Background: Despite treatment innovations and decreasing cancer mortality, Black and White patients (pts) in the United States have persistent inequities in breast cancer outcomes. Non-Hispanic Black women have the highest incidence rates of breast cancer between 20 and 39 years of age. The American College of Radiology (ACR) recommends breast cancer risk assessment for all women, particularly Black women, by the age of 25. In the St. Louis metropolitan area, pts residing in the North and Eastern regions with high Black populations are more likely to have late-stage breast cancer diagnoses. Methods: In 2023, the Breast Cancer Equity Group at Siteman Cancer Center began a program to give on-site real-time screening mammography results and a hereditary cancer risk assessment delivered by a breast health nurse navigator to pts in North County. During the under-30-minute waiting period from completion of the mammogram to the delivery of results, the nurse navigator asked pts 5 family cancer history questions developed by medical oncology, genetics, surgical oncology, and public health researchers based on NCCN guidelines. If they would meet NCCN criteria for genetic counseling and testing, they were referred to a high-risk breast clinic. We performed retrospective chart review on all pts screened to determine screening outcomes of high-risk vs normal-risk pts and which pts were previously flagged as high-risk in the electronic medical record (EMR). Results: Between September 2023 and April 2024, 154 pts were seen in the same day screening mammography and breast cancer risk assessment clinic, of whom 72.1% (111/154) self-identified as Black and 19.5% (30/154) were under the age of 50. Over one third of the pts coming in for a routine screening mammogram - 34.4% (53/154) - were determined to be high-risk for breast cancer, of whom 69.8% (37/53) were Black. All pts that screened as high-risk were offered referral to the high-risk breast clinic by the navigator. 75.5% (40/53) of the high-risk pts agreed to be referred to this clinic for further evaluation. In the high-risk group, 11.3% (6/53) of the pts had a mammogram at the appointment requiring follow-up, defined as BI-RADS 0, and 3.8% (2/53) were diagnosed with breast cancer. None of the pts requiring further imaging were lost to follow-up. In the normal risk group 3.0% (3/99) had abnormal mammograms and 1.0% (1/99) were diagnosed with breast cancer. In pts under the age of 50, 50% (15/30) screened as high-risk, 73.3% (11/15) of whom were Black. 75.5% (40/53) of the high-risk pts had relevant cancer family history data already documented in the EMR, but only 9.4% (5/53) had their cancer risk mentioned in the EMR by a physician. In this high-risk cohort, whose family cancer history was generally documented in the EMR, 54.7% (29/53) were overdue for a mammogram. Discussion: While it is imperative that we understand the socioeconomic factors behind the ongoing racial inequities in breast cancer, it is also important to consider potential differences in cancer gene mutation prevalence between Black and White pts and their associated risks for cancer development at a young age. Our findings in this population highlight the need for more widespread genetic risk screening, as over a third of the pts screened positive as high familial risk for breast cancer. It may not be enough to rely on the EMR, as most of these pts had documented family cancer history but very few were flagged as high-risk. It is also key to consider risk screening at a younger age as per ACR guidelines, as 50% of the women under age 50 were classified as high-risk by family history yet over half were overdue for a mammogram. Our future implementation science projects will focus on disseminating this risk assessment to more clinics including primary care, bolstering the existing infrastructure to further support the high-risk breast clinic, and improving communication on screening benefits in the community to improve timely screening mammography. Citation Format: Emily L. Podany, Shaili Tapiavala, Katherine Glover-Collins, Erin Linnenbringer, Stacey Ballard, Helen Blair, Tabassum Ahmad, Amy Cyr, Meg Thaier, Jessica McDowell, Amanda Golden, Sarah Addison, Elizabeth McFarland, Lannis Hall, Foluso Ademuyiwa, Graham Colditz, Timothy Eberlein, Bettina Drake, Debbie Bennett, Katherine Weilbaecher. Hereditary breast cancer risk assessment and referral at a high-volume, diverse mammography clinic [abstract]. In: Proceedings of the San Antonio Breast Cancer Symposium 2024; 2024 Dec 10-13; San Antonio, TX. Philadelphia (PA): AACR; Clin Cancer Res 2025;31(12 Suppl):Abstract nr P3-02-12.

1Department of Surgery, Washington University School of Medicine, The Alvin J Siteman Cancer Center at Barnes Jewish Hospital and Washington University School of Medicine, St Louis, MO Disclosure Information: Nothing to disclose. Presented at the 104th Annual meeting of the New England Surgical Society, Newport, RI, September 2023. Corresponding Author: Dr Timothy J Eberlein, MD, FACS Center for Advanced Medicine Breast Health Center 4921 Parkview Place St Louis, MO 63110 Suite: F; Floor: 5 Fax: 314-454-1898

PDF - 352K, Human pancreatic cancers upregulate CCL2 expression, and are infiltrated by abundant myeloid cells.

PDF - 26K, Inflammatory monocytes persist in the blood of PC patients undergoing chemotherapy.

PDF - 101K, Additional details of experiments performed in manuscript.

PDF - 99K, Monocytes are increased in the peripheral blood of pancreatic cancer patients.

This table shows the statistical analysis of significantly changed genes and pathways by treatment with anastrozole alone and by the addition of palbociclib.

Supplementary Fig. S1 is the consort diagram; Supplementary Fig. S2 describes the clinicopathologic and molecular features of the 6 palbociclib resistant tumors; Supplementary Fig S3 shows the proliferation score and correlation with Ki67 at each time point; Supplementary Fig S4 shows the heatmap of the proliferation score genes and ER regulated genes

The caption provides the title and description for the Supplementary Tables S3 adn S4.

PDF - 192K, CCR2i alters the immune infiltrate in murine PC.

PDF - 156K, Monocytes and macrophages are increased in the premetastatic livers of tumor bearing mice.

Supplementary Table S3 provides the result of the 83-gene panel next generation sequencing

PDF - 59K, Patient demographic and pathologic variables in blood monocyte analysis.

PDF - 432K, CCL2 expression in increased in murine pancreatic cancer.

Pugh, Carla M. MD, PhD*; Kirton, Orlando C. MD†; Tuttle, J.E. “Betsy” MD‡; Maier, Ronald V. MD§; Hu, Yue-Yung MD∥; Stewart, John H. IV MD, MBA¶; Freischlag, Julie Ann MD#; Sosa, Julie Ann MD**; Vickers, Selwyn M. MD††; Hawn, Mary T. MD*; Eberlein, Timothy J. MD‡‡; Farmer, Diana L. MD§§; Higgins, Robert S. MD, MSHA∥∥; Pellegrini, Carlos A. MD¶¶; Roman, Sanziana A. MD**; Crandall, Marie L. MD, MPH##; De Virgilio, Christian M. MD***; Tsung, Allan MD†††; Britt, L.D. MD, MPH‡‡‡ Author Information

BACKGROUND: The COVID-19 pandemic disrupted the delivery of surgical services. The purpose of this communication was to report the impact of the pandemic on surgical training and learner well-being and to document adaptations made by surgery departments. STUDY DESIGN: A 37-item survey was distributed to educational leaders in general surgery and other surgical specialty training programs. It included both closed- and open-ended questions and the self-reported stages of GME during the COVID-19 pandemic, as defined by the ACGME. Statistical associations for items with stage were assessed using categorical analysis. RESULTS: The response rate was 21% (472 of 2,196). US stage distribution (n = 447) was as follows: stage 1, 22%; stage 2, 48%; and stage 3, 30%. Impact on clinical education significantly increased by stage, with severe reductions in nonemergency operations (73% and 86% vs 98%) and emergency operations (8% and 16% vs 34%). Variable effects were reported on minimal expected case numbers across all stages. Reductions were reported in outpatient experience (83%), in-hospital experience (70%), and outside rotations (57%). Increases in ICU rotations were reported with advancing stage (7% and 13% vs 37%). Severity of impact on didactic education increased with stage (14% and 30% vs 46%). Virtual conferences were adopted by 97% across all stages. Severity of impact on learner well-being increased by staged-physical safety (6% and 9% vs 31%), physical health (0% and 7% vs 17%), and emotional health (11% and 24% vs 42%). Regardless of stage, most but not all made adaptations to support trainees' well-being. CONCLUSIONS: The pandemic adversely impacted surgical training and the well-being of learners across all surgical specialties proportional to increasing ACGME stage. There is a need to develop education disaster plans to support technical competency and learner well-being. Careful assessment for program advancement will also be necessary. The experience during this pandemic shows that virtual learning and telemedicine will have a considerable impact on the future of surgical education. ((C) 2020 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: The leadership of the American Surgical Association (ASA) appointed a Task Force to objectively address issues related to equity, diversity, and inclusion with the discipline of academic surgery. Summary of Background Data: Surgeons and the discipline of surgery, particularly academic surgery, have a tradition of leadership both in medicine and society. Currently, we are being challenged to harness our innate curiosity, hard work, and perseverance to address the historically significant deficiencies within our field in the areas of diversity, equity, and inclusion. Methods: The ASA leadership requested members to volunteer to serve on a Task Force to comprehensively address equity, diversity, and inclusion in academic surgery. Nine work groups reviewed the current literature, performed primary qualitative interviews, and distilled available guidelines and published primary source materials. A work product was created and published on the ASA Website and made available to the public. The full work product was summarized into this White Paper. Results: The ASA has produced a handbook entitled: Ensuring Equity, Diversity, and Inclusion in Academic Surgery, which identifies issues and challenges, and develops a set of solutions and benchmarks to aid the academic surgical community in achieving these goals. Conclusion: Surgery must identify areas for improvement and work iteratively to address and correct past deficiencies. This requires honest and ongoing identification and correction of implicit and explicit biases. Increasing diversity in our departments, residencies, and universities will improve patient care, enhance productivity, augment community connections, and achieve our most fundamental ambitiondoing good for our patients.

Abstract Purpose: Cyclin-dependent kinase (CDK) 4/6 drives cell proliferation in estrogen receptor–positive (ER+) breast cancer. This single-arm phase II neoadjuvant trial (NeoPalAna) assessed the antiproliferative activity of the CDK4/6 inhibitor palbociclib in primary breast cancer as a prelude to adjuvant studies. Experimental Design: Eligible patients with clinical stage II/III ER+/HER2− breast cancer received anastrozole 1 mg daily for 4 weeks (cycle 0; with goserelin if premenopausal), followed by adding palbociclib (125 mg daily on days 1–21) on cycle 1 day 1 (C1D1) for four 28-day cycles unless C1D15 Ki67 > 10%, in which case patients went off study due to inadequate response. Anastrozole was continued until surgery, which occurred 3 to 5 weeks after palbociclib exposure. Later patients received additional 10 to 12 days of palbociclib (Cycle 5) immediately before surgery. Serial biopsies at baseline, C1D1, C1D15, and surgery were analyzed for Ki67, gene expression, and mutation profiles. The primary endpoint was complete cell cycle arrest (CCCA: central Ki67 ≤ 2.7%). Results: Fifty patients enrolled. The CCCA rate was significantly higher after adding palbociclib to anastrozole (C1D15 87% vs. C1D1 26%, P < 0.001). Palbociclib enhanced cell-cycle control over anastrozole monotherapy regardless of luminal subtype (A vs. B) and PIK3CA status with activity observed across a broad range of clinicopathologic and mutation profiles. Ki67 recovery at surgery following palbociclib washout was suppressed by cycle 5 palbociclib. Resistance was associated with nonluminal subtypes and persistent E2F-target gene expression. Conclusions: Palbociclib is an active antiproliferative agent for early-stage breast cancer resistant to anastrozole; however, prolonged administration may be necessary to maintain its effect. Clin Cancer Res; 23(15); 4055–65. ©2017 AACR.

BACKGROUND:Axillary surgery is not considered therapeutic in patients with clinical T1-T2 N0 breast cancer. The importance of axillary staging is eroding in an era in which tumor biology, as defined by biomarker and gene expression profile, is increasingly important in medical decision making. We hypothesized that axillary ultrasound (AUS) is a noninvasive alternative to sentinel lymph node biopsy (SLNB), and AUS could replace SLNB without compromising patient care. STUDY DESIGN:Patients with clinical T1-T2 N0 breast cancer and normal AUS were eligible for enrollment. Subjects were randomized to no further axillary staging (arm 1) vs SLNB (arm 2). Descriptive statistics were used to describe the results of the pilot phase of the randomized controlled trial. RESULTS:Sixty-eight subjects were enrolled in the pilot phase of the trial (34 subjects in arm 1, no further staging; 32 subjects in arm 2, SLNB; and 2 subjects voluntarily withdrew from the trial). The median age was 61 years (range 40 to 80 years) in arm 1 and 59 years (range 31 to 81 years) in arm 2, and there were no significant clinical or pathologic differences between the arms. Median follow-up was 17 months (range 1 to 32 months). The negative predictive value (NPV) of AUS for identification of clinically significant axillary disease (>2.0 mm) was 96.9%. No axillary recurrences have been observed in either arm. CONCLUSIONS:Successful completion of the pilot phase of the randomized controlled trial confirms the feasibility of the study design, and provides prospective evidence supporting the ability of AUS to exclude clinically significant disease in the axilla. The results provide strong support for a phase 2 randomized controlled trial.