Breast Neoplasms: Edge SB

Taylor ME, Haffty BG, Rabinovitch R, Arthur DW, Halberg FE, Strom EA, White JR, Cobleigh MA, Edge SB. · Washington University, Saint Louis, Missouri 63110-1032, USA. · Int J Radiat Oncol Biol Phys. · Pubmed #19251087 No free full text.

Abstract: This summary focuses on the role of postoperative radiation therapy in patients treated with modified radical mastectomy for invasive breast cancer, particularly in patients receiving systemic therapy.

Carlson RW, Allred DC, Anderson BO, Burstein HJ, Carter WB, Edge SB, Erban JK, Farrar WB, Goldstein LJ, Gradishar WJ, Hayes DF, Hudis CA, Jahanzeb M, Kiel K, Ljung BM, Marcom PK, Mayer IA, McCormick B, Nabell LM, Pierce LJ, Reed EC, Smith ML, Somlo G, Theriault RL, Topham NS, Ward JH, Winer EP, Wolff AC, Anonymous00042. · No affiliation provided · J Natl Compr Canc Netw. · Pubmed #19200416 No free full text.

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White JR, Halberg FE, Rabinovitch R, Green S, Haffty BG, Solin LJ, Strom EA, Taylor ME, Edge SB. · Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin 53226-4801 , USA. · J Am Coll Radiol. · Pubmed #18514949 No free full text.

Abstract: BACKGROUND: During the past 2 decades, breast conservation therapy (BCT) has become firmly established as a standard therapeutic approach for eligible women with early-stage breast cancer. Breast radiation after conservative surgery is an integral component of BCT, resulting in comparable local control and equivalent survival to mastectomy. Successful breast conservation relies on understanding key elements for patient selection, evaluation, treatment contraindications, radiation therapy methods, and integration with systemic therapy. METHODS: The Appropriateness Criteria Committee of the American College of Radiology convened an expert panel to examine BCT for early-stage breast cancer. By using a modified Delphi technique to generate consensus, the expert panel responded to questionnaires on 9 clinical cases that address various key elements of breast conservation. A literature review on BCT led to the generation of an evidence table to support the consensus and overview. RESULTS: Consensus for appropriateness criteria for BCT was produced for various clinical scenarios commonly encountered in practice. These topics include radiation oncology management issues related to young patient age, sentinel node biopsy, elderly patients, other histology, positive margins, extensive intraductal component, node-positive breast cancer, genetic breast cancer, partial breast irradiation, and systemic therapy. Radiation methods for BCT are reviewed. CONCLUSION: The Breast Cancer Panel has generated a consensus of up-to-date guidelines for the appropriate use of radiation for BCT by using a modified Delphi process for the American College of Radiology Appropriateness Criteria.

Lyman GH, Giuliano AE, Somerfield MR, Benson AB, Bodurka DC, Burstein HJ, Cochran AJ, Cody HS, Edge SB, Galper S, Hayman JA, Kim TY, Perkins CL, Podoloff DA, Sivasubramaniam VH, Turner RR, Wahl R, Weaver DL, Wolff AC, Winer EP, Anonymous00154. · University of Rochester School of Medicine and Dentistry, Rochester, NY, USA. · J Clin Oncol. · Pubmed #16157938 No free full text.

Abstract: PURPOSE: To develop a guideline for the use of sentinel node biopsy (SNB) in early stage breast cancer. METHODS: An American Society of Clinical Oncology (ASCO) Expert Panel conducted a systematic review of the literature available through February 2004 on the use of SNB in early-stage breast cancer. The panel developed a guideline for clinicians and patients regarding the appropriate use of a sentinel lymph node identification and sampling procedure from hereon referred to as SNB. The guideline was reviewed by selected experts in the field and the ASCO Health Services Committee and was approved by the ASCO Board of Directors. RESULTS: The literature review identified one published prospective randomized controlled trial in which SNB was compared with axillary lymph node dissection (ALND), four limited meta-analyses, and 69 published single-institution and multicenter trials in which the test performance of SNB was evaluated with respect to the results of ALND (completion axillary dissection). There are currently no data on the effect of SLN biopsy on long-term survival of patients with breast cancer. However, a review of the available evidence demonstrates that, when performed by experienced clinicians, SNB appears to be a safe and acceptably accurate method for identifying early-stage breast cancer without involvement of the axillary lymph nodes. CONCLUSION: SNB is an appropriate initial alternative to routine staging ALND for patients with early-stage breast cancer with clinically negative axillary nodes. Completion ALND remains standard treatment for patients with axillary metastases identified on SNB. Appropriately identified patients with negative results of SNB, when done under the direction of an experienced surgeon, need not have completion ALND. Isolated cancer cells detected by pathologic examination of the SLN with use of specialized techniques are currently of unknown clinical significance. Although such specialized techniques are often used, they are not a required part of SLN evaluation for breast cancer at this time. Data suggest that SNB is associated with less morbidity than ALND, but the comparative effects of these two approaches on tumor recurrence or patient survival are unknown.

Carlson RW, Anderson BO, Burstein HJ, Cox CE, Edge SB, Farrar WB, Goldstein LJ, Gradishar WJ, Hayes DF, Hudis C, Jahanzeb M, Ljung BM, Marks LB, McCormick B, Nabell LM, Pierce LJ, Reed EC, Silver SM, Smith ML, Somlo G, Theriault RL, Ward JH, Winer EP, Wolff AC, Anonymous00249. · Stanford Hospital & Clinics, USA. · J Natl Compr Canc Netw. · Pubmed #16002000 No free full text.

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Carlson RW, Edge SB, Theriault RL, Anonymous00376. · Stanford University Medical Center, USA. · Cancer Control. · Pubmed #11760559 No free full text.

Abstract: The 2001 NCCN Breast Cancer Guidelines reflect the results of 5 generations of NCCN Breast Cancer Guidelines. Evidence-based guidelines, such as the NNCN Breast Cancer Guidelines, are possible only because of the availability of high-level evidence at multiple decision points in treatment. The continued performance of high quality clinical trials is central to our ability to further improve the treatment of breast cancer. The panel believes that participation in high quality clinical trials is the preferred treatment at all points in breast cancer therapy.

Recht A, Edge SB, Solin LJ, Robinson DS, Estabrook A, Fine RE, Fleming GF, Formenti S, Hudis C, Kirshner JJ, Krause DA, Kuske RR, Langer AS, Sledge GW, Whelan TJ, Pfister DG, Anonymous00352. · Beth Israel Deaconess Medical Center, Boston, MA, USA. · J Clin Oncol. · Pubmed #11230499 No free full text.

Abstract: OBJECTIVE: To determine indications for the use of postmastectomy radiotherapy (PMRT) for patients with invasive breast cancer with involved axillary lymph nodes or locally advanced disease who receive systemic therapy. These guidelines are intended for use in the care of patients outside of clinical trials. POTENTIAL INTERVENTION: The benefits and risks of PMRT in such patients, as well as subgroups of these patients, were considered. The details of the PMRT technique were also evaluated. OUTCOMES: The outcomes considered included freedom from local-regional recurrence, survival (disease-free and overall), and long-term toxicity. EVIDENCE: An expert multidisciplinary panel reviewed pertinent information from the published literature through July 2000; certain investigators were contacted for more recent and, in some cases, unpublished information. A computerized search was performed of MEDLINE data; directed searches based on the bibliographies of primary articles were also performed. VALUES: Levels of evidence and guideline grades were assigned by the Panel using standard criteria. A "recommendation" was made when level I or II evidence was available and there was consensus as to its meaning. A "suggestion" was made based on level III, IV, or V evidence and there was consensus as to its meaning. Areas of clinical importance were pointed out where guidelines could not be formulated due to insufficient evidence or lack of consensus. RECOMMENDATIONS: The recommendations, suggestions, and expert opinions of the Panel are described in this article. VALIDATION: Seven outside reviewers, the American Society of Clinical Oncology (ASCO) Health Services Research Committee members, and the ASCO Board of Directors reviewed this document.

Carlson RW, Anderson BO, Bensinger W, Cox CE, Davidson NE, Edge SB, Farrar WB, Goldstein LJ, Gradishar WJ, Lichter AS, McCormick B, Nabell LM, Reed EC, Silver SM, Smith ML, Somlo G, Theriault R, Ward JH, Winer EP, Wolff A, Anonymous00205. · Stanford Hospital and Clinics, Palo Alto, CA, USA. · Oncology (Williston Park). · Pubmed #11195418 No free full text.

Abstract: The therapeutic options for patients with noninvasive or invasive breast cancer are complex and varied. In many situations, the patient and physician have the responsibility to jointly explore and ultimately select the most appropriate option from among the available alternatives. With rare exception, the evaluation, treatment, and follow-up recommendations contained within these guidelines were based largely on the results of past and present clinical trials. However, there is not a single clinical situation in which the treatment of breast cancer has been optimized with respect to either maximizing cure or minimizing toxicity and disfigurement. Therefore, patient and physician participation in prospective clinical trials allows patients not only to receive state-of-the-art cancer treatment but also to contribute to the improvement of treatment of future patients.

Edge SB. · No affiliation provided · J Natl Cancer Inst. · Pubmed #18364503 links to  free full text

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Lehman CD, DeMartini W, Anderson BO, Edge SB. · Department of Radiology, University of Washington, Seattle, Washington; Seattle Cancer Care Alliance, Seattle, Washington 98109, USA. · J Natl Compr Canc Netw. · Pubmed #19200417 No free full text.

Abstract: Use of breast MRI in the preoperative evaluation of patients recently diagnosed with breast cancer has increased significantly over the past 10 years because of its well-documented high sensitivity for detecting otherwise occult breast cancer in the affected and contralateral breasts. However, published research reports on the impact of this improved cancer detection are limited. Equally important are growing concerns that the quality of breast MRI may vary significantly across practice sites, and therefore the published value of MRI may not be achieved for many patients. This article describes the peer-reviewed, published clinical research trials evaluating breast MRI in patients with newly diagnosed breast cancer on which the National Comprehensive Cancer Network (NCCN) practice guidelines are based. The current NCCN guidelines recommend that breast MRI be considered for patients with a newly diagnosed breast cancer to evaluate the extent of ipsilateral disease and to screen the contralateral breast, particularly for women at increased risk for mammographically occult disease. In addition, the guidelines indicate that breast MRI may be used for patients with axillary nodal adenocarcinoma to identify the primary malignancy. The guidelines stress the importance of having proper equipment, imaging technique, and provider training necessary to achieve high-quality breast MRI, and emphasize that MRI practice sites should have the ability to perform MRI-guided biopsy or needle localization. In addition to describing the data regarding use of breast MRI in women with newly diagnosed cancer, this article provides recommendations for the performance of high-quality breast MRI and suggestions for future research.

Fernando SA, Edge SB. · Department of Radiation Medicine, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263, USA. · J Natl Compr Canc Netw. · Pubmed #17439761 No free full text.

Abstract: Radiation after mastectomy is recommended for women with positive nodes, larger tumors, or positive margins. In addition to its role in reducing the risk for locoregional recurrence, it has an additive effect to the survival benefit seen with adjuvant systemic therapy. This article reviews the role of post-mastectomy radiation (PMRT) based on the recommendations in the 2007 NCCN Breast Cancer Clinical Practice Guidelines in Oncology and addresses the risk factors for recurrence after mastectomy. The data supporting both improvement in locoregional failure and survival are reviewed in detail. This article also discusses controversial areas in PMRT, including regional nodal radiation in women with 1 to 3 positive lymph nodes, PMRT in node-negative women with large tumors, and inclusion of internal mammary nodes. The final section discusses radiation field design and potential complications.

Carlson RW, Anderson BO, Burstein HJ, Carter WB, Edge SB, Farrar WB, Goldstein LJ, Gradishar WJ, Hayes DF, Hudis CA, Jahanzeb M, Ljung BM, Kiel K, Marks LB, McCormick B, Nabell LM, Pierce LJ, Reed EC, Silver SM, Smith ML, Somlo G, Theriault RL, Ward JH, Winer EP, Wolff AC. · National Comprehensive Cancer Network · J Natl Compr Canc Netw. · Pubmed #17439758 No free full text.

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James TA, Edge SB. · Department of Surgical Oncology, Roswell Park Cancer Institute, University at Buffalo, Buffalo, New York 14263, USA. · Curr Opin Obstet Gynecol. · Pubmed #16493261 No free full text.

Abstract: PURPOSE OF REVIEW: Sentinel lymph node biopsy has become an accepted standard in staging axillary lymph nodes for breast cancer, but there are still unresolved questions regarding the application of the sentinel node procedure. The purpose of this review is to highlight recent developments in sentinel lymph node biopsy for breast cancer. RECENT FINDINGS: Recent evidence has demonstrated that subareolar injection immediately before surgery is an acceptable and accurate alternative to peritumoral injection, and that lymphoscintigraphy is not always necessary. The use of sentinel lymph node biopsy with neoadjuvant chemotherapy and ductal carcinoma in situ continues to undergo investigation. Recently completed clinical trials will answer questions relating to the value of identifying isolated tumor cells in the sentinel node by immunohistochemistry, and the need for axillary node dissection when the sentinel node is positive. SUMMARY: Sentinel lymph node biopsy is an accepted standard for stage I and II breast cancer, and is investigational with stage III cancer or with neoadjuvant therapy, as well as with ductal carcinoma in situ. Patients should be made aware of relevant issues as part of providing informed consent for surgery and subsequent therapy.

Winer EP, Hudis C, Burstein HJ, Wolff AC, Pritchard KI, Ingle JN, Chlebowski RT, Gelber R, Edge SB, Gralow J, Cobleigh MA, Mamounas EP, Goldstein LJ, Whelan TJ, Powles TJ, Bryant J, Perkins C, Perotti J, Braun S, Langer AS, Browman GP, Somerfield MR. · Dana-Farber Cancer Institute, 44 Binney St, D1210, Boston, MA 02115, USA. · J Clin Oncol. · Pubmed #15545664 No free full text.

Abstract: PURPOSE: To update the 2003 American Society of Clinical Oncology technology assessment on adjuvant use of aromatase inhibitors. RECOMMENDATIONS: Based on results from multiple large randomized trials, adjuvant therapy for postmenopausal women with hormone receptor-positive breast cancer should include an aromatase inhibitor in order to lower the risk of tumor recurrence. Neither the optimal timing nor duration of aromatase inhibitor therapy is established. Aromatase inhibitors are appropriate as initial treatment for women with contraindications to tamoxifen. For all other postmenopausal women, treatment options include 5 years of aromatase inhibitors treatment or sequential therapy consisting of tamoxifen (for either 2 to 3 years or 5 years) followed by aromatase inhibitors for 2 to 3, or 5 years. Patients intolerant of aromatase inhibitors should receive tamoxifen. There are no data on the use of tamoxifen after an aromatase inhibitor in the adjuvant setting. Women with hormone receptor-negative tumors should not receive adjuvant endocrine therapy. The role of other biomarkers such as progesterone receptor and HER2 status in selecting optimal endocrine therapy remains controversial. Aromatase inhibitors are contraindicated in premenopausal women; there are limited data concerning their role in women with treatment-related amenorrhea. The side effect profiles of tamoxifen and aromatase inhibitors differ. The late consequences of aromatase inhibitor therapy, including osteoporosis, are not well characterized. CONCLUSION: The Panel believes that optimal adjuvant hormonal therapy for a postmenopausal woman with receptor-positive breast cancer includes an aromatase inhibitor as initial therapy or after treatment with tamoxifen. Women with breast cancer and their physicians must weigh the risks and benefits of all therapeutic options.

Recht A, Edge SB. · Department of Radiation Oncology, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA. · Surg Clin North Am. · Pubmed #12875606 No free full text.

Abstract: The ASCO guidelines panel found that PMRT reduces the risks of both local-regional recurrence and distant recurrence, and improves survival rates for patients with invasive breast cancer with involved axillary lymph nodes receiving systemic therapy. The benefits of PMRT, however, vary with regards to particular patient subsets (such as those defined by the number of involved axillary nodes). The panel agreed that PMRT is indicated routinely for patients with four or more positive axillary nodes, tumors larger than 5 cm in size, or locally advanced cancers. There was insufficient evidence for the panel to make recommendations or suggestions for the use of PMRT for patients with T1-2 tumors with one to three positive axillary nodes or for all patients receiving neoadjuvant systemic therapy. Physicians and patients are encouraged to participate in randomized trials exploring such issues, such as the ongoing intergroup study for patients with one to three positive axillary nodes.

Singletary SE, Allred C, Ashley P, Bassett LW, Berry D, Bland KI, Borgen PI, Clark GM, Edge SB, Hayes DF, Hughes LL, Hutter RV, Morrow M, Page DL, Recht A, Theriault RL, Thor A, Weaver DL, Wieand HS, Greene FL. · Department of Surgical Oncology, University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Boulevard, Box 106, Houston, TX 77030-4009, USA. · Surg Clin North Am. · Pubmed #12875597 No free full text.

Abstract: Since its inception, the AJCC staging system for breast cancer has been in an almost constant state of evolution, striving with each revision to reflect the most up-to-date clinical research as well as the widespread consensus among physicians about appropriate diagnostic and treatment standards. To date, these revisions have essentially represented a "fine-tuning" of the initial judgment that tumor size, lymph node status, and presence of distant metastases are the most significant prognostic factors for breast cancer. With the problems of standardization and reproducibility being resolved, it is likely that histologic grade will join this group of independent markers and be incorporated into the AJCC staging system in the near future. Over the last 15 years. considerable attention has been focused on the discovery of new markers visualized with immunohistochemistry and RT-PCR that may be validated as independent prognostic indicators (reviewed by Mirza et al). To date, the usefulness of many of these markers has been limited by lack of standardization in measurement techniques, but several show great promise for the future. By increasing the number of prognostic markers that can give independent information about patient outcome, physicians will be better able to determine optimal treatment approaches for individual patients.

Winer EP, Hudis C, Burstein HJ, Chlebowski RT, Ingle JN, Edge SB, Mamounas EP, Gralow J, Goldstein LJ, Pritchard KI, Braun S, Cobleigh MA, Langer AS, Perotti J, Powles TJ, Whelan TJ, Browman GP. · Health Services Research Department, American Society of Clinical Oncology, 1900 Duke Street, Suite 200, Alexandria, VA 22314, USA. · J Clin Oncol. · Pubmed #12149306 No free full text.

Abstract: OBJECTIVE: To conduct an evidence-based technology assessment to determine whether the routine use of anastrozole or any of the aromatase inhibitors in the adjuvant breast cancer setting is appropriate for broad-based conventional use in clinical practice. POTENTIAL INTERVENTIONS: Anastrozole, letrozole, and exemestane. OUTCOMES: Outcomes of interest include breast cancer incidence, breast cancer-specific survival, overall survival, and net health benefit. EVIDENCE: A comprehensive, formal literature review was conducted for relevant topics and is detailed in the text. Testimony was collected from invited experts and interested parties. The American Society of Clinical Oncology (ASCO)-prescribed technology assessment procedure was followed. BENEFITS/HARMS: The ASCO panel recognizes that a woman and her physician's decision regarding adjuvant hormonal therapy is complex and will depend on the importance and weight attributed to information regarding both cancer and non-cancer-related risks and benefits. CONCLUSION: The panel was influenced by the compelling, extensive, and long-term data available on tamoxifen. Overall, the panel considers the results of the Arimidex (anastrozole) or Tamoxifen Alone or in Combination (ATAC) trial and the extensive supporting data to be very promising but insufficient to change the standard practice at this time (May 2002). A 5-year course of adjuvant tamoxifen remains the standard therapy for women with hormone receptor-positive breast cancer. The panel recommends that physicians discuss the available information with patients, and, in making a decision, acknowledge that treatment approaches can change over time. Individual health care providers and their patients will need to come to their own conclusions, with careful consideration of all of the available data. (Specific questions addressed by the panel are summarized in Appendix 3.) VALIDATION: The conclusions of the panel were endorsed by the ASCO Health Services Research Committee and the ASCO Board of Directors.

Fitzgibbons PL, Page DL, Weaver D, Thor AD, Allred DC, Clark GM, Ruby SG, O'Malley F, Simpson JF, Connolly JL, Hayes DF, Edge SB, Lichter A, Schnitt SJ. · Good Samaritan Hospital, Los Angeles, Calif., USA. · Arch Pathol Lab Med. · Pubmed #10888772 No free full text.

Abstract: BACKGROUND: Under the auspices of the College of American Pathologists, a multidisciplinary group of clinicians, pathologists, and statisticians considered prognostic and predictive factors in breast cancer and stratified them into categories reflecting the strength of published evidence. MATERIALS AND METHODS: Factors were ranked according to previously established College of American Pathologists categorical rankings: category I, factors proven to be of prognostic import and useful in clinical patient management; category II, factors that had been extensively studied biologically and clinically, but whose import remains to be validated in statistically robust studies; and category III, all other factors not sufficiently studied to demonstrate their prognostic value. Factors in categories I and II were considered with respect to variations in methods of analysis, interpretation of findings, reporting of data, and statistical evaluation. For each factor, detailed recommendations for improvement were made. Recommendations were based on the following aims: (1) increasing uniformity and completeness of pathologic evaluation of tumor specimens, (2) enhancing the quality of data collected about existing prognostic factors, and (3) improving patient care. RESULTS AND CONCLUSIONS: Factors ranked in category I included TNM staging information, histologic grade, histologic type, mitotic figure counts, and hormone receptor status. Category II factors included c-erbB-2 (Her2-neu), proliferation markers, lymphatic and vascular channel invasion, and p53. Factors in category III included DNA ploidy analysis, microvessel density, epidermal growth factor receptor, transforming growth factor-alpha, bcl-2, pS2, and cathepsin D. This report constitutes a detailed outline of the findings and recommendations of the consensus conference group, organized according to structural guidelines as defined.

Lamonica D, Edge SB, Hurd T, Proulx G, Stomper PC. · Department of Diagnostic Imaging, Roswell Park Cancer Institute, School of Medicine and Biosciences, SUNY at Buffalo, New York 14263, USA. · Clin Nucl Med. · Pubmed #12819408 No free full text.

Abstract: PURPOSE: The authors' purpose was to explore the association between mammographic findings and drainage patterns on lymphoscintigrams obtained during sentinel node procedures for breast carcinoma. MATERIALS AND METHODS: From July 1997 to March 2000, 132 patients with breast cancer who were included in a prospective mammography-pathology correlation and staging database were imaged 2 hours after perilesional injection of 1 mCi filtered (0. 22 microm) Tc-99m sulfur colloid (4 ml volume) before sentinel node procedures. RESULTS: Sixty-four percent of the scans showed axillary drainage only, 9% showed axillary and internal mammary drainage, and 4% revealed internal mammary drainage only. Twenty-three percent of scans showed no drainage. Of the patients who showed drainage, 17% showed drainage to the internal mammary basin, and 5% showed this exclusively. Internal mammary drainage was seen in 18% (10 of 57) of lateral, 21% (6 of 29) of medial, and 14% (1 of 7) of subareolar lesions (P = NS). No drainage was seen in 22% of patients with predominantly fatty mammographic parenchymal density (>50%) compared with only 8% of patients with predominantly dense (>50%) parenchyma (P < 0.05). Failure to show drainage was more common in women older than 50 years (P < 0.05). Axillary sentinel nodes were identified surgically in 73% of patients with negative scan findings. There was no significant association between scintigraphic drainage and mammographic soft tissue tumor size and appearance, histologic findings, or axillary node status. CONCLUSIONS: Dense mammographic parenchyma and age less than 50 years are associated with identification of lymphatic drainage on lymphoscintigrams performed before sentinel node procedures in 91% to 92% of patients. Internal mammary drainage, present in 18% of lateral and 21% of medial lesions, may direct therapy to include internal mammary lymph nodes.

Mandelblatt JS, Edge SB, Meropol NJ, Senie R, Tsangaris T, Grey L, Peterson BM, Hwang YT, Kerner J, Weeks J. · Department of Oncology, Cancer Control Program, Lombardi Cancer Center, Georgetown University School of Medicine, Washington, DC, USA. · J Clin Oncol. · Pubmed #12610185 No free full text.

Abstract: PURPOSE: There are few data on sequelae of breast cancer treatments in older women. We evaluated posttreatment quality of life and satisfaction in a national population. PATIENTS AND METHODS: Telephone surveys were conducted with a random cross-sectional sample of 1,812 Medicare beneficiaries 67 years of age and older who were 3, 4, and 5 years posttreatment for stage I and II breast cancer. Regression models were used to estimate the adjusted risk of decrements in physical and mental health functioning by treatment. In a subset of women (n = 732), additional data were used to examine arm problems, impact of cancer, and satisfaction, controlling for baseline health, perceptions of ageism and racism, demographic and clinical factors, region, and surgery year. RESULTS: Use of axillary dissection was the only surgical treatment that affected outcomes, increasing the risk of arm problems four-fold (95% confidence interval, 1.56 to 10.51), controlling for other factors. Having arm problems, in turn, exerted a consistently negative independent effect on all outcomes (P </=.001). Processes of care were also associated with quality of life and satisfaction. For example, women who perceived high levels of ageism or felt that they had no choice of treatment reported significantly more bodily pain, lower mental health scores, and less general satisfaction. These same factors, as well as high perceived racism, were significantly associated with diminished satisfaction with the medical care system. CONCLUSION: With the exception of axillary dissection, the processes of care, and not the therapy itself, are the most important determinants of long-term quality of life in older women.

Tao MH, Shields PG, Nie J, Marian C, Ambrosone CB, McCann SE, Platek M, Krishnan SS, Xie B, Edge SB, Winston J, Vito D, Trevisan M, Freudenheim JL. · Department of Social and Preventive Medicine, School of Public Health and Health Professions, 270 Farber Hall, University at Buffalo, Buffalo, NY 14214, USA. · Cancer Epidemiol Biomarkers Prev. · Pubmed #19240236 No free full text.

Abstract: Aberrant promoter methylation is recognized as an important feature of breast carcinogenesis. We hypothesized that genetic variation of genes for methylenetetrahydrofolate reductase (MTHFR) and methionine synthase (MTR), two critical enzymes in the one-carbon metabolism, may alter DNA methylation levels and thus influence DNA methylation in breast cancer. We evaluated case-control association of MTHFR C677T, A1298C, and MTR A2756G polymorphisms for cases strata-defined by promoter methylation status for each of three genes, E-cadherin, p16, and RAR-beta2 in breast cancer; in addition, we evaluated case-case comparisons of the likelihood of promoter methylation in relation to genotypes using a population-based case-control study conducted in Western New York State. Methylation was evaluated with real-time methylation-specific PCRs for 803 paraffin-embedded breast tumor tissues from women with primary, incident breast cancer. We applied unordered polytomous regression and unconditional logistic regression to derive adjusted odds ratios and 95% confidence intervals. We did not find any association of MTHFR and MTR polymorphisms with breast cancer risk stratified by methylation status nor between polymorphisms and likelihood of promoter methylation of any of the genes. There was no evidence of difference within strata defined by menopausal status, estrogen receptor status, folate intake, and lifetime alcohol consumption. Overall, we found no evidence that these common polymorphisms of the MTHFR and MTR genes are associated with promoter methylation of E-cadherin, p16, and RAR-beta2 genes in breast cancer.

Svahn TH, Niland JC, Carlson RW, Hughes ME, Ottesen RA, Theriault RL, Edge SB, Schott AF, Bookman MA, Weeks JC. · Division of Oncology, Stanford University, Stanford, California 94305, USA. · J Natl Compr Canc Netw. · Pubmed #19200415 No free full text.

Abstract: After the first report of the ATAC (Arimidex, Tamoxifen, Alone or in Combination) trial, adjuvant aromatase inhibitor use increased rapidly among National Comprehensive Cancer Network member institutions. Increased aromatase inhibitor use was associated with older age, vascular disease, overexpression of human epidermal growth factor receptor 2 (HER2), or more advanced stage, and substantial variation was seen among institutions. This article examines adjuvant endocrine therapy in postmenopausal women after the first report of the trial, identifies temporal relationships in aromatase inhibitor use, and examines characteristics associated with choice of endocrine therapy among 4044 postmenopausal patients with hormone receptor-positive nonmetastatic breast cancer presenting from July 1997 to December 2004. Multivariable logistic regression analysis examined temporal associations and characteristics associated with aromatase inhibitor use. Time-trend analysis showed increased aromatase inhibitor and decreased tamoxifen use after release of ATAC results (P < .0001). In multivariable regression analysis, institution (P <. 0001), vascular disease (P <. 0001), age (P = .0002), stage (P = .0002), and HER2 status (P = .0009) independently predicted aromatase inhibitor use. Institutional rates of use ranged from 15% to 66%. Adjuvant aromatase inhibitor use increased after the first report of ATAC, with this increase associated with older age, vascular disease, overexpression of HER2, or more advanced stage. Substantial variation was seen among institutions.

Friese CR, Neville BA, Edge SB, Hassett MJ, Earle CC. · Division of Nursing Business and Health Systems, University of Michigan School of Nursing, Ann Arbor, Michigan 48109-5482, USA. · Cancer. · Pubmed #19152430 No free full text.

Abstract: BACKGROUND: Despite known benefits to needle biopsy for suspicious breast lesions, variability in the use of this technique has been documented in practice. We sought to study the use of needle biopsy and open surgical biopsy in women with breast cancer, predictors of needle biopsy use, and the effect of biopsy choice on overall number of surgical procedures needed to treat breast cancer. METHODS: We analyzed Surveillance, Epidemiology, and End Results (SEER)-Medicare data for 45,542 women diagnosed between 1991 and 1999 with ductal carcinoma in situ and stage I-II breast cancer. By using diagnosis and procedure codes from 3 months before to 6 months after the SEER diagnosis, we classified the initial biopsy as needle or surgical. By using multivariate logistic regression, we identified patient and tumor characteristics associated with needle biopsy use, and estimated the association between initial biopsy type and likelihood for multiple breast surgeries. RESULTS: Needle biopsy was the initial procedure for 11,073 (24.3%) women. In multivariate analyses, needle biopsy use varied significantly by race, year of diagnosis, and tumor size. After controlling for patient and tumor characteristics, needle biopsy use was associated with a reduced likelihood of multiple breast surgeries (odds ratio, 0.35; 95% confidence interval, 0.34-0.37). CONCLUSIONS: Use of needle biopsy as the initial breast cancer procedure was more common among black women and those with larger tumors, and increased significantly over time. Providers should consider needle biopsy when clinically feasible as the initial breast procedure, because it may reduce the number of surgeries needed to treat breast cancer.

Hassett MJ, Hughes ME, Niland JC, Edge SB, Theriault RL, Wong YN, Wilson J, Carter WB, Blayney DW, Weeks JC. · Department of Medical Oncology, Dana-Farber Cancer Institute, 44 Binney St, Boston, MA 02115, USA. · J Clin Oncol. · Pubmed #18955448 No free full text.

Abstract: PURPOSE: To describe the frequency of chemotherapy use for hormone receptor (HR)-positive, lymph node (LN)-negative breast cancer from 1997 to 2004 at eight National Comprehensive Cancer Network institutions, to explore whether chemotherapy use varied over time and between institutions, and to identify factors associated with the decision to forego chemotherapy. PATIENTS AND METHODS: Among women younger than age 70 years with HR-positive, LN-negative breast cancer measuring more than 1 cm, we analyzed the frequency of chemotherapy use on a yearly basis. A multivariable logistic regression model assessed the relationship between receipt of chemotherapy and year of diagnosis, institution, tumor features, and patient characteristics. Interaction terms were added to the model, and stratified analyses were conducted to further explore the determinants of chemotherapy use. RESULTS: Fifty-five percent of 3,190 women received chemotherapy. Chemotherapy use was less common for patients with 1.1- to 2-cm tumors than for patients tumors greater 2 cm (47% v 87%, respectively; P < .01) and for women age 60 to 69 years versus women younger than age 50 years (24% v 76%, respectively; P < .01). On multivariable analysis, predictors independently associated with receiving chemotherapy included larger tumor size, higher grade, human epidermal growth factor receptor 2 overexpression, younger age, and institution (P < .01 for all). Institutions exhibited dramatically different rates of chemotherapy use (from 46% to 65%) and patterns of change in chemotherapy use over time (from a 79% relative increase to a 22% relative decrease). CONCLUSION: Although institutions seemed to agree that not all women with HR-positive, LN-negative breast cancer need chemotherapy, there did not seem to be consensus regarding which women should get chemotherapy. Only prospective randomized controlled trials will conclusively establish which subtypes of HR-positive, LN-negative breast cancer benefit from chemotherapy.

Hassett MJ, Hughes ME, Niland JC, Ottesen R, Edge SB, Bookman MA, Carlson RW, Theriault RL, Weeks JC. · Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts 02115, USA. · Med Care. · Pubmed #18665055 No free full text.

Abstract: BACKGROUND: Although many quality measures have been created, there is no consensus regarding which are the most important. We sought to develop a simple, explicit strategy for prioritizing breast cancer quality measures based on their potential to highlight areas where quality improvement efforts could most impact a population. METHODS: Using performance data for 9019 breast cancer patients treated at 10 National Comprehensive Cancer Network institutions, we assessed concordance relative to 30 reliable, valid breast cancer process-based treatment measures. We identified 4 attributes that indicated there was room for improvement and characterized the extent of burden imposed by failing to follow each measure: number of nonconcordant patients, concordance across all institutions, highest concordance at any 1 institution, and magnitude of benefit associated with concordant care. For each measure, we used data from the concordance analyses to derive the first 3 attributes and surveyed expert breast cancer physicians to estimate the fourth. A simple algorithm incorporated these attributes and produced a final score for each measure; these scores were used to rank the measures. RESULTS: We successfully prioritized quality measures using explicit, objective methods and actual performance data. The number of nonconcordant patients had the greatest influence on the rankings. The highest-ranking measures recommended chemotherapy and hormone therapy for hormone-receptor positive tumors and radiation therapy after breast-conserving surgery. CONCLUSIONS: This simple, explicit approach is a significant departure from methods used previously, and effectively identifies breast cancer quality measures that have broad clinical relevance. Systematically prioritizing quality measures could increase the efficiency and efficacy of quality improvement efforts and substantially improve outcomes.