Patterns of care for younger women with breast cancer.
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Adult↗
Biomedical subjects
B Cady
Publications and source records attributed to B Cady.
1991 national survey of carcinoma of the breast by the Commission on Cancer.
A nationwide survey of patterns of care for carcinoma of the breast was conducted by the Commission on Cancer of the American College of Surgeons. Information regarding patient history, diagnostic tests, treatment, survival and disease status was obtained for 17,295 patients treated during 1983 and 24,356 patients treated during 1990. The results indicate that patients diagnosed in recent years (1990) are being treated at an earlier stage of the disease compared with the 1983 survey and the findings of earlier years, probably because of the use of mammography. Surgical treatment for conservation of the breast is being used more frequently, but modified radical mastectomy remains the most commonly used surgical treatment.
Aged↗
Continuing trends in the prevalence of right-sided lesions among colorectal carcinomas.
The shift of colorectal carcinoma location toward the proximal colon has been reported. This study documents that this statistically significant trend has continued through 1992. An increase in transverse and descending colon cancers is now apparent also. Only 59% of all large-bowel cancers occurred distal to the descending colon between 1978 and 1992. Both right-sided and distal large-bowel cancers have significantly decreased in size, yet the incidence and frequency of lymph node metastases have not changed over a 65-year interval (from 1928 to 1992). This constant proportion of lymph node metastases may suggest distinct biological subsets of cancers (lymph node avid vs lymph node avoidance). The progression from small size with fewer metastases to large size with more lymph node metastases occurs only in some of the smallest distal colorectal cancers.
Boston↗
Neoadjuvant therapy for unresectable pancreatic adenocarcinoma.
The purposes of this study were to determine whether continuous infusion of fluorouracil combined with external-beam radiation therapy improved the resectability and survival of patients with pancreatic carcinoma. Sixteen patients with unresectable disease confined to the pancreas and celiac nodes were treated, and their outcome was compared with that of 24 patients with potentially resectable disease who were treated concurrently. The neoadjuvant therapy was completed with acceptably few toxic effects but with only a minor decrease in tumor size. Two patients underwent resection and remained free of disease 20 and 22.5 months later. However, the median survival of the entire neoadjuvant group was 8 months. All 24 patients with potentially resectable carcinoma underwent surgical exploration. Fifteen of the 24 patients underwent resection and survived a median of 12.5 months. Neoadjuvant chemoradiation may have improved outcome and resectability for two (12.5%) of 16 patients with unresectable pancreatic carcinoma, but more effective therapy options must be developed to improve outcome.
Adenocarcinoma↗
New therapeutic possibilities in primary invasive breast cancer.
OBJECTIVE: Current therapy for small invasive breast cancer, particularly when discovered mammographically, was re-examined. Axillary dissection may be avoided when lymph node metastases incidence is low (< 10%) or when primary cancer features determine adjuvant therapy. Radiation therapy may be avoided when risk of recurrence is very low. SUMMARY BACKGROUND DATA: Recent studies by the Surveillance, Epidemiology, and End Results program (SEER) have shown increases in small invasive breast cancers (< 1 cm) attributable to mammographic screening. The incidence of axillary metastases in mammographically discovered small cancers (< 1 cm) may be less than 10%. Follow-up data from the Breast Cancer Detection Demonstration Project (BCDDP) indicate a disease-free survival rate exceeding 95% at 8 years if the cancer was discovered mammographically. METHODS: Maximum diameter and lymph node metastases of invasive breast cancer diagnosed between 1969 and 1988 were analyzed and compared to cases diagnosed between 1929 and 1968. One hundred thirty patients have been treated without either axillary dissection or radiation therapy since 1980. RESULTS: The mean and median diameters of invasive breast cancers decreased to 2.31 and 2.0 cm, respectively, between 1984 and 1988; 13% were less than 1 cm in diameter. Only 13% of patients had axillary metastases if the primary cancer was 1 cm or less in diameter in the last 10 years; 71% had only 1 or 2 nodes involved. Isolated local recurrence, total local recurrence, and distant metastases were unchanged when radiated and nonirradiated patients were compared. Axillary nodal recurrence was decreased in irradiated patients because the lower half of the axilla was treated. CONCLUSION: In selected patients with very small invasive breast cancers detected by mammography, breast conservation without axillary dissection or radiation therapy may be used. Entirely outpatient treatment markedly reduces morbidity and cost, and furthers the gains from screening programs.
Axilla↗
Technical and biological factors in disease-free survival after hepatic resection for colorectal cancer metastases.
Careful patient selection for hepatic resection of colorectal cancer metastases is essential to improve current poor results. Carcinoembryonic antigen level and number of metastases were significant preoperative prognostic indicators of 5-year disease-free survival in patients selected clinically for hepatic surgery. Surgical margin, weight of hepatic tissue resected, carcinoembryonic antigen level, and flow cytometry were significant postoperative prognostic indicators. Patients with a carcinoembryonic antigen level less than 200 ng/mL, 1-cm surgical margins, and less than 1,000 g of liver tissue removed had a greater than 50% estimated 5-year disease-free survival rate. If the metastases were diploid on flow cytometry, an additional survival advantage may have been gained. Inadequate surgical margins led to high rates of liver-only recurrence. Nonhepatic recurrence was unrelated to surgical margins. Intraoperative liver examination by ultrasound during primary colon cancer resection and adjuvant chemotherapy may offer earlier selection of biologically appropriate patients and improved outcome; both recommendations require clinical trials.
Adult↗
A plea for support of referenda to increase excise taxes on tobacco.
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Plants, Toxic↗
Recurrence in the breast following conservative surgery and radiation therapy for early-stage breast cancer.
This report summarizes the experience of the Joint Center for Radiation Therapy (JCRT) in treating patients with clinical stage I and II breast cancer with conservative surgery and radiation therapy. The study population consisted of 1396 patients treated between 1968 and 1985. All patients underwent a gross excision of the tumor and received breast irradiation (with or without nodal irradiation) including a "boost" to bring the primary tumor site to a total dose of at least 60 Gy. The method of treatment evolved over the study-time period. During the interval from 1968 to 1982, patients typically underwent a limited gross excision of the tumor without regard to the microscopic margins of resection. During the period 1983 to 1985, film-screen mammography, inking of specimen margins, and reexcisions for inevaluable or involved margins were more commonly performed. With a median follow-up of 80 months, the 5-year crude rate of failure in the breast (as the first site of failure) was 8% (106/1396) and the crude rate of regional nodal/distant failure (as the first site of failure) was 16% (228/1396). The time-course of failures in the breast was protracted, occurring at a fairly constant rate over the first 7 years after treatment, but still seen beyond that point. Most recurrences in the breast (75%) developed at or near the original tumor site. The most important risk factor for developing a breast recurrence was the presence of an extensive intraductal component in the tumor. The cosmetic results following treatment were excellent or good in the majority of patients (87%) and were most adversely affected by extensive surgery.(ABSTRACT TRUNCATED AT 250 WORDS)
Breast Neoplasms↗
Results of treating ductal carcinoma in situ of the breast with conservative surgery and radiation therapy.
To determine the frequency, pattern, and time course of tumor recurrence in the breast, the outcome of 38 women with ductal carcinoma in situ (DCIS) treated with conservative surgery and radiation therapy between 1976 and 1985 was studied. Surgery typically consisted of local excision without evaluation of the microscopic margins of resection. The median radiation dose to the tumor site was 6400 cGy. With a median follow-up time of 81 months, eight patients (21%) have experienced a recurrence in the breast. The time course to recurrence was protracted in some cases, with failures occurring at 17, 27, 43, 63, 71, 83, 92, and 104 months. The 5-year and 8-year actuarial rates of tumor recurrence in the breast were 8% and 27%, respectively. Seven patients had a recurrence at or near the primary tumor site, four with invasive carcinoma, and one had an invasive recurrence at a site elsewhere in the breast. No clinical or pathologic factor was significantly associated with an increased risk of recurrence, but the number of patients in the study population was small. The authors reached the following conclusions for patients with DCIS treated with conservative surgery and radiation therapy without careful mammographic and pathologic evaluation: (1) recurrence in the breast may be seen in at least one fifth of the patients; (2) recurrence typically occurs at or near the primary site; and (3) recurrence can occur long after treatment. Careful mammographic and pathologic assessment may be useful in reducing the local recurrence rate and should be considered essential if patients are considered for conservative surgery and radiation therapy.
Adult↗
A 5-year study of cryosurgery in the treatment of liver tumors.
This report summarizes our 5-year experience with cryosurgery for in situ ablation of liver tumors. The liver was exposed with laparotomy, and the tumors were subjected to two freeze-thaw cycles using liquid nitrogen delivered by insulated probes; cryoablation was monitored with intraoperative ultrasonography. Tumor markers and computed tomography evaluated tumor response during long-term follow-up. From 1985 to 1990, 32 patients (19 men and 13 women) were entered into this study. The histologic characteristics of the tumors were as follows: colorectal, 24 patients; hepatoma, three patients; neuroendocrine, two patients; and others, three patients. After a follow-up period of 5 to 60 months (median follow-up, 24 months), nine patients (28%) remained disease free, 11 patients (34%) were alive with disease, and 12 patients (38%) died. The patterns of failure included liver and extrahepatic disease in 54% of cases, liver disease only in 32% of cases, and extrahepatic disease only in 14% of cases. In patients with "liver only" failure, recurrence at the treatment site occurred in three patients (9%). This study establishes the long-term effectiveness of cryosurgery in the treatment of primary and metastatic liver tumors.
Adult↗
The role of surgical resection of liver metastases in colorectal carcinoma.
While hepatic resection of colorectal carcinoma, metastatic to the liver, is a suitable and effective treatment, it nevertheless remains applicable only to a highly selective group of patients. Even within this highly selective group of patients only a minority will survive 5 years disease-free indicating the increased sophistication needed to understand the biological factors that control outcome. It is clear that the good results come from biological suitability and not temporal acceleration of the detection process. Appropriate patients after careful selection and sophisticated diagnostic studies should be subjected to exploration and attempted hepatic resection. A preliminary prognostic scoring system has been presented to illustrate the usefulness of this approach.
Aftercare↗
Conservative surgery and radiotherapy for early breast cancer.
In 1984, as part of a prior American Cancer Society National Conference on Breast Cancer, the authors reported on the status of conservative surgery (CS) and radiotherapy (RT) as primary local treatment for women with early stage breast cancer. Since that time, additional data have become available regarding the use of this approach and its comparability to mastectomy. In general, these data support the use of CS and RT and, as a result, this approach is now more widely employed in the United States and abroad than it was in 1984. The current focus of inquiry has shifted from whether or not CS and RT is an acceptable option for patients with early stage breast cancer to the following questions. For which patients are CS and RT suitable? What are the best techniques of surgery and RT? Are there any patients who can be treated safely with CS without RT? How should RT and systemic therapy be integrated when both are to be used? In this report, recent results on the use of CS and RT from both retrospective and prospective trials are summarized, and these current areas of inquiry are addressed.
Breast Neoplasms↗
New diagnostic, staging, and therapeutic aspects of early breast cancer.
Many advances have occurred in breast cancer through research and clinical trials. More confidence in new biological consumptions about invasive breast cancer indicate that: (1) details of the primary breast cancer do not control survival; (2) breast-only failures after local excision do not bias against survival; and (3) cancer cell dissemination occurs at the same time via both lymphatic and hematogenous routes. Early detection with mammographic screening has indicated a greater number of smaller breast cancers, including sharp increases in ductal carcinoma in situ (DCIS). With proper analysis and control, DCIS of limited extent can be treated by local excision with or without radiation. Invasive breast cancer of limited extent can frequently be managed by lumpectomy and radiation therapy with survival rates equivalent to the more traditional mastectomy. Patient desires regarding breast preservation and quality of life are paramount. Risk: benefit analyses for individual patients need to be emphasized in issues of breast preservation and in selecting adjuvant therapy, both regional (radiotherapy) and systemic (chemotherapy) and hormonal therapy). We are entering an era of highly selective therapy based on more sophisticated analysis of the primary cancer. In the future, not only statistical predictions of outcome as achieved by flow cytometry, for example, will be more widely used, but individual prognostic factors may be developed such as with oncogene expression. Such individual prognostic factors will enable more selective therapy.
Adult↗
The Society of Surgical Oncology at a crossroads: thoughts for the future. Presidential address.
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Forecasting↗
Surgical therapy for recurrent liver metastases from colorectal cancer.
Forty percent of patients whose disease recurs after hepatic resection for liver metastases from colorectal cancer initially will have liver-only metastases. We have retrospectively reviewed our experience with repeated surgical treatment for liver-only recurrence after previous hepatic resection for colorectal metastases. Repeated hepatic procedures were performed with no mortality in 10 patients. Intraoperative ultrasound allowed identification of three unsuspected metastases and determination of unresectability of two metastases during 11 procedures. Three patients were free of disease at 31, 41, and 48 months from the first hepatic procedure and at 15, 31, and 43 months from the second procedure. Five patients have remained free of hepatic disease. Patients whose initial metastases were less than 6 cm in diameter and had single liver recurrences after hepatic resection appeared to be the best candidates for further surgical therapy. These data and a review of the literature suggest that surgical treatment of recurrent liver metastases from colorectal cancer can be performed safely, and it is associated with long-term disease-free survival in up to 38% of highly selected patients.
Aged↗
Early breast cancer: predictors of breast recurrence for patients treated with conservative surgery and radiation therapy.
The identification of factors associated with breast recurrence following conservative surgery (CS) and radiation therapy (RT) is of potential use in refining patient selection criteria and treatment technique. In an attempt to define such factors we examined the relationship between various clinical, pathologic and treatment characteristics and the likelihood of breast recurrence in 783 patients with clinical stage I or II breast cancer treated between July 1968 and December 1982. Treatment consisted of complete gross excision of the primary tumor and RT to a total dose of at least 60 Gy to the primary site. During this period, pre-treatment mammograms and detailed histologic assessment of the margins of resection were not routinely performed. Median follow-up for surviving patients was 80 months. Thirteen patients (1.6%) were lost to follow-up. Ninety-one patients (12%) have developed a breast recurrence, corresponding to 5- and 10-year actuarial rates of 10 and 18%, respectively. The major feature associated with breast recurrence was the presence of an "extensive intraductal component" (EIC+). An EIC+ tumor was seen in 28% of evaluable cases with infiltrating ductal carcinoma and accounted for 60% of breast recurrences. Forty-three of 166 patients (26%) with EIC+ tumors developed a breast recurrence compared with 29 of 418 patients (7%) without an EIC (EIC-) (p = 0.0001). The 5-year actuarial rates of breast relapse were 24 and 6%, respectively (p = 0.0001). Very young age (defined as 34 years of age or younger) was also a significant factor associated with the risk of breast recurrence. Very young patients comprised 8% of the patient population and accounted for 16% of breast recurrences. Fifteen of 61 very young patients (25%) developed a breast recurrence compared with 76 of 722 older patients (11%) (p = 0.001). The corresponding 5-year actuarial rates of breast recurrence were 21 and 9% (p = 0.005). None of the other clinical or pathological factors examined by univariate analysis were significantly correlated with recurrence in the breast. A multivariate model of site of first failure (polychotomous logistic regression) also showed that EIC+ tumors and very young age were the main factors associated with a high relative risk of breast recurrence. We conclude that EIC+ tumors and very young age are associated with a high risk of breast recurrence for patients treated with limited excision prior to RT.
Actuarial Analysis↗
Techniques of lumpectomy and axillary dissection.
Preservation of the breast with a good or excellent cosmetic appearance is achievable in most patients. Careful attention to the details of surgical technique allows these procedures to be carried out easily and comfortably for the patient and the surgeon alike.
Anesthesia↗
Selection of breast-preservation therapy for primary invasive breast carcinoma.
Breast-preservation treatment for primary breast cancer should not be used for all women. Women frequently excluded from consideration for such treatment or who choose not to have it may be elderly and not concerned about cosmetic appearance or live at a distance so that 6 weeks of daily trips to radiotherapy would be inconvenient or even impossible. Also, if radiotherapeutic expertise or facilities are not available, a breast-preservation program is difficult. In Massachusetts, a full course of just over 6000 cGy (4500 cGy to the whole breast and a 1600-cGy local boost) costs roughly $6000. Thus, breast preservation is more expensive than mastectomy even with reconstruction, as patients still frequently require a hospital admission with general anesthesia for an axillary dissection. Although insurance policies cover such expenses, patients who do not have insurance or have inadequate coverage may find the extra expense of the breast-preservation technique burdensome or impossible. Women with a small breast and a proportionately large cancer may have an unsatisfactory cosmetic outcome after appropriate lumpectomy. The cosmetic result in such patients frequently cannot be predicted beforehand; this fact adds emphasis to the need for a two-step process of lumpectomy and then re-evaluation of the cosmetic outcome as well as pathologic features for decisions regarding breast preservation. Finally, women may have strikingly different attitudes toward breast preservation than expected by the surgeon. For some women, the urge to preserve the breast is so strong that they will accept virtually any risk to achieve this option, whereas for other women, the constant anxiety about a recurrence or undergoing radiation therapy is traumatic enough that they readily accept mastectomy. In our referral surgical oncology practice, roughly 60% of patients are currently treated with breast-preservation techniques; the remainder undergo mastectomy, with immediate reconstruction in approximately three fourths of the cases. The proportion of patients who elect to have breast preservation depends greatly on local medical customs and attitudes; the radiotherapeutic skills available; women's attitudes, which frequently are dependent on the local press and publicity; and the surgeon's interest and enthusiasm for such a program. There is no appropriate proportion of patients who should be treated by breast-preservation techniques, but clearly, the proportion of patients so treated increases with experience, acceptability, publicity, and availability. Thus, the selection of breast-preserving therapy for individual patients is a result of an extraordinary array of factors that need to be considered in each patient.(ABSTRACT TRUNCATED AT 400 WORDS)
Breast↗