Showing papers by "Benjamin O. Anderson published in 2016"

Invasive breast cancer version 1.2016

Abstract: Breast cancer is the most common malignancy in women in the United States and is second only to lung cancer as a cause of cancer death. The overall management of breast cancer includes the treatment of local disease with surgery, radiation therapy, or both, and the treatment of systemic disease with cytotoxic chemotherapy, endocrine therapy, biologic therapy, or combinations of these. This article outlines the NCCN Guidelines specific to breast cancer that is locoregional (restricted to one region of the body), and discusses the management of clinical stage I, II, and IIIA (T3N1M0) tumors. For NCCN Guidelines on systemic adjuvant therapy after locoregional management of clinical stage I, II and IIIA (T3N1M0) and for management for other clinical stages of breast cancer, see the complete version of these guidelines at NCCN.org.

NCCN Framework for Resource Stratification: A Framework for Providing and Improving Global Quality Oncology Care.

Abstract: More than 14 million new cancer cases and 8.2 million cancer deaths are estimated to occur worldwide on an annual basis. Of these, 57% of new cancer cases and 65% of cancer deaths occur in low- and middle-income countries. Disparities in available resources for health care are enormous and staggering. The WHO estimates that the United States and Canada have 10% of the global burden of disease, 37% of the world's health workers, and more than 50% of the world's financial resources for health; by contrast, the African region has 24% of the global burden of disease, 3% of health workers, and less than 1% of the world's financial resources for health. This disparity is even more extreme with cancer. NCCN has developed a framework for stratifying the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) to help health care systems in providing optimal care for patients with cancer with varying available resources. This framework is modified from a method developed by the Breast Health Global Initiative. The NCCN Framework for Resource Stratification (NCCN Framework) identifies 4 resource environments: basic resources, core resources, enhanced resources, and NCCN Guidelines, and presents the recommendations in a graphic format that always maintains the context of the NCCN Guidelines. This article describes the rationale for resource-stratified guidelines and the methodology for developing the NCCN Framework, using a portion of the NCCN Cervical Cancer Guideline as an example.

African Breast Cancer—Disparities in Outcomes (ABC-DO): protocol of a multicountry mobile health prospective study of breast cancer survival in sub-Saharan Africa

Abstract: Introduction Sub-Saharan African (SSA) women with breast cancer (BC) have low survival rates from this potentially treatable disease. An understanding of context-specific societal, health-systems and woman-level barriers to BC early detection, diagnosis and treatment are needed. Methods The African Breast Cancer—Disparities in Outcomes (ABC-DO) is a prospective hospital-based study of overall survival, impact on quality of life (QOL) and delays along the journey to diagnosis and treatment of BC in SSA. ABC-DO is currently recruiting in Namibia, Nigeria, South Africa, Uganda and Zambia. Women aged 18 years or older who present at participating secondary and tertiary hospitals with a new clinical or histocytological diagnosis of primary BC are invited to participate. For consented women, tumour characteristics, specimen and treatment data are obtained. Over a 2-year enrolment period, we aim to recruit 2000 women who, in the first instance, will be followed for between 1 and 3 years. A face-to-face baseline interview obtains information on socioeconomic, cultural and demographic factors, QOL, health and BC attitudes/knowledge, and timing of all prediagnostic contacts with caregivers in orthodox health, traditional and spiritual systems. Responses are immediately captured on mobile devices that are fed into a tailored mobile health (mHealth) study management system. This system implements the study protocol, by prompting study researchers to phone women on her mobile phone every 3 months and, failing to reach her, prompts contact with her next-of-kin. At follow-up calls, women provide updated information on QOL, care received and disease impacts on family and working life; date of death is asked of her next-of-kin when relevant. Ethics and dissemination The study was approved by ethics committees of all involved institutions. All participants provide written informed consent. The findings from the study will be published in peer-reviewed scientific journals, presented to funders and relevant local organisations and at scientific conferences.

Increased breast cancer screening and downstaging in Colombian women: A randomized trial of opportunistic breast-screening.

Abstract: The lack of breast cancer screening in low and middle-income countries results in later stage diagnosis and worsened outcomes for women. A cluster randomized trial was performed in Bogota, Colombia between 2008 and 2012 to evaluate effects of opportunistic breast cancer screening. Thirteen clinics were randomized to an intervention arm and 13 to a control arm. Physicians in intervention clinics were instructed to perform clinical breast examination on all women aged 50-69 years attending clinics for non-breast health issues, and then refer them for mammographic screening. Physicians in control clinics were not explicitly instructed to perform breast screening or mammography referrals, but could do so if they thought it indicated ("usual care"). Women were followed for 2-years postrandomization. 7,436 women were enrolled and 7,419 (99.8%) screened in intervention clinics, versus 8,419 enrolled and 1,108 (13.1%) screened in control clinics. Incidence ratios (IR) of early, advanced and all breast cancers were 2.9 (95% CI 1.1-9.2), 1.0 (0.3-3.5) and 1.9 (0.9-4.1) in the first (screening) year of the trial, and the cumulative IR for all breast cancers converged to 1.4 (0.7-2.8) by the end of follow-up (Year 2). Eighteen (69.2%) of 26 women with early stage disease had breast conservation surgery (BCS) versus 6 (42.5%) of 14 women with late-stage disease (p = 0.02). Fifteen (68.2%) of 22 women with breast cancer in the intervention group had BCS versus nine (50.0%) of 18 women in the control group (p = 0.34). Well-designed opportunistic clinic-based breast cancer screening programs may be useful for early breast cancer detection in LMICs.

Clinical Breast Examination and Breast Cancer Screening Guideline.

Abstract: We did not explicitly cite in our article any estimate of the ratio of overdiagnosis to breast cancer death prevented, whether the Cochrane estimate of 10 overdiagnoses per breast cancer death prevented1 or the 3 to 1 estimate of the UK Independent Panel,2 but we should have clarified that the pooled overdiagnosis presented in Table 3 did not include results from the Health Insurance Plan of Greater New York trial,5 whereas the mortality estimates were based on all trials regardless of judgments about randomization and included this study. The article has been corrected online. We believe the available evidence shows that mammographic screening reduces breast cancer mortality, but there is substantial uncertainty about the precision of this estimate for any specific country, given questions of study methodology, differences in health systems and approaches to screening, changes in screening and treatment technologies, and changes in exposures and behaviors that may affect the natural history of breast cancer. We note that, even using the more restrictive estimate of the Cochrane analysis, there is an approximately 95% probability that the relative risk is less than 1.0 based on the cumulative density function of the log-normal distribution of the odds ratio. The methodological challenges in estimating the extent of overdiagnosis under different screening regimens are even more daunting, not the least because of lack of consensus on definitions and approaches to estimation.6 The uncertainties inherent in the individual estimates of overdiagnosis and mortality reduction are amplified when attempting to integrate them into a single harm to benefit ratio when numerator and denominator may be derived from different sources, and when there may be some correlation between the 2 estimates analogous to sensitivity and specificity. Discussion about optimal breast cancer screening policy should include not only attempts at consensus about how best to estimate specific benefits and harms in the context of current and future practice, but also a frank consideration of what the maximum acceptable harm to benefit ratio should be. This would, at the least, allow an estimation of the likelihood that a given policy would result in an unacceptable trade-off.

Management of locally advanced and metastatic breast cancer: guidelines, infrastructures and low resource settings

Abstract: Breast cancer incidence is rising and it accounts for over 1.6 million cases per year worldwide. It represents about one-third of female cancers and is a significant health issue in countries at all economic levels. In this article, we review global cancer statistics, breast cancer staging including late-stage presentation in limited resource settings, disparities in the breast cancer outcomes and requirements for optimal management, including infrastructure needs for optimal surgery, radiation treatment and systemic therapy. We will discuss controversies related to drug pricing and availability, process and delays in registration of new drugs as well as resource stratification and resource-stratified guidelines for locally advanced breast cancer and metastatic breast cancer.

Fine-Needle Aspiration for Breast Cancer Diagnosis: One Size Does Not Fit All

Abstract: The role of fine-needle aspiration biopsy (FNAB) for the diagnosis of palpable breast masses has been a hotly debated topic since the 1980s. Despite well-executed studies from highly qualified centers demonstrating the diagnostic efficacy of FNAB,1,2 in the United States this technique has largely been replaced by core biopsy (CB) as the primary method for percutaneous sampling of both palpable and screen-detected breast abnormalities. The rationale for this transition is that CB provides histologic (rather than cytologic) samples that can distinguish invasive from noninvasive cancers and are more easily amendable to immunohistochemical staining (estrogen receptor, progesterone receptor, HER2/neu) to facilitate surgical and systemic treatment planning. Hematoxylin-eosin–stained CB slides can be interpreted by the same histopathologist who provides diagnoses of surgical specimens, but FNAB requires cytopathologic expertise to provide accurate breast interpretation. Although these points are commonly used to justify dependence on CB by centers that have not incorporated FNAB into their organization, biases against FNAB may have caused some to overlook the significant strengths and benefits that FNAB can provide as a valuable component of a well-organized breast health diagnosis and treatment system. In this issue of JNCCN, the article by Ly et al (page 527) shows that FNAB can be effectively used for the evaluation of palpable breast masses. The diagnostic schemes for the work up of palpable and nonpalpable breast lesions were compared between 2 hospitals, one of which integrates FNAB and CB together with surgical excision for definitive diagnosis and management, whereas the other uses the now more-traditional approach of nearly exclusive image-guided CB sampling followed by surgical excision in indicated cases. This retrospective analysis shows that when FNAB is performed by an interventional cytopathologist, wait time for diagnosis is significantly shortened by more than 1 week and, in a large fraction of cases, same-day diagnosis is possible. In the dual-sampling integrated facility, FNAB was particularly useful for the diagnosis of low-suspicion lesions, while CB was more often reserved for lesions more likely to be cancer (BI-RADS ≥ 4). FNAB and CB had similar diagnostic accuracy and rates of diagnostic discordance that warranted additional sampling. No false-positive or false-negative diagnoses occurred with either biopsy method. The investigators point out that waiting time for definitive diagnosis has been shown in other studies to augment patient anxiety and stress that can be relieved through the availability of immediate FNAB diagnosis. Further, the investigators demonstrate significant cost-effectiveness and cost savings through the use of FNAB, even when repeat CB is required in a subset of patients. Today, it is less valuable to consider FNAB and CB as competitive needle sampling techniques than it is to evaluate how integrated diagnostic approaches can best be systematically applied in given clinical settings. Although FNAB is recognized as the most cost-effective procedure with short turnaround times,3 the choice of sampling procedures must be based on the availability and access to cytopathologists and histopathologists in each medical community, and the training and experience of the available pathology specialists in relation to breast diagnosis.4 At the same time, it is useful to consider how effective systems can be designed and implemented when these resources are available. Palpable breast masses are common, and most do not represent cancer. Thus, the ability to distinguish benign findings that can be followed clinically from malignancies that require prompt diagnosis and treatment is quite important. A recent study from Benjamin O. Anderson, MD

Breast Cancer Initiative 2.5 (BCI2.5): A Global Campaign to Reduce Disparities in Breast Cancer Outcomes

Abstract: 20Aim:Breast Cancer Initiative 2.5 (BCI2.5) is a global campaign to reduce disparities in breast cancer outcomes for 2.5 million women by 2025.About BCI2.5:BCI2.5 represents a new commitment to unite the global breast cancer community behind a common goal to make breast health a global priority and reduce disparities in breast cancer outcomes worldwide. The initiative began as a call for action in 2014, supported by the American Cancer Society, Susan G. Komen and UICC. Since that initial pledge, BCI2.5 has been engaging partners around the world, assessing need, identifying priorities and defining a strategy to meet this goal. Its consensus-based approach empowers regional champions to bring about change with the aid of BCI2.5 analytic, assessment and planning tools, educational materials and implementation science research methodology. BCI2.5 delivers evidence-based technical expertise and a resource-stratified approach to improving breast health services and care at any resource level. The init...