https://dash.harvard.edu/bitstream/handle/1/17820849/4511219.pdf?sequence=1

Tailoring therapies—improving the management of early breast cancer: St Gallen International Expert Consensus on the Primary Therapy of Early Breast Cancer 2015

De-escalating and escalating treatments for early-stage breast cancer: the St. Gallen International Expert Consensus Conference on the Primary Therapy of Early Breast Cancer 2017

Advances in the prevention, early detection, and treatment of cancer have resulted in an almost 14% decrease in the death rates from all cancers combined from 1991 to 2004 in the overall US population, with remarkable declines in mortality for the top 3 causes of cancer death in men (lung, colorectal, and prostate cancer) and 2 of the top 3 cancers in women (breast and colorectal cancer). However, not all segments of the population have benefited equally from this progress, and evidence suggests that some of these differences are related to lack of access to health care. Lack of adequate health insurance appears to be a critical barrier to receipt of appropriate health care services. This article provides an overview of systems of health insurance in the United States, demographic and socioeconomic characteristics associated with health insurance coverage, and economic burdens related to health care among individuals and families. This article also presents data on the association between health insurance status and screening, stage at diagnosis, and survival for breast and colorectal cancer based on analyses of the National Health Interview Survey and the National Cancer Data Base. Although this article focuses on associations between health insurance and cancer care utilization and outcomes, it is important to recognize that barriers to receipt of optimal cancer care are complex and involve patient-level, provider, and health system factors. Evidence presented in this paper suggests that addressing insurance and cost-related barriers to care is a critical component of efforts to ensure that all Americans are able to share in the progress that can be achieved by access to high-quality cancer prevention, early detection, and treatment services.

Association of insurance with cancer care utilization and outcomes.

PurposePlacing clips in nodes with biopsy-confirmed metastasis before initiating neoadjuvant therapy allows for evaluation of response in breast cancer. Our goal was to determine if pathologic changes in clipped nodes reflect the status of the nodal basin and if targeted axillary dissection (TAD), which includes sentinel lymph node dissection (SLND) and selective localization and removal of clipped nodes, improves the false-negative rate (FNR) compared with SLND alone.MethodsA prospective study of patients with biopsy-confirmed nodal metastases with a clip placed in the sampled node was performed. After neoadjuvant therapy, patients underwent axillary surgery and the pathology of the clipped node was compared with other nodes. Patients undergoing TAD had SLND and selective removal of the clipped node using iodine-125 seed localization. The FNR was determined in patients undergoing complete axillary lymphadenectomy (ALND).ResultsOf 208 patients enrolled in this study, 191 underwent ALND, with residual dise...

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Improved Axillary Evaluation Following Neoadjuvant Therapy for Patients With Node-Positive Breast Cancer Using Selective Evaluation of Clipped Nodes: Implementation of Targeted Axillary Dissection

Estimating the Benefits of Therapy for Early Stage Breast Cancer The St Gallen International Consensus Guidelines for the Primary Therapy of Early Breast Cancer 2019

Purpose An increasing proportion of patients (> 30%) with node-positive breast cancer will obtain an axillary pathologic complete response after neoadjuvant chemotherapy (NAC) If sentinel node (SN) biopsy (SNB) is accurate in this setting, completion node dissection (CND) morbidity could be avoided Patients and Methods In the prospective multicentric SN FNAC study, patients with biopsy-proven node-positive breast cancer (T0-3, N1-2) underwent both SNB and CND Immunohistochemistry (IHC) use was mandatory, and SN metastases of any size, including isolated tumor cells (ypN0[i+], ≤ 02 mm), were considered positive The optimal SNB identification rate (IR) ≥ 90% and false-negative rate (FNR) ≤ 10% were predetermined Results From March 2009 to December 2012, 153 patients were accrued to the study The SNB IR was 876% (127 of 145; 95% CI, 822% to 930%), and the FNR was 84% (seven of 83; 95% CI, 24% to 144%) If SN ypN0(i+)s had been considered negative, the FNR would have increased to 133% (11 of 83;

Sentinel node biopsy after neoadjuvant chemotherapy in biopsy-proven node-positive breast cancer: the SN FNAC study.

Purpose

Multiple prospective, randomized studies show that breast conservation therapy (BCT) results in survival rates equal to mastectomy (Mx) for patients with early stage breast cancer (ESBC). Nevertheless, BCT remains underused in certain areas of the nation, without clearly definable reasons. Several studies have implicated socioeconomic status as one potential cause for this disparity in BCT usage. We sought to compare BCT rates in the medically indigent versus insured patients, within the same institution.



Methods

Data from 1993 to 2000, collected from the institutional tumor registry and the hospital's claims records, were analyzed for 928 patients with ESBC (Stages 0, I, and II), treated at a single medical center. The same surgeons treated both insured and indigent patients. Patients treated by BCT or Mx were compared for age, race, stage, insurance status, access to a radiation therapy center, surgeon, and year of diagnosis.



Results

Patient age, race, surgeon, or insurance status did not significantly affect the rate of mastectomy. Stage I patients (P  40 miles distant.



Conclusions

These data refute the hypothesis that socioeconomic status, as reflected by medical insurance, is a determinant of BCT in women with ESBC. Distance of <40 miles to a radiation therapy facility, Stage I disease, and diagnosis after 1995 were factors associated with higher BCT rates. J. Surg. Oncol. 2003;84:57–62. © 2003 Wiley-Liss, Inc.

Breast conservation therapy rates are no different in medically indigent versus insured patients with early stage breast cancer.

52 Background: Sentinel node biopsy (SNB) is used in breast cancer patients that present with clinically negative nodes. In this setting, most guidelines do not support the use of immunohistochemistry (IHC) and recommend against completion node dissection (CND) when only isolated tumor cells (pN0(i+)) or micrometasases (pN1mi) are identified. When SNB is used after neoadjuvant therapy (NAT), the relevance of ypN0(i+) and ypN1mi sentinel nodes (SNs) and the value of IHC are not well established. The goals of this study are to determine if CND should be recommended in the presence of ypN0(i+) or ypN1mi SNs and if IHC should be used to evaluate SNs after NAT. Methods: From March 2009 to December 2012, 152 women with biopsy proven node positive breast cancer were accrued to the multicentric prospective SN FNAC trial. After NAT, SNB was followed by a CND in all participants. SNs were cut in serial slices no thicker than 2 mm. Hematoxylin and eosin stains (H and E) were done on all slices, and if negative, IHC ...

Stephen E. Karp

Papers

Sentinel node biopsy after neoadjuvant chemotherapy in biopsy-proven node-positive breast cancer: the SN FNAC study.

Breast conservation therapy rates are no different in medically indigent versus insured patients with early stage breast cancer.

Sentinel node biopsy after neoadjuvant therapy: Relevance of sentinel node micrometastases, isolated tumor cells, and value of immunohistochemistry.