Rachel Greenup

Overview:

Dr. Greenup is an Associate Professor of Surgery and Population Health Sciences at the Duke School of Medicine and Duke Cancer Institute. She is the founder and co-director of the Duke Breast Cancer Outcomes Research Group, and Core Faculty for the Duke Margolis Center for Health Policy.

She earned her undergraduate degrees in Zoology and Psychology at the University of Wisconsin, where she later completed a Masters in Public Health. She attended the Medical College of Wisconsin for Medical School and General Surgery Residency, and went on to complete a Breast Surgical Oncology Fellowship at the Massachusetts General Hospital, Dana Farber Cancer Institute, and Brigham and Women’s Hospital. In 2016, she received the National Institutes of Health Building Interdisciplinary Research Careers in Women’s Health (BIRCWH) Award to evaluate how financial costs and burden relate to preference-sensitive decisions for breast cancer surgery. In 2017, she was named the American College of Surgeons & American Society of Breast Surgeons Health Policy Scholar. More broadly, her research focuses on aligning patient-centered care with high quality, lower cost treatment.

Dr. Greenup serves on several national committees, including the Alliance in Clinical Oncology Ethics and Value Committees, the American College of Surgeons Cancer Care Delivery Task Force, the American Society of Breast Surgeons Legislative Committee, and the Editorial Board for the Annals of Surgical Oncology. 

Positions:

Associate Professor of Surgery

Surgical Oncology
School of Medicine

Associate Professor in Population Health Sciences

Population Health Sciences
School of Medicine

Core Faculty Member, Duke-Margolis Center for Health Policy

Duke - Margolis Center For Health Policy
Institutes and Provost's Academic Units

Member of the Duke Cancer Institute

Duke Cancer Institute
School of Medicine

Education:

M.D. 2004

Medical College of Wisconsin

M.P.H. 2009

University of Wisconsin - Madison

Internship/General Surgery Residency

Medical College of Wisconsin

Breast Surgical Oncology Fellow

Massachusetts General Hospital

Grants:

Clinical and Biological Characterization of Male Breast Cancer: an International EORTC, BIG, TBCRC, and NABCG intergroup Study

Administered By
Duke Cancer Institute
Awarded By
Johns Hopkins University
Role
Principal Investigator
Start Date
End Date

Publications:

Surgery for Men with Breast Cancer: Do the Same Data Still Apply?

BACKGROUND: Men represent a small proportion of breast cancer diagnoses, and they are often excluded from clinical trials. Current treatments are largely extrapolated from evidence in women. We compare practice patterns between men and women with breast cancer following the publication of several landmark clinical trials in surgery. PATIENTS AND METHODS: Patients with invasive breast cancer (2004-2015) from the National Cancer Data Base were identified; subcohorts were created based on eligibility for NSABP-B06, CALGB 9343, and ACOSOG Z0011. Practice patterns were stratified by gender and compared. Cox proportional hazards regression analyses were utilized to estimate the association between OS and gender. RESULTS: Of the 1,664,746 patients identified, 99% were women and 1% were men. Among NSABP-B06 eligible men, mastectomy rates did not change (consistently ~ 80%), and their adjusted OS was minimally worse compared with women (HR 1.19, 95% CI 1.11-1.28). Following publication of CALGB 9343, omission of radiation after lumpectomy was less likely in men and lagged behind that of women, despite similar OS (male HR 0.92, 95% CI 0.59-1.44). Application of ACOSOG Z0011 findings resulted in deescalation of axillary surgery for men and women with comparable OS (male HR 0.69, 95% CI 0.33-1.45). CONCLUSIONS: Uptake of clinical trial results for men with breast cancer often mirrors that for women, despite exclusion from these studies. Furthermore, when study findings were applied to eligible patients, men and women demonstrated similar survival. Observational studies can help inform the potential application of study findings to this unique population and improve patient enrollment in clinical trials.
Authors
MLA Citation
Plichta, Jennifer K., et al. “Surgery for Men with Breast Cancer: Do the Same Data Still Apply?Ann Surg Oncol, July 2020. Pubmed, doi:10.1245/s10434-020-08901-z.
URI
https://scholars.duke.edu/individual/pub1452159
PMID
32705510
Source
pubmed
Published In
Annals of Surgical Oncology
Published Date
DOI
10.1245/s10434-020-08901-z

Financial toxicity and contralateral prophylactic mastectomy: an analysis using propensity score methods.

PURPOSE: Contralateral prophylactic mastectomy (CPM) is increasingly performed in average-risk patients despite the lack of survival benefit. In an era of heightened awareness of healthcare costs, we sought to determine the impact of CPM on financial toxicity in breast cancer. METHODS: A single-institution propensity-matched analysis of female patients who underwent unilateral mastectomy (UM) with or without CPM for breast cancer over an 18-month period. Patients with a history of genetic predisposition or bilateral cancer were excluded. The validated Comprehensive Score for financial Toxicity (COST) evaluated financial toxicity among participants. Multivariable regression analysis evaluated the relationship between CPM and financial toxicity. Relevant domains of the Breast Q and SF12 instruments were examined as secondary outcomes. Sensitivity analysis was performed using propensity-weighting to examine robustness of results and increase our sample size. RESULTS: Overall, 104 patients were identified, equally distributed across UM and CPM. CPM was not associated with financial toxicity, as evidenced by comparable COST scores (adjusted difference, 1.53 [- 3.24 to 6.29]). Minor complications were significantly lower in UM patients (UM, 8%; CPM, 31%). CPM was associated with significantly higher Breast Q psychosocial well-being score (adjusted difference, 10.58 [1.34 to 19.83]). BREAST Q surgeon satisfaction, SF12 mental and physical component scores were comparable. Similar results were noted on sensitivity analysis involving 194 patients. CONCLUSIONS: Choice for CPM was associated with higher minor complications, but led to improved psychosocial well-being without a higher degree of patient-reported financial toxicity. Prospective studies are needed to discern the influence of CPM on the incidence and trajectory of financial toxicity.
Authors
Asaad, M; Boukovalas, S; Chu, CK; Lin, Y-L; Checka, CM; Clemens, MW; Greenup, RA; Offodile, AC
MLA Citation
Asaad, Malke, et al. “Financial toxicity and contralateral prophylactic mastectomy: an analysis using propensity score methods.Breast Cancer Res Treat, July 2020. Pubmed, doi:10.1007/s10549-020-05805-0.
URI
https://scholars.duke.edu/individual/pub1452842
PMID
32691378
Source
pubmed
Published In
Breast Cancer Res Treat
Published Date
DOI
10.1007/s10549-020-05805-0

Quantitative assessment of distant recurrence risk in early stage breast cancer using a nonlinear combination of pathological, clinical and imaging variables.

Use of genomic assays to determine distant recurrence risk in patients with early stage breast cancer has expanded and is now included in the American Joint Committee on Cancer staging manual. Algorithmic alternatives using standard clinical and pathology information may provide equivalent benefit in settings where genomic tests, such as OncotypeDx, are unavailable. We developed an artificial neural network (ANN) model to nonlinearly estimate risk of distant cancer recurrence. In addition to clinical and pathological variables, we enhanced our model using intraoperatively determined global mammographic breast density (MBD) and local breast density (LBD). LBD was measured with optical spectral imaging capable of sensing regional concentrations of tissue constituents. A cohort of 56 ER+ patients with an OncotypeDx score was evaluated. We demonstrated that combining MBD/LBD measurements with clinical and pathological variables improves distant recurrence risk prediction accuracy, with high correlation (r = 0.98) to the OncotypeDx recurrence score.
Authors
Nichols, BS; Chelales, E; Wang, R; Schulman, A; Gallagher, J; Greenup, RA; Geradts, J; Harter, J; Marcom, PK; Wilke, LG; Ramanujam, N
MLA Citation
Nichols, Brandon S., et al. “Quantitative assessment of distant recurrence risk in early stage breast cancer using a nonlinear combination of pathological, clinical and imaging variables.J Biophotonics, June 2020, p. e201960235. Pubmed, doi:10.1002/jbio.201960235.
URI
https://scholars.duke.edu/individual/pub1447971
PMID
32573935
Source
pubmed
Published In
J Biophotonics
Published Date
Start Page
e201960235
DOI
10.1002/jbio.201960235

Pathologic Complete Response after Neoadjuvant Chemotherapy and Impact on Breast Cancer Recurrence and Survival: A Comprehensive Meta-analysis.

PURPOSE: While various studies have highlighted the prognostic significance of pathologic complete response (pCR) after neoadjuvant chemotherapy (NAT), the impact of additional adjuvant therapy after pCR is not known. EXPERIMENTAL DESIGN: PubMed was searched for studies with NAT for breast cancer and individual patient-level data was extracted for analysis using plot digitizer software. HRs, with 95% probability intervals (PI), measuring the association between pCR and overall survival (OS) or event-free survival (EFS), were estimated using Bayesian piece-wise exponential proportional hazards hierarchical models including pCR as predictor. RESULTS: Overall, 52 of 3,209 publications met inclusion criteria, totaling 27,895 patients. Patients with a pCR after NAT had significantly better EFS (HR = 0.31; 95% PI, 0.24-0.39), particularly for triple-negative (HR = 0.18; 95% PI, 0.10-0.31) and HER2+ (HR = 0.32; 95% PI, 0.21-0.47) disease. Similarly, pCR after NAT was also associated with improved survival (HR = 0.22; 95% PI, 0.15-0.30). The association of pCR with improved EFS was similar among patients who received subsequent adjuvant chemotherapy (HR = 0.36; 95% PI, 0.19-0.67) and those without adjuvant chemotherapy (HR = 0.36; 95% PI, 0.27-0.54), with no significant difference between the two groups (P = 0.60). CONCLUSIONS: Achieving pCR following NAT is associated with significantly better EFS and OS, particularly for triple-negative and HER2+ breast cancer. The similar outcomes with or without adjuvant chemotherapy in patients who attain pCR likely reflects tumor biology and systemic clearance of micrometastatic disease, highlighting the potential of escalation/deescalation strategies in the adjuvant setting based on neoadjuvant response.See related commentary by Esserman, p. 2771.
Authors
Spring, LM; Fell, G; Arfe, A; Sharma, C; Greenup, R; Reynolds, KL; Smith, BL; Alexander, B; Moy, B; Isakoff, SJ; Parmigiani, G; Trippa, L; Bardia, A
MLA Citation
Spring, Laura M., et al. “Pathologic Complete Response after Neoadjuvant Chemotherapy and Impact on Breast Cancer Recurrence and Survival: A Comprehensive Meta-analysis.Clin Cancer Res, vol. 26, no. 12, June 2020, pp. 2838–48. Pubmed, doi:10.1158/1078-0432.CCR-19-3492.
URI
https://scholars.duke.edu/individual/pub1431636
PMID
32046998
Source
pubmed
Published In
Clinical Cancer Research : an Official Journal of the American Association for Cancer Research
Volume
26
Published Date
Start Page
2838
End Page
2848
DOI
10.1158/1078-0432.CCR-19-3492

Surgical Management of the Axilla in Elderly Women With Node-positive Breast Cancer.

BACKGROUND: Elderly women with clinically node-positive (cN+) breast cancer (BC) often have comorbidities that limit life expectancy and complicate treatment. We sought to determine whether the number of lymph nodes (LNs) retrieved among older women with node-positive BC was associated with overall survival (OS). METHODS: Using the National Cancer Database (2010-2015), women 70-90 y with cN + BC and ≥1 LNs removed were categorized by treatment sequence: upfront surgery or neoadjuvant chemotherapy (NAC). Multivariable Cox proportional hazards models with restricted cubic splines characterized the functional association of LN retrieval with OS; threshold values of LN retrieval were estimated. Cox proportional hazards models were used to estimate the association of LN retrieval groups with OS. RESULTS: In the upfront surgery cohort, a nonlinear association was identified between LNs retrieved and OS. In the NAC cohort, no association was identified. For the upfront surgery cohort, the optimal threshold value of LN retrieval was 21 LNs (90% confidence interval 18-23). Based on this estimate, LN retrieval groups were created: <6, 6-11, 12-17, 18-23, and >23 LNs. After adjustment, retrieval of <12 LNs in the upfront surgery group was associated with a worse OS. No differences were observed in the NAC group. CONCLUSIONS: For elderly women receiving upfront surgery, there is no survival benefit to removing more than 12 LNs, and for those receiving NAC, there is no association between number of LNs removed and survival. In older women who present with cN + BC, aggressive surgery to remove more than 12 LNs may not be necessary.
Authors
Marks, CE; Ren, Y; Rosenberger, LH; Thomas, SM; Greenup, RA; Fayanju, OM; McDuff, S; Kimmick, G; Shelley Hwang, E; Plichta, JK
MLA Citation
Marks, Caitlin E., et al. “Surgical Management of the Axilla in Elderly Women With Node-positive Breast Cancer.J Surg Res, vol. 254, May 2020, pp. 275–85. Pubmed, doi:10.1016/j.jss.2020.04.036.
URI
https://scholars.duke.edu/individual/pub1446657
PMID
32480072
Source
pubmed
Published In
J Surg Res
Volume
254
Published Date
Start Page
275
End Page
285
DOI
10.1016/j.jss.2020.04.036