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2007 New Hampshire Chapter American College of Surgeons

2007 New Hampshire Chapter American College of Surgeons Breast Cancer Care: Where? By Whom? Monica Morrow, M.D., FACS Chair, Department of Surgical Oncology G. Willing Pepper Chair in Cancer Research Fox Chase Cancer Center Optimal Care State of the Art Practice Structure

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2007 New Hampshire Chapter American College of Surgeons

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  1. 2007 New Hampshire ChapterAmerican College of Surgeons Breast Cancer Care: Where? By Whom? Monica Morrow, M.D., FACS Chair, Department of Surgical Oncology G. Willing Pepper Chair in Cancer Research Fox Chase Cancer Center

  2. Optimal Care State of the Art Practice Structure Patient Preference

  3. Breast Cancer Mortality 1975-2000 Weir, HK JNCI 2003;95:1276

  4. What’s the Issue In Breast Cancer? • Common disease • Standard part of general surgery training ( at least for PGY 1 & 2) • 30 day operative mortality well below 1% • Morbidity of therapy decreasing ANYONE CAN DO IT!

  5. Evidence of a Problem • Significant variation in treatment based on geography and volume • Use of non-standard care • Volume-outcome data

  6. Breast Cancer Surgery, 1972 - 1981 80 70 60 50 Modified Radical Mastectomy Failure Rate 40 Radical (Halsted) Mastectomy 30 20 10 0 1972 1976 1977 1981 Year

  7. Randomized Trials of Mastectomy vs. CS + RT Overall Survival Trial Follow-up (yrs.)CS+RTMastectomy Gustave-Roussy 15 73 65 Milan 20 42 41 NSABP B06 20 46 47 NCI 18 59 58 EORTC 10 65 66 Danish 6 79 82

  8. Time Trends in Breast Conserving SurgeryNCDB

  9. Incidence of LR: Randomized Trials % LR Trial Follow-up (yrs) BCT Mastectomy Institut Gustave-Roussy 15 9 14 Milan I 20 9 2 NSABP B06 20 14 10 NCI* 18 22 6 EORTC* 10 20 12 Danish 6 3 4 *Negative margin not required

  10. Local Recurrence in Patients Receiving Systemic Therapy: NSABP Trials StudyER Statusn% 10 yr IBTR B 13 - 116 3.5 B 14 + 530 3.6 B 19 - 389 6.5 B 20 + 1027 4.7 B 23 - 1084 4.3 Wapnir, ASCO 2005

  11. Reasons for High Mastectomy Rates • Medical Contraindications • Lack of Access • Physician Bias • Patient Preference

  12. How Common Are Contraindications to BCT? N = 456 Stage % Eligible BCT 0 67 1 90 2 72 Morrow J Am Coll Surg, 1998

  13. The ACoS - ACR Collaborative Study of Breast CancerFactors Predicting the Use of Breast Conserving Therapy in Stage I and II Breast Cancer M Morrow, DP Winchester, JS Chimel, J Moughan, J Owens, T Pajak, J Sylvester, JF Wilson JCO 2001;192254-61

  14. Multivariate Analysis of MastectomyVs Lumpectomy Variable OR 95% CI pvalue Clinical T2 2.33 2.15, 2.54 .0001 Clinical N+ 1.50 1.29, 1.75 .0001 Grade 2 1.19 1.07, 1.31 .0008 Grade ¾ 1.30 1.17, 1.44 .0001 Favorable Histology 0.75 0.65, 0.88 .0002 Ext. DCIS 1.96 1.76, 2.17 .0001

  15. Results of the Lynn Sage Second Opinion Program n = 231 • DCIS, Stage I or II cancer • Seen 01/96 - 03/99 • Mean age 51.4 years , 89% Caucasian • 70% > HS education, 80% employed • 71% private/PPO insurance Clauson, Cancer 2002

  16. Characteristics of Initial Consultation • 83 % reported surgical options discussed 46%: BCT, M, M+R 22%: BCT only 27%: M + R only 3%: Couldn’t remember Clauson, Cancer 2002

  17. Compliance with BCT Standards of ACoS, ACR, CAP, SSO Disseminated 1992 Evaluated 1994 n = 7097 White, Cancer 2003

  18. BCT Standards Standard% Compliance Pre biopsy mammogram 88 Size lesion in mammo report 47 Specimen oriented 67 Histologic grade 81 Margins assessed 90 ER done 92 Adjuvant Rx N+ 84 * *

  19. Factors Associated with Significant Compliance Variation % Compliance VariableDifference Geographic Region 87 Hospital Type 80 Race 47 Age 33 Payer 20

  20. Geographic Variation in the Use of BCT1994 56% 48% 39% 41% 46% 33% n = 16,643 Morrow, JCO; 2001.

  21. Geographic Variation in the Use of Immediate Breast Reconstruction 1994-1995 7.8% 12.6% 6.6% 11.4% 7.5% 6.4% n = 68,348 Morrow, J Am Coll Surg; 2001.

  22. The Role of Patient Preference in Treatment Choice Breast Implant Size by Region New England 200-225cc Midwest 275-300cc Texas 400-450cc Southern California 400-450cc Data from Mentor Corp.

  23. Trends in Local Therapy Nattinger, Lancet 2000;356:1148-53

  24. Oxford Overview: Trials of BCS +/- RT

  25. Can Anyone Treat Breast Cancer? Effect of Volume on: • Lumpectomy • Sentinel Node Biopsy • Survival

  26. Surgeon Perspectives on the Local Therapy of Breast Cancer • Population based sample • Treatment 2002 • Pathology reports used to identify >1 surgeon for 98.5% of patient sample • Survey response rate 80.0% Katz, Cancer 2005

  27. Surgeon Characteristics n=365 Mean age: 49.4 yrs Female: 14.4% Yrs in Practice: 17.2 (1-49) % Practice Breast: 31.3% (2-100) Practice Setting Community 48.2% Teaching 33.0% Cancer Center 18.8%

  28. Surgeon Characteristics n=365 # Breast Surgeries/yr %Respondents <10 11.5 11-20 17.0 21-50 37.0 51-100 17.0 >100 14.0 *Definitive cancer surgeries

  29. Relationship of Volume to Practice Setting High Volume: >50% Breast Surgery Practice Setting% High Volume Cancer Center 59Teaching Hospital 30Community 18 Female Surgeons: 14% of sample, 35% of high volume surgeons

  30. Scenario 1: Invasive Carcinoma • 40/65 yr old • 2 cm palpable mass, clinical N0 • Bx: Infiltrating Ductal CA 73% BCT 7% Mastectomy 20% No preference Katz, Cancer 2005

  31. Surgical Treatment Favored for InvasiveDisease Scenario, by Surgical Volume 100 p<.001 90 80 70 60 Neither BCS Mastectomy % 50 40 30 20 10 0 Low Moderate Surgical Volume High

  32. What is the 5 yr risk of LR after lumpectomy to clear margins and RT? % Risk% Respondents < 5 33 5-10 53 > 10 14

  33. Surgeon Perspectives in Invasive Cancer • Choice of BCT did not correlate with estimate of risk of local recurrence 72% of surgeons estimating 5 yr LR <5% chose BCT 72% of surgeons estimating 5 yr LR 11-20% chose BCT • Women were more likely to be neutral than men OR 2.1; 95% CI 0.9, 4.9

  34. Surgeon Perspectives in Invasive Cancer • Surgeons favoring BCT were significantly more likely to believe QOL was better at 1 yr • High volume surgeons significantly more likely to believe QOL better • Female surgeons more likely to believe QOL at 1 yr the same (OR 2.0, 95% CI 1.0, 4.2)

  35. Scenario 2: DCIS • 40/65 yr old • Mammogram with small area of calcifications • Bx: Unicentric, low grade DCIS 96% BCS: 61% with RT, 35% without 3% No Preference 0.9% Mastectomy

  36. Surgeon Perspectives in Invasive Cancer • Difference in preference for BCS in DCIS (96%) and invasive cancer (73%) significant (p<.001) • Preference for BCT in invasive cancer did not correlate with estimates of recurrence • Preference for RT in DCIS did not correlate with estimates of recurrence

  37. Correlates of Between Surgeon Variation in Treatment Method: 1477 patients matched to 311 surgeons by unique identifier  65% of eligible patients  70% of eligible surgeons Mean # patients/surgeon 4.6 (1-41) Hawley, Medical Care 2006; 44: 609-16

  38. Between Surgeon Variation in Treatment Mastectomy rate 15-63% cases Variable% Variation Explained Tumor characteristics 23 Patient demographics 1 Surgeon volume 12 Surgeon demographics 5 Surgeon recommendations 5 Hawley, Medical Care 2006; 44: 609-16

  39. Goals of Lumpectomy OutcomeSurgical Correlate Low rate of local Negative margin recurrence Good cosmesis Limited excision normal breast

  40. Patient Population • 217 consecutive cancers 163 invasive, 64 DCIS • Nonpalpable • Treated with BCT All surgery at Lynn Sage Staradub V., JACS 2003; 196: 518-24

  41. Surgeon Volume Median % Neg Case n STVR margin p-value <10 37 80 78 0.004 10-40 85 104 81 >40 95 44 80 Staradub V., JACS 2003; 196: 518-24

  42. Learning Curve for SN Biopsy n=226 100 95 90 85 SLN identification rate (%) SLN false negative rate (%) 80 75 ID rate 70 FN rate 65 1-5 6-10 11-15 16-20 21-25 26-30 >30 # cases performed McMasters Ann Surg 2001

  43. Surgical Cases/Month n=16 surgeons 13.77%  8.3% 11.27%  6.36% 2.19%  0.44% 1-3 Cases (1.72) 3-6 Cases (4.45) >6 Cases (10.19) Cox, Moffitt Cancer Ctr

  44. Volume of Breast Cancer Surgery in the US LA County SEER Registry 1990 - 1998 n=29,666 Breast Cancer Non-surgical Surgical Case Volume Oncologist%Oncologist% per year 1 61 17 < 5 85 39 6 -10 9 17 11-15 4 14 >15 2 31 Skinner, Ann Surg Oncol 2003

  45. Patient Population • 173,401 patients diagnosed 1985-1991 • TNM stage available • Surgical therapy (r = 0.9 for hospital total breast cancer cases vs. surgical cases)

  46. Hospital Volume Calculated as mean of the two years between 1985 and 1991 with the greatest number of cases Survival Ratio of observed overall survival at each hospital to the survival of the aggregate, corrected for age and stage

  47. Hospital Volume n= 1304

  48. Patient Characteristics and Hospital Volume Unrelated SignificantlyDifferent AGE p = 0.0001 Volume Mean Age ( ± SEM) Income (zipcode) < 10 63.7(0.31) Stage Nodal positivity 11 – 25 63.3(0.14) Histologic Grade 26 – 50 62.7 (7.9 ) Type of surgery 51 – 100 62.1 (5.6) Systemic therapy 101 – 150 61.4 ( 7.1) Radiation > 151 60.4 ( 9.7)

  49. Five-Year Overall Survival, All Cases 1.1 1.0 O/E Survival (Mean) 0.9 0.8 All Cases (p=0.0001) DCIS Only (p = NS) 0.7 1 - 10 11 - 25 26 - 50 51 - 100 101 - 150 151+ Hospital Caseload

  50. Five-Year Overall Survival by Treatment 1.1 1.0 O/E Survival (Mean) 0.9 MRM + Systemic (p = 0.0001) BCT+ Systemic (p=0.0001) 0.8 0.7 1 - 10 11 - 25 26 - 50 51 - 100 101 - 150 151+ Hospital Caseload

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