Eun-Sil Hwang

Positions:

Mary and Deryl Hart Distinguished Professor of Surgery, in the School of Medicine

Surgical Oncology
School of Medicine

Professor of Surgery

Surgical Oncology
School of Medicine

Vice-Chair of Research in the Department of Surgery

Surgery
School of Medicine

Professor of Radiology

Radiology
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. 1991

University of California - Los Angeles

M.P.H. 2006

University of California - Berkeley

Intern, General Surgery

Kaiser Foundation Hospital

Resident, General Surgery

Cornell University

Fellow, Breast Surgical Oncology

Memorial Sloan-Kettering Cancer Center

Senior Reigstrar, General Surgical Oncology

Singapore General Hospital (Singapore)

Assistant Professor in Residence, Surgery

University of California San Francisco, School of Medicine

Associate Professor in Residence, Surgery

University of California San Francisco, School of Medicine

Chief, Division Of Breast Surgery Oncology

University of California San Francisco, School of Medicine

Professor in Residence, Surgery

University of California San Francisco, School of Medicine

Surgeon-in-Chief, Ucsf Helen Diller Family Cancer Center

University of California San Francisco, School of Medicine

Grants:

Genomic Diversity and the Microenvironment as Drivers of Progression in DCIS

Administered By
Surgical Oncology
Awarded By
Department of Defense
Role
Principal Investigator
Start Date
End Date

Preoperative Breast Radiotherapy: A Tool to Provide Individualized and Biologically-Based Radiation Therapy

Administered By
Radiation Oncology
Awarded By
Gateway for Cancer Research
Role
Collaborator
Start Date
End Date

(PQC3) Genomic Diversity and the Microenvironment as Drivers of Metastasis in DCIS

Administered By
Surgical Oncology
Awarded By
National Institutes of Health
Role
Principal Investigator
Start Date
End Date

NCI National Clinical Trials Network U10 (Year 5)

Administered By
Duke Cancer Institute
Awarded By
National Institutes of Health
Role
Co-Principal Investigator
Start Date
End Date

Regional Oncolytic Poliovirus Immunotherapy for Breast Cancer

Administered By
Surgery, Surgical Sciences
Awarded By
Department of Defense
Role
Co Investigator
Start Date
End Date

Publications:

Mixed-Methods Study to Predict Upstaging of DCIS to Invasive Disease on Mammography.

BACKGROUND. The incidence of ductal carcinoma in situ (DCIS) has steadily increased, as have concerns regarding overtreatment. Active surveillance is a novel treatment strategy that avoids surgical excision, but identifying patients with occult invasive disease who should be excluded from active surveillance is challenging. Radiologists are not typically expected to predict the upstaging of DCIS to invasive disease, though they might be trained to perform this task. OBJECTIVE. The purpose of this study was to determine whether a mixed-methods two-stage observer study can improve radiologists' ability to predict upstaging of DCIS to invasive disease on mammography. METHODS. All cases of DCIS calcifications that underwent stereotactic biopsy between 2010 and 2015 were identified. Two cohorts were randomly generated, each containing 150 cases (120 pure DCIS cases and 30 DCIS cases upstaged to invasive disease at surgery). Nine breast radiologists reviewed the mammograms in the first cohort in a blinded fashion and scored the probability of upstaging to invasive disease. The radiologists then reviewed the cases and results collectively in a focus group to develop consensus criteria that could improve their ability to predict upstaging. The radiologists reviewed the mammograms from the second cohort in a blinded fashion and again scored the probability of upstaging. Statistical analysis compared the performances between rounds 1 and 2. RESULTS. The mean AUC for reader performance in predicting upstaging in round 1 was 0.623 (range, 0.514-0.684). In the focus group, radiologists agreed that upstaging was better predicted when an associated mass, asymmetry, or architectural distortion was present; when densely packed calcifications extended over a larger area; and when the most suspicious features were focused on rather than the most common features. Additionally, radiologists agreed that BI-RADS descriptors do not adequately characterize risk of invasion, and that microinvasive disease and smaller areas of DCIS will have poor prediction estimates. Reader performance significantly improved in round 2 (mean AUC, 0.765; range, 0.617-0.852; p = .045). CONCLUSION. A mixed-methods two-stage observer study identified factors that helped radiologists significantly improve their ability to predict upstaging of DCIS to invasive disease. CLINICAL IMPACT. Breast radiologists can be trained to better predict upstaging of DCIS to invasive disease, which may facilitate discussions with patients and referring providers.
Authors
Grimm, LJ; Neely, B; Hou, R; Selvakumaran, V; Baker, JA; Yoon, SC; Ghate, SV; Walsh, R; Litton, TP; Devalapalli, A; Kim, C; Soo, MS; Hyslop, T; Hwang, ES; Lo, JY
MLA Citation
Grimm, Lars J., et al. “Mixed-Methods Study to Predict Upstaging of DCIS to Invasive Disease on Mammography.Ajr Am J Roentgenol, vol. 216, no. 4, Apr. 2021, pp. 903–11. Pubmed, doi:10.2214/AJR.20.23679.
URI
https://scholars.duke.edu/individual/pub1456309
PMID
32783550
Source
pubmed
Published In
Ajr. American Journal of Roentgenology
Volume
216
Published Date
Start Page
903
End Page
911
DOI
10.2214/AJR.20.23679

Treatment Patterns and Outcomes of Women with Breast Cancer and Supraclavicular Nodal Metastases.

<h4>Background</h4>In 2002, breast cancer patients with supraclavicular nodal metastases (cN3c) were downstaged from AJCC stage IV to IIIc, prompting management with locoregional treatment. We sought to estimate the impact of multimodal therapy on overall survival (OS) in a contemporary cohort of cN3c patients.<h4>Methods</h4>Women ≥ 18 years with cT1-T4c/cN3c invasive breast cancer who underwent systemic therapy were identified from the 2004-2016 National Cancer Database. We compared three patient cohorts: (a) cN3c + multimodal therapy (systemic therapy, surgery, and radiation); (b) cN3c + non-standard therapy; and, (c) cM1. Logistic regression identified factors associated with receipt of multimodal therapy and Kaplan-Meier was used to estimate unadjusted OS. The Cox proportional hazards model estimated effects of diagnosis and treatment on OS after adjustment.<h4>Results</h4>Overall, 1827 (3.7%) patients with cN3c disease and 46,919 (96.3%) cM1 patients were identified. Of cN3c patients, 74.5% (n = 1362) received multimodal therapy and 25.5% (n = 465) received non-standard therapy; receipt of multimodal therapy was associated with improved 5-year OS (multimodal: 59% vs. M1: 28% vs. non-standard: 28%, log-rank p < 0.001). Adjusting for covariates, non-standard therapy was associated with an increased risk of death compared with receipt of multimodal therapy (HR 2.20, 95% CI 1.71-2.83, p < 0.001). Private insurance was the only patient characteristic associated with a greater likelihood of receiving multimodal therapy (OR 2.81; 95% CI, 1.64-4.82; p < 0.001).<h4>Conclusion</h4>Women with cN3c breast cancer who received multimodal therapy demonstrated improved overall survival when compared with patients undergoing non-standard therapy and those with metastatic (M1) disease. Although selection bias may contribute to worse overall survival among cN3c patients undergoing non-standard therapy, national guidelines should encourage locoregional treatment in carefully selected patients.
Authors
Tamirisa, NP; Ren, Y; Campbell, BM; Thomas, SM; Fayanju, OM; Plichta, JK; Rosenberger, LH; Force, J; Hyslop, T; Hwang, ES; Greenup, RA
MLA Citation
Tamirisa, Nina P., et al. “Treatment Patterns and Outcomes of Women with Breast Cancer and Supraclavicular Nodal Metastases.Annals of Surgical Oncology, vol. 28, no. 4, Apr. 2021, pp. 2146–54. Epmc, doi:10.1245/s10434-020-09024-1.
URI
https://scholars.duke.edu/individual/pub1460793
PMID
32946012
Source
epmc
Published In
Annals of Surgical Oncology
Volume
28
Published Date
Start Page
2146
End Page
2154
DOI
10.1245/s10434-020-09024-1

Tumour-associated macrophages drive stromal cell-dependent collagen crosslinking and stiffening to promote breast cancer aggression.

Stromal stiffening accompanies malignancy, compromises treatment and promotes tumour aggression. Clarifying the molecular nature and the factors that regulate stromal stiffening in tumours should identify biomarkers to stratify patients for therapy and interventions to improve outcome. We profiled lysyl hydroxylase-mediated and lysyl oxidase-mediated collagen crosslinks and quantified the greatest abundance of total and complex collagen crosslinks in aggressive human breast cancer subtypes with the stiffest stroma. These tissues harbour the highest number of tumour-associated macrophages, whose therapeutic ablation in experimental models reduced metastasis, and decreased collagen crosslinks and stromal stiffening. Epithelial-targeted expression of the crosslinking enzyme, lysyl oxidase, had no impact on collagen crosslinking in PyMT mammary tumours, whereas stromal cell targeting did. Stromal cells in microdissected human tumours expressed the highest level of collagen crosslinking enzymes. Immunohistochemical analysis of biopsies from a cohort of patients with breast cancer revealed that stromal expression of lysyl hydroxylase 2, an enzyme that induces hydroxylysine aldehyde-derived collagen crosslinks and stromal stiffening, correlated significantly with disease specific mortality. The findings link tissue inflammation, stromal cell-mediated collagen crosslinking and stiffening to tumour aggression and identify lysyl hydroxylase 2 as a stromal biomarker.
Authors
Maller, O; Drain, AP; Barrett, AS; Borgquist, S; Ruffell, B; Zakharevich, I; Pham, TT; Gruosso, T; Kuasne, H; Lakins, JN; Acerbi, I; Barnes, JM; Nemkov, T; Chauhan, A; Gruenberg, J; Nasir, A; Bjarnadottir, O; Werb, Z; Kabos, P; Chen, Y-Y; Hwang, ES; Park, M; Coussens, LM; Nelson, AC; Hansen, KC; Weaver, VM
MLA Citation
Maller, Ori, et al. “Tumour-associated macrophages drive stromal cell-dependent collagen crosslinking and stiffening to promote breast cancer aggression.Nature Materials, vol. 20, no. 4, Apr. 2021, pp. 548–59. Epmc, doi:10.1038/s41563-020-00849-5.
URI
https://scholars.duke.edu/individual/pub1466321
PMID
33257795
Source
epmc
Published In
Nature Materials
Volume
20
Published Date
Start Page
548
End Page
559
DOI
10.1038/s41563-020-00849-5

Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study.

BACKGROUND: The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. METHODS: This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. FINDINGS: This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28-2·40], p<0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65-3·22], p<0·0001), American Society of Anesthesiologists grades 3-5 versus grades 1-2 (2·35 [1·57-3·53], p<0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01-2·39], p=0·046), emergency versus elective surgery (1·67 [1·06-2·63], p=0·026), and major versus minor surgery (1·52 [1·01-2·31], p=0·047). INTERPRETATION: Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. FUNDING: National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research.
Authors
COVIDSurg Collaborative,
MLA Citation
COVIDSurg Collaborative, Sang-June. “Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study.Lancet, vol. 396, no. 10243, July 2020, pp. 27–38. Pubmed, doi:10.1016/S0140-6736(20)31182-X.
URI
https://scholars.duke.edu/individual/pub1452990
PMID
32479829
Source
pubmed
Published In
Lancet
Volume
396
Published Date
Start Page
27
End Page
38
DOI
10.1016/S0140-6736(20)31182-X

Patient-reported causes of distress predict disparities in time to evaluation and time to treatment after breast cancer diagnosis.

BACKGROUND: We examined whether the National Comprehensive Cancer Network distress thermometer (DT), a patient-reported outcome measure, could be used to identify levels and causes of distress associated with racial/ethnic disparities in time to care among patients with breast cancer. METHODS: We identified women aged ≥18 years with stage 0-IV breast cancer who were diagnosed in a single health system between January 2014 and July 2016. The baseline visit was defined as the first postdiagnosis, pretreatment clinical evaluation. Zero-inflated negative binomial (ZINB) regression (modeling non-zero DT scores and DT scores = 0) and logistic regression (modeling DT score ≥ 4, threshold for social services referral) were used to examine associations between baseline score (0 = none to 10 = extreme) and types of stressors (emotional, familial, practical, physical, spiritual) after adjustment for race/ethnicity and other characteristics. Linear regression with log transformation was used to identify predictors of time to evaluation and time to treatment. RESULTS: A total of 1029 women were included (median baseline DT score = 4). Emotional, physical, and practical stressors were associated with distress in both the ZINB and logistic models (all P < .05). Black patients (n = 258) were more likely to report no distress than Whites (n = 675; ZINB zero model odds ratio, 2.72; 95% CI, 1.68-4.40; P < .001) despite reporting a similar number of stressors (P = .07). Higher DT scores were associated with shorter time to evaluation and time to treatment while being Black and having physical or practical stressors were associated with delays in both (all P < .05). CONCLUSIONS: Patient-reported stressors predicted delays in time to care, but patient-reported levels of distress did not, with Black patients having delayed time to care despite reporting low levels of distress. We describe anticipatory, culturally responsive strategies for using patient-reported outcomes to address observed disparities.
Authors
Fayanju, OM; Ren, Y; Stashko, I; Power, S; Thornton, MJ; Marcom, PK; Hyslop, T; Hwang, ES
MLA Citation
Fayanju, Oluwadamilola M., et al. “Patient-reported causes of distress predict disparities in time to evaluation and time to treatment after breast cancer diagnosis.Cancer, vol. 127, no. 5, Mar. 2021, pp. 757–68. Pubmed, doi:10.1002/cncr.33310.
URI
https://scholars.duke.edu/individual/pub1464167
PMID
33175437
Source
pubmed
Published In
Cancer
Volume
127
Published Date
Start Page
757
End Page
768
DOI
10.1002/cncr.33310