Published research - Paper abstracts

Screen-detected breast cancer compared to symptomatic presentation: an analysis of surgical treatment and end-points of effective mammographic screening

Spillane AJ. Kennedy CW. Gillett DJ. Carmalt HL. Janu NC. Rickard MT. Donnellan MJ
Australian & New Zealand Journal of Surgery. 2001 Jul, 71(7):398-402

Background: Mammographic screening has been shown to reduce mortality from breast cancer and to offer more opportunity for breast conservation surgery (BCS). The minimum standards (or surrogate end-points) that need to be achieved by a screening programme if it is to reduce mortality have been derived from the Two County Study. Three surrogate end-points that can be used to gauge the quality of the screening service are that 50% of the identified infiltrating cancers should be < 15 mm; at least 30% of grade 3 cancers should be < 15 mm; and 70% of screen-detected cancers should have a negative axillary dissection. The present study assesses these end-points of effective screening in an urban population referred to The Strathfield Breast Centre (TSBC). The screening end-points and surgical treatment of one group of women referred with a BreastScreen New South Wales (NSW)-detected breast cancer (screen group) were compared to all the other, mostly symptomatic, breast cancer referrals (symptom group). The problems with the current pattern of acceptance of mammographic screening in TSBC's referral area are discussed.

Methods: A prospective non-randomized study was done via analysis of the prospective database at The Strathfield Breast Centre (TSBC).

Results: There were 224 women in the screen group and 657 women in the symptom group. The mean tumour size was 18.1 mm in the screen group and 22.1 mm in the symptom group. There were significantly more small invasive cancers (< 15 mm) in the screen group (58%) compared with the symptom group (33%; P < 0.001). In the screen group there were more low-grade tumours but 30% of grade 3 tumours were < 15 mm compared with 16% in the symptom group (P = 0.009). In patients with invasive cancers who underwent axillary dissection, there was a significant difference in axillary node negativity, being 72% in the screen group and 59% in the symptom group (P = 0.003). In the screen group 64% of women had BCS compared with 51% in the symptom group (P = 0.002).

Conclusions: These end-points of effective mammographic screening were met in the BreastScreen NSW group of women who were referred to TSBC despite the biases involved which could lessen the effectiveness of the screening programme. This crudely translated into a significant reduction in breast cancer mortality but selection and lead-time bias has to be taken into account in evaluation of these data. There was a significantly greater chance of BCS in the screen group.

Implications of extranodal spread in node positive breast cancer: a review of survival and local recurrence

J. A. Bucci, C. W. Kennedy, J. Burn, D. J. Gillett, H. L. Carmalt, M. J. Donnellan, M. G. Joseph and S. C. Pendlebury.
The Breast (2001) 10, 213-219

Abstract: An evaluation of extra nodal spread (ENS) in predicting overall survival and locoregional relapse rates in 311 node positive breast cancer patients was undertaken: the study group comprised 71 patients with ENS and the control group comprised 240 patients with no ENS. A review of pathology reports that described ENS was performed and a scoring system to categorize focal involvement, extensive axillary fat involvement, and positive axillary surgical margins was devised. Median follow up time was 3.1 years. Overall survival, disease specific survival and disease-free survival rates were significantly worse in the study group in comparison with the control group. Poorer survival with more extensive pathological invasion of ENS was demonstrated. Multivariate analysis of disease specific survival in those patients with 1–3 involved lymph nodes demonstrated that ENS positivity was prognostically significant (P=0.013). Although locoregional relapse was increased in the presence of ENS, axillary relapses were uncommon and do not warrant axillary radiation.

Sentinel node biopsy in breast cancer: results of 103 cases.

Molland JG. Dias MM. Gillett DJ.
Australian & New Zealand Journal of Surgery. 70(2):98-102, 2000 Feb.

Background: In early breast cancer the status of the axillary nodes has been shown to be one of the primary prognostic indicators. Biopsy of the sentinel node, or first draining lymph node, of a tumour has been investigated as an alternative to axillary dissection in early breast cancer. A series of sentinel node biopsies in 103 patients is reported here.

Methods: Both pre-operative lymphoscintigraphy and intra-operative blue dye were used to map the sentinel nodes.

Results: Mapping was successful in 87 (84.4%) cases and sentinel nodes were retrieved in 94.2% of these patients. Where lymphoscintigraphic mapping was unsuccessful, sentinel nodes were found in 37.5%. When sentinel nodes were retrieved, correlation of the sentinel node status with the axillary nodes was accurate in 97.5%. There were two false negatives, both in large tumours. The sentinel node status was an accurate predictor of axillary status in 95.7% of the node positive patients.

Conclusion: If only the 86 patients with invasive carcinoma and four or more axillary nodes removed at surgery are considered, the sentinel node was accurate in assessing the axillary status in 97.7% of the total patient group (2.3% false negative rate), 97.2% of those in whom sentinel nodes were successfully retrieved (2.8% false negative rate) and 94.9% of the patients with positive axillary nodes (5.1% false negative rate). Sentinel node biopsy is a valid technique providing an accurate reflection of the axillary node status and having a low false negative rate.

Carcinoma of the male breast: a review and recommendations for management.

Carmalt HL, Mann LJ, Kennedy CW, Fletcher JM, Gillett DJ
Australian & New Zealand Journal of Surgery 1998 Oct;68(10):712-5

Background: Male breast cancer is rare and experience of it in any single institution is limited. The aim of this study was to evaluate the presentation, management and outcome of male patients with breast cancer treated at Concord Repatriation General Hospital over a 38-year period and to determine a best-practice protocol based on the results and a review of the literature.

Methods: A total of 42 patients were retrospectively reviewed, pathology slides were re-examined and reclassified where necessary. Outcome was assessed and compared with results obtained from a literature review.

Results: A trend towards less radical surgery has emerged. Overall 5-year survival was 50%, but, due to the late age at presentation, more than half the deaths were non-breast cancer related. One quarter of the patients presented with locally advanced or metastatic disease.

Conclusions: The presentation, diagnosis pathology and outcome of breast cancer are similar in men and women, although the disease occurs at a later age in men. Radical surgery is not required in order to gain local control, but knowledge of axillary node status is important in determining prognosis and the need for adjuvant therapy.

Breast cancer outcomes at the Strathfield Breast Centre.

Loveridge KH, Kennedy CW, Janu NC, Carmalt HL, Gillett DJ
Australian & New Zealand Journal of Surgery 1998 Jun;68(6):411-4

Background: Breast cancer is the most commonly diagnosed cancer and the most common cause of cancer death in women. This report presents outcomes from a multidisciplinary breast clinic established in 1989 with the specific aim of providing a rapid, integrated assessment service for patients with breast disease.

Methods: A prospective data collection and analysis using a Microsoft Access (Microsoft Corp., North Ryde, NSW, Australia) database was established and has collected information on all patients presenting for diagnosis or ongoing management of breast cancer. Data on survival were obtained by routine follow-up visits or contact with the patient's general practitioner.

Results: Patient age, mode of presentation and histopathology were similar to other population-based studies in Australia. Ninety-three per cent of the patients had a diagnosis confirmed on the day of consultation. The average time between diagnosis and surgery was 11.9 days. Breast preserving surgery was attempted in 68% and achieved in 50% of cases, 67% of patients had one stage surgery. Five-year disease-free survival was 74% and is comparable with other reports.

Conclusions: The centralization of services and expertise has enabled us to provide efficient service and achieve internationally comparable outcomes.

Pulmonary resection for metastatic breast cancer.

Simpson R, Kennedy CW, Carmalt HL, McCaughan B, Gillett DJ
Australian & New Zealand Journal of Surgery 1997 Oct;67(10):717-9

Background: A patient with a solitary pulmonary metastasis who had breast cancer in the past may benefit from pulmonary resection.

Methods: Between 1984 and 1996, 17 patients underwent metastatectomy for metastatic breast cancer. There were 15 females and two males whose average age was 59 (range: 40-74 years). The median tumour-free interval after the primary breast-cancer operation was 5.1 years (range: 8 months-18.2 years). Sixteen patients had complete resections, which included six lobectomies and 10 lesser resections.

Results: The postoperative mortality was nil and the morbidity rate was 6%. Follow-up was complete in all patients. Recurrent disease developed in four patients and two patients died of their disease. The 5-year survival was 62%.

Conclusion: An aggressive surgical approach is warranted in patients with isolated resectable pulmonary metastases from breast cancer.

A review of pathology reporting for breast cancer.

Wijetunga LH, Carmalt HL, Gillett DJ
Australian & New Zealand Journal of Surgery 1996 Nov;66(11):723-6

Background: A detailed pathology report is important in the determination of treatment options and prognosis in breast cancer. Australia's first National Cancer Consensus Conference, held in 1994, recommended guidelines for the standardization of the clinical information to be provided to the pathologist, the specifications relating to the handling of specimens, and the resultant pathology report.

Methods: We examined the current status of pathology reporting in invasive breast cancer in three New South Wales hospitals from 1986 to 1994.

Results: Histopathologic type was documented in 99% of reports, grade was documented in 47%, size in 46%, and lymph node status in 98%. Only 27% of pathology reports reviewed documented the status of all the above parameters in the one report. Other features such as lymphatic and vascular invasion were documented in only 21% and 9% of pathology reports, respectively, while sex steroid receptor status was reported in almost 90% of cases.

Conclusions: In view of the wide range in the percentage of features reported, we recommend the use of a standardized checklist for the pathological assessment of surgically resected invasive breast cancer specimens.

Mammographically negative breast cancer at the Strathfield Breast Centre.

Chew SB, Hughes M, Kennedy C, Gillett D, Carmalt H
Australian & New Zealand Journal of Surgery 1996 Mar;66(3):134-7

Background: The current diagnostic modalities used to detect breast cancer are mammography, together with clinical examination, ultrasound and fine needle aspiration biopsy (FNAB). The accuracy rates for each modality varies and a combination of the modalities is recommended to detect cancer early. Some authors have suggested that mammography should be used primarily as a screening tool because of the false negative mammography results that have been reported in the past 10 years. The records of patients at the Strathfield Breast Centre were reviewed to determine the accuracy of other modalities.

Methods: The records of 371 breast cancer patients treated at the Strathfield Breast Centre in the 6 years form 1989 to 1994 were reviewed to determine the accuracy of mammography, ultrasound, clinical examination and fine needle aspiration biopsy. Of the 371 women with histopathologically diagnosed breast cancer, 349 had mammography.

Results: The accuracy rate of mammography in the present study was 91% with a false negative rate of 9%. It was found that there was no significant delay in treatment of breast cancer in mammogram-negative patients.

Conclusions: Mammographically negative breast cancer was found to be more common in younger women, to be similar in size to mammogram-positive cancer, to occur in all histological types and grades and was usually invasive rather than noninvasive. The rate of lymph node involvement was similar to the mammogram-positive group.