For the study, Bin Huang, DrPH, of the University of Kentucky Markey Cancer Center, and his colleagues analyzed data from the Kentucky Cancer Registry to identify adult women diagnosed with primary invasive breast cancer in 2007–2011. Utilizing the health claims–linked cancer registry data, the team classified patients as having no depression diagnosis, depression diagnosis only before cancer diagnosis, depression diagnosis only after cancer diagnosis, or persistent depression defined as depression before and after cancer diagnosis. The team also assessed patients’ receipt of first course guideline-recommended treatment as indicated by the National Comprehensive Cancer Network breast cancer treatment guidelines.

 Among 6,054 patients, 4.1%, 3.7%, and 6.2% of patients had persistent depression, depression pre-diagnosis only, and depression post-diagnosis only, respectively. Analyses indicated that 29.2% of patients did not receive guideline-recommended breast cancer treatment. Also, during a median follow-up of 4 years, 26.3% of patients died.

Compared with patients with no depression, patients with post-diagnosis only or persistent depression had a similar likelihood of receiving guideline-recommended treatment, but patients with depression pre-diagnosis only had 25% lower odds of receiving guideline-concordant care, although this finding was marginally significant. Additional research is needed to determine the potential reasons for this association.

 Depression pre-diagnosis only and depression post-diagnosis only (but not persistent depression) were linked with worse survival compared with no depression. Specifically, depression pre-diagnosis was associated with a 26% higher risk of death, and depression post-diagnosis was associated with a 50% higher risk. Also, patients who did not receive guideline-recommended treatment faced a 118% higher risk of death than those who received recommended care.

 Compared with patients residing in non-Appalachian Kentucky, patients residing in Appalachia were 18% less likely to receive recommended care, but investigators did not find any significant differences in survival.

 The findings suggest that diagnosing and treating depression at the time of breast cancer diagnosis and beyond can be critical to patient care and survival.

“A surprising result from this study is that patients with persistent depression did not experience worse survival compared with patients with no depression,” said Huang. “Given that under-diagnosis and under-treatment of depression are common among cancer patients, persistent depression could be an indication that patients’ depression may have been well managed. Hence, this particular result suggests the importance of depression screening and management throughout a cancer patient’s care.”

Huang noted that population-based cancer registry data enhance population-based cancer outcomes research. “Utilizing linked health claims data and cancer registry data in this study demonstrated the value of data linkages across various sources for examining potential health disparities and identifying where improvements in cancer care are needed,” he said. “More rigorous studies are needed in depression management and across various cancer sites and patient populations. Subsequently, results from these research studies may further shape policies and guidelines for depression management in cancer care.”

CANCER is a peer-reviewed publication of the American Cancer Society integrating scientific information from worldwide sources for all oncologic specialties. CANCER is published on behalf of the American Cancer Society by Wiley, one of the world’s largest health publishers.

This discovery  holds out new hope for people with an aggressive type of breast cancer, The immunotherapy trial showed that lives can be extended in people with triple-negative breast cancer.

The research, which was published October 20^th 2018 in the New England Journal of Medicine and presented at the European Society for Medical Oncology 2018 Congress in Munich, also showed that the combined treatment reduced the risk of death or the cancer progressing by up to 40 per cent.

A release from the university explains that triple-negative breast cancer often affects young women, with many people diagnosed in their 40s or 50s. The standard treatment is chemotherapy, to which most patients quickly develop resistance. If the disease spreads to other parts of the body, survival is often only 12 to 15 months.

The new treatment combines standard weekly chemotherapy with the immunotherapy medication atezolizumab which is given once every two weeks. The combination works by chemotherapy ‘roughening up’ the surface of the cancer, which enables the immune system to better recognise and therefore fight the cancer as a foreign object.

The release quotes the author of the trial, Professor Peter Schmid, Professor of Cancer Medicine at Queen Mary University of London and Clinical Director of the Breast Cancer Centre at St Bartholomew’s Hospital, as saying, “These results are a massive step forward. We are changing how triple-negative breast cancer is treated in proving for the first time that immune therapy has a substantial survival benefit. In a combined treatment approach, we are using chemotherapy to tear away the tumor’s ‘immune-protective cloak’ to expose it as well as enabling people’s own immune system to get at it.

“Triple-negative breast cancer is an aggressive form of breast cancer; we have been desperately looking for better treatment options. It is particularly tragic that those affected are often young, with many themselves having young families. I’m thrilled that by using a combination of immunotherapy and chemotherapy we are able to significantly extend lives compared to the standard treatment of chemotherapy alone.”

Based on the results of this trial this new treatment is currently under review by health authorities and will hopefully become available in the NHS in the near future. In the interim, patients at St Bartholomew’s Hospital with triple-negative breast cancer are offered immunotherapy within ongoing trials.

In 1998, Congress passed the Women’s Health and Cancer Rights Act (WHCRA), a federal law that requires group health plans and individual health policies that cover mastectomy to also cover breast reconstruction in connection with such mastectomy. Before the passage of the WHCRA, insurers could refuse coverage for reconstruction on the grounds that these were cosmetic procedures and not medically necessary. Women had to pay for reconstruction themselves or forgo it. Supporters of the WHCRA recognized that ensuring that a woman has the option of reconstructive surgery following mastectomy is important to her physical and emotional well-being.

But even with the protection of the law there is no escaping the anxiety and uncertainty that accompany decisions about breast reconstruction – anxiety that is compounded by the difficulty of navigating the rules and regulations that govern insurance coverage and claims. A critical decision at this time is the woman’s choice of surgeon. She must choose a doctor who offers a full range of reconstructive options, including the most advanced techniques, but she must also feel comfortable that her medical team understands her unique concerns and preferences and understands how to work with her insurer to ensure that she receives all the benefits to which she is entitled.

Given the importance of this decision, whether or not the doctor is in her insurer’s network is an important concern – but it is one that a woman may be able to overcome. Out-of-network” simply means that a doctor does not have a pre-negotiated contract with a given health insurance program or company. “In-network” providers have contracted with insurers to provide services to plan members at pre-negotiated rates. Patients have been conditioned to avoid out-of-network providers for fear that their costs will be higher. But that will not always be the case and often an out-of-network surgeon will be exactly the right choice for breast reconstruction.

There are many reasons a woman may choose an out-of-network provider for breast reconstruction: She may have researched restorative options, decided on a particular one, and found that in-network providers either do not offer the procedure or do not have the experience and expertise to instill confidence. Or her research might have pointed her to a particular doctor who has developed or perfected an advanced technique. She may have a compelling recommendation from a family member, a friend, or a trusted medical source. Or she may have met with in-network providers and felt that they were not right for her for any number of reasons.

The most important criterion in choosing a surgeon is the patient’s confidence and comfort level. This is relevant not just for the surgery itself but to ensure that her care will not impose an undue financial burden. The surgeon’s team must work with the patient to help her understand – in advance – her insurer’s requirements, to accurately estimate her expected out-of-pocket costs, and to minimize the risk of unexpected costs.

In our practice, the surgeon focuses exclusively on the clinical aspect of the patient’s condition and treats every person without considering her insurance status. My job is to make sure that every patient who wants to go out of network has full access to our services. We want women to be able to focus their energies on getting well. We have many years of experience working with insurers and we do everything we can to relieve our patient of the anxiety and stress of managing the financial aspects of her care.

Andrea Smith is the Practice Manager for Constance M Chen, MD, PC, a boutique plastic and reconstructive surgery office located in New York City that focuses on innovative natural techniques to optimize medical and aesthetic outcomes for women undergoing breast reconstruction. The practice is committed to patient advocacy and a woman’s right to choose her own breast reconstruction journey.  www.constancechenmd.com

Since implants are foreign bodies, they can cause various problems: Many women find that that their implants feel hard and look unnatural, or that they’ve lost all feeling in the breast, or that their breasts are distorted and asymmetrical. Further complications include infection; rupture; capsular contracture, in which scar tissue forms around the implant and becomes hard and painful; and extrusion, in which the implant erodes through the skin. All of these problems are exacerbated by radiation treatment, which is considered a relative contraindication to implants. In general, implants problems can be resolved by removing the implant with the entire surrounding capsule and repairing any muscle or skin around it. When faced with the prospect of multiple repeated surgeries that are often required to remove and replace an implant throughout a lifetime, a woman should consider the alternative – surgery that creates a breast from her own tissue, a permanent breast that is also natural.

Multiple studies have shown that any breast reconstruction that uses the body’s own tissue, known as autologous tissue reconstruction, provides higher levels of patient satisfaction over the long term compared to implants. Since it is made of your own tissue, the restored breast is soft, warm, and behaves just like any other part of your body, growing or shrinking as you gain or lose weight, for example. If nerves are reconnected, the breasts can even regain sensation. Autologous tissue breast reconstruction has been around for a while, but older procedures sacrificed muscle to rebuild the breast. New advances have made it unnecessary to sacrifice muscle from the donor site to create a new breast. Preserving muscle enables faster recovery and means a woman can maintain muscle strength over the long term.

This new type of breast reconstruction, called “perforator flap” breast reconstruction, has become the gold standard of breast restoration. Perforator flaps are achieved by using microsurgical techniques to carefully transfer fat and skin along with a blood supply to create a new breast, while preserving the underlying muscle. Perforator flaps adhere to the plastic surgery principle of replacing “like with like.” Perforator flaps are appropriate for most women. “Patients falsely believe that very thin women are not candidates for natural tissue breast reconstruction. This isn’t true. In our experience the body provides the right amount of donor site tissue to suit a woman’s proportions.

There are two basic types of perforator flaps that are appropriate for different women, depending on body shape, with each using tissue from a different donor site and preserving muscle at those sites:
●     Abdomen: The most common option is the deep inferior epigastric perforator (DIEP) flap, which preserves abdominal muscles and improves outcomes for patients compared to the traditional TRAM flap which, sacrificed the muscles. The DIEP flap reduces the risk of infection and other postoperative complications and speeds recovery time. The DIEP flap removes excess abdominal fat, providing the equivalent of a cosmetic tummy tuck.
●     Thigh: The profunda artery perforator (PAP) flap uses fat from the upper inner and posterior thigh to reconstruct the breast and is typically used when the abdomen is not serviceable as a donor site, either because a woman is too thin or because of previous abdominal surgery. The PAP flap removes excess inner thigh fat, providing the equivalent of a cosmetic thigh lift.

While less common, other perforator flaps can also be used to transfer excess fat and skin (while preserving muscle) from other areas like the back or the buttocks to restore the breasts. Women today have a lot of options for breast reconstruction and can make educated decisions about what is best for them. State-of-the-art procedures restore a soft, warm, and living breast that looks and feels natural while preserving muscle strength and minimizing postoperative recovery time. Nerves can be reconnected to the living tissue to bring back sensation. For women who have suffered from pain and discomfort after implant-based breast reconstruction, natural tissue breast reconstruction is a safe and reliable way to bring back health, confidence, and quality of life.

Constance M. Chen, MD, MPH, is a board-certified plastic surgeon with special expertise in the use of innovative natural techniques to optimize medical and cosmetic outcomes for women undergoing breast reconstruction. She is Director of Microsurgery at New York Eye and Ear Infirmary of of Mount Sinai, Clinical Assistant Professor of Surgery (Plastic Surgery) at Weill Cornell Medical College and Clinical Assistant Professor of Surgery (Plastic Surgery) at Tulane University School of Medicine. www.constancehenmd.com

• Women ages 50 to 74 should be screened regularly.
• For women in their 40s, the Task Force found that mammography screening every two years can also be effective and recommends that the decision to start screening should be an individual one, taking into account a woman’s health history, preferences, and how she values the potential benefits and harms.
• Women in their 40s who have a mother, sister, or daughter with breast cancer may benefit more than average-risk women by beginning screening before age 50.
• The Task Force concluded that evidence is insufficient to determine the balance of benefits and harms in three important areas: the benefits and harms of screening women age 75 and older; adjunctive screening in women with dense breasts; and the effectiveness of 3-D mammography for the detection of breast cancer.
• Due to this lack of evidence, the Task Force is unable to make a recommendation for or against these services. The Task Force strongly encourages additional research in these areas and notes that women should speak to their doctors to determine what is best for their individual needs.

That said, the release goes on to emphasize that “it’s important to note that the Task Force does not make recommendations for or against insurance coverage; coverage decisions are the responsibility of payers, regulators and legislators. Legislators recently extended a guarantee that women who have private insurance, beginning at age 40, will not have a co-pay for their screening mammogram. The role and mission of the Task Force is to provide all people with the best available information about the current science of prevention to empower them to make informed decisions about their health and health care.”

However, on January 19^th 2016 Georgetown professors issued a release saying that Congress made “scientific judgment for which it is distinctly unqualified.” The professors contend that a section of the recently passed Congressional spending bill effectively undermines science and the health of women. Their JAMA Viewpoint, “A Public Health Framework for Screening Mammography: Evidence-Based Versus Politically Mandated Care,” was published online.

A release from Georgetown states that at issue is the FY 2016 Consolidated Appropriations Act (H.R. 2019), passed in December, in which Congress requires private insurers to follow “outdated scientific guidance” for breast cancer screening coverage, say Lawrence O. Gostin, JD, and Kenneth Lin, MD, MPH.

The professors remind us that on January 11th 2016, after a rigorous review of scientific evidence, “the U.S. Preventive Services Task Force recommended, as it did in 2009, mammography screening every other year for average-risk women beginning at age 50. There was no screening recommendation for women younger than 50. In 2002, the Task Force had recommended screening every one to two years beginning at 40.”

The release goes on to say that under the Affordable Care Act, private insurers are required to follow the recommendations of the Task Force, which is comprised of independent, volunteer experts. However, language in the recent spending bill overrides the ACA by directing insurers to follow the 2002 recommendations for mammography screening.

The release quotes Gostin, Georgetown University Law Professor and faculty director of its O’Neill Institute for National and Global Health Law, as saying, “The Task Force reviewed thousands of research studies over the past decade. Yet legislators with no medical or scientific education decided that the rigorous work carried out by the Task Force was all wrong, and that they have better advice for women. Congress is sowing public distrust in the integrity of science.”

The release also quotes Lin, a family medicine physician at Georgetown University School of Medicine and an expert on cancer screening in the primary care setting, as saying, “By insisting on referring to the 2002 recommendations, Congress is in fact making a scientific judgment. This action strikes at the Task Force’s credibility by saying it was right 2002, but was wrong in 2009 and is wrong now.”

Prior to the ACA, insurers had discretion to determine what screening, counseling and vaccinations to cover. Under the ACA, insurers provide cost-free access to preventive services based on modern evidence of effectiveness, as determined by groups such as the Task Force.

But when Congress required insurance coverage to link to “outdated public health guidance, it was making a scientific judgment for which it is distinctly unqualified,” Lin and Gostin write.

“The public’s health is best served when women’s personal decisions about screening are informed by evidence rather than political considerations,” they write. “Rather than benefiting women, political interference with science can discourage shared decision-making, increase harms from screening, and foster public doubt about the value and integrity of science.”

A release from the publisher notes that the number of breast cancers is increasing across the globe, with over 1.6 million new cases of the disease in 2010, resulting in the deaths of over 425,000 women. Additionally, 2.1 million new breast cancer cases are expected by 2030. While mammography is an effective method in detecting breast cancer in developed countries, it is not commonly available in less developed nations, and alternative methods, such as ultrasound, need to be tested.

To determine the effectiveness of using ultrasound to detect breast cancer, Wendie A. Berg, M.D., Ph.D., Department of Radiology, Magee-Womens Hospital, and colleagues recruited 2,809 women across 20 different sites in the United States, Canada, and Argentina to the American College of Radiology Imaging Network protocol 6666 breast cancer screening study. Of the participants, 2,662 completed three annual breast screenings by US and film-screen or digital mammography, and then had a biopsy or a 12-month follow-up.

The researchers found that the number of US screens to detect breast cancer was comparable to that of mammography, and found that there was a greater proportion of invasive and node-negative cancers in those who had US; however, there was also a greater number of false-positives among the women screened with US. While the false-positive rate of US exceeds that of mammography, the number of women recalled for extra testing becomes more comparable on incidence screening rounds, the authors write. “Where mammography is available, US should be seen as a supplemental test for women with dense breasts who do not meet high-risk criteria for screening MRI and for high-risk women with dense breasts who are unable to tolerate MRI.”

A release from the medical center explains that researchers analyzed the records of more than 3,700 women who had no history of breast cancer, and who had long-term use of calcium channel blocker medications to control their blood pressure. Researchers found only a minimal increase in risk in one study and a 50 percent reduced risk in a second, leading them to recommend the continued use of these important medications to help prevent heart attack and stroke.

Findings from the Intermountain Medical Center Heart Institute study were presented at the 2014 American Heart Association Scientific in Chicago on Wednesday, November 19th.
Calcium channel blockers are commonly used to help prevent calcium from entering cells of the heart and blood vessel walls, resulting in lower blood pressure.

The release quotes Jeffery L. Anderson, MD, a cardiologist and researcher at the Intermountain Medical Center Heart Institute, as saying, “We found no robust data that calcium channel blocker medications increase a person’s risk of breast cancer. Given the important role calcium channel blocker medications play in treating heart conditions, we think it’s premature to discontinue their use. At this point we recommend that patients continue taking these medications to treat their hypertension.”

The Intermountain Heart Institute study was in response to a similar study released last year by the Fred Hutchinson Cancer Research Center in Seattle. That study suggested that the odds of getting breast cancer was 2.5 times higher for women who take calcium channel blocker medications. Results of the Intermountain study indicated small to no increased risk.

The Intermountain Medical Center Heart Institute study carefully examined data collected from more than 3,700 women ages 50 to 70 with no history of breast cancer in two Intermountain Healthcare databases. For each group, researchers compared women who were prescribed calcium channel blocker medications to similar women who weren’t prescribed the medications.
In their review of a general population medical records database, researchers found the odds of breast cancer to be 1.6 times higher by using calcium channel blockers, which was significant, but much smaller than reported by the Seattle group.

But, in contrast, in the data collected from patients treated in the Intermountain Cardiac Catheterization Laboratory, a reverse relationship was found — a 50 percent reduction in risk of developing breast cancer for women who took the calcium channel blockers. The contrasting results found in these two independent analyses led researchers at the Intermountain Medical Center Heart Institute to conclude that it is likely not the medication that caused the changes in breast cancer risk but other factors (e.g., selection biases).

The study was led by Jeffrey Anderson, MD, and Uyen Lam, MD, from the Intermountain Medical Center Heart Institute and the Internal Medicine Residency Program at the University of Utah School of Medicine.

The Intermountain Medical Center Heart Institute study and the Fred Hutchinson study were both analyses of existing patient data and not clinical trials. Both studies recommend further research.
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Researchers involved in the study include Uyen T. Lam, MD; Stacy Knight, PhD; Tami L. Bair; Viet Li, PA-C; J. Brent Muhlestein, MD; and Jeffrey L. Anderson, MD. Intermountain Medical Center is the flagship facility for the Intermountain Healthcare system, which is based in Salt Lake City.