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Background: Postoperative lymph node irradiation can affect shoulder morbidity in breast cancer patients, yet widely accepted dose-volume constraints for the shoulder joint are lacking. The SENOMAC trial randomized patients with breast cancer and 1–2 sentinel lymph node (SLN) macrometastases to axillary lymph node dissection (ALND) or SLN biopsy only. We aimed to analyze the association between the radiation dose to the shoulder joint and patient-reported arm morbidity one and three years after surgery using SENOMAC data.

Methods: Radiotherapy plans from 868 Swedish SENOMAC patients randomized 2015–2019 were collected. The humeral head was auto-segmented, and a 1 cm margin added to represent the shoulder joint. Arm morbidity was assessed using the Lymph-ICF questionnaire, focusing on questions regarding physical arm function and shoulder-related mobility tasks.

Results: The radiation dose was evaluable for 386 patients receiving ALND and 421 receiving SLN biopsy. The dose distribution to the shoulder joint was similar in both study groups. In the SLN group, a higher near-maximum dose (D0.5cc) was associated with significantly worse arm morbidity scores three years after surgery, particularly among patients treated with breast-conserving surgery. No association was found in the ALND group. No dose thresholds for development of arm/shoulder related side effects could be identified.

Conclusion: Our results indicate a possible association between maximum radiation dose to the shoulder joint and subsequent side effects. Extended follow-up within SENOMAC will provide further insights into the incidence of arm morbidity in relation to radiotherapy dose over time.

The aim was to determine the frequency of altered receptor expression between primary breast cancer and liver metastases, and to examine the impact of receptor expression on survival. The conversion frequency of estrogen- (ER), progesterone- (PgR) and human epidermal growth factor receptor 2 (HER2) was investigated. The prognostic value of the receptor status in the primary tumor versus the metastases was estimated. Data on a population-based regional cohort of 7292 breast cancer patients from 2009 to 2018 were collected from the National Breast Cancer Register. Biomarker expression and intrinsic subtype was studied among those who developed liver metastases with available histopathological records. The study included 311 patients with liver metastases. Conversion of ER, PgR and HER2 occurred in 16%, 47% and 12% of patients, respectively. The subtype converted in 26%. HER2 amplification in the primary tumor or metastases was associated with improved survival. Positive ER and PgR in breast cancer and positive ER in liver metastases were beneficial for survival. A combined primary tumor and metastasis receptor evaluation had the highest prognostic value. Receptor conversion from primary tumor to liver metastases is common. HER2 amplification and positive ER or PgR are associated with improved survival. Accordingly, luminal HER2 positive tumors have improved survival compared to other intrinsic subtypes. To personalize treatment for each patient, a liver biopsy is warranted at diagnosis of breast cancer liver metastases.

Background: The prognostic relevance of multifocal and multicentric breast cancer remains unclear and current staging systems do not consider focality. The aim of this study was to explore whether women with multifocal breast cancer have less favourable tumour characteristics and worse survival compared with women with unifocal breast cancer.

Methods: Patient and tumour characteristics were obtained from Breast Cancer Database Sweden 3.0, which includes data for all Swedish women diagnosed with invasive breast cancer between 2008 and 2019 and who underwent surgery. Overall and breast cancer-specific survival rates were calculated using the Kaplan–Meier method and multivariable analysis was used to identify independent predictors of survival using the Cox proportional hazard model.

Results: A total of 71 419 women were included in the study: 59 445 (83.2%) had unifocal breast cancer, 7286 (10.2%) had multifocal breast cancer with two invasive foci, and 4688 (6.6%) had multifocal breast cancer with three or more invasive foci. Multifocal breast cancer was associated with higher clinical T and N categories compared with unifocal breast cancer. The median follow-up time was 5.96 (interquartile range 3.078.80) years. The breast cancer-specific 10-year survival rates were 86.1% for women with multifocal breast cancer with three or more foci, 86.5% for women with multifocal breast cancer with two foci, and 88.4% for women with unifocal breast cancer. In a multivariable analysis adjusted for patient and tumour characteristics, the HR for breast cancer-specific death was 1.17 (95% c.i. 1.03 to 1.32) for women with multifocal breast cancer with three or more foci compared with women with unifocal breast cancer. There was no statistically significant difference in overall survival between the three groups.

Conclusion: The present study suggests that focality provides prognostic information that is additional to that provided by traditional tumour characteristics.

Background: Healthcare systems face challenges in optimizing resources while maintaining high-quality care. Breast cancer surgery represents a substantial share of elective surgery and provides an opportunity to evaluate different organizational models. This study presents a health economic analysis comparing two models for breast cancer surgery at the same hospital.

Methods: A bottom-up micro-costing approach was employed to evaluate potential cost-savings of breast cancer surgeries performed at a general surgical department (GS) versus a cardiothoracic surgery department (CT). We analyzed 543 consecutive patients undergoing elective breast cancer surgery between January 2014 and September 2016. Resource use was identified through direct observation, hospital administrative systems, and operating room logs. Personnel, disposables, medications, and facility costs were quantified based on observed resource use within the study dataset; no external benchmarking was performed.

Results: CT was less expensive, with an average saving of 3,547 Swedish krona (SEK) per operation (95% CI: -674 to 7,510 SEK). Bootstrap analysis with 1,000 iterations showed CT was less costly in 96.2% of samples. Procedures were shorter at CT (170.8 vs. 221.3 min), enabling more operations per day (3.2 vs. 2.4). In our deterministic simulation, removing CT capacity increased waiting times by 15%, from 39 to 45.1 days, conditional on steady inflow and constant OR availability. Annual savings at the observed annual volume (~ 192 patients) were 681,104 SEK and could reach ~ 1.77 million SEK if volumes increased to 500 patients/year.

Conclusions: The CT organizational model was more likely to be less costly while maintaining shorter waiting times. These findings suggest that CT capacity may be prioritized, particularly at higher patient volumes, to support both economic efficiency and patient access.

Background: Breast cancer (Bc) is the leading cause of cancer-related death in women. In many patients, BC liver metastases (BCLM) are associated with short survival. The aims of this study were to investigate the risk of and time to BCLM in each BC surrogate subtype, and to determine the incidence of BCLM in a population-based setting.

Methods: The Swedish national breast cancer registry identified patients with Bc in a regional cohort from 2009 to 2018. The cohort was followed until January 2023. Cox regression analysis was used to determine the risk of BCLM for each subtype. Kaplan–Meier estimates determined the probability of BCLM for each subtype over time.

Results: In all, 7292 patients with Bc were included in the study. Distant metastases developed in 755 patients (10.4%); of these, 345 (45.7%) developed BCLM. The BCLM incidence rate was 8 per 1000 person-years. Only 13 patients had oligometastases isolated to the liver. Triple-negative, non-luminal human epidermal growth factor receptor 2 (HER2)-positive and luminal B cancers had the highest risk of BCLM. T category, nodal status, and Nottingham histological grade III were also strongly associated with BCLM. The median time from Bc diagnosis to BCLM was 36 months. Patients with HER2-positive BC subtypes developed BCLM early, at a median of only 9 months.

Conclusion: Bc subtype is correlated to the risk and timing of BCLM development. BCLM are common in advanced Bc, but isolated oligometastases are rare.

Global reporting of obesity is commonly based on comparisons over multiple decades and lacks a granular and systematic analysis of its dynamics. We used 4,050 population-based studies with measured height and weight data on 232 million participants to assess the worldwide dynamics of obesity from 1980 to 2024. The rise in obesity decelerated in school-aged children and adolescents throughout the 1990s in many high-income countries, and subsequently plateaued in most at age-standardized prevalences spanning 20 percentage points, from 3–4% for girls in Japan, Denmark and France to 23% for boys in the USA. There were indications of a small decline in obesity in children and adolescents in some high-income western countries (for example, Italy, Portugal and France) since the 2000s. Similar trends were seen in some countries in Central and Eastern Europe. In adults, the rise in obesity slowed down in high-income western countries about a decade after children, followed by a plateau or possibly a small reversal of the rise in some countries (for example, Spain). In most low-income and middle-income countries, the annual absolute change in prevalence has remained stable or increased over time, even though prevalence has surpassed that of high-income countries. These highly varied dynamics suggest that the social, economic and technological trends that influence the availability, affordability and use of different foods may have helped control the rise in obesity in high-income countries, but require policy interventions in low-income and middle-income countries.

Background: Patients with sleep apnoea are at increased risk of postoperative cardiac and respiratory complications, but its prevalence in patients undergoing abdominal cancer surgery is poorly defined. The aim of this study was to estimate the prevalence of sleep apnoea in patients undergoing colorectal cancer surgery compared with community-based controls, and to assess the utility of symptoms, signs, and the STOP-Bang questionnaire in identifying sleep apnoea.

Methods: This prospective observational study included consecutive patients scheduled for colorectal cancer surgery at Umeå University Hospital, Sweden, between 7 January 2015 and 24 May 2020. Overnight polysomnography, including electroencephalogram-based sleep scoring, was undertaken before operation. Prevalence estimates were compared with those of two community-based cohorts from Uppsala, Sweden (female participants from the Sleep and Health in Women cohort; male participants from the Men in Uppsala: A Study of Sleep Apnoea and Cardiometabolic Health cohort). The primary outcome was the prevalence of sleep apnoea.

Results: Of 268 eligible patients, 5 were receiving continuous positive airway pressure therapy and 201 underwent successful polysomnography. Moderate-to-severe sleep apnoea was identified in 98 of 206 patients (48 (95% confidence interval 41 to 54)%) undergoing colorectal cancer surgery, with a similar prevalence in men and women. Among 597 community-based controls, moderate-to-severe sleep apnoea was present in 27 (24 to 31)%. After adjustment for age, sex, and body mass index, the odds ratio for moderate-to-severe sleep apnoea in patients with colorectal cancer was 1.57 (95% confidence interval 1.08 to 2.29; P = 0.019). The STOP-Bang questionnaire demonstrated acceptable sensitivity (85 (95% confidence interval 76 to 91)%) but low specificity (42 (33 to 52)%).

Conclusion: Approximately half of patients undergoing colorectal cancer surgery have moderate-to-severe sleep apnoea, exceeding the prevalence in community-based controls. Clinical symptoms, signs, and STOP-Bang screening are insufficient to reliably identify affected patients, indicating that overnight sleep apnoea assessment is required in this population.

Importance Long-term follow-up studies regarding the safety of risk-reducing mastectomy (RRM) in terms of cancer risk and surgical complications among women with germline pathogenic variants (gPVs) in BRCA1 or BRCA2 (BRCA1/2) are scarce.

Objective To analyze cancer risk and surgical complications after RRM.

Design, Setting, and Participants This nationwide cohort study investigated 1208 Swedish women with a confirmed gPV in BRCA1/2 without previous breast cancer identified through the Swedish Cancer Genetic Units between March 31, 1994, and January 2, 2019. Data were extracted from the National Patient Care Register, the Cancer Register, and the Cause of Death Register. Women were followed up from the date of RRM (RRM group) or genetic testing (no RRM group) until breast cancer diagnosis, death, emigration, or end of follow-up (December 31, 2023).

Main Outcomes and Measures Breast cancer incidence was calculated per 10 000 person-years, with women undergoing RRM contributing person-years to the no RRM group until RRM, and women with occult breast cancer contributing breast cancer cases to the no RRM group.

Results In the RRM group (507 women; median age at RRM, 39.7 years [range, 19.6-72.1 years]), 1 woman developed breast cancer, corresponding to a breast cancer incidence of 2 cases per 10 000 person-years. In the no RRM group (701 women; median age at genetic testing, 50.6 years [range, 4.3-93.6 years]), 112 women developed breast cancer, corresponding to a breast cancer incidence of 162 cases per 10 000 person-years. At RRM, 17 of 507 women (3.4%) received a diagnosis of occult breast cancer. In the RRM group, 296 of 507 women (58.4%) underwent simple mastectomy, 143 of 507 (28.2%) underwent nipple-sparing mastectomy, and 68 of 507 (13.4%) underwent skin-sparing mastectomy. Most women (382 of 507 [75.3%]) underwent implant-based breast reconstruction, with only 73 of 507 (14.4%) undergoing autologous tissue reconstruction with or without implants. Early major surgical postoperative complications associated with reoperation occurred in 19 of 507 women (3.7%).

Conclusions and Relevance In this cohort study of 1208 women with a gPV in BRCA1/2, the risk of developing breast cancer or early major surgical complications after RRM was very low. The low occurrence of primary breast cancer precluded meaningful statistical comparisons between different RRM techniques.

Importance Long-term follow-up studies regarding the safety of risk-reducing mastectomy (RRM) in terms of cancer risk and surgical complications among women with germline pathogenic variants (gPVs) in BRCA1 or BRCA2 (BRCA1/2) are scarce. Objective To analyze cancer risk and surgical complications after RRM. Design, Setting, and Participants This nationwide cohort study investigated 1208 Swedish women with a confirmed gPV in BRCA1/2 without previous breast cancer identified through the Swedish Cancer Genetic Units between March 31, 1994, and January 2, 2019. Data were extracted from the National Patient Care Register, the Cancer Register, and the Cause of Death Register. Women were followed up from the date of RRM (RRM group) or genetic testing (no RRM group) until breast cancer diagnosis, death, emigration, or end of follow-up (December 31, 2023). Main Outcomes and Measures Breast cancer incidence was calculated per 10 000 person-years, with women undergoing RRM contributing person-years to the no RRM group until RRM, and women with occult breast cancer contributing breast cancer cases to the no RRM group. Results In the RRM group (507 women; median age at RRM, 39.7 years [range, 19.6-72.1 years]), 1 woman developed breast cancer, corresponding to a breast cancer incidence of 2 cases per 10 000 person-years. In the no RRM group (701 women; median age at genetic testing, 50.6 years [range, 4.3-93.6 years]), 112 women developed breast cancer, corresponding to a breast cancer incidence of 162 cases per 10 000 person-years. At RRM, 17 of 507 women (3.4%) received a diagnosis of occult breast cancer. In the RRM group, 296 of 507 women (58.4%) underwent simple mastectomy, 143 of 507 (28.2%) underwent nipple-sparing mastectomy, and 68 of 507 (13.4%) underwent skin-sparing mastectomy. Most women (382 of 507 [75.3%]) underwent implant-based breast reconstruction, with only 73 of 507 (14.4%) undergoing autologous tissue reconstruction with or without implants. Early major surgical postoperative complications associated with reoperation occurred in 19 of 507 women (3.7%). Conclusions and Relevance In this cohort study of 1208 women with a gPV in BRCA1/2, the risk of developing breast cancer or early major surgical complications after RRM was very low. The low occurrence of primary breast cancer precluded meaningful statistical comparisons between different RRM techniques.

Introduction: The management of breast cancer has evolved dramatically over the past 25 years. In stark contrast to the radical mastectomy proposed by Halsted1 over 100 years ago, patients can benefit from individualized treatment programmes with less extensive surgery, possibly with oncoplastic techniques, complex and highly effective chemotherapeutic regimens (±immunotherapy and human epidermal growth factor receptor 2 (HER2) direct therapy), and focused radiation. Surgery has become more refined and offers the maximal benefit, whilst minimising morbidity. It is the surgical management of regional axillary lymph nodes that however has undergone the most significant changes over the last 25 years. Whilst all patients were previously subjected to an axillary lymph node dissection (ALND), this morbid procedure is now reserved for those with advanced lymph node involvement. The therapeutic value of axillary surgery is limited to specific cases and such surgery is now performed predominantly for staging and prognostic purposes as well as guiding, in selected cases, the provision of adjuvant therapy. Surgeons continue to investigate whether a more minimal approach to the axilla in patients with breast cancer could be employed. Conversely, there remains a group of patients who still require ALND and techniques to minimise associated complications, such as lymphoedema, have been increasingly investigated. As the rate of change within this area continues to increase, the purpose of this BJS Commission is to provide an overview, at this point, of all aspects of surgical management of the axilla including future considerations.

To undertake this overview, the editorial board of the BJS selected experts within the different domains of axillary management of breast cancer. All those selected had a significant record of high-quality publications within their special interest. Once a list of expert authors was compiled, it was then approved by the BJS Editorial team and of those invited, all agreed to partake within this Commission. All authors were also asked to include ‘future experts’ at a senior trainee or early consultant level, to complement the authorship group. Authors were then split into five groups, each tasked with providing a detailed contemporary review of certain key aspects of axillary surgery. By selecting an international group of experts, the aim was to formulate a balanced and collaborative analysis that represents practice within this realm of breast surgery, globally. The overview was approved by the BJS Editors.