Comparative Analysis of Pembrolizumab and Chemotherpay with Radiology Among Patients of Untreated Pd-L1 Positive Metastatic Triple Negative Breast Cancer

Objective: The aim of this study is to compare the outcomes of chemotherapy with radiology and use of pembrolizumab among the patients had metastatic triple negative breast cancer and did not receive any treatment yet. Study Design: Comparative/Observational study. Place and Duration: Breast Clinic Ganga Ram Hospital Mazang Road, Lahore. April 2021-Sep 2021 Methods: Total 70 patients of aged 25-75 years were presented in this study. Patients had metastatic triple negative breast cancer and did not receive any treatment yet were included. Demographically detailed of enrolled cases age, body mass index, co-morbidities and literacy were calculated after taking informed written consent. Patients were equally divided into two groups, I and II. Group I had 35 patients and received pembrolizumab 200 mg every 2-weeks for six months while in group II 35 patients received chemotherapy (75mg Adriamycin) every 21-days for six months. Regular follow up among patients were conducted. Post-treatment outcomes among both groups were assessed and compared in terms of efficacy, control of disease, mortality and recurrence rate. SPSS 24.0 version was used to analyze complete data. Results: Mean age of the patients in group I was 58.01±4.34 years with mean BMI 28.21±6.22 kg/m2 and in group II mean age was 57.88±6.88 years with mean BMI 27.94±9.42 kg/m2. Frequency of literacy in group I was 18 (51.4%) and in group II 20 (57.1%) patients were literate. Hypertension was the most common comorbidity found in 13 (37.1%) in group I and 14 (40%) in group II followed by arthritis and diabetes mellitus. Post-treatment effectiveness in group I was 15 (42.9%) higher as compared to group II 10 (28.6%), partial recovery found in 11 (31.4%) and 8 (22.9%) among both groups, stability in disease was found higher among patients of group II 12 (34.3%) as compared to group I 7 (20%). Mortality in group I was 3 (8.6%) and in group II 5 (14.3%). Recurrence rate in pembrolizumab group was 2 (5.7%) lower as compared to chemotherapy group 4 (11.4%). Conclusion: In this research we concluded that the use of pembrolizumab injection for the treatment of breast cancer was effective and useful in terms of low mortality rate with recurrence rate and higher number of recovery, but rate of stability among disease was higher in chemotherapy group. Both treatments were effective for reduction in the prevalence of disease. Keywords: Breast Cancer, Chemotherapy, Pembrolizumab, Mortality, Recurrence

TP10.2.9The effect of COVID-19 on Breast clinic follow ups – a change in future practice?

Aims Prior to March 2020, at Princess Royal University Hospital (PRUH), Kings College NHS Foundation Trust, almost daily face to face benign/malignant breast clinic follow ups occurred. On March 23rd 2020 the UK went into official COVID-19 pandemic lockdown. The effect on elective follow up practice was swift with cancellation, triaging and replacement of face-to-face by telephonic/virtual consultations. We compared the change of follow up pattern, pre and post COVID-19. Could this effect the future of consultations at PRUH? Methods A comparison of all patients attending PRUH breast unit outpatients in January 2020 (preCOVID-19) for follow up, with those attending in April 2020 (postCOVID-19). Data collection from clinic lists and electronic patient records, with Excel version 16 analysis. Results 343 patient follow up consultations 01/2020. 53 patient follow up consultations 04/2020. Malignant cases: January 65%, April 60% Benign/B3 cases: January 35%, April 20% Summary follow up types. Conclusions Impact of COVID has been widespread in our practice. Our results show a significant reduction in face-to-face appointments, to allow social distancing. Further evaluation of this model will show its sustainability. Patient satisfaction will have to be assessed, with a view to a full move to video/telephone consultation where indicated.

EP.TH.81Contribution of Information on GP Referral Letters to Patient Management in a Rapid-diagnosis Breast Clinic

Aims GP referral letters to rapid-diagnosis breast clinics are often poorly scanned copies of standard 2 week-wait proforma that are difficult to read, lengthy, and contain a large amount of irrelevant information. We studied the contribution of information in referral letters in patient management and compared this with information provided by patients themselves. Methods Patients completed a standard questionnaire (one side of A4) on arrival at clinic. This included all information relevant to a breast clinic such as family history and comorbidities. A consultant surgeon then saw the patients with the questionnaire and performed clinical assessment and imaging as necessary, without referring to GP letters. The letters were read before patients left clinic. Any additional useful information was noted. Results 202 consecutive new patients, median age 44 (16-93) seen in 23 clinics by 2 consultants were studied. The median number of pages in referral letter was 5 (1-14). Patient questionnaire took less than 30 seconds to read. The presenting complaints were real or perceived lump (n = 105), pain (n = 44), both (n = 14) and others (n = 39). 21 patients had cancer. Additional useful information in the referral letter was noted in 20 patients (10%). However, in no case this affected the patient management adversely. Conclusions GP letters are lengthy but contribute relatively little to the initial assessment and management of patients in a busy rapid diagnosis breast clinic. A patient-completed targeted questionnaire is quicker and can potentially replace a GP referral letter in most patients.

Role of contrast enhanced mammography in diagnosis of malignant breast lesion with histopathological correlation

Background Contrast-enhanced spectral mammography (CESM) is a relatively new tool in breast imaging, which combines the benefits of full field digital mammography (FFDM) with intravenous contrast utilization. FFDM alone is a two-dimensional modality in which summation of overlapping tissues accounts for false-negative and false-positive findings, resulting in increased recall rates and limited sensitivity of the examination, especially in the setting of heterogeneously dense or extremely dense breast tissue. CESM advantageously uses the concept of angiogenesis in tumors by allowing contrast agents to highlight the areas of blood vessel proliferation relative to the surrounding normal breast tissue (Bhimani et al, 2017). Objectives The purpose of this study is to assess the role of contrast-enhanced (CEM) mammography for detecting malignant lesions compared to histopathological results. Methods A cross sectional study including 35 patients suspecting breast mass clinically, concluded at Ain Shams University hospitals, Radiology Department, in the outpatient breast clinic, the patients were investigated using SenoBright spectral mammography device, the period between January 2018 till the end of b June 2019. Results In our study CESM had a sensitivity of 95.7 %, a specificity of 66.7 %, a positive predictive value of 84.6% (PPV), a negative predictive value of 88.9 % (NPV) and efficacy 85.7 %. Conclusions CESM has better diagnostic performance than the standard conventional imaging; mammography plus ultrasound and provides a valuable tool to evaluate equivocal and suspicious breast lesions and detect multifocal/multicenteric disease accurately.

Breast myeloid sarcoma presenting as a palpable breast lump after allogeneic stem cell transplantation for acute myelomonocytic leukemia: a rare case report

Background Myeloid sarcoma (MS) is a tumor secondary to myeloid leukemia that consists of immature granulocytes with or without mature granulocytes and is a rare extramedullary manifestation of acute myeloid leukemia (AML). Case presentation We report a case of a 34-year-old woman diagnosed with AML-M4 who achieved remission after chemotherapy and received allogeneic stem cell transplantation (allo-SCT) for consolidation. Her past medical history showed that she received bilateral breast implants 7 years ago. This patient underwent ultrasound examination of the breast and multiple bilateral breast nodules were revealed that were not considered by clinicians to be concerning. Several months later, the patient’s bilateral nodules rapidly progressed to large palpable masses. Ultrasound-guided biopsy revealed diffuse infiltration of undifferentiated tumor cells and immunohistochemistry (IHC) indicated that the tumor was positive for myeloperoxidase (MPO), cluster of differentiation (CD) 34, CD43, CD68, CD117, and Ki67. The pathological diagnosis was extramedullary recurrence of AML as MS of breast. After the diagnosis, the patient received systemic chemotherapy and drugs containing cytarabine, azacitidine, and methotrexate. However, 1 year after achieving partial remission, the patient died from intracranial invasion of leukemia, brain herniation, and respiratory failure. Conclusion It is necessary for the specialist to have a high suspicion index by careful inquiry of the patient’s medical history if a patient presents at the breast clinic with a breast tumor as the chief complaint. Combining information from the patient’s medical history with a tumor biopsy is critical for obtaining the correct diagnosis of the disease.

Development, Validation, and Implementation of a Short Breast Health Questionnaire

Background Health status and perception can be assessed by general or disease-specific questionnaires, the latter are more sensitive. Considering the importance of breast health in women’s lives and the lack of any pertinent questionnaire, we performed this study to develop a valid and reliable short BH questionnaire (BHQ); and then use it for the assessment of participants. Methods We first designed and developed the instrument, followed by measurement of inter-rater agreement IRA, content validity including content validity index (I-CVI) and scale content validity index (S-CVI), and reliability (through internal consistency and test-retest). We then included eligible women with normal breasts and benign breast disorders who attended our breast clinic. Results The IRA index (78.6%) showed optimal relevance and clarity of the questionnaire. The content validity was acceptable; with an S-CVI of 87.35 and 84.42 for clarity and relevance, respectively. One question was eliminated (I-CVI < 70%). The internal reliability was high (Cronbach’s alpha = 0.93). For external consistency, three questions were eliminated (intraclass correlation coefficient < 0.7), the rest of the questions showed good and excellent reliability. In the next step, BH in the 350 eligible participants showed an overall score of 55.86 ± 11.57. Among different variables, age was the only one that showed a significant direct relationship with BH. A history of breast surgery for benign lesions and a family history of breast cancer did not affect BH. Conclusion This study introduces a valid reliable 11-item BHQ. We propose its use in various conditions throughout breast cancer screening, diagnosis, and treatment; and in the assessment of BH in various physiologic and reproductive situations.

315 Chaperone Documentation in The Breast Clinic: A Closed Loop Audit

Aim Intimate examinations are potentially uncomfortable and embarrassing. In addition to offering chaperones routinely, it is also important to clearly document the circumstances, with implications on patient dignity and safeguarding both patients and staff. We aimed to analyse the quality of chaperone documentation in the breast clinic before and after intervention. Method Audit standards (GMC and Chelsea & Westminster Trust guidelines): [1] Consent [2] Chaperone use/refusal, and [3] Chaperone role and identity should be clearly documented in the notes. We collected breast clinic data prospectively over one week, then re-audited after interventions including teaching sessions to the breast MDT, introduction of electronic (e)-notes (Cerner©), and creation of an instructional video demonstrating how to create an automatic template to easily document the aspects of chaperone use. Results 110 patients’ notes were analysed in the first cycle, and 74 in the second. Documentation improved significantly between cycle 1 and 2 for: consent (0% vs. 38%, p &lt; 0.0001), identity of chaperone (12% vs. 35%, p = 0.0003), and role of chaperone (8% vs. 23%, p = 0.0091). Documentation for chaperone use or refusal improved, but this was not significant (27% vs. 35%, p = 0.3305). Conclusions Documentation improved significantly for most standards, likely due to the template prompting the clinician. However, documentation remains suboptimal. Possible reasons include forgetfulness in a busy clinic, or shortage of staff available to chaperone. Future recommendations include creating a mandatory template on the e-notes for all breast clinic documentation including a section for chaperone use, role, and identity, and providing more staff such as HCAs for the clinic.

551 Patient Satisfaction with Telephone Consultations in A One-Stop Breast Clinic During COVID-19 Pandemic

Aim Telemedicine has gained an important role in medical practice lately, particularly in the outpatient setting. In our unit, virtual consultations were previously used for results clinics only. However, the first wave of COVID-19 pandemic necessitated change of practice to address issues of triage, infection control, cancer target times, and decreased capacity in the face of maintained demand. New patients underwent a telephone consultation followed by a clinic visit one week afterwards to complete triple assessment. We aimed to assess patient satisfaction with the phone consultation and subsequent care. Method Patients referred from general practice to the Breast Unit at West Middlesex University Hospital, who had a telephone appointment in the period 15/04/2020 to 15/07/2020, were included. The study was registered with the Clinical governance department. Patients received text messages with anonymised links to an online survey and were contacted over the telephone to explain the survey. Results 219 successful phone calls were made to eligible patients, and 126 patients responded to the survey (57.5%). 78% felt that they were able to express all or most of their concerns over the phone. 86% spent less than 2 hours in clinic. 87% felt social distancing and safety measures were adequate. More than 75% were overall satisfied with their care. Conclusions We further discuss responses to this survey. Patients were largely satisfied; however, areas of improvement were identified, and changes need to be made to ensure telemedicine is used to its full potential and is appropriately incorporated in the post COVID-19 practice.

915 An Unusual Case of Breast Tuberculosis: A Case Report

Background Breast Tuberculosis (TB) is a rare form of extra-pulmonary tuberculosis. It can mimic the presentation of many breast diseases including malignancy. We present a case of breast tuberculosis that had negative cultures from breast tissue while positive on lymph node biopsy. Case presentation A 36-year-old Libyan British lady presented to the symptomatic breast clinic with a large left breast mass during the first trimester of her fifth pregnancy. She has received antibiotics to treat mastitis but with no improvement. On Examination she had large left upper quadrant mass with skin tethering as well as palpable left axillary lymph nodes. Ultrasound imaging suggested features suspicious for malignancy and hence core biopsies were obtained which showed chronic inflammatory changes only. Ziehl Neelson stain was negative at this stage. A week later she developed low grade fever as well as signs of infection at biopsy site, this was treated with flucloxacillin, pus aspirated from underlying mass and sent for culture and sensitivity. Unfortunately, this lady travelled to Tunisia after her review and was subsequently diagnosed with breast tuberculosis on cultures from lymph node biopsies. On her return to our clinic, she was on appropriate treatment for TB, she had good response to treatment and follow up ultrasound showed stable residual collection. Conclusions This case illustrates the challenges in the diagnosis of breast tuberculosis as it is a rare entity of a disease that remains less prevalent in European countries. In most cases full recovery can be expected with anti- tuberculous treatment.

1344 Assessment of Appropriateness of Red Flag Referrals to One Stop Breast Clinic in Antrim Area Hospital

Aim To assess the appropriateness of red flag referrals to breast clinic. Method Retrospective study of patients attending breast clinic as red flag referrals within a few months period. 149 patients were identified. Their referrals and clinic notes were accessed through electronic care records. Out of the 149 patients used, 2 were routine referrals and the others were red flag. Various sources of referrals were seen such as from GP, Screening programme, SDA programme, and other departments. Results From the referrals, 95% are female (N = 142) and the remaining N = 7 (5%) were males. The youngest patient referred was 14 years old and the oldest 92. The average age for the referrals were 50 years old. From all the 125 referrals from GPs, 81.6% are in accordance with NI guideline and 78.4% are in accordance to NICE guidance. Of the 10 referrals made by other specialties, only 80% are in accordance with NICE and NI guidelines. The remaining 12 of the patients were from the SDA programme/ Breast screening programme. Interestingly of all the red flag referrals, only (9%, N = 13) are cancer. Conclusions Currently there is no triage system for red flag referrals in Antrim Area Hospital for breast clinic. We are currently seeing all the patients that are referred as red flag although some of them are inappropriate. A triage system needs to be placed.