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The New Zealand Cancer Control Strategy was launched in 2003 and one of its goals is to reduce the incidence and impact of cancer through research and surveillance in New Zealand.1 As an initiative to fulfill this goal, the New Zealand Breast Cancer Foundation (NZBCF) funded the establishment of breast cancer registers at four main centres of Auckland, Waikato, Christchurch and Wellington.Established in 2009, Christchurch Breast Cancer Patient Register (CBCR) is the only register in the South Island collecting breast cancer data for the Canterbury region. Based at Christchurch Hospital, the CBCR governance group consists of a breast surgeon, anatomical pathologist and oncology consultant.To date, 750 breast cancer patients are on the Register comprising 92% of eligible patients. Combined with the Cancer Society Tissue Bank2 based at University of Otago, this provides a powerful research facility. The database employed by the four registers consists of core data fields and CBCR has updated the local database with additional data fields for self-declared ethnicity; clinical notes; reconstruction surgery and pathological data.Because of local and growing international interest in prognostic factors of lobular carcinoma in situ (LCIS), patients with such lesions are also eligible and recorded on the database.In this article we present the first year's findings on 337 patients recorded on the database. The aim of the CBCR is to prospectively record clinical and pathological data and outcomes of breast cancer patients in the Canterbury region.Methods All eligible breast cancer patients treated at breast centres in Canterbury are invited by clinical staff to consent to join CBCR at the time of establishing their diagnosis. The software CBCR uses, Microsoft Access Database (2007 version), has common components to the database used by the other three established registers. Patient confidentiality is maintained at all times with password protected access to the database held by the data coordinator. Ethical approval was granted by the Upper South A & B Regional Ethics Committees in Aug 2007 to collect data on consented breast cancer patients. Types of data collected from patients' clinical records include clinical; pathological; surgical and/or oncological management and follow up status (outcome). Data collation and analysis is undertaken by the data coordinator who is also a registered nurse with the findings presented to the governance group for further analysis and discussion. The main breast centres in the Canterbury region are Christchurch and Ashburton Public Hospitals and private facilities at Canterbury Breastcare and St George's Cancer Care Centre. Breast cancer registration data is provided by New Zealand Cancer Registry (Ministry of Health) to ensure completeness. Three main laboratories process and report on breast samples in Christchurch: Canterbury Health Laboratories (public), Medlab South (private) and Southern Community Laboratories (private). Original pathology reports are obtained for each individual patient. Fluorescent in situ hybridisation (FISH) assessment for further HER2 proto-oncogene verification has been undertaken by LabPLUS and from 1 Sept 2010 IGENZ in Auckland which is subsidised by Roche Pharma. The inclusion criteria for the Register include Canterbury or West Coast residents who are diagnosed with breast cancer after June 2009 receiving treatment at breast centres in the Canterbury region. Patients are excluded from the Register for the following reasons: previous history of breast cancer before June 2009; residents outside Canterbury or West Coast regions; patients who have declined or deceased before consent was obtained. These patients are recorded separately as a breast cancer diagnosis in order to determine the proportion entered onto the database. Results Demographics In the first year of recruitment (from 15 June 2009 to 15 June 2010), a total of 337 patients (including one male) consented comprising 202 (60%) from the public sector and 135 (40%) from the private sector. 289 (85.8%) patients had invasive breast carcinoma whereas 47 (13.9%) patients had ductal carcinoma in situ (DCIS) with no invasive component and one (0.3%) patient with lobular carcinoma in situ. The consent rate was 93.6% with 360 eligible patients. Patients not consented include 12 who had declined to participate; eight who had deceased before consent was given with three remaining patients who are yet to give consent. Menopausal status of female patients included 113 (34%) premenopausal; 196 (58%) post; 16 (5%) peri and 11 (3%) unknown status. At diagnosis, 231 (68.5%) were aged 50 years or over. Figure 1 shows the age distribution of all registered patients. Figure 1. Demographics: breast cancer by age group for all registered patients (n=337) Self-declared ethnicity data (based on the 2006 Census) is collected by CBCR to ensure accurate categorisation of ethnic groups, including Maori, affected by breast cancer. The demographics of patient ethnicity recorded on CBCR comprise of Asian 14 (4.1%); European 297 (88.1%); Maori 15 (4.5%); Other 5 (1.5%) and Pacific Islander 6 (1.8%). This is consistent with census data for the Canterbury region3. Detection methods 146 (43.3%) patients presented with a screen detected abnormality and 191 (56.7%) symptomatically. Of those presenting with clinical symptoms, 171 (89.5%) patients had a lump while remaining patients had nipple, skin or other changes. Surgical treatment Invasive carcinoma—Twenty-three (8%) of 289 patients with invasive carcinoma did not undergo any primary breast surgery. Of these, eight (34.8%) patients had metastatic disease at the time of diagnosis; 11 (47.8%) were elderly or unfit for surgery and received endocrine therapy alone. The remaining four (17.4%) patients either had inoperable locally advanced disease or declined surgery. Breast surgery such as mastectomy or breast conserving surgery was performed on 266 (92%) of 289 patients with invasive carcinoma. All types of breast conserving surgery including wide local excision (WLE), either by palpation or hook wire localisation, and excision biopsy are categorised into "WLE" in this article. The majority of patients were self-declared European, 5% were Maori, and 7% were of other ethnicities, including Asian and Pacific Island. Surgery type by ethnicity for patients with invasive carcinoma is shown in Table 1 and surgery for patients with invasive carcinoma, as well as DCIS, by tumour size, in Table 2. Mastectomy was performed in 50.6% (43) of women under 50 years of age, 41.9% (57) of those 50-69 years of age, and 54.4% (37) of those older than 70 years. Multifocal invasive cancer was present in 62 women (21.4%). Table 1: Types of surgery by ethnicity - invasive carcinoma Ethnic group No primary surgery MAST WLE Number of cases Percentage European 21 122 111 254 87.9% Maori - 4 10 14 4.8% All Others 2 11 8 21 7.3% Total 23 137 129 289 100% Ductal carcinoma in situ (DCIS)—Forty-seven patients were diagnosed with DCIS without any invasive component, including one patient with Paget's disease of the nipple. Whilst 33 (70.2%) patients did not require axillary surgery, 12 (25.5%) patients had sentinel node biopsy (SNB) and two (4.3%) others had axillary node dissection (AND) without SNB. One of the patients who had AND was found to have enlarged lymph nodes intra-operatively and a decision was made by the surgeon to perform immediate AND. All the patients who had axillary surgery were found to be node negative. Table 2: Types of surgery by tumour size - invasive carcinoma & DCIS Tumour size No primary surgery Mastectomy WLE Number of cases Percentage Invasive carcinoma ≤ 2cm - 58 (36.9%) 99 (63.1%) 157 54.3% 2 - 5cm - 67 (69.8%) 29 (30.2%) 96 33.2% > 5cm - 10 (90.9%) 1 (9.1%) 11 3.8% Unknown 23 (92%) 2 (8%) - 25 8.7% Total 23 137 129 289 Percentage 8% 47.4% 44.6% 100% DCIS ≤ 2cm - 2 24 26 55.3% 2 - 5cm - 4 7 11 23.4% > 5cm - 5 2 7 14.9% Unknown - 1 2 3 6.4% Total - 12 35 47 100% Percentage - 25.5% 74.5% 100% Of 202 breast cancer patients, with invasive carcinoma and/or DCIS only who were treated at Christchurch Hospital, 147 (72.8%) had voluntarily donated their tissue to the Cancer Society Tissue Bank for use in breast cancer research. Axillary staging - invasive cancers 263 patients with invasive carcinoma had axillary surgery to assess their nodal status. Of these, 191 (72.6%) patients had SNB with or without AND whereas 72 (27.4%) had AND without SNB. There were three patients who had SNB followed by immediate or delayed AND with final histology showing node negativity. One of these patients had isolated tumour cells identified in three of her sentinel nodes but was advised to have delayed AND following a multidisciplinary team discussion. The other two cases had immediate AND following SNB due to sentinel nodes being unidentifiable by blue dye or isotope so AND up to level one was undertaken. Amongst the patients who had AND without SNB (n=72), 22 (30.6%) patients were found to be node negative while 50 (69.4%) of them were node positive. Table 3 shows the overall nodal status of patients who had SNB with/without AND. Table 3. Nodal status for patients undergoing sentinel node biopsy & axillary dissection for invasive carcinoma Axillary surgery Nodal status Number of cases Percentage \r\

Summary

Abstract

Aim

The aim of this article is to present the first years findings of the Christchurch Breast Cancer Patient Register (CBCR) to establish the incidence and management of breast cancer in the Canterbury region.

Method

CBCR commenced recruitment of breast cancer patients in Canterbury from June 2009. Ethical approval was granted by regional ethics committees to collect data. Patient data is recorded onto the database once informed consent is obtained.

Results

A total of 337 patients (including one male) consented. At diagnosis, 231 (68.5%) were aged 50 years or over. 48 (14.2%) patients had carcinoma in situ with no invasive component. 289 (85.8%) patients had invasive carcinoma with 47.4% undergoing mastectomy and 44.6% breast conserving surgery whereas 8% had no primary surgery. Nodes were positive in 102 (38.8%), and the predominant tumour type was Ductal NST (no special type) in 68.9% (199) of patients with invasive carcinoma. Additional data incorporating ethnicity, oncology, additional surgical management and pathological variables are also presented in detail.

Conclusion

Findings on 337 patients recruited and recorded on CBCR database in the first year are discussed. Due to the short follow up, outcome data is not analysed.

Author Information

Valerie C L Davey, Data Coordinator, Christchurch Breast Cancer Patient Register, Christchurch; Bridget A Robinson, Mackenzie Chair of Cancer Medicine, Dept of Medicine, Otago University, Christchurch; Birgit Dijkstra, Consultant Breast & Endocrine Surgeon, Dept of Surgery, Christchurch Hospital, Christchurch; Gavin C Harris, Consultant Anatomical Pathologist, Canterbury Health Laboratories, Christchurch

Acknowledgements

We thank for the following organisations for their support during this study: New Zealand Breast Cancer Foundation (premier sponsor), Canterbury District Health Board, Canterbury Breastcare, St Georges Cancer Care Centre

Correspondence

Valerie Davey, Christchurch Breast Cancer Patient Register, c/o Dept of Surgery, Christchurch Hospital, Private Bag 4710, Christchurch 8140, New Zealand. Fax: +64 (0)3 3640352

Correspondence Email

valerie.davey@cdhb.health.nz

Competing Interests

None declared.

Cancer Control Taskforce. The New Zealand Cancer Control Strategy: Action Plan 2005-2010. Wellington: Ministry of Health. 2005.Morrin H, Gunningham S, Currie M, et al. The Christchurch Tissue Bank to support cancer research. N Z Med J. 2005;118(1735). http://journal.nzma.org.nz/journal/118-1225/1735/content.pdfStatistics New Zealand. 2006. 2006 Census data available from www.stats.govt.nzMoshin S. Molecular markers in invasive breast cancer. In: Breast Pathology - A Volume in the Foundations in Diagnostic Pathology, 2nd edition. Eds OMalley F.P., Pinder S.E. & Mulligan, A.M. Churchill Livingstone Elsevier. 2011.Neave L, Harvey V, Benjamin C, et al. The Auckland Breast Cancer Register: A Special project of the Auckland Breast Cancer Study Group. N Z Med J. 2003;116(1184). http://journal.nzma.org.nz/journal/116-1184/648/content.pdfHabermann E, Abbott A, Parsons H, et al. Are mastectomy rates really falling in the United States. J Clin Oncol. 2010;28:3437-3441.Freedmen R, He Y, Winer E, Keating N. Trends in racial and age disparities in definitive local therapy of early-stage breast cancer. J Clin Oncol. 2009;27:713-719.Gomez S, Lichtensztajn D, Kurian A, et al. Increasing mastectomy rates for early-stage breast cancer? Population-based trends from California. J Clin Oncol. 2010;28:e155-e157.Krag D, Anderson S, Julian T, et al. Sentinel-lymph-node resection compared with conventional axillary-lymph-node dissection in clinically node-negative patients with breast cancer: overall survival findings from NSABP B-32 randomised phase 3 trial. Lancet Onc. 2010;11:927-933.Gill G. The SNAC Trial Group of the Royal Australasian College of Surgeons (RACS) and NHMRC Clinical Trials Centre, Sentinel-Lymph-Node-based management or routine axillary clearance? One-year outcomes of sentinel node biopsy versus axillary clearance (SNAC): a randomized controlled surgical trial. Ann Surg Onc. 2009;16:266-275.Wolff A, Hammond M, Schwartz J, et al. American Society of Clinical Oncology/College of American Pathologists guideline recommendation for human epidermal growth factor receptor 2 testing in breast cancer. J Clin Oncol. 2007;25:118-145. Epub 2006 Dec 11.

For the PDF of this article,
contact nzmj@nzma.org.nz

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The New Zealand Cancer Control Strategy was launched in 2003 and one of its goals is to reduce the incidence and impact of cancer through research and surveillance in New Zealand.1 As an initiative to fulfill this goal, the New Zealand Breast Cancer Foundation (NZBCF) funded the establishment of breast cancer registers at four main centres of Auckland, Waikato, Christchurch and Wellington.Established in 2009, Christchurch Breast Cancer Patient Register (CBCR) is the only register in the South Island collecting breast cancer data for the Canterbury region. Based at Christchurch Hospital, the CBCR governance group consists of a breast surgeon, anatomical pathologist and oncology consultant.To date, 750 breast cancer patients are on the Register comprising 92% of eligible patients. Combined with the Cancer Society Tissue Bank2 based at University of Otago, this provides a powerful research facility. The database employed by the four registers consists of core data fields and CBCR has updated the local database with additional data fields for self-declared ethnicity; clinical notes; reconstruction surgery and pathological data.Because of local and growing international interest in prognostic factors of lobular carcinoma in situ (LCIS), patients with such lesions are also eligible and recorded on the database.In this article we present the first year's findings on 337 patients recorded on the database. The aim of the CBCR is to prospectively record clinical and pathological data and outcomes of breast cancer patients in the Canterbury region.Methods All eligible breast cancer patients treated at breast centres in Canterbury are invited by clinical staff to consent to join CBCR at the time of establishing their diagnosis. The software CBCR uses, Microsoft Access Database (2007 version), has common components to the database used by the other three established registers. Patient confidentiality is maintained at all times with password protected access to the database held by the data coordinator. Ethical approval was granted by the Upper South A & B Regional Ethics Committees in Aug 2007 to collect data on consented breast cancer patients. Types of data collected from patients' clinical records include clinical; pathological; surgical and/or oncological management and follow up status (outcome). Data collation and analysis is undertaken by the data coordinator who is also a registered nurse with the findings presented to the governance group for further analysis and discussion. The main breast centres in the Canterbury region are Christchurch and Ashburton Public Hospitals and private facilities at Canterbury Breastcare and St George's Cancer Care Centre. Breast cancer registration data is provided by New Zealand Cancer Registry (Ministry of Health) to ensure completeness. Three main laboratories process and report on breast samples in Christchurch: Canterbury Health Laboratories (public), Medlab South (private) and Southern Community Laboratories (private). Original pathology reports are obtained for each individual patient. Fluorescent in situ hybridisation (FISH) assessment for further HER2 proto-oncogene verification has been undertaken by LabPLUS and from 1 Sept 2010 IGENZ in Auckland which is subsidised by Roche Pharma. The inclusion criteria for the Register include Canterbury or West Coast residents who are diagnosed with breast cancer after June 2009 receiving treatment at breast centres in the Canterbury region. Patients are excluded from the Register for the following reasons: previous history of breast cancer before June 2009; residents outside Canterbury or West Coast regions; patients who have declined or deceased before consent was obtained. These patients are recorded separately as a breast cancer diagnosis in order to determine the proportion entered onto the database. Results Demographics In the first year of recruitment (from 15 June 2009 to 15 June 2010), a total of 337 patients (including one male) consented comprising 202 (60%) from the public sector and 135 (40%) from the private sector. 289 (85.8%) patients had invasive breast carcinoma whereas 47 (13.9%) patients had ductal carcinoma in situ (DCIS) with no invasive component and one (0.3%) patient with lobular carcinoma in situ. The consent rate was 93.6% with 360 eligible patients. Patients not consented include 12 who had declined to participate; eight who had deceased before consent was given with three remaining patients who are yet to give consent. Menopausal status of female patients included 113 (34%) premenopausal; 196 (58%) post; 16 (5%) peri and 11 (3%) unknown status. At diagnosis, 231 (68.5%) were aged 50 years or over. Figure 1 shows the age distribution of all registered patients. Figure 1. Demographics: breast cancer by age group for all registered patients (n=337) Self-declared ethnicity data (based on the 2006 Census) is collected by CBCR to ensure accurate categorisation of ethnic groups, including Maori, affected by breast cancer. The demographics of patient ethnicity recorded on CBCR comprise of Asian 14 (4.1%); European 297 (88.1%); Maori 15 (4.5%); Other 5 (1.5%) and Pacific Islander 6 (1.8%). This is consistent with census data for the Canterbury region3. Detection methods 146 (43.3%) patients presented with a screen detected abnormality and 191 (56.7%) symptomatically. Of those presenting with clinical symptoms, 171 (89.5%) patients had a lump while remaining patients had nipple, skin or other changes. Surgical treatment Invasive carcinoma—Twenty-three (8%) of 289 patients with invasive carcinoma did not undergo any primary breast surgery. Of these, eight (34.8%) patients had metastatic disease at the time of diagnosis; 11 (47.8%) were elderly or unfit for surgery and received endocrine therapy alone. The remaining four (17.4%) patients either had inoperable locally advanced disease or declined surgery. Breast surgery such as mastectomy or breast conserving surgery was performed on 266 (92%) of 289 patients with invasive carcinoma. All types of breast conserving surgery including wide local excision (WLE), either by palpation or hook wire localisation, and excision biopsy are categorised into "WLE" in this article. The majority of patients were self-declared European, 5% were Maori, and 7% were of other ethnicities, including Asian and Pacific Island. Surgery type by ethnicity for patients with invasive carcinoma is shown in Table 1 and surgery for patients with invasive carcinoma, as well as DCIS, by tumour size, in Table 2. Mastectomy was performed in 50.6% (43) of women under 50 years of age, 41.9% (57) of those 50-69 years of age, and 54.4% (37) of those older than 70 years. Multifocal invasive cancer was present in 62 women (21.4%). Table 1: Types of surgery by ethnicity - invasive carcinoma Ethnic group No primary surgery MAST WLE Number of cases Percentage European 21 122 111 254 87.9% Maori - 4 10 14 4.8% All Others 2 11 8 21 7.3% Total 23 137 129 289 100% Ductal carcinoma in situ (DCIS)—Forty-seven patients were diagnosed with DCIS without any invasive component, including one patient with Paget's disease of the nipple. Whilst 33 (70.2%) patients did not require axillary surgery, 12 (25.5%) patients had sentinel node biopsy (SNB) and two (4.3%) others had axillary node dissection (AND) without SNB. One of the patients who had AND was found to have enlarged lymph nodes intra-operatively and a decision was made by the surgeon to perform immediate AND. All the patients who had axillary surgery were found to be node negative. Table 2: Types of surgery by tumour size - invasive carcinoma & DCIS Tumour size No primary surgery Mastectomy WLE Number of cases Percentage Invasive carcinoma ≤ 2cm - 58 (36.9%) 99 (63.1%) 157 54.3% 2 - 5cm - 67 (69.8%) 29 (30.2%) 96 33.2% > 5cm - 10 (90.9%) 1 (9.1%) 11 3.8% Unknown 23 (92%) 2 (8%) - 25 8.7% Total 23 137 129 289 Percentage 8% 47.4% 44.6% 100% DCIS ≤ 2cm - 2 24 26 55.3% 2 - 5cm - 4 7 11 23.4% > 5cm - 5 2 7 14.9% Unknown - 1 2 3 6.4% Total - 12 35 47 100% Percentage - 25.5% 74.5% 100% Of 202 breast cancer patients, with invasive carcinoma and/or DCIS only who were treated at Christchurch Hospital, 147 (72.8%) had voluntarily donated their tissue to the Cancer Society Tissue Bank for use in breast cancer research. Axillary staging - invasive cancers 263 patients with invasive carcinoma had axillary surgery to assess their nodal status. Of these, 191 (72.6%) patients had SNB with or without AND whereas 72 (27.4%) had AND without SNB. There were three patients who had SNB followed by immediate or delayed AND with final histology showing node negativity. One of these patients had isolated tumour cells identified in three of her sentinel nodes but was advised to have delayed AND following a multidisciplinary team discussion. The other two cases had immediate AND following SNB due to sentinel nodes being unidentifiable by blue dye or isotope so AND up to level one was undertaken. Amongst the patients who had AND without SNB (n=72), 22 (30.6%) patients were found to be node negative while 50 (69.4%) of them were node positive. Table 3 shows the overall nodal status of patients who had SNB with/without AND. Table 3. Nodal status for patients undergoing sentinel node biopsy & axillary dissection for invasive carcinoma Axillary surgery Nodal status Number of cases Percentage \r\

Summary

Abstract

Aim

The aim of this article is to present the first years findings of the Christchurch Breast Cancer Patient Register (CBCR) to establish the incidence and management of breast cancer in the Canterbury region.

Method

CBCR commenced recruitment of breast cancer patients in Canterbury from June 2009. Ethical approval was granted by regional ethics committees to collect data. Patient data is recorded onto the database once informed consent is obtained.

Results

A total of 337 patients (including one male) consented. At diagnosis, 231 (68.5%) were aged 50 years or over. 48 (14.2%) patients had carcinoma in situ with no invasive component. 289 (85.8%) patients had invasive carcinoma with 47.4% undergoing mastectomy and 44.6% breast conserving surgery whereas 8% had no primary surgery. Nodes were positive in 102 (38.8%), and the predominant tumour type was Ductal NST (no special type) in 68.9% (199) of patients with invasive carcinoma. Additional data incorporating ethnicity, oncology, additional surgical management and pathological variables are also presented in detail.

Conclusion

Findings on 337 patients recruited and recorded on CBCR database in the first year are discussed. Due to the short follow up, outcome data is not analysed.

Author Information

Valerie C L Davey, Data Coordinator, Christchurch Breast Cancer Patient Register, Christchurch; Bridget A Robinson, Mackenzie Chair of Cancer Medicine, Dept of Medicine, Otago University, Christchurch; Birgit Dijkstra, Consultant Breast & Endocrine Surgeon, Dept of Surgery, Christchurch Hospital, Christchurch; Gavin C Harris, Consultant Anatomical Pathologist, Canterbury Health Laboratories, Christchurch

Acknowledgements

We thank for the following organisations for their support during this study: New Zealand Breast Cancer Foundation (premier sponsor), Canterbury District Health Board, Canterbury Breastcare, St Georges Cancer Care Centre

Correspondence

Valerie Davey, Christchurch Breast Cancer Patient Register, c/o Dept of Surgery, Christchurch Hospital, Private Bag 4710, Christchurch 8140, New Zealand. Fax: +64 (0)3 3640352

Correspondence Email

valerie.davey@cdhb.health.nz

Competing Interests

None declared.

Cancer Control Taskforce. The New Zealand Cancer Control Strategy: Action Plan 2005-2010. Wellington: Ministry of Health. 2005.Morrin H, Gunningham S, Currie M, et al. The Christchurch Tissue Bank to support cancer research. N Z Med J. 2005;118(1735). http://journal.nzma.org.nz/journal/118-1225/1735/content.pdfStatistics New Zealand. 2006. 2006 Census data available from www.stats.govt.nzMoshin S. Molecular markers in invasive breast cancer. In: Breast Pathology - A Volume in the Foundations in Diagnostic Pathology, 2nd edition. Eds OMalley F.P., Pinder S.E. & Mulligan, A.M. Churchill Livingstone Elsevier. 2011.Neave L, Harvey V, Benjamin C, et al. The Auckland Breast Cancer Register: A Special project of the Auckland Breast Cancer Study Group. N Z Med J. 2003;116(1184). http://journal.nzma.org.nz/journal/116-1184/648/content.pdfHabermann E, Abbott A, Parsons H, et al. Are mastectomy rates really falling in the United States. J Clin Oncol. 2010;28:3437-3441.Freedmen R, He Y, Winer E, Keating N. Trends in racial and age disparities in definitive local therapy of early-stage breast cancer. J Clin Oncol. 2009;27:713-719.Gomez S, Lichtensztajn D, Kurian A, et al. Increasing mastectomy rates for early-stage breast cancer? Population-based trends from California. J Clin Oncol. 2010;28:e155-e157.Krag D, Anderson S, Julian T, et al. Sentinel-lymph-node resection compared with conventional axillary-lymph-node dissection in clinically node-negative patients with breast cancer: overall survival findings from NSABP B-32 randomised phase 3 trial. Lancet Onc. 2010;11:927-933.Gill G. The SNAC Trial Group of the Royal Australasian College of Surgeons (RACS) and NHMRC Clinical Trials Centre, Sentinel-Lymph-Node-based management or routine axillary clearance? One-year outcomes of sentinel node biopsy versus axillary clearance (SNAC): a randomized controlled surgical trial. Ann Surg Onc. 2009;16:266-275.Wolff A, Hammond M, Schwartz J, et al. American Society of Clinical Oncology/College of American Pathologists guideline recommendation for human epidermal growth factor receptor 2 testing in breast cancer. J Clin Oncol. 2007;25:118-145. Epub 2006 Dec 11.

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

The New Zealand Cancer Control Strategy was launched in 2003 and one of its goals is to reduce the incidence and impact of cancer through research and surveillance in New Zealand.1 As an initiative to fulfill this goal, the New Zealand Breast Cancer Foundation (NZBCF) funded the establishment of breast cancer registers at four main centres of Auckland, Waikato, Christchurch and Wellington.Established in 2009, Christchurch Breast Cancer Patient Register (CBCR) is the only register in the South Island collecting breast cancer data for the Canterbury region. Based at Christchurch Hospital, the CBCR governance group consists of a breast surgeon, anatomical pathologist and oncology consultant.To date, 750 breast cancer patients are on the Register comprising 92% of eligible patients. Combined with the Cancer Society Tissue Bank2 based at University of Otago, this provides a powerful research facility. The database employed by the four registers consists of core data fields and CBCR has updated the local database with additional data fields for self-declared ethnicity; clinical notes; reconstruction surgery and pathological data.Because of local and growing international interest in prognostic factors of lobular carcinoma in situ (LCIS), patients with such lesions are also eligible and recorded on the database.In this article we present the first year's findings on 337 patients recorded on the database. The aim of the CBCR is to prospectively record clinical and pathological data and outcomes of breast cancer patients in the Canterbury region.Methods All eligible breast cancer patients treated at breast centres in Canterbury are invited by clinical staff to consent to join CBCR at the time of establishing their diagnosis. The software CBCR uses, Microsoft Access Database (2007 version), has common components to the database used by the other three established registers. Patient confidentiality is maintained at all times with password protected access to the database held by the data coordinator. Ethical approval was granted by the Upper South A & B Regional Ethics Committees in Aug 2007 to collect data on consented breast cancer patients. Types of data collected from patients' clinical records include clinical; pathological; surgical and/or oncological management and follow up status (outcome). Data collation and analysis is undertaken by the data coordinator who is also a registered nurse with the findings presented to the governance group for further analysis and discussion. The main breast centres in the Canterbury region are Christchurch and Ashburton Public Hospitals and private facilities at Canterbury Breastcare and St George's Cancer Care Centre. Breast cancer registration data is provided by New Zealand Cancer Registry (Ministry of Health) to ensure completeness. Three main laboratories process and report on breast samples in Christchurch: Canterbury Health Laboratories (public), Medlab South (private) and Southern Community Laboratories (private). Original pathology reports are obtained for each individual patient. Fluorescent in situ hybridisation (FISH) assessment for further HER2 proto-oncogene verification has been undertaken by LabPLUS and from 1 Sept 2010 IGENZ in Auckland which is subsidised by Roche Pharma. The inclusion criteria for the Register include Canterbury or West Coast residents who are diagnosed with breast cancer after June 2009 receiving treatment at breast centres in the Canterbury region. Patients are excluded from the Register for the following reasons: previous history of breast cancer before June 2009; residents outside Canterbury or West Coast regions; patients who have declined or deceased before consent was obtained. These patients are recorded separately as a breast cancer diagnosis in order to determine the proportion entered onto the database. Results Demographics In the first year of recruitment (from 15 June 2009 to 15 June 2010), a total of 337 patients (including one male) consented comprising 202 (60%) from the public sector and 135 (40%) from the private sector. 289 (85.8%) patients had invasive breast carcinoma whereas 47 (13.9%) patients had ductal carcinoma in situ (DCIS) with no invasive component and one (0.3%) patient with lobular carcinoma in situ. The consent rate was 93.6% with 360 eligible patients. Patients not consented include 12 who had declined to participate; eight who had deceased before consent was given with three remaining patients who are yet to give consent. Menopausal status of female patients included 113 (34%) premenopausal; 196 (58%) post; 16 (5%) peri and 11 (3%) unknown status. At diagnosis, 231 (68.5%) were aged 50 years or over. Figure 1 shows the age distribution of all registered patients. Figure 1. Demographics: breast cancer by age group for all registered patients (n=337) Self-declared ethnicity data (based on the 2006 Census) is collected by CBCR to ensure accurate categorisation of ethnic groups, including Maori, affected by breast cancer. The demographics of patient ethnicity recorded on CBCR comprise of Asian 14 (4.1%); European 297 (88.1%); Maori 15 (4.5%); Other 5 (1.5%) and Pacific Islander 6 (1.8%). This is consistent with census data for the Canterbury region3. Detection methods 146 (43.3%) patients presented with a screen detected abnormality and 191 (56.7%) symptomatically. Of those presenting with clinical symptoms, 171 (89.5%) patients had a lump while remaining patients had nipple, skin or other changes. Surgical treatment Invasive carcinoma—Twenty-three (8%) of 289 patients with invasive carcinoma did not undergo any primary breast surgery. Of these, eight (34.8%) patients had metastatic disease at the time of diagnosis; 11 (47.8%) were elderly or unfit for surgery and received endocrine therapy alone. The remaining four (17.4%) patients either had inoperable locally advanced disease or declined surgery. Breast surgery such as mastectomy or breast conserving surgery was performed on 266 (92%) of 289 patients with invasive carcinoma. All types of breast conserving surgery including wide local excision (WLE), either by palpation or hook wire localisation, and excision biopsy are categorised into "WLE" in this article. The majority of patients were self-declared European, 5% were Maori, and 7% were of other ethnicities, including Asian and Pacific Island. Surgery type by ethnicity for patients with invasive carcinoma is shown in Table 1 and surgery for patients with invasive carcinoma, as well as DCIS, by tumour size, in Table 2. Mastectomy was performed in 50.6% (43) of women under 50 years of age, 41.9% (57) of those 50-69 years of age, and 54.4% (37) of those older than 70 years. Multifocal invasive cancer was present in 62 women (21.4%). Table 1: Types of surgery by ethnicity - invasive carcinoma Ethnic group No primary surgery MAST WLE Number of cases Percentage European 21 122 111 254 87.9% Maori - 4 10 14 4.8% All Others 2 11 8 21 7.3% Total 23 137 129 289 100% Ductal carcinoma in situ (DCIS)—Forty-seven patients were diagnosed with DCIS without any invasive component, including one patient with Paget's disease of the nipple. Whilst 33 (70.2%) patients did not require axillary surgery, 12 (25.5%) patients had sentinel node biopsy (SNB) and two (4.3%) others had axillary node dissection (AND) without SNB. One of the patients who had AND was found to have enlarged lymph nodes intra-operatively and a decision was made by the surgeon to perform immediate AND. All the patients who had axillary surgery were found to be node negative. Table 2: Types of surgery by tumour size - invasive carcinoma & DCIS Tumour size No primary surgery Mastectomy WLE Number of cases Percentage Invasive carcinoma ≤ 2cm - 58 (36.9%) 99 (63.1%) 157 54.3% 2 - 5cm - 67 (69.8%) 29 (30.2%) 96 33.2% > 5cm - 10 (90.9%) 1 (9.1%) 11 3.8% Unknown 23 (92%) 2 (8%) - 25 8.7% Total 23 137 129 289 Percentage 8% 47.4% 44.6% 100% DCIS ≤ 2cm - 2 24 26 55.3% 2 - 5cm - 4 7 11 23.4% > 5cm - 5 2 7 14.9% Unknown - 1 2 3 6.4% Total - 12 35 47 100% Percentage - 25.5% 74.5% 100% Of 202 breast cancer patients, with invasive carcinoma and/or DCIS only who were treated at Christchurch Hospital, 147 (72.8%) had voluntarily donated their tissue to the Cancer Society Tissue Bank for use in breast cancer research. Axillary staging - invasive cancers 263 patients with invasive carcinoma had axillary surgery to assess their nodal status. Of these, 191 (72.6%) patients had SNB with or without AND whereas 72 (27.4%) had AND without SNB. There were three patients who had SNB followed by immediate or delayed AND with final histology showing node negativity. One of these patients had isolated tumour cells identified in three of her sentinel nodes but was advised to have delayed AND following a multidisciplinary team discussion. The other two cases had immediate AND following SNB due to sentinel nodes being unidentifiable by blue dye or isotope so AND up to level one was undertaken. Amongst the patients who had AND without SNB (n=72), 22 (30.6%) patients were found to be node negative while 50 (69.4%) of them were node positive. Table 3 shows the overall nodal status of patients who had SNB with/without AND. Table 3. Nodal status for patients undergoing sentinel node biopsy & axillary dissection for invasive carcinoma Axillary surgery Nodal status Number of cases Percentage \r\

Summary

Abstract

Aim

The aim of this article is to present the first years findings of the Christchurch Breast Cancer Patient Register (CBCR) to establish the incidence and management of breast cancer in the Canterbury region.

Method

CBCR commenced recruitment of breast cancer patients in Canterbury from June 2009. Ethical approval was granted by regional ethics committees to collect data. Patient data is recorded onto the database once informed consent is obtained.

Results

A total of 337 patients (including one male) consented. At diagnosis, 231 (68.5%) were aged 50 years or over. 48 (14.2%) patients had carcinoma in situ with no invasive component. 289 (85.8%) patients had invasive carcinoma with 47.4% undergoing mastectomy and 44.6% breast conserving surgery whereas 8% had no primary surgery. Nodes were positive in 102 (38.8%), and the predominant tumour type was Ductal NST (no special type) in 68.9% (199) of patients with invasive carcinoma. Additional data incorporating ethnicity, oncology, additional surgical management and pathological variables are also presented in detail.

Conclusion

Findings on 337 patients recruited and recorded on CBCR database in the first year are discussed. Due to the short follow up, outcome data is not analysed.

Author Information

Valerie C L Davey, Data Coordinator, Christchurch Breast Cancer Patient Register, Christchurch; Bridget A Robinson, Mackenzie Chair of Cancer Medicine, Dept of Medicine, Otago University, Christchurch; Birgit Dijkstra, Consultant Breast & Endocrine Surgeon, Dept of Surgery, Christchurch Hospital, Christchurch; Gavin C Harris, Consultant Anatomical Pathologist, Canterbury Health Laboratories, Christchurch

Acknowledgements

We thank for the following organisations for their support during this study: New Zealand Breast Cancer Foundation (premier sponsor), Canterbury District Health Board, Canterbury Breastcare, St Georges Cancer Care Centre

Correspondence

Valerie Davey, Christchurch Breast Cancer Patient Register, c/o Dept of Surgery, Christchurch Hospital, Private Bag 4710, Christchurch 8140, New Zealand. Fax: +64 (0)3 3640352

Correspondence Email

valerie.davey@cdhb.health.nz

Competing Interests

None declared.

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