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BACKGROUND: This study evaluated a new mainstream genetic testing pathway for hereditary cancer, with expanded eligibility for early-stage breast cancer patients. METHODS: The study compared multigene panel (62 genes) germline testing uptake and results for breast cancer patients at 4 pilot sites (n = 502 patients) and 10 non-pilot sites (n = 1792 patients) within Kaiser Permanente Northern California from December 2020, to June 2021. At the pilot sites, breast care coordinators (BCCs) offered and consented patients for testing, with eligibility expanded to include all patients age 65 years or younger. At the non-pilot sites, eligible patients were referred to genetics for pre-test counseling, ordering, and follow-up evaluation with the standard guideline that included all patients age 45 years or younger. RESULTS: Demographic and disease characteristics were similar at the pilot and non-pilot sites. At the pilot verses non-pilot sites, a higher percentage of patients was tested overall (61.6% vs 31.7%) and across all age groups. The median time from breast biopsy to test result also was reduced (22 vs 33 days, respectively). A higher percentage of patients at the pilot sites was identified as having a pathogenic/likely pathogenic variant (PV/LPV) in a breast cancer-related gene (3.6% vs 1.6%). Although the percentage of total patients tested was nearly twofold higher at the pilot sites than at the non-pilot sites, the percentage of total patients seen by genetics was estimated to be similar (33.7% vs 31.7%). CONCLUSION: Mainstream genetic testing of breast cancer patients facilitated by BCCs makes it feasible for a large health care system to expand germline genetic testing to early breast cancer patients age 65 years or younger.

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BACKGROUND: For patients undergoing posttreatment surveillance after ductal carcinoma in situ (DCIS), the NCCN Guidelines for Breast Cancer recommend annual breast imaging and physical examination every 6 to 12 months for 5 years, and then annually. The aim of our study was to evaluate the modes of detection (imaging, patient reported, or physical examination) of second cancers in a cohort of patients undergoing surveillance after primary DCIS treatment to better inform surveillance recommendations. METHODS: We performed a retrospective cohort study of patients with DCIS treated between January 1, 2008, and December 31, 2011, within a large integrated health care system. Information on patient demographics, index DCIS treatment, tumor characteristics, and mode of detection of second breast cancer was obtained from the electronic health record or chart review. RESULTS: Our study cohort consisted of 1,550 women, with a median age of 59 years at diagnosis. Surgical treatment of DCIS included lumpectomy (75.0%; n=1,162), unilateral mastectomy (21.1%; n=327), or bilateral mastectomy (3.9%; n=61), with or without sentinel lymph node biopsy. Additionally, 44.4% (n=688) and 28.3% (n=438) received radiation and endocrine therapies, respectively. Median follow-up was 10 years, during which 179 (11.5%) women were diagnosed with a second breast cancer. Of the second cancers, 43.0% (n=77) were ipsilateral and 54.8% (n=98) contralateral, and 2.2% (n=4) presented with distant metastases; 61.5% (n=110) were invasive, 36.3% (n=65) were DCIS, and 2.2% (n=4) were Paget's disease. Second breast cancers were imaging-detected in 74.3% (n=133) of cases, patient-detected in 20.1% (n=36), physician-detected in 2.2% (n=4), and detected incidentally on imaging or pathology from procedures unrelated to oncologic care in 3.4% (n=6). CONCLUSIONS: In our cohort of patients undergoing surveillance following diagnosis and treatment of DCIS, 2% of second breast cancers were detected by a clinical breast examination. This suggests that survivorship care should prioritize mammography and patient education regarding breast self-examination and symptoms that warrant evaluation to detect second breast cancers.

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BACKGROUND: Young breast cancer (YBC) patients are a unique subpopulation that are often underrepresented in randomized clinical trials. Furthermore, large national cancer databases lack detailed information on recurrence, a meaningful oncologic outcome for young patients. STUDY DESIGN: A retrospective review of YBC patients (age 40 years or younger) with stage I to III breast cancer diagnosed from 2008 to 2018 was performed. Information on clinicopathologic characteristics, demographics, and outcomes was obtained from the electronic health record and chart review. Chi-square and Fisher's exact tests were used for comparisons of categorical variables and parametric and nonparametric tests for continuous variables. RESULTS: The cohort included 1,431 women with a median follow-up of 4.8 years (range 0.3 to 12.9 years). The median age was 37 years (interquartile range 34 to 39). The study population included 598 (41.8%) White, 112 (7.8%) Black, 420 (29.4%) Asian/Pacific Islander, 281 (19.6%) Hispanic, and 20 (1.4%) "other" race/ethnicity patients. Tumor subtype was as follows: [1] hormone receptor (HR) + /human epidermal growth factor 2 (HER2 - ), grade (G) 1 to 2 = 541 (37.8%); [2] HR + /HER2 - , G3 = 268 (18.7%); [3] HR + /HER2 + = 262 (18.3%); [4] HR - /HER2 + = 101 (7.1%); [5] HR - /HER2 - = 259 (18.1%). The majority (64.2%) presented with stage II/III disease. There were 230 (16.1%) recurrences during follow-up; 74.8% were distant. Locoregional-only recurrence was seen in 17 of 463 (3.7%) patients who underwent breast conservation vs 41 of 968 (4.2%) patients undergoing mastectomy (p < 0.001). Recurrence varied by tumor subtype: [1] HR + /HER2 - , G1 to 2 (14.0%); [2] HR + /HER2 - , G3 (20.9%); [3] HR + /HER2 + (11.1%); [4] HR - /HER2 + (22.8%); [5] HR - /HER2 - (17.8%) (p = 0.005). CONCLUSIONS: In this large, diverse YBC cohort, recurrences were most frequent among HR + /HER2 - , G3, or HR - /HER2 + invasive tumors; most were distant. There were numerically similar locoregional-only recurrences after breast conservation vs mastectomy. Additional research is needed to identify predictors of recurrence.

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BACKGROUND: Postoperative prescriptions have contributed to the opioid epidemic. In response, a large, integrated health care delivery system implemented initiatives to reduce outpatient opioid prescriptions. We evaluated the impact of these interventions on opioid-prescribing practices after breast surgery. METHODS: We examined postoperative prescribing practices before and after the 2016-2018 intervention period. Primary endpoints were the use of non-opioid regimens (NORs) and morphine milligram equivalents (MMEs) prescribed for postoperative pain management, while secondary endpoints were emergency department (ED) visits and readmissions within 7 days of surgery. RESULTS: In a survey of breast surgeons, 23% reported using NORs in 2017 versus 79% in 2019 (p < 0.001). Comparing 1917 breast operations from 2016 with 2166 operations from 2019, NORs increased from 9% in 2016 to 39% in 2019 (p < 0.001). Average discharge MMEs per operation decreased from 190 in 2016 to 106 in 2019 (p < 0.001). NOR failure (defined as an additional opioid prescription within 2 weeks of surgery) was < 1%. Significantly fewer postoperative ED visits occurred in the NOR group (1.9% NOR vs. 3.4% opioid regimen [OR]; p < 0.001). The 7-day readmission rates for NOR and OR patients were similar (0.49% NOR vs. 0.32% OR; p = 0.45). CONCLUSION: Between 2016 and 2019, breast surgeons in a large, integrated health care delivery system adopted NORs for nearly 40% of breast operations, and prescribed significantly fewer MMEs, with no increases in ED visits or readmissions for NOR patients. This suggests that initiatives to decrease opioid prescribing were successful and that a NOR for pain management after breast surgery is feasible.

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BACKGROUND: Low-income, minority women with breast cancer experience a range of barriers to receiving survivorship information. Our objective was to test a novel, patient-centered intervention aimed at improving communication about survivorship care. METHODS: We developed a wallet card to provide oncologic and follow-up care survivorship information to breast cancer patients. We used a prospective, pre-post design to assess the intervention at a safety net hospital. The intervention was given by a patient navigator or community health worker. RESULTS: Patient knowledge (n = 130) of personal cancer history improved from baseline pretest to 1 week after the intervention for stage (66-93%; P < .05), treatment (79-92%; P < .05), and symptoms of recurrence (48-89%; P < .05), which was retained at 3 months. The intervention reduced the number of patients who were unsure when their mammogram was due (15-5% at 1 week and 6% at 3 months; P < .05). Nearly 90% reported they would be likely to share their survivorship card with their providers. CONCLUSION: A patient-centered survivorship card improved short-term recall of key survivorship care knowledge and seems to be effective at reducing communication barriers for this population. Further studies are warranted to assess long-term retention and the impact on receipt of appropriate survivorship follow-up care.

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