Clinicopathological Characteristics and Factors Affecting Recurrence of Ductal Carcinoma In Situ in Korean Women

Purpose: As breast cancer screening becomes more popular in Korea, incidence of ductal carcinoma in situ (DCIS) of breast has increased to more than 10% of all breast cancer diagnosed. We aimed to show the clinicopathological characteristics and factors affecting recurrence of DCIS in Korean women. Methods: We retrospectively reviewed 152 DCIS patients who underwent breast conserving surgery in Seoul National University Hospital between January 1995 and December 2005. Results: Mean age at diagnosis was 46.7 years (24 to 66 years). Mean follow up duration of the patients was 73.82 months (0.80 to 168.43 months). Recurrence of disease occurred in 19 (12.5%) patients: 2 in contralateral breast, 15 in ipsilateral breast, and 2 in axilla. One patient showed ipsilateral breast recur after excision of axillary metastasis. Eight (42.11%) of all recurrence was infiltrating ductal carcinoma and one of them showed bone metastasis during follow up. In an multivariate analysis of factors affecting recurrence, younger age at diagnosis and omission of radiotherapy had significant association with recurrence (p=0.005 and p=0.002, respectively). However, tumor size (p=0.862), microinvasion (p=0.988), histologic grade (p=0.157), estrogen receptor status (p=0.401) and resection margin status (p=0.112) were not significantly correlated with recurrence. There was no breast cancer associated mortality. Conclusion: In this study, we found that the younger age at diagnosis and omission of adjuvant radiotherapy are independent predictors of recurrence in Korean DCIS patients.Pinder SE, 2010, BRIT J CANCER, V103, P94, DOI 10.1038/sj.bjc.6605718Bundred NJ, 2010, CLIN CANCER RES, V16, P1605, DOI 10.1158/1078-0432.CCR-09-1623Virnig BA, 2010, J NATL CANCER I, V102, P170, DOI 10.1093/jnci/djp482Allegra CJ, 2010, J NATL CANCER I, V102, P161, DOI 10.1093/jnci/djp485Thomas J, 2010, BRIT J CANCER, V102, P285, DOI 10.1038/sj.bjc.6605513Collins LC, 2009, AM J SURG PATHOL, V33, P1802Hughes LL, 2009, J CLIN ONCOL, V27, P5319, DOI 10.1200/JCO.2009.21.8560Shah DN, 2009, BREAST J, V15, P649, DOI 10.1111/j.1524-4741.2009.00838.xGoodwin A, 2009, BREAST, V18, P143, DOI 10.1016/j.breast.2009.04.003Chung YS, 2009, J BREAST CANCER, V12, P106, DOI 10.4048/jbc.2009.12.2.106Dunne C, 2009, J CLIN ONCOL, V27, P1615, DOI 10.1200/JCO.2008.17.5182Kuerer HM, 2009, J CLIN ONCOL, V27, P279, DOI 10.1200/JCO.2008.18.3103Luini A, 2009, BREAST CANCER RES TR, V113, P397, DOI 10.1007/s10549-008-9929-0von Smitten K, 2008, J SURG ONCOL, V98, P585, DOI 10.1002/jso.21038Ko SS, 2008, J SURG ONCOL, V98, P318, DOI 10.1002/jso.21110Sakorafas GH, 2008, CANCER TREAT REV, V34, P483, DOI 10.1016/j.ctrv.2008.03.001Morrow M, 2008, ANN SURG ONCOL, V15, P2641, DOI 10.1245/s10434-008-0083-zIntra M, 2008, ANN SURG, V247, P315, DOI 10.1097/SLA.0b013e31815b446bAllred DC, 2008, CLIN CANCER RES, V14, P370, DOI 10.1158/1078-0432.CCR-07-1127RHEE J, 2008, BMC CANCER, V8, pNIL19, DOI DOI 10.1186/1471-2407-8-307Moore KH, 2007, ANN SURG ONCOL, V14, P2911, DOI 10.1245/s10434-007-9414-8Sontag L, 2005, J THEOR BIOL, V232, P179, DOI 10.1016/j.jtbi.2004.08.002Boland GP, 2003, BRIT J SURG, V90, P426, DOI 10.1002/bjs.4051Vicini FA, 2002, J CLIN ONCOL, V20, P2736, DOI 10.1200/JCO.2002.07.137Neuschatz AC, 2002, CANCER, V94, P1917, DOI 10.1002/cncr.10460Bartelink H, 2001, NEW ENGL J MED, V345, P1378Bijker N, 2001, J CLIN ONCOL, V19, P2263LEE HD, 2001, J KOREAN SURG SOC, V60, P495FRYKBERG ER, 1997, BREAST J, V3, P227

Efficacy of Breast Ultrasonography for Detection of Local, Regional, and Contralateral Recurrence of Breast Cancer

Purpose: Breast uttrasonography (US) is not recommended for recurrence monitoring after breast cancer surgery due to the lack of evidence for its advantage. The purpose of this study was to evaluate the usefulness of US for detecting local recurrence (LR), regional recurrence (RR) and contralateral breast cancer (CBC) in breast cancer patients during follow-up. Methods: The medical records of 5,833 breast cancer patients who underwent breast cancer surgery between January 2003 and December 2009 were reviewed retrospectively. Physical examination (PE), mammography (MMG), and US were done routinely to detect recurrences. Detection rate for locoregional and contralateral recurrence was compared between the three modalities. Results: During the follow-up period, 125 LR, 46 RR, 83 CBC, and 29 synchronous local and regional recurrences developed in 245 patients among the study population of 5,833 breast cancer patients. Median time to recurrence was 34.7 months. The recurrence detection rate was 51.9%, 43.5%, and 90.1% for PE, MMG, and US, respectively. Mean size of the recurrent lesions detected by US (1.57 cm) was smaller than that of PE (2.69 cm) and MMG (2.03 cm) (p=0.002). Conclusion: Breast US had higher recurrence detection rate for LA, RR, and CBC than PE or MMG after breast cancer surgery. 유방암은 2007년 우리나라 여성 암 발생률 2위(15.1%), 발생 환자 수는 11,606명을 차지하고 있고, 연간 6,6%의 높은 발생률의 증가를 보이고 있다.(1) 또한 지난 10년간 국내의 유방암 치료 성적도 지속적으로 개선되어 5년 생존율은 77.9%에서 89.5%로 11.5% 증가하였다. 이러한 유병률의 증가와 장기 생존율의 향상으로 인해 1999년 이후 9년 동안 유병자 수도 68,136명(11.2%)으로 빠르게 증가하고 있다.(1,2) 이러한 유방암 발생률 증가와 사망률 감소 및 유방암 수술 후 장기생존자의 증가에 따라 동측 유방 내 재발을 포함한 국소재발과 반대측 유방암이 발생하는 환자의 빈도가 최근 증가하고 있다. National Surgical Adjuvant Breast and Bowel Project(NSABP) B-06의 경우 20년의 추적 관찰기간 동안 14.3%의 동측 유방 재발(ipsilateral breast tumor recurrence)을 보고하였고,(3) 10년의 추적 기간 동안 단독 국소-구역 재발(locoregional recurrence)은 12.4%, 4개월 이내 전신재발을 동반한 국소-구역 재발은 19.8% 보고되었다.(4) 유방암으로 치료받은 환자에서 반대측 유방암(contralateral breast cancer)이 생길 확률은 2-11%로 유방암에 걸리지 않은 여성에 비해 2-6배의 높은 위험도를 가진다.(5) 2008년 한국유방암학회 유방암 진료권고안을 비롯하여 서구의 다양한 유방암 진료권고안에서는 국소, 구역, 그리고 반대측 유방암 재발을 진단함에 있어서 1년마다의 추적 관찰과 함께 유방촬영술을 시행하는 것을 권고하고 있다. 그러나 유방초음파나 유방 자기공명영상 등의 추가적 영상검사의 효용은 아직 불확실하여 고위험 환자에서 선택적으로 시행하는 것을 권하고 있다.(6-11)최근 여러 국내외의 연구에서 유방암 수술 후 국소재발이나 액와부 림프절 재발을 조기 발견하는 데 있어 유방초음파의 잠재적 효용성이 보고되고 있다.(12-15) 이에 본 연구에서는 유방암의 국소, 구역, 그리고 반대측 유방암 재발을 진단하는 데 있어서 유방 초음파의 유용성을 단일기관에서 수술받고 추적 관찰받은 한국인 유방암 환자군에서 분석해보고자 하였다.본 논문은 2010년도 정부(교육과학기술부)의 재원으로 한국연구재단의 기초 연구사업 지원을 받아 수행된 것임(2010-0004148).Kelly KM, 2010, EUR RADIOL, V20, P2557, DOI 10.1007/s00330-010-1844-1Kim HJ, 2010, ANN SURG ONCOL, V17, P2670, DOI 10.1245/s10434-010-1087-zJung KW, 2010, J KOREAN MED SCI, V25, P1113, DOI 10.3346/jkms.2010.25.8.1113Aebi S, 2010, ANN ONCOL, V21, pv9, DOI 10.1093/annonc/mdq159Lehman CD, 2009, J NATL COMPR CANC NE, V7, P1109Houssami N, 2009, ANN ONCOL, V20, P1505, DOI 10.1093/annonc/mdp037Moon HJ, 2009, RADIOLOGY, V252, P673, DOI 10.1148/radiol.2523081977Yarnold J, 2009, CLIN ONCOL-UK, V21, P159, DOI 10.1016/j.clon.2008.12.008Kim MJ, 2009, AM J ROENTGENOL, V192, P221, DOI 10.2214/AJR.07.4048Montgomery DA, 2007, BRIT J CANCER, V96, P1802, DOI 10.1038/sj.bjc.6603815Yilmaz MH, 2007, DIAGN INTERV RADIOL, V13, P13Khatcheressian JL, 2006, J CLIN ONCOL, V24, P5091, DOI 10.1200/JCO.2006.08.8575Shin JH, 2005, J ULTRAS MED, V24, P643Taghian A, 2004, J CLIN ONCOL, V22, P4247, DOI 10.1200/JCO.2004.01.042Ciatto S, 2004, EUR J CANCER, V40, P1496, DOI 10.1016/j.ejca.2004.03.010Fisher B, 2002, NEW ENGL J MED, V347, P1233KIM SH, 2000, J KOREAN RADIOL SOC, V42, P1009Chen Y, 1999, CANCER EPIDEM BIOMAR, V8, P855GORDON PB, 1995, CANCER, V76, P626GIUSEPPETTI GM, 1989, RADIOL MED, V78, P339*NAT COMPR CANC NE, NCCN CLIN PRACT GUID*AM COLL RAD, ACR BREAST IM REP DA*NAT CANC INF CTR, CANC STAT*KOR BREAST CANC S, 3 BREAST CANC MAN RE

Factors Affecting the Ipsilateral Breast Tumor Recurrence after Breast Conserving Therapy in Patients with T1 and T2 Tumors

본 논문은 2008년 대한외과학회 추계학술대회에서 구연 발표되었음.Purpose: Nearly half of all breast cancers are treated with breast conserving therapy (BCT). The purpose of this study was to identify the risk factors for ipsilateral breast tumor recurrence (IBTR) after BCT in T1 and T2 breast cancer patients. Methods: The medical records of 294 T1 or T2 breast cancer patients who underwent BCT at Seoul National University Hospital between January 1998 and December 2002 were retrospectively reviewed. Kaplan-Meier curves and Cox proportional regression analysis were used to identify the significant clinicopathologic factors that influence IBTR. Results: Among the 294 patients, 12 patients (4.8%) developed IBTR after a median follow-up of 82 months. Univariate analysis demonstrated that younger age (<= 35 year) had significant associations with IBTR (p=0.006). Tumor size, lymph node status, histologic grade, extensive intraductal component, lymphovascular invasion, and close resection margins were not significant factor associated with IBTR. The triple negative breast cancer subtype also did not have significant association with IBTR. Multivariate analysis showed that the younger age at diagnosis was a significant predictor of IBTR with a FIR of 3.86 (p=0.036; 95% CI, 1.09-13.60). Conclusion: Younger age at diagnosis (<= 35) may be associated with an increased risk of IBTR in patients who underwent BCT.Han W, 2010, BREAST CANCER RES TR, V119, P193, DOI 10.1007/s10549-009-0388-zBenson JR, 2009, LANCET, V373, P1463Luini A, 2009, BREAST CANCER RES TR, V113, P397, DOI 10.1007/s10549-008-9929-0Nguyen PL, 2008, J CLIN ONCOL, V26, P2373, DOI 10.1200/JCO.2007.14.4287Lee JW, 2007, J BREAST CANCER, V10, P206Dent R, 2007, CLIN CANCER RES, V13, P4429, DOI 10.1158/1078-0432.CCR-06-3045KANG SH, 2007, J KOREAN SURG SOC, V73, P385Haffty BG, 2006, J CLIN ONCOL, V24, P5652, DOI 10.1200/JCO.2006.06.5664Ahn SH, 2006, BREAST CANCER RES TR, V99, P209, DOI 10.1007/s10549-006-9188-xWapnir IL, 2006, J CLIN ONCOL, V24, P2028, DOI 10.1200/JCO.2005.04.3273Komoike Y, 2006, CANCER, V106, P35, DOI 10.1002/cncr.21551Abe O, 2005, LANCET, V366, P2087Noh WC, 2005, WORLD J SURG, V29, P1001, DOI 10.1007/s00268-005-7928-4Kim KJ, 2005, JPN J CLIN ONCOL, V35, P126, DOI 10.1093/jjcolyhi039Han WS, 2004, BMC CANCER, V4, DOI 10.1186/1471-2407-4-82MORROW M, 2004, DIS BREAST, P719Arriagada R, 2003, ANN ONCOL, V14, P1617, DOI 10.1093/annonc/mdg452Singletary SE, 2002, AM J SURG, V184, P383Veronesi U, 2002, NEW ENGL J MED, V347, P1227Fisher B, 2002, NEW ENGL J MED, V347, P1233Freedman GM, 2002, J CLIN ONCOL, V20, P4015, DOI 10.1200/JCO.2002.03.155Haffty BG, 2002, LANCET, V359, P1471Jobsen JJ, 2001, EUR J CANCER, V37, P1820Sasson AR, 2001, CANCER, V91, P1862Voogd AC, 2001, J CLIN ONCOL, V19, P1688Park CC, 2000, J CLIN ONCOL, V18, P1668Freedman G, 1999, INT J RADIAT ONCOL, V44, P1005Peterson ME, 1999, INT J RADIAT ONCOL, V43, P1029SUH CO, 1997, J KOREAN SOC THER RA, V15, P331BORGER J, 1994, J CLIN ONCOL, V12, P653WAZER DE, 1992, J CLIN ONCOL, V10, P356SOLIN LJ, 1991, INT J RADIAT ONCOL, V21, P279JACQUEMIER J, 1990, BRIT J CANCER, V61, P873VERONESI U, 1990, EUR J CANCER, V26, P671FOURQUET A, 1989, INT J RADIAT ONCOL, V17, P719LOCKER AP, 1989, BRIT J SURG, V76, P890

The Association between the Adherence to Dietary Guidelines for Breast Cancer Survivors and Health-related Quality of Life among Korean Breast Cancer Survivors

Objectives: We examined the association between the adherence to dietary guidelines for breastcancer survivors and health-related quality of life in a cross-sectional study of Korean breastcancer survivors. Methods: A total of 157 women aged 21 to 79 years who had been diagnosed with stage I toIII breast cancers according to the American Joint Committee on Cancer (AJCC) and hadbreast cancer surgery at least 6 months before the baseline were included. We used a Koreanversion of the Core 30 (C30) and Breast cancer 23 (BR23) module of the EuropeanOrganization for Research and Treatment Cancer Quality of Life Questionnaire (EORTC-QLQ),both of which have been validated for Koreans. Participants were asked about their adherenceto dietary guidelines for breast cancer survivors, suggested by the Korean breast cancer society,using a 5-point Likert scale. We summed dietary guideline adherence scores for each participantand calculated the least squares means of health-related quality of life according to dietaryguideline adherence scores using the generalized linear model. Results: Breast cancer survivors who had higher adherence to dietary guidelines for breastcancer survivors had lower constipation scores than those with lower adherence (p fortrend=0.01). When we stratified by the stage at diagnosis, this association was limited to thosewho had been diagnosed with stage II or III breast cancers. Also, sexual functioning scoresincreased significantly with increasing adherence scores of dietary guidelines among those withstage II or III breast cancers (p for trend &lt; 0.001). However, among those who had beendiagnosed with stage I, higher scores of dietary guidelines were associated with higher scoresof pain (p for trend=0.03) and breast symptoms (p for trend=0.05). Conclusions: Our study suggested that the health-related quality of life levels of breast cancersurvivors are associated with the adherence to dietary guidelines and may differ by the stage ofthe breast cancer.N

Dietary Changes After Breast Cancer Diagnosis: Associations with Physical Activity, Anthropometry, and Health-related Quality of life Among Korean Breast Cancer Survivors

Objectives: We aimed to examine levels of physical activity, anthropometric features, and healthrelated quality of life (HRQoL) among Korean breast cancer survivors who reported changes in their diet after diagnosis. Methods: A total of 380 women who had been diagnosed with stage I to III breast cancer and had breast cancer surgery at least six months before the interview were included. Participants provided information on dietary change after diagnosis, post-diagnostic diet, physical activity, anthropometric measures, and HRQoL through face-to-face interview. We assessed HRQoL levels of breast cancer survivors using a validated Korean version of European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) and Breast Cancer Module (BR23). We used the logistic regression and generalized linear models to identify the associations of dietary changes in relation with physical activity, anthropometry, and HRQoL. Results: The majority of participants (72.6%) reported that they have changed their diet to a healthier diet after diagnosis. Breast cancer survivors who reported to have change to a healthy diet had higher intakes of vegetables and fruits and lower intakes of red and processed meats, and refined grains than those who did not. Also, survivors with a healthy change in their diet were more likely to engage in physical activity (top vs. bottom tertile: odds ratio [OR], 1.85; 95% confidence interval [95% CI], 1.02-3.36) and have lower body mass index (BMI) (OR, 0.90; 95% CI, 0.82-0.98 for one kg/m2 increment in BMI) compared to those who did not. We found that a healthy change in diet was associated with higher scores of physical functioning (p=0.02) and lower scores of constipation (p=0.04) and diarrhea (p=0.006) compared to those who did not. Conclusions: Healthy changes in diet after breast cancer diagnosis may be associated with lower levels of BMI, and higher levels of physical activity and HRQoL.N

120개 유방암 조직의 차세대 염기서열 분석을 통한 융합 전사체 발굴

학위논문 (박사)-- 서울대학교 대학원 : 의학과 외과학전공, 2015. 8. 한원식.Purpose: Although fusion genes serve as an effective target in hematologic malignancies, recurrent gene fusion events are relatively rare in solid tumors. To detect recurrent novel fusion transcripts we performed whole transcriptome sequencing primary breast cancer samples. Experimental Design: Whole-transcriptome sequencing of 120 fresh-frozen primary breast cancer samples and five adjacent normal breast tissues using the Illumina HiSeq2000 platform was performed. Three different fusion-detecting tools (deFuse, Chimerascan, and TopHat) were used, and the results were compared. Results: These tools detected 3831, 6630 and 516 fusion transcripts (FTs) overall. We primarily focused on the results obtained using the deFuse software. More FTs were identified from HER2 subtype breast cancer samples than from the luminal or triple-negative subtypes (p < 0.05). Seventy fusion candidates were selected for validation, and 32 (45.7%) were confirmed by RT-PCR and Sanger sequencing. Of the validated fusions, six were recurrent (found in 2 or more samples), three were in-frame (PRDX1-AKR1A1, TACSTD2-OMA1 and C2CD2-TFF1) and three were off-frame (CEACAM7-CEACAM6, CYP4X1-CYP4Z2P, and EEF1DP3-FRY). Notably, the novel read-through fusion, EEF1DP3-FRY, was identified and validated in 6.7% (8/120) of the breast cancer samples. This off-frame fusion results in early truncation of the FRY gene, which plays a key role in the structural integrity during mitosis. Three previously reported fusions, PPP1R1B-STARD3, MFGE8-HAPL, and ETV6-NTRK3, were detected in 8.3%, 3.3% and 0.8% of the 120 samples, respectively, by both deFuse and Chimerascan. The recently reported MAGI3-AKT3 fusion was not detected in our analysis. Conclusion: Among the 3800s fusions detected by mRNA Sequencing, 32 fusions were validated using Sanger sequencing, including the novel recurrent read-through fusion, EEF1DP3-FRY. Previously reported FTs, such as PPP1R1B-STARD3, MFGE8-HAPLN3 and ETV6-NTRK3, were also identified. Future work is warranted to elucidate the biological significance of these fusions.Abstract ------------------------------------------------------------------------------ i Contents ------------------------------------------------------------------------------- iii List of Tables & Figures List of Tables ------------------------------------------------------------------ iv List of Figures ------------------------------------------------------------------- v I. Introduction ---------------------------------------------------------------- 1-2 II. Materials and Methods --------------------------------------------------- 3-6 III. Results ------------------------------------------------------------------------ 7-32 IV. Discussion ------------------------------------------------------------------ 33-38 V. References ------------------------------------------------------------------ 39-45 Abstract - Korean --------------------------------------------------------------------- 46-48 Acknowledgement ----------------------------------------------------------------- 49Docto

The Impact of Primary Tumor Resection on the Survival of Patients with Stage IV Breast Cancer

Purpose The main treatment for stage IV breast cancer is currently systemic therapy. Surgical resection of the primary tumor is usually done for treating the tumor-related complications Recent studies have suggested that surgery may improve the long-term survival of stage IV breast cancer patients We evaluated the impact of the primary surgical resection site on the survival of stage IV breast cancer patients. Methods We reviewed the records of the stage IV breast cancer patients who were treated at Seoul University Hospital between April 1992 and December 2007 The tumor and clinical characteristics, the type of treatments and the overall survival were compared between the surgically versus nonsurgically treated patients. Results. Of the 198 identified patients, 110 (55 8%) received surgical excision of their primary tumor and 88 (44 2%) did not The mean survival was 67 months vs. 42 months for the surgically treated patients vs the patients without surgery, respectively (p=0 0287) On a multivariate analysis with using the Cox model and after adjusting for the estrogen receptor status, visceral metastases, the number of metastatic sites and trastuzumab treatment, surgery was an independent factor for improved survival (hazard ratio, 0.55; 95% confidence interval, 0.31-0.97; p=0.041). Conclusion Surgical resection of the primary tumor in stage IV breast cancer patients was independently associated with improved survival. Randomized prospective trials are needed to firmly recommend surgical resection of the primary tumor in stage IV breast cancer patients본 연구는 폐암, 유방암/난소암 유전체 연구센터의 연구비를 지원받아 수행 되었음(01-PJ3-PG6-01GN07-0004).Bafford AC, 2009, BREAST CANCER RES TR, V115, P7, DOI 10.1007/s10549-008-0101-7Blanchard DK, 2008, ANN SURG, V247, P732, DOI 10.1097/SLA.0b013e3181656d32*KOR BREAST CANC S, 2008, BREAST CANC FACTS FI, V1, P5Fields RC, 2007, ANN SURG ONCOL, V14, P3345, DOI 10.1245/s10434-007-9527-0Gnerlich J, 2007, ANN SURG ONCOL, V14, P2187, DOI 10.1245/s10434-007-9438-0Rapiti E, 2006, J CLIN ONCOL, V24, P2743, DOI 10.1200/JCO.2005.04.2226Morrow M, 2006, J CLIN ONCOL, V24, P2694, DOI 10.1200/JCO.2006.05.9824Babiera GV, 2006, ANN SURG ONCOL, V13, P776, DOI 10.1245/ASO.2006.03.033Hotta T, 2006, ANTICANCER RES, V26, P1377Abe O, 2005, LANCET, V366, P2087Andre F, 2004, J CLIN ONCOL, V22, P3302, DOI 10.1200/JCO.2004.08.095Giordano SH, 2004, CANCER, V100, P44, DOI 10.1002/cncr.11859Khan SA, 2002, SURGERY, V132, P620, DOI 10.1067/msy.2002.127544Flanigan RC, 2001, NEW ENGL J MED, V345, P1655Demicheli R, 2001, BRIT J CANCER, V85, P490Dauplat J, 2000, SEMIN SURG ONCOL, V19, P42Overgaard M, 1999, SEMIN RADIAT ONCOL, V9, P292DOGHETTO GB, 1999, AM SURGEON, V65, P352BLAND KI, 1998, BREAST COMPREHENSIVE, V2Ragaz J, 1997, NEW ENGL J MED, V337, P956OREILLY MS, 1994, CELL, V79, P315FISHER B, 1989, CANCER RES, V49, P1996*NAT CANC I, BREAST CANC TREATM P