Recent Publications

On this page you will find information about and links to relevant recent publications

 

Summary

This pooled analysis of 2310 patients from four neoadjuvant clinical trials examined survival and treatment response in patients with HER2-low-positive (immunohistochemistry 1+ or 2+/in-situ hybridisation negative; n=1098) versus HER2-zero (immunohistochemistry0; n=1212) breast cancer. HER2-low-positive tumours had significantly lower pathological complete response (29.2% vs. 39%; p=0.0002). This was also seen in the hormone receptor positive subgroup (17.5% vs. 23.6%; p=0.024), but not in the hormone receptor negative subgroup (50.1% vs. 48%; p=0.21). Patients with HER2-low-positive tumours had significantly longer survival (3 year DFS 83.4% vs. 76.1%; p=0.0084). This was seen in hormone receptor negative tumours (3 year DFS 84.5% vs. 74.4%; p=0.0076), but not in hormone receptor positive tumours (3 year DFS 82.8% vs. 79.3%; p=0.39).  

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Summary

This meta-analysis, including 14 studies (n=19819), evaluates the safety of breast conserving surgery (BCS) in triple negative breast cancer. 9828 patients underwent BCS (49.6%) and 9991 patients (50.4%) underwent mastectomy. The pooled odds ratio (OR) for locoregional recurrence was 0.64 (0.48 to 0.85; p=0.002) indicating lower odds for LRR for women who had BCS as opposed to mastectomy.  The pooled OR for distant metastasis was 0.7 (0.53 to 0.94; p=0.02) indicating lower odds of distant metastasis for women who underwent BCS. This difference diminished with follow up time. Pooled hazard ratio of 0.78 (0.69 to 0.89; p<0.001) showed lower hazard ratio for all-cause mortality among women treated with BCS.

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Summary

This secondary analysis of the Mastectomy Reconstruction Outcomes Consortium study aims to compare Patient Reported Outcomes (PROs) of women who underwent immediate implant-based breast reconstruction after receiving nipple sparing mastectomy (NSM) versus mastectomy with subsequent nipple reconstruction. Of the 600 women in the study, 47.7% underwent NSM. Analysis of BREAST-Q scores showed no significant differences in satisfaction with breast, psychosocial well-being, physical well-being or sexual well-being. Mastectomy type was not a significant predictor of complications or reconstructive failure.

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Summary

This cohort study used prospectively collected national data and included women diagnosed with primary invasive T1-2 N0-2 breast cancer. Patients underwent breast surgery in Sweden (2008-2017; n=48986 with median follow up of 6.28 years). Patients received BCS and radiotherapy (n=29367; 59.9%), mastectomy without radiotherapy (n=12413; 25.3%), or mastectomy with radiotherapy (n=7206; 14.7%). 5 year OS was 91.1% and BCSS was 96.3%. OS and BCSS were significantly worse after mastectomy without radiotherapy (HR 1.79 and HR 1.66 respectively) and mastectomy with radiotherapy (HR 1.24 and HR 1.26 respectively) than after BCS and radiotherapy. 

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Summary

This prospective multicentre trial investigated the accuracy of ultrasound-guided biopsies identifying breast pathologically complete response (pCR) after neoadjuvant systemic therapy (NST) in patients with radiological partial (rPR) or complete (rCR) on MRI. Eight ultrasound-guided 14-G core biopsies were obtained before surgery close to the marker clip. Pre-surgical biopsies were obtained in 167 patients (136 rCR / 31 rPR) who had hormone receptor positive/HER2 negative (38%), HER2 positive (38%), or triple negative (36%) breast cancer. The pCR rate was 53% in the entire cohort. Of 78 patients who had residual disease, biopsies were false negative in 29 patients (37%). the multivariable significantly associated with false negative biopsy was rCR (FNR 47%; p=0.01).

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Summary

Targeted axillary dissection (TAD) involves targeted lymph node biopsy and SLNB. SenTa study is a prospective registry study conducted across 50 centres which aims to investigate the feasibility and accuracy of TAD in patients undergoing neoadjuvant systemic therapy (NST). Patients had clip inserted into the biopsy-confirmed positive lymph nodes. After NST, the clipped node was resected in 329 of 423 patients (77.8%). TAD was successful in 199 of 229 patients (detection rate of 86.9%) with sentinel lymph node and targeted lymph node identical in 129 patients (64.8%). The FNR was 4.3% for TAD followed by ALND.  

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Summary

This systematic review and meta-analysis examined whether the timing of surgery post-neoadjuvant chemotherapy (NACT) impacted overall survival (OS) and disease free survival (DFS). Five studies (including 8794 patients) were eligible for inclusion. Patients who had surgery <8 weeks post-NACT had significantly improved OS (OR 0.47) and DFS (OR 0.71). Furthermore, there were no survival advantages in having surgery <4 weeks post-NACT with no difference in pCR rate between those that had surgery <4 weeks and 4-8 weeks post-NACT.

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Summary

Poly(adenosine diphosphate–ribose) polymerase inhibitors target cancers with defects in homologous recombination. This study was a phase 3, double-blind, RCT involving patients with HER2–negative early breast cancer with BRCA1 or BRCA2 or likely pathogenic variants who had received local treatment and neoadjuvant or adjuvant chemotherapy. Patients were randomly assigned (in a 1:1 ratio) to 1 year of oral olaparib or placebo.

The primary end point was invasive disease–free survival. A total of 1836 patients underwent randomization.       The 3-year distant disease–free survival was 87.5% in the olaparib group and 80.4% in the placebo group (difference, 7.1 percentage points; 95% CI, 3.0 to 11.1; hazard ratio for distant disease or death, 0.57; 99.5% CI, 0.39 to 0.83; P<0.001). Olaparib was associated with fewer deaths than placebo (59 and 86, respectively) (hazard ratio, 0.68; 99% CI, 0.44 to 1.05; P=0.02); however, the between-group difference was not significant at an interim-analysis boundary of a P value of less than 0.01. Safety data were consistent with known side effects of olaparib, with no excess serious adverse events or adverse events of special interest.

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Summary

This was a multicentre, prospective, observational cohort study of surgery or primary endocrine therapy in women aged over 70 years with operable breast cancer (n=3416 with 56 UK breast units who participated). Adverse effects on quality-of-life outcomes were seen in the first few months after surgery, which largely resolved by 24 months.

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Summary

The B-Map-C investigated alterations to breast cancer management during the peak transmission period of the UK COVID-19 pandemic (March to May 2020). 64 UK breast units participated (n=3776) with 59% determined to have had ‘COVID-altered’ management. However, the majority of ‘COVID-altered’ management decisions were largely in line with pre-COVID evidence-based guidelines, implying that breast cancer outcomes are unlikely to be negatively impacted.

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Summary

This systematic review aimed to determine if pathological margin proximity is associated with local or distant recurrence for patients with early invasive breast cancer or ductal carcinoma in situ who were treated with mastectomy (including skin sparing mastectomy). 34 studies (n=34,833 patients) were included for analysis. Positive margins were associated with increased risk of local and distant recurrence. Patients with a positive or close margin are at two to threefold increased risk of local recurrence.

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Roszkowski N, Lam SS, Copson E, Cutress RI, Oeppen R. Expanded criteria for pretreatment staging CT in breast cancer. BJS Open. 2021 Mar 5;5(2):zraa006. doi: 10.1093/bjsopen/zraa006. PMID: 33715004; PMCID: PMC7955978.

 

Summary

This study sought to identify factors predictive of distant metastatic disease at presentation to enable appropriate selection of patients for pretreatment CT. A total of 1377 patients with newly diagnosed breast cancer were identified, of whom 1025 had complete data; 323 staging CT examinations were performed. Distant metastases were identified at presentation in 47 (4.6 per cent).Some 30 of 47 patients with metastatic disease met established criteria for staging (T4, recurrence, symptoms of possible distant metastases), leaving 17 patients with metastatic disease potentially missed by use of these criteria alone. Multivariable analysis showed that tumour size at least 3 cm combined with sonographically abnormal axillary lymph nodes predicted a high probability of distant metastatic disease at pre- sentation (positive predictive value 18.8 per cent, odds ratio 4.83, P < 0.001).

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Summary

This study aimed to examine the planned long-term recurrence and survival outcomes from the ELIOT trial. Eligible women, aged 48-75 years with a clinical diagnosis of a unicentric breast carcinoma with an ultrasound diameter not exceeding 25 mm, clinically negative axillary lymph nodes, and who were suitable for breast-conserving surgery, were randomly assigned (1:1) via a web-based system, with a random permuted block design (block size of 16) and stratified by clinical tumour size, to receive post-operative whole breast irradiation (WBI) with conventional fractionation (50 Gy given as 25 fractions of 2 Gy, plus a 10 Gy boost), or 21 Gy intraoperative radiotherapy with electrons (ELIOT) in a single dose to the tumour bed during surgery. The trial was open label and no-one was masked to treatment group assignment. The primary endpoint was the occurrence of IBTR. After a median follow-up of 12·4 years (IQR 9·7-14·7), 86 (7%) patients developed IBTR, with 70 (11%) cases in the ELIOT group and 16 (2%) in the WBI group, corresponding to an absolute excess of 54 IBTRs in the ELIOT group (HR 4·62, 95% CI 2·68-7·95, p<0·0001). At final follow-up on March 11, 2019, 193 (15%) women had died from any cause, with no difference between the two groups (98 deaths in the ELIOT group vs 95 in the WBI group; HR 1·03, 95% CI 0·77-1·36, p=0·85.

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Annals of Surgery: Mar 2020 - Volume 271 - Issue 3 – p574-580

This study examined pathological complete response (pCR) in the breast and the axilla in 4084 patients treated with neoadjuvant chemotherapy (NACT). The data was derived from the Netherlands Cancer Registry. Overall breast pCR rate of 24.1% was observed in cT1-3N0-1 breast cancer patients treated with NACT. In patients who achieved breast pCR, 97.7% of clinically node negative (cN0) patients had no tumour in the lymph nodes (ypN0) post-NACT. Furthermore, 45% of cN1 patients had converted to ypN0 after NACT. The study findings support the need for future clinical trials to investigate potential de-escalation of axillary surgery in this patient cohort when image-guided tissue sampling identifies a breast pCR.

British Journal of Surgery: Feb 2020 

This study examines whether biological subtype in patients diagnosed with inflammatory breast cancer (IBC) influences their outcome using a national cancer database. Amongst 4068 patients diagnosed with IBC, 38.7% were ER+HER2-, 32.5% HER2+, and 28.8% were ER-HER2-. 84% were clinically node positive at presentation. Total pCR rates were 6.2% (ER+HER2-), 38.8% (HER2+), and 19.1% (ER-/HER2-). The 5 year overall survival was rates were 64.9% (ER+HER2-), 74% (HER2+), and 44% (ER-/HER2-). Multivariate analysis showed that ER-/HER2- subtype and the absence of pCR predicted for worse survival. The study findings support the concept that IBC is not a distinct biological entity with uniformly poor outcomes and highlights the recent improved outcomes in HER2+ IBC. However, future studies are needed to improve outcome for patients with ER-/HER2- IBC. 

Annals of Surgical Oncology (2019) 26: 4246-4253

Women with dense breasts may have less accurate pre-operative imaging estimation of tumour size. This may in turn affect the margin re-excision rates in women receiving breast conserving surgery (BCS). This study examined the association between breast density (using the BIRADS classification) and re-excision rates in 701 patients with invasive breast cancer. 15.1% of women had at least one re-excision. Younger age was associated with increased breast density (p<0.001). Median tumour size was 1.2cm (range 0.1-4.5cm) with multifocal disease present in 19.8%. MRI was performed in 14.7% of patients, and more frequently utilised in women with denser breasts (27.6% vs. 9%; p<0.001). Extensive Intraductal Component (EIC) was seen in 7.4%.

On multivariate analysis, breast density was significantly associated with increased odds of re-excision (OR 1.37; p=0.049), as did multifocality (p<0.001) and the presence of EIC. The study findings support the need for developing techniques that can reduce re-excision rates for women with dense breasts who undergo BCS.

Medication to Reduce Risk of Breast Cancer: USPS Task Force Recommendation

Journal: JAMA

Young patients with breast cancer and BRCA mutation have similar survival to sporadic breast cancer patients (POSH trial)

Journal: Lancet Oncol

TEAM study

Therapeutic mammaplasty is a safe and effective alternative to mastectomy or standard breast-conserving surgery

Journal: Brit J Surg

 Targeted axillary dissection (TAD) has a low false negative rate – removal of clipped node during sentinel node biopsy

Journal: J Clin Oncol

 RCT Quality of Life Outcomes no better with 1-stage versus 2-stage implant reconstruction  

Journal: Lancet Oncol

Quality of life improved following PMRT to autologous versus implant based reconstruction

Journal: JNCI

Complications following implant based reconstruction in the UK from iBRA group

Journal: Lancet Oncol

RCT Lymphoedema rates reduced with reverse mapping

Journal: Ann Surg Oncol

S-LYMPHA (simplified LYMPHA) may reduce rates of lymphoedema after axillary clearance

Journal: Annals of Surgery

BRASS  Jenny Banks

Breast Angiosarcoma Surveillance Study (BRASS) – A National Audit of Management and Outcomes of Angiosarcoma of the Breast and Chest Wall

The BRASS study is a collaborative project led by practising breast and plastic surgeons in the UK and ROI.

Shave margins reduce positive margin rates

Journal: Annals of Surgery

Shave margins reducer re-excision rate by 50% but increase volume of excised tissue

Journal: NEJM