourage patients to undergo axillary nodal staging during the core needle biopsy (CNB), thus avoiding a second procedure.
“The risk factors have been well described, but they haven’t helped give individual risk or individual percentages. Our goal was to try to individualize that risk so that we could counsel patients,” said lead researcher James Jakub, MD, chair of the division of breast endocrine and metabolic surgery at Mayo Clinic Rochester, at the annual meeting of the American Society of Breast Surgeons.
The researchers found that grade on CNB, mass lesion on imaging, multifocal/centric disease, and linear dimension combined to predict the likelihood of being upstaged to invasive disease (C statistic, 0.71; 95% confidence interval, 0.66-0.77).
They then combined those characteristics to create a nomogram and tested it against the validation set. In that group, 11% of patients were upstaged to invasive disease. The nomogram performed almost identically in the external validation set (C statistic, 0.71; 95% CI, 0.63-0.79). The model predicted 56 upstages, and 46 occurred.
This wasn’t the first attempt to create a nomogram to predict upstaging in DCIS patients, but others were not tested against external datasets. “That’s a weakness with other studies. Unless it’s validated externally, you don’t really know if you can apply it to your population. That was a very large plus: having colleagues who were willing to collaborate to validate it,” said Dr. Jakub.
The team is working on posting the nomogram online for widespread use.
It remains to be seen whether the availability of the nomogram will, in fact, change patients’ decision-making and result in more axillary nodal biopsies during CNB procedures in high risk patients.
“We haven’t looked into that. It will be interesting to see how it influences [sentinel lymph node] biopsy rate at our institution, and we’d love to hear from institutions who apply it. My sense is that patients who are at high risk are going to be interested in doing that. I think it will definitely change their management,” said Dr. Jakub.
AT ASBS 2017
Key clinical point: High risk patients who choose axillary biopsy could avoid a second procedure.
Major finding: The 4-item nomogram predicted upstaging with a C statistic of 0.71.
Data source: A retrospective sample (n = 827) and validation study (n = 579).
Disclosures: The source of funding was not disclosed. Dr. Jakub reported having no financial disclosures.
VIDEO: Surgery use declines for non–small cell lung cancer
BOSTON – The use of surgical therapy for early stage lung cancer in the United States has declined as other nonsurgical treatment options have become available, according to a study reported at the annual meeting of the American Association for Thoracic Surgery.
Most notably, the study finds that surgery for early stage non–small cell lung cancer decreased by 12% from 2004 to 2013.
In a video interview, Keith Naunheim, MD, a professor of surgery at Saint Louis University, discusses the study findings and the potential reasons behind declining surgery use for lung cancer. Dr. Naunheim also addresses why physicians should keep an open mind about alternative therapy options for lung cancer, while ensuring that the treatments are safe and effective for patients.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @legal_med
BOSTON – The use of surgical therapy for early stage lung cancer in the United States has declined as other nonsurgical treatment options have become available, according to a study reported at the annual meeting of the American Association for Thoracic Surgery.
Most notably, the study finds that surgery for early stage non–small cell lung cancer decreased by 12% from 2004 to 2013.
In a video interview, Keith Naunheim, MD, a professor of surgery at Saint Louis University, discusses the study findings and the potential reasons behind declining surgery use for lung cancer. Dr. Naunheim also addresses why physicians should keep an open mind about alternative therapy options for lung cancer, while ensuring that the treatments are safe and effective for patients.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @legal_med
BOSTON – The use of surgical therapy for early stage lung cancer in the United States has declined as other nonsurgical treatment options have become available, according to a study reported at the annual meeting of the American Association for Thoracic Surgery.
Most notably, the study finds that surgery for early stage non–small cell lung cancer decreased by 12% from 2004 to 2013.
In a video interview, Keith Naunheim, MD, a professor of surgery at Saint Louis University, discusses the study findings and the potential reasons behind declining surgery use for lung cancer. Dr. Naunheim also addresses why physicians should keep an open mind about alternative therapy options for lung cancer, while ensuring that the treatments are safe and effective for patients.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @legal_med
AT THE AATS ANNUAL MEETING
