Design and Evaluation of a Computational Phenotype to Identify Patients With Metastatic Breast Cancer Within the Electronic Health Record.

PURPOSE: Outcomes for patients with metastatic breast cancer (MBC) are continually improving as more effective treatments become available. Granular data sets of this unique population are lacking, and the standard method for data collection relies largely on chart review. Therefore, using electronic health records (EHR) collected at a tertiary hospital system, we developed and evaluated a computational phenotype designed to identify all patients with MBC, and we compared the effectiveness of this algorithm against the gold standard, clinical chart review. METHODS: A cohort of patients with breast cancer were identified according to International Classification of Diseases codes, the institutional tumor registry, and SNOMED codes. Chart review was performed to determine whether distant metastases had occurred. We developed a computational phenotype, on the basis of SNOMED concept IDs, which was applied to the EHR to identify patients with MBC. Contingency tables were used to aggregate and compare results. RESULTS: A total of 1,741 patients with breast cancer were identified using data from International Classification of Diseases codes, the tumor registry, and/or SNOMED concept identifiers. Chart review of all patients classified each patient as having MBC (n = 416; 23.9%) versus not (n = 1,325; 75.9%). The final computational phenotype successfully classified 1,646 patients (95% accuracy; 82% sensitivity; 99% specificity). CONCLUSION: Hospital systems with robust EHRs and reliable mapping to SNOMED have the ability to use standard codes to derive computational phenotypes. These algorithms perform reasonably well and have the added ability to be run at disparate health care facilities. Better tooling to navigate the polyhierarchical structure of SNOMED ontology could yield better-performing computational phenotypes.

Metastatic breast cancer: Who benefits from surgery?

BACKGROUND: We sought to identify characteristics of metastatic breast cancer (MBC) patients who may benefit most from primary tumor resection. METHODS: Recursive partitioning analysis (RPA) was used to categorize non-surgical patients with de novo MBC in the NCDB (2010-2015) into 3 groups (I/II/III) based on 3-year overall survival (OS). After bootstrapping (BS), group-level profiles were applied, and the association of surgery with OS was estimated using Cox proportional hazards models. RESULTS: All patients benefitted from surgery (median OS, surgery vs no surgery): 72.7 vs 42.9 months, 47.3 vs 30.4 months, 23.8 vs 14.4 months (all p < 0.001) in BS-groups I, II, and III, respectively. After adjustment, surgery remained associated with improved OS (HR 0.52, 95% CI 0.50-0.55). The effect of surgery on OS differed quantitatively across groups. CONCLUSION: Prognostic groups may inform the degree of benefit from surgery, with the greatest benefit seen in those with the most favorable survival.

Disparities between Operative Time and Relative Value Units for Plastic Surgery Procedures.

BACKGROUND: Plastic surgeons are evaluated not only by the number of patients served but also by relative value, quantified by the Medicare relative value unit system, which can affect advancement and compensation. Procedures that demand a high operative time without an increase in relative value units are, by definition, inefficient. The purpose of this study was to determine whether the number of relative value units actually corresponds to operative time. METHODS: The National Surgical Quality Improvement Program data sets over a 9-year period were queried for plastic surgery operations. The primary CPT codes representing the 100 most common operations were compared for operative time and total relative value units. RESULTS: A total of 53,701 cases were included. There was a high degree of correlation between operative time and number of relative value units (Pearson correlation coefficient, 0.82). The average efficiency was 10.201 ± 3.386 relative value units per hour. Pressure ulcer excisions and breast reconstruction were among the most efficient (e.g., Excision, sacral pressure ulcer, CPT 19357, generated 20.819 relative value units per hour). Skin excisions, débridements, and flap delays were among the least efficient (e.g., Excision, excessive skin and subcutaneous tissue, CPT 15847, generated 1.752 relative value units per hour). CONCLUSIONS: As a general trend, the most common plastic surgical procedures requiring longer operative times are associated with more relative value units. Cases with higher relative value units assigned tended to be more efficient. For the 100 most common procedures, relative value units and operative time are not evenly distributed. These data suggest modifications to the current relative value unit designation system to more equally allocate these units based on effort and time.

The Effect of Lavender Oil on Perioperative Pain, Anxiety, Depression, and Sleep after Microvascular Breast Reconstruction: A Prospective, Single-Blinded, Randomized, Controlled Trial.

BACKGROUND: Psychosocial distress, depression, or anxiety can occur in up to 50% of women after a breast cancer diagnosis and mastectomy. The purpose of this study was to assess the potential benefit of lavender oil as a perioperative adjunct to improve anxiety, depression, pain, and sleep in women undergoing microvascular breast reconstruction. METHODS: This was a prospective, single-blinded, randomized, controlled trial of 49 patients undergoing microvascular breast reconstruction. Patients were randomized to receive lavender oil or placebo (coconut oil) throughout their hospitalization. The effect of lavender oil on perioperative stress, anxiety, depression, sleep, and pain was measured using the hospital anxiety and depression scale, Richards-Campbell Sleep Questionnaire, and the visual analogue scale. RESULTS: Twenty-seven patients were assigned to the lavender group and 22 patients were assigned to the control group. No significant differences were seen in the perioperative setting between the groups with regard to anxiety (p = 0.82), depression (p = 0.21), sleep (p = 0.86), or pain (p = 0.30) scores. No adverse events (i.e., allergic reaction) were captured, and no significant differences in surgery-related complications were observed. When evaluating the entire cohort, postoperative anxiety scores were significantly lower than preoperative scores (p < 0.001), while depression scores were significantly higher postoperatively as compared with preoperatively (p = 0.005). CONCLUSION: In the setting of microvascular breast reconstruction, lavender oil and aromatherapy had no significant adverse events or complications; however, there were no measurable advantages pertaining to metrics of depression, anxiety, sleep, or pain as compared with the control group.

The Influence of Fat Grafting on Breast Imaging after Postmastectomy Reconstruction: A Matched Cohort Analysis.

BACKGROUND: Fat grafting to the reconstructed breast may result in the development of benign lesions on physical examination, prompting further investigation with imaging and biopsy. The aim of this study was to assess the influence of fat grafting on the incidence of imaging and biopsies after postmastectomy reconstruction. METHODS: Patients who underwent autologous or implant-based reconstruction following mastectomy from 2010 to 2018 were identified. Those receiving fat grafting as part of their reconstructive course were propensity matched 1:1 to those that did not with body mass index, reconstruction timing, and reconstruction type as covariates in a multivariable logistic regression model. RESULTS: A total of 186 patients were identified, yielding 93 propensity-matched pairs. Fat-grafted patients had higher incidences of palpable masses (38.0 percent versus 18.3 percent; p = 0.003) and postreconstruction imaging (47.3 percent versus 29.0 percent; p = 0.01), but no significant difference in the number of biopsies performed (11.8 percent versus 7.5 percent; p = 0.32). Imaging was predominately interpreted as normal (Breast Imaging-Reporting and Data System 1, 27.9 percent) or benign (Breast Imaging-Reporting and Data System 2, 48.8 percent), with fat necrosis being the most common finding [n = 20 (45.5 percent)]. No demographic, oncologic, reconstructive, or fat grafting-specific variables were predictive of receiving postreconstruction imaging on multivariate analysis. Fat grafting was not associated with decreased 5-year overall survival or locoregional recurrence-free survival. CONCLUSIONS: Fat grafting to the reconstructed breast is associated with increased incidences of palpable masses and subsequent postreconstruction imaging with benign radiographic findings. Although the procedure is oncologically safe, both patients and providers should be aware that concerning physical examination findings can be benign sequelae of fat grafting and may lead to increased imaging after breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

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.

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.