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Sentinel Node Biopsy Examination for Breast Cancer in a Routine Laboratory Practice: Results of a Pilot Study

Khoo JJ, Ng CS, Sabaratnam S, Arulanantham S

Asian Pac J Cancer Prev, 2016;17(3):1149-55.
PMID: 27039740

BACKGROUND: Examination of sentinel lymph node (SLN) biopsies provides accurate nodal staging for breast cancer and plays a key role in patient management. Procurement of SLNs and the methods used to process specimens are equally important. Increasing the level of detail in histopathological examination of SLNs increases detection of metastatic tumours but will also increase the burden of busy laboratories and thus may not be carried out routinely. Recommendation of a reasonable standard in SLN examination is required to ensure high sensitivity of results while maintaining a manageable practice workload.
MATERIALS AND METHODS: Twenty-four patients with clinically node-negative breast cancer were recruited. Combined radiotracer and blue dye methods were used for identification of SLNs. The nodes were thinly sliced and embedded. Serial sectioning and immunohistochemical (IHC) staining against AE1/AE3 were performed if initial HandE sections of the blocks were negative.
RESULTS: SLNs were successfully identified in all patients. Ten cases had nodal metastases with 7 detected in SLNs and 3 detected only in axillary nodes (false negative rate, FNR=30%). Some 5 out of 7 metastatic lesions in the SLNs (71.4%) were detected in initial sections of the thinly sliced tissue. Serial sectioning detected the remaining two cases with either micrometastases or isolated tumour cells (ITC).
CONCLUSIONS: Thin slicing of tissue to 3-5mm thickness and serial sectioning improved the detection of micro and macro-metastases but the additional burden of serial sectioning gave low yield of micrometastases or ITC and may not be cost effective. IHC validation did not further increase sensitivity of detection. Therefore its use should only be limited to confirmation of suspicious lesions. False negative cases where SLNs were not involved could be due to skipped metastases to non-sentinel nodes or poor technique during procurement, resulting in missed detection of actual SLNs.
Fulltext Lung metastases, triple receptor negativity, multiple organ metastases and no adjuvant radiotherapy as predictors of poorer survival after palliative mastectomy

Tan HCL, Tan JH, Sikin SM, Arulanantham S

Asian J Surg, 2020 Feb;43(2):447-450.
PMID: 31959577 DOI: 10.1016/j.asjsur.2019.11.001
A retrospective study on breast cancer presentation, risk factors, and protective factors in patients with a positive family history of breast cancer

Liaw YY, Loong FS, Tan S, On SY, Khaw E, Chiew Y, et al.

Breast J, 2020 Mar;26(3):469-473.
PMID: 31486157 DOI: 10.1111/tbj.13520

Women with a positive family history of breast cancer are greatly predisposed to breast cancer development. From January 2007 to December 2016, 1101 patients with a histologically confirmed breast cancer were divided into two groups: patients with and without a positive family history of breast cancer. Variables including age at presentation, ethnicity, tumor size, age at menarche, age at menopause, oral contraceptive pill (OCP) use, hormone replacement therapy (HRT), alcohol intake, smoking, body mass index (BMI), diabetes mellitus, parity, and breastfeeding were recorded. One hundred and fifty-nine out of 1101 (14.4%) of the patients had a family history of breast cancer. There was no significant difference in the incidence of breast cancer among Malays, Chinese, and Indians. Both patient groups presented at a mean age of about 60 years (+FH 60; -FH 61.2 P-value = .218). Significantly higher prevalence of history of benign breast disease (11.3%, P .018), nulliparity (13.2%, P .014), tumor size at presentation of more than 5 cm (47.3%, P 0.001), and bilateral site presentation (3.1%, P 0.029) were noted among respondents with a positive family history of breast cancer compared to those with a negative family history of breast cancer. The odds of having a tumor size larger than 5cm at presentation were almost two times higher in patients with a positive family history as compared to those without a family history (adjusted OR = 1.786, 95% CI 1.211-2.484) (P-value .003). Women in Malaysia, despite having a positive family history of breast cancer, still present late at a mean age of 60 with a large tumor size of more than 5 cm, reflecting a lack of awareness. Breastfeeding does not protect women with a family history from developing breast cancer.
Fulltext Complementary and alternative medicine (CAM) use and delays in presentation and diagnosis of breast cancer patients in public hospitals in Malaysia

Mohd Mujar NM, Dahlui M, Emran NA, Abdul Hadi I, Wai YY, Arulanantham S, et al.

PLoS One, 2017;12(4):e0176394.
PMID: 28448541 DOI: 10.1371/journal.pone.0176394

Complementary and alternative medicine (CAM) is widely used among the breast cancer patients in Malaysia. Delays in presentation, diagnosis and treatment have been shown to impact the disease prognosis. There is considerable use of CAM amongst breast cancer patients. CAM use has been cited as a cause of delay in diagnosis and treatments in qualitative studies, however there had not been any confirmatory study that confirms its impact on delays. The purpose of this study was to evaluate whether the use of CAM among newly diagnosed breast cancer patients was associated with delays in presentation, diagnosis or treatment of breast cancer. This multi-centre cross-sectional study evaluating the time points of the individual breast cancer patients' journey from first visit, resolution of diagnosis and treatments was conducted in six public hospitals in Malaysia. All newly diagnosed breast cancer patients from 1st January to 31st December 2012 were recruited. Data were collected through medical records review and patient interview by using a structured questionnaire. Complementary and alternative medicine (CAM) was defined as the use of any methods and products not included in conventional allopathic medicine before commencement of treatments. Presentation delay was defined as time taken from symptom discovery to first presentation of more than 3 months. The time points were categorised to diagnosis delay was defined as time taken from first presentation to diagnosis of more than 1 month and treatment delay was defined as time taken from diagnosis to initial treatment of more than 1 month. Multiple logistic regression was used for analysis. A total number of 340 patients participated in this study. The prevalence of CAM use was 46.5% (n = 158). Malay ethnicity (OR 3.32; 95% CI: 1.85, 5.97) and not interpreting symptom as cancerous (OR 1.79; 95% CI: 1.10, 2.92) were significantly associated with CAM use. The use of CAM was associated with delays in presentation (OR 1.65; 95% CI: 1.05, 2.59), diagnosis (OR 2.42; 95% CI: 1.56, 3.77) and treatment of breast cancer (OR 1.74; 95% CI: 1.11, 2.72) on univariate analyses. However, after adjusting with other covariates, CAM use was associated with delays in presentation (OR 1.71; 95% CI: 1.05, 2.78) and diagnosis (OR 2.58; 95% CI: 1.59, 4.17) but not for treatment of breast cancer (OR 1.58; 95% CI: 0.98, 2.55). The prevalence of CAM use among the breast cancer patients was high. Women of Malay ethnicity and not interpreting symptom as cancerous were significantly associated with CAM use. The use of CAM is significantly associated with delay in presentation and resolution of diagnosis. This study suggests further evaluation of access to breast cancer care is needed as poor access may cause the use of CAM. However, since public hospitals in Malaysia are heavily subsidized and readily available to the population, CAM use may impact delays in presentation and diagnosis.
Fulltext Breast Cancer Care Timeliness Framework: A Quality Framework for Cancer Control

Mohd Mujar NM, Dahlui M, Emran NA, Hadi IA, Yan YW, Arulanantham S, et al.

JCO Glob Oncol, 2022 Mar;8:e2100250.
PMID: 35286134 DOI: 10.1200/GO.21.00250

PURPOSE: The aim of this study is to determine the pathway that women follow for Breast Cancer Care (BCC) and the time intervals from symptom discovery to treatment initiation and to develop a quality matrix framework.
METHODS: A retrospective cohort study was conducted at six tertiary centers in Malaysia. All women with newly diagnosed breast cancer were interviewed, and a medical records review was conducted using a structured questionnaire. The BCC timeliness framework showed that the total time between a woman discovering their first breast changes and the date of initial treatment was divided into three distinct intervals: presentation interval, diagnostic interval, and treatment interval. Four diagnosis subintervals, referral, biopsy, report, and diagnosis resolution intervals, were also looked into.
RESULTS: The BCC timeliness framework was used to capture important time points. The median total time, presentation interval, diagnostic interval, and treatment interval were 4.9 months (range, 1 month to 10 years), 2.4 months (range, 7 days to 10 years), 26 days (range, 4 days to 9.3 months), and 21 days (range, 1 day to 7.2 months), respectively. Meanwhile, the median time for the diagnosis subinterval of referral, biopsy, report, and diagnosis resolution was 8 days (range, 0 day to 8 months), 0 day (range, 0 day to 20 days), 7 days (range, 3 days to 3.5 months), and 4 days (range, 1 day to 1.8 months), respectively.
CONCLUSION: The BCC timeliness framework is based on the current sequenced trajectory of the BCC journey. Clarity in the measurement of timeliness provides a standardized language for monitoring and outcome research. It can serve as a quality indicator for community and hospital-based breast cancer programs.