Women Have the Same Desflurane Minimum Alveolar Concentration as Men: A Prospective Study

Background: Women generally report greater sensitivity to pain than do men, and healthy young women require 20% more anesthetic than healthy age-matched men to prevent movement in response to noxious electrical stimulation. In contrast, minimum alveolar concentration (MAC) for xenon is 26% less in elderly Japanese women than in elderly Japanese men. Whether anesthetic requirement is similar in men and women thus remains in dispute. The authors therefore tested the hypothesis that the desflurane concentration required to prevent movement in response to skin incision (MAC) differs between men and women.

Methods: Using the Dixon "up and down" method, the authors determined MAC for desflurane in 15 female and 15 male patients (18-40 yr old) undergoing surgery.

Results: MAC was 6.2 +/- 0.4% desflurane for women versus 6.0 +/- 0.3% for men (P = 0.31), a difference of only 3%. These data provide 90% power to detect a 9% difference between the groups.     

Women Appear to Have the Same Minimum Alveolar Concentration as Men: A Retrospective Study

Background: A recent report finds that elderly Japanese women given xenon have a significantly smaller (26% less) MAC (minimum alveolar concentration required to eliminate movement in response to surgical incision in 50% of patients) than Japanese men of the same age. The authors assessed whether this finding applied to other/all anesthetics.

Methods: The authors reviewed data obtained previously for 258 patients (127 women and 131 men) anesthetized with desflurane, diethyl ether, halothane, methoxyflurane, sevoflurane, or xenon. Data were normalized to the MAC for the anesthetic as determined by logistic regression (i.e., MAC would equal a value of 1.000.)

Results: The MAC for the normalized combined (all) data for women (1.013 +/- 0.017; mean +/- SEM) did not differ significantly from the normalized combined data for men (1.005 +/- 0.009), and neither differed significantly from 1.000. However, a significantly smaller MAC value was found for women in two studies of sevoflurane (subsets of the above studies) given to Japanese patients: 12% in one study and 16% in the other.     

Local Recurrence and Survival Among Black Women With Early-Stage Breast Cancer Treated With Breast-Conservation Therapy or Mastectomy

Background: Black women with breast cancer have significantly worse survival rates and receive diagnoses at relatively younger ages, compared with white patients with breast cancer, in the United States. Young age at diagnosis has been associated with increased risk for local recurrence (LR) after breast-conservation therapy (BCT). The goal of this study was to evaluate the impact of age and BCT on LR and survival rates among black patients with breast cancer.Methods: The records for 363 black women treated for breast cancer (excluding stage IV disease) at a comprehensive cancer center were reviewed.Results: Fifty-eight percent of patients (n = 211) had tumors 5 cm in diameter. Forty-two of these patients (19.9%) received BCT; the LR rate for this group was 9.8%. A total of 168 patients (79.6%) underwent mastectomy; the LR rate for this group was 8.9%. Data on the primary operation were unavailable for one patient. Five-year disease-free survival rates were similar for patients treated with BCT and those treated with mastectomy (88% and 73%, respectively). LR was associated with significant decreases in 5-year overall survival rates for both the BCT group (67% vs. 95%, P < .01) and the mastectomy group (43% vs. 76%, P < .01). LR and 5-year diseasespecific survival rates were similar for patients <50 years of age and patients 50 years of age, regardless of treatment.Conclusions: LR and survival rates are not compromised by the use of BCT among black American patients. LR is associated with an increased risk of breast cancer death, regardless of treatment type. Younger age at diagnosis was not associated with an increased rate of LR after BCT in this series.     

Differences in Breast Cancer Treatment and Survival Between Older and Younger Women

▪  Abstract: The study aim was to compare breast cancer treatment and survival between older and younger women treated at the University of Texas M. D. Anderson Cancer Center over a 30-year period, 1958–1987. Data were obtained from the Medical Informatics Tumor Registry and were examined by 15-year time periods. Treatments were stratified by no surgery, surgery alone, or surgery and additional treatment. Mantel–Haenszel chi-square statistics and actuarial life tables were used for comparisons. Among 3,382 women treated for breast cancer, treatment differed by age groups (p < 0.01). The most consistent finding by disease stage was that older women were less likely to receive treatment in addition to surgery compared to younger women (p < 0.01–0.05). Among women with local or regional involvement who received surgery and additional treatment, 5-year survival was similar regardless of age group. However, among women with distant disease who received surgery and additional treatment, 5-year survival differed significantly by age group (p = 0.03); women in the 65- to 74-year age group experienced the best survival. In this hospital population, older women with breast cancer who received surgery and additional treatment experienced similar, sometimes better, 5-year survival compared with younger women, which suggests that older women, in some cases, may benefit from combined modality treatment for breast cancer. ▪     

Tumor Location of the Lower-Inner Quadrant Is Associated with an Impaired Survival for Women With Early-Stage Breast Cancer

Background There is growing evidence that tumors of the inner quadrants (especially the lower-inner quadrant) metastasize more often to the internal mammary chain (IMC). As these metastases are not investigated, patients with lower-inner quadrant tumors have an increased risk of being under-staged and under-treated and may therefore have a higher risk of death from breast cancer. Methods We identified all 1522 women operated for stage I breast cancer between 1984 and 2002 recorded at the population-based Geneva Cancer Registry. We compared breast cancer mortality risk by tumor location with multivariate Cox regression analysis that accounted for all factors linked to tumor location and survival. Results Ten-year disease-specific survival was 93% (95%CI: 91–94%). Patients with breast cancer of the lower-inner quadrant (n = 118; 7.8%) had an importantly increased risk of dying of breast cancer compared to women with breast cancer of the upper-outer quadrant (multiadjusted Hazard Ratio: 2.3, 95%CI: 1.1–4.5, P = 0.0206). The over-mortality associated with this quadrant was particularly evident for tumors >10 mm (multiadjusted HR: 3.6, 95%CI: 1.6–7.9, P = 0.0016). There was no increased breast cancer mortality risk for tumors located in other quadrants. Conclusions Tumor location in the lower-inner quadrant is an independent and important prognostic factor of stage I breast cancer. Further research is needed to evaluate if the over-mortality of patients with stage I cancer of the lower-inner quadrant is indeed a result of under-treatment due to undetected IMC metastases. If so, patients with stage I breast cancer of the lower-inner quadrant are good candidates for systematic IMC investigation. Part of this study was presented as a poster at the 28^th San Antonio Breast Cancer Symposium, December 8-11, 2005.     

Patient Age and Preoperative Breast MRI in Women With Breast Cancer: Biopsy and Surgical Implications

Background

The influence of patient age on multidisciplinary treatment planning after preoperative breast magnetic resonance imaging (MRI) and its influence on the surgical decision-making process are unclear.

Methods

We performed a retrospective review of 710 women with breast cancer who underwent preoperative MRI at our institution between January 2003 and December 2008. Analysis by patient age included the number of additional ipsilateral MRI findings, the number of biopsies recommended/performed, the number of additional cancers found, and the percentage of patients undergoing mastectomy.

Results

Of the 710 patients, 343 (48%) had additional ipsilateral MRI findings. After stratifying by age, the incidence of additional ipsilateral findings differed between decades (P = 0.004). However, fewer biopsies were recommended in older patients (P = 0.043). The number of women pursuing preoperative needle biopsy increased with age (P = 0.0018), while the incidence of a second focus of breast cancer did not change with age (P = 0.07). The mastectomy rate decreased from 65% in women younger than 50 to 40% in women older than 70 (P < 0.001).

Conclusions

In the setting of newly diagnosed breast cancer, the value of MRI is not influenced by patient age, with at least 40% of women in all age groups having additional findings on MRI. Insisting on preoperative needle biopsy of additional findings may decrease mastectomy rates. Further study is needed to determine the reasons for the increased percentage of mastectomies in younger women.     

Breast Cancer: Presentation and Intervention in Women With Gastrointestinal Metastasis and Carcinomatosis

Background Breast cancer metastatic to the gastrointestinal tract or peritoneum is rare. We reviewed the natural history of ductal and lobular carcinoma in women with breast cancer metastatic to the gastrointestinal tract, peritoneum, or both. Methods We performed a retrospective review of all patients (1985–2000) with a pathologic diagnosis of breast cancer metastatic to the gastrointestinal tract or peritoneum. Patients were categorized into three groups: those with gastrointestinal metastasis, carcinomatosis, or both. Results Of 73 patients, 23 (32%) had gastrointestinal metastasis only, 32 (44%) had carcinomatosis only, and 18 (25%) had both. The median age at initial breast cancer diagnosis was 55 years. The mean interval between the primary diagnosis and metastatic presentation was 7 years. Sites of gastrointestinal metastases included the esophagus (8%), stomach (28%), small intestine (19%), and colon and rectum (45%). Infiltrating lobular carcinoma represented 34 (64%) of the 53 gastrointestinal metastases. The median overall survival after diagnosis was 28 months. Palliative surgical intervention in 47 patients (64%) did not affect overall survival. Some survival benefit may have accrued to select patients with gastrointestinal metastasis who underwent surgical palliation (44 vs. 9 months). Advanced age at diagnosis and gastric metastases had a negative effect on survival, whereas treatment with systemic chemotherapy or tamoxifen had a positive effect on survival. Conclusions Gastrointestinal metastasis occurred more often in patients with invasive lobular carcinoma. Surgical intervention did not significantly extend overall survival but may be considered in a select group of patients.     

Breast Cancer in Older Women

Abstract: This review addresses the management of breast cancer in women over 65 years of age. In 1995, approximately 50% of breast cancers will be diagnosed in this quickly growing segment of our population. Breast cancer screening and treatment modalities including surgery, radiation therapy, and chemotherapy are underutilized in the geriatric population. Several recent studies demonstrate that healthy older women, like younger women, benefit from screening and tolerate surgery, radiation therapy, and chemotherapy well. We will discuss current screening and treatment recommendations based on a review of pertinent literature.     

Breast Cancer in Young Women

There are a number of issues specific to breast cancer diagnosis in young women:

1 Breast cancer is uncommon in young women. It is associated with more-aggressive behavior and a worse prognosis. These clinical observations have recently been verified by histologic and biochemical analyses of these cancers.

2 Young women undergoing breast-conservation therapy can have a higher rate of local recurrence than older women, and this issue should be specifically addressed in preoperative counseling of these women.

3 Long life expectancy, issues of fertility, and risk of premature menopause resulting from cytotoxic chemotherapy are concerns unique to the young breast cancer patient.

4 Issues related to a new diagnosis of breast cancer associated with pregnancy bring up a multitude of issues in this vulnerable population.

5 Psychosocial issues of sexuality and self-image can warrant interventions in this population.

Breast Cancer in Older Women

Abstract: Breast cancer remains the most common malignancy and the leading cause of cancer death in women of all ages. The American Cancer Society has estimated that 180,200 women will develop breast cancer in the United States in 1997 and 43,900 will die from the disease (1). Age is an important variable affecting both breast cancer biology and management. The risk of developing breast cancer increases with age. Feuer et al., using data from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) Program, have estimated that the cumulative probability of developing invasive breast cancer from birth, which is less than 0.5% at the age of 40, increases approximately 20-fold for those women that reach the age of 95 years (2). As the duration of life continues to increase in the western world, the percentage of older women who have breast cancer will also increase. It is estimated that by the end of the 20th century more than 50% of all new cases of breast cancer will occur in women aged 65 years or older (3). Despite this high prevalence of disease, there is a great lack of definitive information about outcome from breast cancer in this segment of the population. Patients over the age of 65 years have frequently been excluded from large prospective randomized clinical trials, and as a consequence, no clear practice guidelines about the optimal management of these patients have been released. Many studies have indicated that elderly women with breast cancer are more likely to receive less aggressive treatment when compared to their younger counterparts (4–6). This lesser treatment has stemmed from several widely held assumptions: that older women (a) have less aggressive breast cancers, (b) have a greater likelihood of presenting with more advanced disease, (c) have a life expectancy so limited not to justify the use of standard treatment, and (d) are poor candidates for surgery more extensive than biopsy and for adjuvant treatments. Evidence to support these assumptions remains controversial. This article will provide an overview of available data on the main unresolved issues, including biology, screening, local treatment, and adjuvant therapy, and will try to indicate practice guidelines for the management of elderly women based on the current knowledge.     

Intraoperative Gamma Detection Of125I-Lanreotide in Women With Primary Breast Cancer

Background: Somatostatin receptors are present in most human breast cancers. We performed a pilot trial of intraoperative tumor-gamma detection using the radiolabeled somatostatin analog 125I-lanreotide in 13 women with 14 primary breast carcinomas.Methods: All patients were given¹²⁵I-lanreotide intravenously before surgery. Patients underwent lumpectomy, and postresection margins were evaluated with the gamma probe. Axillary dissection specimens were evaluated ex vivo.Results: Seven of 13 women had gamma probe-positive or clinically suspicious margins reexcised at the time of lumpectomy. Four of six probe-positive margins were histologically positive, and two of six probe-positive margins were histologically negative; a single clinically suspicious margin was histologically positive. A total of 270 axillary lymph nodes were evaluated ex vivo by gamma probe and histology. McNemars contingency tests demonstrated a highly statistical correlation between histology and gamma probe counts (P < .0001).Conclusions: The overall accuracy of nodal evaluation with¹²⁵I-lanreotide/intraoperative gamma detection was 77%; the negative predictive value of this technique was 97%, however. This technique predicted the presence of tumor in 20% of axillary lymph nodes that were negative by routine histology. This technique appears safe and is able to detect positive tumor resection margins and accurately predict axillary lymph node negativity. Further trials of this technique are required to validate its utility.     

Survival in Breast Cancer Patients Undergoing Immediate Breast Reconstruction

Abstract: Immediate and early‐delayed breast reconstruction are the preferred methods of reconstruction in breast cancer patients treated with mastectomy. These options for reconstruction allow for superior outcomes through peri‐operative planning between the oncologic surgeon and reconstructive team. We used the Surveillance, Epidemiology, and End Results (SEER) database to study the overall survival of patients treated with immediate or early‐delayed breast reconstruction after mastectomy. Population level de‐identified data was abstracted from the National Cancer Institute’s SEER cancer database. We obtained data for all female patients with breast cancer treated with mastectomy from 2000 to 2002. Patients with missing or incomplete data were excluded. Univariate and multivariate statistics were performed using Intercooled Stata 7.0 (College Station, TX). A total of 51,702 patients were included in the study. The mean age was 60.8 (range 20–104) years old. Reconstruction was performed in 16.7% of patients. Multivariate analysis showed that patients treated with mastectomy and reconstruction had a significantly lower hazard ratio of death (HR = 0.62, p < 0.001) compared with patients treated with mastectomy only, when controlling for demographic and oncologic covariates. Black patients comprised 7.5% of the total population, and multivariate analysis showed that black patients had a significantly increased hazard ratio of death (HR = 1.43, p < 0.001) when compared with white patients, when controlling for all other covariates including reconstruction status. We show that women with breast cancer who undergo breast reconstruction after mastectomy do not have a worse overall survival than those not undergoing breast reconstruction. This is true when patient age, race, income, and marital status; and tumor stage, histology, grade, use of radiotherapy, and mastectomy site (bilateral or unilateral) are controlled for.     

Breast Cancer in Women With Recent Exposure to Fertility Medications is Associated With Poor Prognostic Features

Background: Fertility drug therapy (FDT) induces supraphysiologic endogenous estrogen production and might transiently increase breast cancer risk. Tumors developing following FDT exposure have not been extensively studied.Methods: Thirty-eight breast cancer patients with 40 primary tumors and with history of FDT exposure were identified and compared with two other breast cancer groups: women with pregnancy-associated breast cancer (PABC, 22 patients with 23 tumors) and premenopausal women born during same calendar years and not exposed to hormonal manipulations or recent pregnancy (controls, 192 patients with 201 tumors). Patients were diagnosed and treated mostly during the last decade.Results: Compared with controls, tumors of patients with FDT exposure presented at advanced stages (P < .005), were more likely to be estrogen or progesterone receptor negative (P < .03) and of poor histology grade (P <.0002). Aggressive features predominated among women diagnosed within 2 years of an FDT cycle (P <.05). FDT and PABC groups shared similarities. With a median follow-up of 43 months, relapse-free and cancer-free survival rates were significantly reduced in the FDT and PABC groups (P < .01 and P < .01, respectively). Multivariate analysis revealed only treatment-defined tumor stage (operable, locally advanced, or metastatic) as predictive of survival (P < .0001).Conclusion: Breast tumors in women with recent FDT exposure present with poor prognostic features and share similarities with PABC. Survival is stage dependent.