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Biomedical subjects

B Cady

Publications and source records attributed to B Cady.

At least 55 records · Page 3Linked to original sources
PubMed1997

Traditional and future management of nonpalpable breast cancer.

Under the impact of mammographic screening, sizeable proportions of breast cancer patients today are nonpalpable with either a very small invasive breast cancer (T1a or T1b) or ductal carcinoma in situ. At the Deaconess Hospital in Boston between 1989 and 1993, 29 per cent of all invasive cancers were T1a or T1b (1 cm or smaller). The median maximum diameter of all invasive breast cancer in that 5-year period was only 1.5 cm. The dramatic downward slope of the maximum size clearly reflects the impact of widespread mammographic screening. Within a decade, the median maximum diameter of all invasive breast cancer will be 1 cm. Thus, modifications of contemporary therapy need to be investigated by trials, but they can be practiced in selected patients now. While standard therapy in 1996 includes routine radiotherapy with breast conservation, many small, low-grade, or mammographically discovered cancers can safely, efficiently, and with minimum morbidity be treated by local excision only with careful follow-up; highly selective use of systemic and local adjuvant therapies (i.e., radiotherapy) should also be practiced. Recent reports summarizing adjuvant radiotherapy and axillary dissection in invasive breast cancer do not recognize the changing presentation of invasive breast cancer under the impact of mammographic screening.

Breast Neoplasms↗
PubMed1997

New era in breast cancer. Impact of screening on disease presentation.

Mammographic screening produces markedly smaller breast cancers with fewer axillary lymph nodes and more ductal carcinoma in situ. Over the past 25 years at the New England Deaconess Hospital, the mean maximum diameter of breast cancers has decreased by 10% every 5 years and is now only 2.1 cm. The median maximum diameter in the years from 1989 to 1993 is only 1.5 cm. Axillary lymph node metastases also are declining progressively. This continuing decline in mean and median maximum diameters and incidence of axillary lymph node metastases shows no signs of abating at the present time. Universal mammographic screening of appropriately aged women should be a public health goal to further this trend towards markedly earlier breast cancer detection with much higher survival and new opportunities for modified therapy.

Axilla↗
PubMed1997

How to perform adequate local excision of mammographically detected lesions.

With an increasing proportion of nonpalpable breast cancers being discovered by mammography, the opportunities for breast conservation are increasing commensurately. It is important to have a practical surgical approach for local excision to preserve cosmetic appearance and simplify management. Skin incisions should be circular and central for the bulk of local excisions and lumpectomies of both invasive and noninvasive breast cancers to allow both the greatest flexibility for later mastectomy if it is required and the best cosmetic appearance. Suggestions are based on two decades of clinical practice and careful evaluation of consultant patients encountered and patients operated upon and managed. Adherence to Langer's lines of skin orientation and meticulous attention to surgical detail, with better cosmetic appearance, will pay large dividends in patient satisfaction. Guidelines for use of local anesthesia, handling of the residual cavity after local excision, management of the surgical specimen, and wound closures are elaborated.

Anesthesia, Local↗
PubMed1997

Pathologic prognostic factors for patients with breast carcinoma. Which factors are important.

Current technologies can identify subsets of patients who are at greater risk for developing recurrent carcinoma. This article presents conventional and generally accepted pathologic features of breast carcinoma that allow breast carcinoma patients to be placed into low-risk or high-risk categories for recurrence-free or overall survival. Also, the role of flow cytometry, estrogen-progesterone receptor measurement, tumor angiogenesis, and selection oncoprotein expression, such as c-erbB2, are reviewed.

Breast Neoplasms↗
PubMed1996

The new era in breast cancer. Invasion, size, and nodal involvement dramatically decreasing as a result of mammographic screening.

OBJECTIVE: To describe the magnitude of changes and opportunities that may arise for simplified surgical procedures for women with breast cancer because of the decreasing size and lymph node involvement in invasive breast cancer and earlier presentation of noninvasive and invasive breast cancer. DESIGN AND MAIN OUTCOME ASSESSMENT: Cases (N=1001) of breast cancer from a tertiary and a community hospital between 1989 and 1993 were analyzed for invasion, size, nodal status, and change over time. RESULTS: Ductal carcinoma in situ constituted 14% and 18% of the cancers at the two hospitals. At the tertiary and community hospitals, the mean maximum diameters were 2.1 and 2.0 cm, respectively, and the median maximum diameters were 1.5 and 1.7 cm, respectively, for invasive breast cancer. Twenty-nine percent and 28%, respectively, were 1 cm or less in diameter. Axillary nodal metastases occurred in only 31% of the invasive cancers (tertiary hospital); only 10% had more than three nodal metastases. In the T1a and T1b cases, nodal metastases occurred in only 10% and 43% of the positive nodes were solitary; only 16% had more than three nodal metastases. The proportion of ductal carcinoma in situ, T1a and T1b, and node-negative cases increased significantly over time. CONCLUSIONS: Within the next decade, the proportion of all breast cancers that are ductal carcinoma in situ will approach 33%, and invasive cancers will approach 1 cm in median maximum diameter. Therapy simplification will be logical because of very small size, low risk of recurrence after breast conservation, and excellent prognosis, and might include increased breast conservation, avoidance of axillary nodal dissection, and omission of radiation therapy to conserve breasts. Adjuvant therapy will be based on the prognostic features of the primary cancer and findings from careful histologic examination of the sentinel lymph nodes.

Adult↗
PubMed1996

Cost-effective preoperative evaluation, operative treatment, and postoperative follow-up in the breast cancer patient.

Although medical criteria based on retrospective and prospective studies form the basic foundation for the strategies enunciated in this article, efficiency in management and cost effectiveness follow because of the simplification that has been found to be appropriate by analyzing reports over the past decade and using common sense. In addition, the realization of the effectiveness of mammographic screening programs should encourage all surgeons to promote and practice yearly mammographic screening in appropriately aged women. At present, this means women between the ages of 50 and 75, but there is increasing evidence that women between the ages of 40 and 49 may benefit. A compromise would suggest women over 45 years of age as appropriate, recognizing the controversy now raging over the effectiveness of screening in women 40 to 49 years old. Wide appreciation of the major gains in breast cancer detection by use of mammographic screening programs needs to be emphasized. We have predicted that within a decade the median maximum diameter of all invasive breast cancer in the United States will be only 1 cm if mammographic screening programs are widespread. If this occurs, there would be extraordinary gains in reduced patient morbidity and cost savings and undoubtedly changes will occur in the previously unyielding age-adjusted mortality rate. The goal of entirely outpatient management in the vast majority of breast cancer patients can be achieved by such mammographic screening as well as by the adaptation of induction chemotherapy and breast conservation in the majority of advanced primary breast cancer patients that still appear.

Adult↗
PubMed1995

How to perform breast biopsies.

Current breast biopsy techniques should recognize the changing presentation and management of breast cancer. Nonpalpable lesions detected and localized by mammography are common, and the proportion of women suitable for and desirous of breast conservation is increasing. Careful evaluation of the features of the excised cancer and sophisticated decisions are to be emphasized, not spared, as there are a wide variety of suitable treatments available.

Adult↗
PubMed1994

Shifting proportions of gastric adenocarcinomas.

OBJECTIVES: To substantiate reports of increasing proportions of gastric adenocarcinoma of diffuse histologic type and in the proximal portion of the stomach, to better understand the prognostic features that govern survival, and to determine whether alterations of operative strategy might improve the surgical results. DESIGN: Retrospective analysis of 289 consecutive patients with gastric adenocarcinoma operated on by general surgeons over a 26-year period. Records were reviewed for location, histologic type, resection, operative mortality, lymph node status, and outcome. SETTING: The Section of Surgical Oncology, the New England Deaconess Hospital, Boston, Mass. MAIN OUTCOME MEASURES: Survival rate, length of life of the patients who died, and operative mortality. RESULTS: A marked and significant shift of gastric adenocarcinoma to a proximal location (54% between 1985 and 1990) occurred over 26 years (P = .0075) with a significant stage improvement at presentation (P = .0235). Percentages of cancers that were of the diffuse, poorly differentiated histologic type increased to 48%. More curative operations were performed in the last period (61%), and this upward trend from 37% was significant. Proximal gastric cancers had a poorer prognosis with more operative deaths, more lymph node metastases, and worse survival rates than distal cancers. Poor survival rates occurred even when comparing patients with negative lymph nodes or favorable histologic features with patients with similar distal cancers. CONCLUSIONS: Despite significant increases in the proportion of proximal cancers, survival rates have improved only slightly. Nodal status plays a less prognostic role than does location or histologic type but does provide prognostic information for individual locations. Survival rates for diffuse histologic cancer were consistently worse than those for intestinal histologic cancer, which emphasizes the underlying disease biology controlling outcome. Radical lymphadenectomy for gastric adenocarcinoma would not improve surgical outcome in the United States.

Actuarial Analysis↗
PubMed1994

Intraoperative ultrasound imaging of the liver at the time of colorectal cancer resection.

OBJECTIVES: To evaluate the accuracy of intraoperative ultrasound (IOUS) liver imaging at the time of primary colorectal cancer resection, which might eliminate incurable patients from adjuvant chemotherapy trials or permit earlier resection of curable metastases. DESIGN: A prospective trial of routine IOUS liver imaging during resections of primary colorectal cancer. The rate of detection of occult metastases by IOUS imaging alone and the false-negative rate over 22.7 months of follow-up were determined. SETTING: A tertiary care referral center in Boston, Mass. PATIENTS: Fifty-five patients undergoing 56 operations for colorectal carcinoma between May 1990 and June 1992. MAIN OUTCOME MEASURES: The rate of detection, by IOUS imaging alone, of otherwise occult hepatic metastases, the total number of patients with metastases detected at any time during follow-up, and the rate of false-negative findings on IOUS imaging and direct examination. RESULTS: Occult hepatic metastases were detected by IOUS imaging alone in 5% of patients. Restriction of IOUS imaging to patients with T3 or T4 lesions or recurrent cancers would have identified all metastases and increased the detection rate to 10%. Occult metastases were detected by IOUS imaging alone in 12.5% of patients with T3, N0 lesions. The rate of false-negative findings on IOUS imaging was 13% overall, 0% for patients with T1 or T2 lesions, 3% for patients with node-negative findings, and 7% for patients with T3, N0 lesions. CONCLUSIONS: The small increment in the detection of occult metastases by IOUS liver imaging does not warrant its use in all patients with colorectal cancer. Selective use in patients with T3 or T4 lesions or recurrent cancers increased the incremental gain in detection. The observed frequency of occult metastases in patients with T3, N0 lesions is sufficient to impact on results of adjuvant chemotherapy trials. Longer follow-up in more patients is needed to determine whether a negative IOUS study is an additional favorable prognosticator in patients with T1 and T2 lesions and node-negative findings.

Adult↗
PubMed1994

Hepatoma registry of the Western world. Repeat Hepatic Resection Registry.

The western HCC registry comprised data from 322 patients who underwent hepatic resection for HCC over a 50-year period. The majority of patients had lesions > 4 cm and were symptomatic at presentation. Lesions were mostly unicentric. Cirrhosis was not a prevalent problem, unlike the East. In the most recent decade, 1980-1989, we noted a significant decrease in operative mortality from 19% to 10% overall, and 15% to 4% in the noncirrhotic group. We identified four variables that resulted in poorer postresectional outcome: cirrhosis, regional nodal disease, multicentric disease, and tumor-free resectional margin < 1 cm. Although these factors are associated with a poorer outcome after resection, whether they should serve as contraindications to surgery should be determined by individual surgeons, taking into account the patient's overall status, concomitant risk factors, and treatment objectives.

Adolescent↗
PubMed1994

Insurance coverage of patients with breast cancer in the 1991 commission on cancer patient care evaluation study.

BACKGROUND: Trends in the care of patients with cancer are monitored annually by the Commission on Cancer of the American College of Surgeons. In 1991 a patient care evaluation study of breast cancer was conducted, which among other questions examined the correlation of health insurance with type or quality of care delivered for breast cancer on a national basis. METHODS: The tumor registry system of the American College of Surgeons was used to obtain data on patients with breast cancer diagnosed in 1983 and 1990. Trends in diagnosis and treatment were correlated with the type of insurance or lack of insurance. RESULTS: Data were obtained from hospitals in 50 states on a total of 41,651 patients. The largest number of patients were covered by Medicare. Fewer than 5% were considered medically indigent. Medically indigent patients presented with higher stage disease and did not participate in a trend toward downstaging, which occurred between the two study years. The treatment of medically indigent patients appeared to be appropriate and comparable with better insured patients. Insurance type (health maintenance organization vs. private) did not affect stage, treatment, or outcome. Decisions to use controversial therapies, such as chemotherapy for stage I disease, did not appear to be financially driven. CONCLUSION: A nationwide pattern of care study for breast cancer indicates that medically indigent patients present with more advanced disease compared with better insured patients, but once the diagnosis is made, treatment and outcome have little to do with insurance type.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1994

The impact of intraoperative ultrasonography on surgery for liver neoplasms.

To analyze the effect of IOUS on surgical decision making, we performed a retrospective study of 45 patients who had exploratory laparotomy and IOUS for liver neoplasms. Preoperative lesion detection was compared with intraoperative findings. The effect of IOUS on the choice of surgical procedure was analyzed. Preoperative imaging detected 67% of lesions, 78% when combined with surgical inspection and palpation, and 97% were recognized by IOUS. Surgery was modified in 23 of 45 cases (51%); 19 of those 23 cases (83%) were based on IOUS findings alone. IOUS demonstrated superior lesion detection over noninvasive preoperative liver imaging, and IOUS significantly affected surgical decision making.

Adult↗