Omission of axillary surgery in early breast cancer with negative lymph nodes: a systematic review and meta-analysis of randomized clinical trials Bárbara Bizzo Castelo, Luiz Gustavo Oliveira Brito, Renato Zocchio Torresan, Cássio Cardoso Filho, Giuliano Mendes Duarte Breast Cancer Research and Treatment, 2026 Purpose To evaluate whether the omission of axillary surgery impacts clinical outcomes in patients with early-stage breast cancer and clinically negative lymph nodes. Methods We conducted a systematic review and meta-analysis of randomized clinical trials (RCTs) comparing no axillary surgery with standard axillary interventions (sentinel lymph node biopsy [SLNB] or axillary dissection [AD]). This study followed PRISMA guidelines and was registered in PROSPERO (CRD420250653779). Searches were conducted in PubMed, Web of Science, and Embase through June 2025. Outcomes assessed included overall survival (OS), disease-free survival (DFS), and axillary recurrence (AR). Meta-analyses were performed using RevMan 5.4. Risk of bias was assessed using the RoB 2 tool. Results Out of 853 records, seven RCTs including 8806 patients met the inclusion criteria. Among them, 2,915 patients underwent no axillary surgery, while 5891 received surgical axillary treatment. Two trials compared no surgery with SLNB, and five compared no surgery with AD. No significant differences were found in OS (OR = 1.02; 95% CI, 0.86–1.20; p = 0.84; I 2 = 36%) or DFS (OR = 0.80; 95% CI, 0.63–1.00; p = 0.05; I 2 = 63%). AR was significantly lower in the axillary surgery group (OR = 0.18; 95% CI, 0.10–0.31; p < 0.01; I 2 = 39%). Conclusion The omission of axillary surgery in early-stage breast cancer with clinically negative lymph nodes does not negatively impact overall or disease-free survival. However, it is associated with a higher—though still low—risk of axillary recurrence.
Clinicopathological characteristics, treatments and oncological outcomes in metaplastic breast cancer: a Brazilian multicenter analysis Talita Aparecida Riegas Mendes, Idam de Oliveira-Junior, Fabrício Palermo Brenelli, Cassio Cardoso-FIlho, Luiz Carlos Zeferino Frontiers in Oncology, 2025 IntroductionMetaplastic breast carcinoma (MBC) is a highly heterogenous group of tumors. MBC differs from other invasive carcinomas in clinical presentation, prognosis and response to treatment. The tumor is more aggressive and the most effective form of treatment is still uncertain for this patient population, given the particularities of the disease.Subjects and methodsThis is a retrospective, descriptive study analyzing data from women admitted for MBC treatment to participating centers (Hospital de Amor, Barretos, and Center for Integral Attention to Women’s Health, CAISM/UNICAMP) between 2010 and 2020.ResultsA total of 102 women with pathologically confirmed MBC and presenting non-metastatic disease were included. The average age at diagnosis was 53 years, 73.3% were triple-negative (TN) subtype and mean tumor size at diagnosis was 7.4 cm. We found that 59% of patients were clinical stage III at diagnosis and 82.3% of the cases underwent mastectomy. Despite the use of neoadjuvant treatment in 52.9% of patients, the pathological complete response (pCR) rate was only 7.4%. Around 46% of patients underwent adjuvant chemotherapy and 79.4% received adjuvant radiotherapy. We observed a 5-year overall survival (OS) of 59,7% and a 5-year disease-free survival (DFS) of 54.4%. Adjuvant chemotherapy, smaller tumor size and absence of lymph node disease were associated to better DFS and OS.ConclusionMBC presented as a large nodular lesion at diagnosis, the most frequent metaplastic subtypes presented squamous and mesenchymal differentiation, almost 80% were triple-negative tumors, however, responses to neoadjuvant chemotherapy can be considered poor. A higher number of metastatic lymph nodes and larger tumor size were associated with worse DFS and OS, meanwhile the women who undergone to adjuvant chemotherapy showed better DFS and OS. Furthermore, most recurrences occurred in the first 24 months of follow-up, stabilizing at approximately 50% after 36 months, and most deaths occurred in the first 36 months, stabilizing thereafter, which is a clinical pattern of very aggressive tumors.
Subsequent mammography reduces recall and increases breast cancer detection: an audit of a screening program Erika Marina Solla Negrao, Mariana Alves Almeida, Emanuele Françoso Cardoso, Alvaro Silva Almeida, Samanta Santos Sousa, Cassio Cardoso-Filho, Rodrigo Menezes Jales, Diama Bhadra Vale Revista Brasileira De Ginecologia E Obstetricia Revista Da Federacao Brasileira Das Sociedades De Ginecologia E Obstetricia, 2025 Objective: To analyze recall rates in a public breast cancer screening facility in Campinas, Brazil. Methods: A prospective assessment of outcomes on screening mammographies (MMG) between July 2023 and August 2024. BI-RADS® 0,4/5 indicated positive results, and women recalled. The variables were age, whether first or subsequent MMG, and biopsy (cancer positive or negative). The outcomes were recall rate and cancer detection rate on the recall (CDR). Prevalence ratio with 95% confidence interval (PR) estimated the risk. Results: There were included 19,377 MMG on women over 40: 15,983 subsequent MMG (82.5%), and 1,646 women recalled (BR 0,4/5). Adherence to recall was over 99%. The recall rates were 12.4% at first and 7.7% at subsequent MMG. Recall rate was 1.6 times higher at first than at subsequent MMG (PR 1.61;1.45-1.79). CDR was higher at subsequent MMG. A first MMG reduced the risk of cancer detection by 71% (PR 0.29-0.15;0.58). Compared to women 50-69, there were no differences in the risks of recall and cancer detection at first MMG. At subsequent MMG the recall risk was higher in women 40-49 (PR 1.16;1.03-1.30), and over 69 (PR 1.47;1.03-2.12). The risk of cancer detection was 60% lower in women 40-49 (PR 0.60;0.36-0.99), and 2.7 times higher in women over 69 (PR 2.78;1.32-5.84). Conclusion: The recall rates were 12.4% at first and 7.7% at subsequent MMG. Adherence was high. Screening efficiency was higher in women 50-69. At subsequent screenings women 40-49 showed a higher recall rate and a lower CDR when compared to women 50-69.
Subsequent mammography reduces recall and increases breast cancer detection: an audit of a screening program Erika Marina Solla Negrao, Mariana Alves Almeida, Emanuele Françoso Cardoso, Alvaro Silva Almeida, Samanta Santos Sousa, Cassio Cardoso-Filho, Rodrigo Menezes Jales, Diama Bhadra Vale Revista Brasileira De Ginecologia E Obstetricia, 2025 Objective: To analyze recall rates in a public breast cancer screening facility in Campinas, Brazil. Methods: A prospective assessment of outcomes on screening mammographies (MMG) between July 2023 and August 2024. BI-RADS® 0,4/5 indicated positive results, and women recalled. The variables were age, whether first or subsequent MMG, and biopsy (cancer positive or negative). The outcomes were recall rate and cancer detection rate on the recall (CDR). Prevalence ratio with 95% confidence interval (PR) estimated the risk. Results: There were included 19,377 MMG on women over 40: 15,983 subsequent MMG (82.5%), and 1,646 women recalled (BR 0,4/5). Adherence to recall was over 99%. The recall rates were 12.4% at first and 7.7% at subsequent MMG. Recall rate was 1.6 times higher at first than at subsequent MMG (PR 1.61;1.45-1.79). CDR was higher at subsequent MMG. A first MMG reduced the risk of cancer detection by 71% (PR 0.29-0.15;0.58). Compared to women 50-69, there were no differences in the risks of recall and cancer detection at first MMG. At subsequent MMG the recall risk was higher in women 40-49 (PR 1.16;1.03-1.30), and over 69 (PR 1.47;1.03-2.12). The risk of cancer detection was 60% lower in women 40-49 (PR 0.60;0.36-0.99), and 2.7 times higher in women over 69 (PR 2.78;1.32-5.84). Conclusion: The recall rates were 12.4% at first and 7.7% at subsequent MMG. Adherence was high. Screening efficiency was higher in women 50-69. At subsequent screenings women 40-49 showed a higher recall rate and a lower CDR when compared to women 50-69.
Breast cancer survival after mammography dissemination in Brazil: a population-based analysis of 2,715 cases Juliana O. Fernandes, Beatriz F. Machado, Cassio Cardoso-Filho, Juliana Nativio, Cesar Cabello, Diama B. Vale BMC Women S Health, 2023 Background This study aims to assess breast cancer survival rates after one decade of mammography in a large urban area of Brazil. Methods It is a population-based retrospective cohort of women with breast cancer in Campinas, São Paulo, from 2010 to 2014. Age, vital status and stage were accessed through the cancer and mortality registry, and patients records. Statistics used Kaplan–Meier, log-rank and Cox's regression. Results Out of the 2,715 cases, 665 deaths (24.5%) were confirmed until early 2020. The mean age at diagnosis was 58.6 years. Women 50–69 years were 48.0%, and stage I the most frequent (25.0%). The overall mean survival was 8.4 years (8.2–8.5). The 5-year survival (5yOS) for overall, 40–49, 50–59, 60–69, 70–79 years was respectively 80.5%, 87.7%, 83.7%, 83.8% and 75.5%. The 5yOS for stages 0, I, II, III and IV was 95.2%, 92.6%, 89.4%, 71.1% and 47.1%. There was no significant difference in survival in stage I or II (p = 0.058). Compared to women 50–59 years, death's risk was 2.3 times higher for women 70–79 years and 26% lower for women 40–49 years. Concerning stage I, the risk of death was 1.5, 4.1 and 8.6 times higher, and 34% lower, respectively, for stage II, III, IV and 0. Conclusions In Brazil, breast cancers are currently diagnosed in the early stages, although advanced cases persist. Survival rates may reflect improvements in screening, early detection and treatment. The results can reflect the current status of other regions or countries with similar health care conditions.
Differences in breast cancer survival and stage by age in off-target screening groups: a population-based retrospective study Juliana Oliveira Fernandes, Cassio Cardoso-Filho, Maria Beatriz Kraft, Amanda Sacilotto Detoni, Barbara Narciso Duarte, Julia Yoriko Shinzato, Diama Bhadra Vale Ajog Global Reports, 2023 Age is an important prognostic factor in breast cancer. The target age to screen is under debate. This study aimed to assess the influence of age on the diagnosis and survival among women with breast cancer. This was a retrospective cohort study of the Population-Based Cancer Registry of Campinas, Brazil, and included all women diagnosed from 2010 to 2014. The outcomes assessed were overall survival and stage. For statistical analyses, the Kaplan-Meier method, log-rank tests, and chi-square tests were used. The sample comprised 1741 women aged 40 to 79 years. Diagnoses at stages 0 to II were the more frequent. In the 40 to 49 years and 50 to 59 years age groups, the frequency of stage 0 (in situ) was 20.5% and 14.9% (P=.022), respectively, and the frequency of stage I was 20.2% and 25.8% (P=.042), respectively. The mean overall survival was 8.9 years (8.6–9.2) in the 40 to 49 years age group and 7.7 years (7.3–8.1) in the 70 to 79 years age group. The 5-year overall survival was higher in the 40 to 49 years age group than in the 50 to 59 years age group for stage 0 (in situ) (100.0% vs 95.0%; P=.036) and stage III (77.4% vs 66.2%; P=.046) diagnoses. The 5-year overall survival was higher in 60 to 69 years age group than in the 70 to 79 years age group for stages I (94.6% vs 86.5%; P=.002) and III (83.5% vs 64.9%; P=.010). In all age groups, significant differences in survival were not observed for stage 0 (in situ) vs stage I diagnoses, stage 0 vs stage II diagnoses, and stage I vs stage II diagnoses. Women aged 40 to 49 years had the highest proportion of in situ tumors, and stages III and IV accounted for about one-third of the cases in all age groups. There was no difference in the overall survival for stage 0 (in situ) vs stage I or II diagnoses in all age groups.
Race disparities in mortality by breast cancer from 2000 to 2017 in São Paulo, Brazil: a population-based retrospective study Ana Cláudia Marcelino, Bruno Gozzi, Cássio Cardoso-Filho, Helymar Machado, Luiz Carlos Zeferino, Diama Bhadra Vale BMC Cancer, 2021 Background In Brazil, inequalities in access may interfere with cancer care. This study aimed to evaluate the influence of race on breast cancer mortality in the state of São Paulo, from 2000 to 2017, contextualizing with other causes of death. Methods A population-based retrospective study using mortality rates, age and race as variables. Information on deaths was collected from the Ministry of Health Information System. Only white and black categories were used. Mortality rates were age-adjusted by the standard method. For statistical analysis, linear regression was carried out. Results There were 60,940 deaths registered as breast cancer deaths, 46,365 in white and 10,588 in black women. The mortality rates for 100,000 women in 2017 were 16.46 in white and 9.57 in black women, a trend to reduction in white (p = 0.002), and to increase in black women (p = 0.010). This effect was more significant for white women (p < 0.001). The trend to reduction was consistent in all age groups in white women, and the trend to increase was observed only in the 40–49 years group in black women. For ‘all-cancer causes’, the trend was to a reduction in white (p = 0.031) and to increase in black women (p < 0.001). For ‘ill-defined causes’ and ‘external causes’, the trend was to reduce both races (p < 0.001). Conclusion The declared race influenced mortality rates due to breast cancer in São Paulo. The divergences observed between white and black women also were evident in all cancer causes of death, which may indicate inequities in access to highly complex health care in our setting.
Comparative study of surgical and oncological outcomes in oncoplastic versus non oncoplastic breast-conserving surgery for breast cancer treatment Natalie R. Almeida, Fabrício P. Brenelli, Cesar C. dos Santos, Renato Z. Torresan, Júlia Y. Shinzato, Cassio Cardoso-Filho, Giuliano M. Duarte, Nicoli S. de Azevedo, Luiz Carlos Zeferino Jpras Open, 2021 BACKGROUND: Oncoplastic surgery has been increasingly used in breast cancer treatment and allows the performance of breast-conserving surgery in cases of larger tumors with unfavorable location or tumor-breast disproportion. PURPOSE: To compare surgical and oncological outcomes of patients undergoing oncoplastic and nononcoplastic breast-conserving surgery. METHODS: Retrospective cohort study with convenience sampling of 866 patients who consecutively underwent breast-conserving surgery from 2011 to 2015. RESULTS: The mean follow-up was 50.4 months. Nononcoplastic breast conservation surgery was performed on 768 (88.7%) patients and oncoplastic surgery on 98 (11.3%) patients. Patients in the oncoplastic group were younger (p<0.0001) and most were premenopausal (p<0.0001). Comorbidities such as diabetes (p=0.003) and hypertension (p=0.0001) were less frequent in this population. Invasive carcinoma >2 cm (p<0.0001), multifocality (p=0.004), ductal in situ carcinoma (p=0.0007), clinically positive axilla (p=0.004), and greater weight of surgical specimens (p<0.0001) were more frequent in the oncoplastic group. A second surgery for margin re-excision was more frequently performed in the nononcoplastic group (p=0.027). There was more scar dehiscence in the oncoplastic group (p<0.001), but there was no difference in early major complications (p=0.854), conversion to mastectomy (p=0.92), or local recurrence (p=0.889). CONCLUSION: Although used for the treatment of larger and multifocal tumors, surgical re-excisions were performed less often in the oncoplastic group, and there was no increase in conversion to mastectomy or local recurrence. In spite of the higher rate of overall complications in the oncoplastic group, major complications were similar in both groups.
Potential Impact of the Z0011 Trial on the Omission of Axillary Dissection: A Retrospective Cohort Study Julia Yoriko Shinzato, Katia Piton Serra, Caroline Eugeni, Cesar Cabello, Cassio Cardoso-Filho, Luís Carlos Zeferino Revista Brasileira De Ginecologia E Obstetricia, 2021 Objective To evaluate the number of patients with early-stage breast cancer who could benefit from the omission of axillary surgery following the application of the Alliance for Clinical Trials in Oncology (ACOSOG) Z0011 trial criteria. Methods A retrospective cohort study conducted in the Hospital da Mulher da Universidade Estadual de Campinas. The study population included 384 women diagnosed with early-stage invasive breast cancer, clinically negative axilla, treated with breast-conserving surgery and sentinel lymph node biopsy, radiation therapy, chemotherapy and/or endocrine therapy, from January 2005 to December 2010. The ACOSOG Z0011 trial criteria were applied to this population and a statistical analysis was performed to make a comparison between populations. Results A total of 384 patients underwent breast-conserving surgery and sentinel lymph node biopsy. Of the total number of patients, 86 women underwent axillary lymph node dissection for metastatic sentinel lymph nodes (SNLs). One patient underwent axillary node dissection due to a suspicious SLN intraoperatively, thus, she was excluded from the study. Among these patients, 82/86 (95.3%) had one to two involved sentinel lymph nodes and met the criteria for the ACOSOG Z0011 trial with the omission of axillary lymph node dissection. Among the 82 eligible women, there were only 13 cases (15.9%) of lymphovascular invasion and 62 cases (75.6%) of tumors measuring up to 2 cm in diameter (T1). Conclusion The ACOSOG Z0011 trial criteria can be applied to a select group of SLN-positive patients, reducing the costs and morbidities of breast cancer surgery.
