Breast density is increasingly recognized as an independent risk factor for the development of breast cancer, because it has been shown to be associated with a four- to sixfold increase in a woman's ...risk of malignant breast disease. Increased breast density as identified on mammography is also known to decrease the diagnostic sensitivity of the examination, which is of great concern to women at increased risk for breast cancer. Dense tissue has generally been associated with younger age and premenopausal status, with the assumption that breast density gradually decreases after menopause. However, the actual proportion of older women with dense breasts is unknown. The purpose of this study was to examine the relationship between age and breast density, particularly focusing on postmenopausal women.
All screening mammograms completed at the New York University Langone Medical Center in 2008 were retrospectively reviewed. Analysis of variance and descriptive analyses were used to evaluate the relationship between patient age and breast density.
A total of 7007 screening mammograms were performed. The median age of our cohort was 57 years. Within each subgroup categorized by decade of age, there was a normal distribution among the categories of breast density. There was a significant inverse relationship between age and breast density (p < 0.001). Seventy-four percent of patients between 40 and 49 years old had dense breasts. This percentage decreased to 57% of women in their 50s. However, 44% of women in their 60s and 36% of women in their 70s had dense breasts as characterized on their screening mammograms.
In general, we found an inverse relationship between patient age and mammographic breast density. However, there were outliers at the extremes of age. A meaningful proportion of young women had predominantly fatty breasts and a subset of older women had extremely dense breasts. Increased density renders mammography a less sensitive tool for early detection. Breast density should be considered when evaluating the potential benefit of extended imaging for breast cancer screening, especially for women at increased risk for the disease.
Oncologic outcomes with nipple-sparing mastectomy continue to be established. The authors examine oncologic trends, outcomes, and risk factors, including tumor-to-nipple distance, in therapeutic ...nipple-sparing mastectomies.
Demographics, outcomes, and overall trends for all nipple-sparing mastectomies performed for a therapeutic indication from 2006 to 2017 were analyzed. Oncologic outcomes were investigated with specific focus on recurrence and associated factors, including tumor-to-nipple distance.
A total of 496 therapeutic nipple-sparing mastectomies were performed, with an average follow-up time of 48.25 months. The most common tumor types were invasive carcinoma (52.4 percent) and ductal carcinoma in situ (50.4 percent). Sentinel lymph node sampling was performed in 79.8 percent of nipple-sparing mastectomies; 4.1 percent had positive frozen sentinel lymph node biopsy results, whereas 15.7 percent had positive nodal status on permanent pathologic examination. The most common pathologic cancer stage was stage IA (42.5 percent) followed by stage 0 (31.3 percent). The rate of local recurrence was 1.6 percent (n = 8), and the rate of regional recurrence was 0.6 percent (n = 3). In all, 171 nipple-sparing mastectomies had magnetic resonance imaging available with which to assess tumor-to-nipple distance. Tumor-to-nipple distance of 1 cm or less (25.0 percent versus 2.4 percent; p = 0.0031/p = 0.1129) and of 2 cm or less (8.7 percent versus 2.0 percent; p = 0.0218/p = 0.1345) trended to higher rates of locoregional recurrence. In univariate analysis, tumor-to-nipple distance of 1 cm or less was the only significant risk factor for recurrence (OR, 13.5833; p = 0.0385). No factors were significant in regression analysis.
In early stage and in situ breast carcinoma, therapeutic nipple-sparing mastectomy appears oncologically safe, with a locoregional recurrence rate of 2.0 percent. Tumor-to-nipple distances of 1 cm or less and 2 cm or less trended to higher recurrence rates.
Risk, III.
Nipple-sparing mastectomy (NSM) has become widely available for breast cancer prophylaxis. There are limited data on its long-term oncologic safety. The objective of this study was to determine the ...incidence of breast cancer in patients who underwent prophylactic NSM.
All patients undergoing prophylactic NSM at a single institution from 2006 through 2019 were retrospectively reviewed. Patient demographic factors, genetic predispositions, mastectomy specimen pathology, and oncologic occurrences at follow-up were recorded. Descriptive statistics were performed where necessary to classify demographic factors and oncologic characteristics.
A total of 871 prophylactic NSMs were performed on 641 patients, with median follow-up of 82.0 months (standard error 1.24). A total of 94.4% of patients ( n = 605) underwent bilateral NSMs, although only the prophylactic mastectomy was considered. The majority of mastectomy specimens (69.6%) had no identifiable pathology. A total of 38 specimens (4.4%) had cancer identified in mastectomy specimens, with ductal carcinoma in situ being the most common (92.1%; n = 35). Multifocal or multicentric disease was observed in seven cases (18.4%) and lymphovascular invasion was identified in two (5.3%). One patient (0.16%), who was a BRCA2 variant carrier, was found to have breast cancer 6.5 years after prophylactic mastectomy.
Overall primary oncologic occurrence rates are very low in high-risk patients undergoing prophylactic NSM. In addition to reducing the risk of oncologic occurrence, prophylactic surgery itself may be therapeutic in a small proportion of patients. Continued surveillance for these patients remains important to assess at longer follow-up intervals.
Risk, IV.
Studies suggest that adjuvant chemotherapy for early stage breast cancer (BC) is associated with cognitive impairment related to attention, memory, and visuospatial functioning. However, other ...studies have failed to confirm that relationship. We report one of the first longitudinal, controlled studies of cognitive effects of chemotherapy in older post-menopausal women. Sixty-one post-menopausal women with non-metastatic BC were administered neuropsychological tests before adjuvant therapy (Time1), six months after treatment (Time2), and at a final 6-month follow-up (Time3). Thirty women were treated with chemotherapy; thirty-one women who received no chemotherapy were controls. Cognitive domains measured included motor, language, attention/concentration/working memory, visuospatial, and memory (verbal and visual). Time-by-treatment interaction was significant in the motor domain (P = 0.007) with poorer performance in women treated with chemotherapy. For the other domains, scores did not significantly vary over time by group. In post-menopausal women, chemotherapy was not associated with changes in cognitive function in areas reported by BC survivors: attention, memory, and information processing. Motor slowing in women treated with chemotherapy could be secondary to peripheral neuropathy rather than an indication of more general declines in cognitive processing. Future studies should control for the independent effects of slowed motor functioning when looking to study possible chemotherapy related cognitive processing deficits.
Prophylactic nipple-sparing mastectomies (NSM) have become increasingly common, although there is little long-term data on its efficacy in prevention of breast cancer. The objective of this study was ...to assess the incidence of breast cancer in a cohort of patients undergoing prophylactic NSM with a median follow-up of 10 years.
Patients receiving prophylactic NSM at a single institution from 2006 to 2019 were included in a retrospective nature. Patient demographics, genetic mutations, operative details, and specimen pathology were recorded, and all postoperative patient visits and documentation were screened for cancer occurrence. Descriptive statics were performed where appropriate.
Two hundred eighty-four prophylactic NSMs were performed on 228 patients with a median follow-up of 120.5 ± 15.7 months. Roughly, a third of patients had a known genetic mutation, with 21% BRCA1 and 12% BRCA2. The majority (73%) of prophylactic specimens had no abnormal pathology. The most commonly observed pathologies were atypical lobular hyperplasia (10%) and ductal carcinoma in situ (7%). Cancer was identified in 10% of specimens, with only one case of lymphovascular invasion. Thus far, there have been no incidences of locoregional breast cancer occurrence in this cohort.
The long-term breast cancer occurrence rate in this cohort of prophylactic NSM patients at the time of this study is negligible. Despite this, continued surveillance of these patients is necessary until lifetime risk of occurrence following NSM has been established.
Abstract Objectives To better understand the practices and preferences of women at elevated risk of breast cancer by merging registries from two separate institutions and comparing clinical ...characteristics and outcomes. Methods Women were enrolled in IRB-approved registries between 2003-2015 at the NYU Langone Medical Center and University of Vermont. We compared variables including risk categories, uptake of prevention methods and cancer rates. Results There were 1035 women included in this analysis. We found a 99% concordance of variables collected between the two registries. There were significant differences in age, risk characteristics, uptake of prevention methods and cancer rates between the registries. There was low uptake of chemoprevention (8% for all women), with higher uptake among women with atypia on biopsy (66%) than those with a strong family history or BRCA mutations. Women with BRCA mutations accounted for 76% of those undergoing risk-reducing surgeries. 43 individuals (4% of the entire cohort) developed breast cancer. Of these, 86% were diagnosed with AJCC stage 0 or 1 disease, 95% with tumors under 2 cm, and 70% with poor to moderately differentiated pathology. Only one of the women who developed breast cancer was on chemoprevention and none had prior prophylactic surgery. Conclusions We demonstrate a high degree of concordance between registries suggesting no barriers to multi-institutional collaboration. Overall, there was low uptake of prevention opportunities in this high-risk population. Women developing cancer had predominantly low stage but higher grade disease, which may suggest a benefit to participation in surveillance (or high-risk) programs.
Use of nipple‐sparing mastectomy (NSM) for risk‐reduction and therapeutic breast cancer resection is growing. The role for intraoperative frozen section of the nipple‐areolar complex remains ...controversial. Records of patients undergoing NSM at our institution from 2006 to 2013 were reviewed. Records from 501 nipple‐sparing mastectomies were reviewed (216 therapeutic, 285 prophylactic). Of the 480 breasts with sub‐areolar biopsies, 307 had intraoperative frozen sections and 173 were evaluated with permanent paraffin section only. Among the 307 intraoperative frozen sections, 12 biopsies were positive on permanent paraffin section (3.9% or 12/307). Of the 12 positive permanent biopsies, five were false negative and the remaining seven concordant intraoperatively. Sensitivity and specificity of sub‐areolar frozen section were 0.58 and 1, respectively. Positive sub‐areolar biopsies consisted primarily of ductal carcinoma in situ (62% or 13/21). The nipples or nipple‐areolar complex were resected in a separate procedure following mastectomy (10/21), intraoperatively following frozen section results (7/21) or during second‐stage breast reconstruction (3/21; 1 additional scheduled). Only 30% (6/20) of resected specimens had abnormal residual pathology. Intraoperative frozen section is highly specific and moderately sensitive for the detection of positive sub‐areolar biopsies in NSM. Its use can help guide intraoperative reconstructive planning. The presence of positive sub‐areolar biopsies in both contralateral and high‐risk prophylactic mastectomy specimens emphasizes the need to perform sub‐areolar biopsies in all nipple‐sparing mastectomies.
Malignant phyllodes tumors are an extremely rare breast tumor. Prognostic features and overall survival data have not been consistent across studies.
Retrospectively, we examined the ...clinicopathologic features of 27 breast cancer patients treated for malignant phyllodes tumors from 1995 to 2004 and analyzed their recurrence and survival outcomes using contingency tables, a logistic regression model, or a proportional hazard model.
The mortality rate was 12% (n = 3) of the cohort and 75% of the group with distant metastases. The median follow-up period was 51 months (range, 12–192 mo). A mitotic index greater than 10 per high-powered field, the presence of stromal overgrowth, mastectomy at initial surgery, and larger tumor size were associated with an increased incidence of distant metastases. Larger tumor size also was associated with an increased incidence of death.
Most patients with malignant phyllodes tumors will enjoy significant long-term survival if treated appropriately with local excision with clear margins.
