Transforming Perceptions: The Impact of a Formal Parental Leave Policy on Surgical Trainees.

OBJECTIVE: Surgical trainees who welcome a new child during residency often face challenges related to appropriate parental leave. To address this, we instituted a comprehensive family medical leave policy within our training program and assessed resident perceptions before and after the policy's introduction. We hypothesized that this new formal policy would enhance feelings of support amongst all (not just childbearing) trainees. DESIGN: A web-based survey to gauge resident perceptions on parental leave was distributed to all residents at a single academic general surgery residency at 2 intervals: prior to policy implementation and 1 year after policy implementation. SETTING: The study was conducted at a single institution, academic general surgery residency program. PARTICIPANTS: All general surgery residents at the institution were included (n = 95). RESULTS: About 40 out of 95 (42%) residents participated in the initial survey and 25 of 95 (26%) completed the subsequent survey. There was a significant improvement in resident reported satisfaction with the policy from pre to post: 15% pre to 68% post, p < 0.001, report the policy frequently supported trainees' needs, 20% pre to 88% post, p < 0.001, perceived the policy as fair. Most residents (90.0% pre and 80.0% post) perceived pregnancy as a risk during surgical training. There were no differences in perception of the new policy between residents who were parents and residents who were not parents. CONCLUSIONS: The introduction of a comprehensive family medical leave policy improved all surgical trainees' (including nonparents) perception of policy effectiveness and policy fairness. This is counter to the published perception that parental leave creates a burden on fellow trainees. However, pregnancy remains a stressor for the individual new parent. Surgical programs can develop supportive formal family medical leave policies; it is important to address the inherent systemic and cultural barriers surrounding childrearing during surgical training.

Preliminary Development of a Program ABSITE Dashboard (PAD) to Guide Curriculum Innovation.

PURPOSE: Medical Knowledge for general surgery residents' is assessed by the American Board of Surgery In- Training Examination (ABSITE). ASBITE score reports contain many metrics residency directors can utilize to assess resident progress and perform program evaluation. The purpose of this study was to develop a framework to evaluate program effectiveness in teaching specific subtest and subtopic areas of the ABSITE, using ABSITE score reports as an indicator. The aim is to demonstrate the identification of topic areas of weakness in program-wide performance on the ABSITE to guide proposed modification of the general surgery residency program curriculum, and to initiate development of a data visualizing dashboard to communicate these metrics. METHODS: A single institution retrospective study was performed utilizing ABSITE score reports from general surgery residents at a large academic training program from 2017 to 2020. ABSITE performance metrics from 320 unique records were entered into a database; statistical analysis for linear trends and variance were conducted for standard scores, subtest standard scores, and incorrect subtest topics. Deviation from national average scores were calculated by subtracting the national average score from each subtest score for each trainee. Data were displayed as medians or proportions and are displayed to optimize visualization as a proof-of-concept for the development of a program dashboard. RESULTS: Trends and variance in general surgery program and cohort performance on various elements of the ABSITE were visualized using figures and tables that represent a prototype for a program dashboard. Figure A1 demonstrates one example, in which a heatmap displays the median deviation from national average scores for each subtest by program year. Boxplots show the distribution of the deviation from national average, range for national average scores, and the recorded scores for each subtest by program year. Trends in median deviation from the national average scores are displayed for each program year paneled by subtest or for each exam year paneled by cohort. Median change in overall test scores from one program year to another in a cohort is visualized as a table. Bar graphs show the most often missed topics across all program years and heatmaps were generated showing the proportion of times each topic was missed for each subtest and exam year. CONCLUSIONS: We demonstrate use of ABSITE reports to identify specific thematic areas of opportunities for curriculum modification and innovation as an element of program evaluation. In this study we demonstrate, through data analysis and visualization, feasibility for the creation of a Program ABSITE Dashboard (PAD) that enhances the use of ABSITE reports for formative program evaluation and can guide modifications to surgery program curriculum and educational practices.

Barriers and facilitators to measuring patient reported outcomes in an academic breast cancer clinic: An application of the RE-AIM framework.

BACKGROUND: Patient reported outcome measures (PROMs) are important for patient-centered, value-based care; however, implementation into surgical practice remains limited. We aimed to demonstrate feasibility of measuring PROMs in an academic breast cancer clinic. METHODS: We conducted a pilot study implementing the patient-reported outcome measure BREAST-Q among patients with Stage 0-III breast cancer at a single institution from 06/2019-03/2023 using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Barriers and facilitators were characterized. Survey completion was assessed pre-operatively and up to 12 months post-operatively. RESULTS: Barriers included limited time and lack of incorporation into the electronic medical record. Facilitators included utilizing trained team members and an automated workflow. Among eligible patients, 74% completed BREAST-Q at 2-weeks post-operatively and 55% at 12 months post-operatively. CONCLUSIONS: We describe the implementation of a PROM using the RE-AIM framework, highlighting facilitators and barriers that may assist others in collecting patient-reported outcome data.

Are Diagnostic Delays Associated with Distress in Breast Cancer Patients?

Introduction: Receiving a new breast cancer diagnosis can cause anxiety and distress, which can lead to psychologic morbidity, decreased treatment adherence, and worse clinical outcomes. Understanding sources of distress is crucial in providing comprehensive care. This study aims to evaluate the relationship between delays in breast cancer diagnosis and patient-reported distress. Secondary outcomes include assessing patient characteristics associated with delay. Methods: Newly diagnosed breast cancer patients who completed a distress screening tool at their initial evaluation at an academic institution between 2014 and 2019 were retrospectively evaluated. The tool captured distress levels in the emotional, social, health, and practical domains with scores of "high distress" defined by current clinical practice guidelines. Delay from mammogram to biopsy, whether diagnostic or screening mammogram, was defined as >30 days. Result: 745 newly diagnosed breast cancer patients met inclusion criteria. Median time from abnormal mammogram to core biopsy was 12 days, and 11% of patients experienced a delay in diagnosis. The non-delayed group had higher emotional (p = 0.04) and health (p = 0.03) distress than the delayed group. No statistically significant differences in social distress were found between groups. Additionally, patients with higher practical distress had longer time interval between mammogram and surgical intervention compared to those with lower practical distress. Older age, diagnoses of invasive lobular carcinoma or ductal carcinoma in situ, and clinical anatomic stages 0-I were associated with diagnostic delay. Conclusion: Patients with higher emotional or health-related distress were more likely to have timely diagnoses of breast cancer, suggesting that patients with higher distress may seek healthcare interventions more promptly. Improved understanding of sources of distress will permit early intervention regarding the devastating impact of breast cancer diagnosis.

Gestating Healthy Policies for Young Parents.

This Viewpoint discusses the need for modernized national and program-level policies that foster a culture to support early-career physicians balancing their professional growth and personal family desires.

Implementation of a Holistic Review Process of US Allopathic Medical Students Eliminates Non-Comparable Metrics and Bias in General Surgery Residency Interview Invitations.

OBJECTIVE: Use of traditional scoring metrics for residency recruitment creates racial and gender bias. In addition, widespread use of pass/fail grading has led to noncomparable data. To adjust to these challenges, we developed a holistic review (HR) rubric for scoring residency applicants for interview selection. DESIGN: Single-center observational study comparing the proportion of underrepresented in medicine (URM) students and their United States Medical Licensing Exam (USMLE) scores who were invited for interview before (2015-2020) and after (2022) implementation of a holistic review process. SETTING: General surgery residency program at a tertiary academic center. PARTICIPANTS: US allopathic medical students applying for general surgery residency. RESULTS: After initial screening, a total of 1514 allopathic applicants were narrowed down to 586 (38.7%) for HR. A total of 52% were female and 17% identified as URM. Based on HR score, 20% (118/586) of applicants were invited for an interview. The median HR score was 11 (range 4-19). There was a fourfold higher coefficient of variation of HR scores (22.3; 95% CI 21.0-23.7) compared to USMLE scores (5.1; 95% Cl 4.8-5.3), resulting in greater spread and distinction among applicants. There were no significant differences in HR scores between genders (p = 0.60) or URM vs non-URM (p = 0.08). There were no significant differences in Step 1 (p = 0.60) and 2CK (p = 0.30) scores between those who were invited to interview or not. On multivariable analysis, USMLE scores (OR 1.01; 95% CI 0.98-1.03), URM status (OR 1.71 95% CI 0.98-2.92), and gender (OR 0.94, 95% CI 0.60-1.45) did not predict interview selection (all p > 0.05). There was a meaningful increase in the percentage of URM interviewed after HR implementation (12.9% vs 23.1%, p = 0.016). CONCLUSION: The holistic review process is feasible and eliminates the use of noncomparable metrics for surgical applicant interview invitations and increases the percentage of URM applicants invited to interview.

De-implementation of Axillary Dissection in Women Undergoing Mastectomy for Breast Cancer.

BACKGROUND: Completion axillary lymph node dissection (cALND) was standard treatment for breast cancer with positive sentinel lymph nodes (SLNs) until 2011, when data from the Z11 and AMAROS trials challenged its survival benefit in early stage breast cancer. We assessed the contribution of patient, tumor, and facility factors on cALND use in patients undergoing mastectomy and SLN biopsy. PATIENTS AND METHODS: Using the National Cancer Database, patients diagnosed from 2012 to 2017 who underwent upfront mastectomy and SLN biopsy with at least one positive SLN were included. A multivariable mixed effects logistic regression model was used to determine the effect of patient, tumor, and facility variables on cALND use. Reference effect measures (REM) were used to compare the contribution of general contextual effects (GCE) to variation in cALND use. RESULTS: From 2012 to 2017, the overall use of cALND decreased from 81.3% to 68.0%. Overall, younger patients, larger tumors, higher grade tumors, and tumors with lymphovascular invasion were more likely to undergo cALND. Facility variables, including higher surgical volume and facility location in the Midwest, were associated with increased use of cALND. However, REM results showed that the contribution of GCE to the variation in cALND use exceeded that of the measured patient, tumor, facility, and time variables. CONCLUSIONS: There was a decrease in cALND use during the study period. However, cALND was frequently performed in women after mastectomy found to have a positive SLN. There is high variability in cALND use, mainly driven by interfacility practice variation rather than specific high-risk patient and/or tumor characteristics.

Clinical implications of receptor conversions in breast cancer patients who have undergone neoadjuvant chemotherapy.

PURPOSE: In this study, we aimed to determine the incidence of receptor conversions after neoadjuvant chemotherapy (NAC) for breast cancer and assess the rate at which receptor conversion leads to changes in adjuvant therapy regimens. METHODS: We performed a retrospective review of female breast cancer patients treated with NAC at an academic breast center between January 2017 and October 2021. Patients with residual disease on surgical pathology and complete receptor status information for both pre-NAC and post-NAC specimens were included. Incidence of receptor conversions, defined as a change in at least one hormone receptor (HR) or HER2 status compared to preoperative specimens, was tabulated, and adjuvant therapy modalities were reviewed. Factors associated with receptor conversion were analyzed using chi-square tests and a binary logistic regression. RESULTS: Of the 240 patients with residual disease after NAC, 126 (52.5%) had receptor testing repeated. After NAC, 37 specimens (29%) had a receptor conversion. Receptor conversion resulted in the addition or removal of an adjuvant therapy in 8 patients (6%), indicating a number needed to screen of 16. Prior history of cancer, receipt of initial biopsy at an outside site, HR-positive tumors, and a pathologic stage of II or lower were factors associated with receptor conversions. CONCLUSION: HR and HER2 expression profiles frequently change after NAC and drive adjustments in adjuvant therapy regimens. Repeat testing of HR and HER2 expression should be considered in patients who receive NAC, especially in patients with early stage, HR-positive tumors whose initial biopsies were performed externally.

Proactive Coaching in General Surgery Internship: Incorporating Well-being Practices into Resident Professional Life.

OBJECTIVE: Coaching can provide learners with space to reflect on their performance while ensuring well-being and encouraging professional achievement and personal satisfaction outside of traditional mentorship and teaching models. We hypothesized that a proactive coaching program for general surgery interns coupled with individualized learning plans would help build foundational skills necessary for residency success and facilitate the incorporation of well-being practices into resident professional life. Here, we present the development, implementation, and outcomes of a novel well-being coaching program for surgical interns. DESIGN AND SETTING: A well-being coaching program was developed and implemented from July 2020 through June 2021 at a single university-based surgical residency program. To assess impact of the coaching program, we designed a mixed-methods study incorporating end-of-program survey results as well as participant narratives from commitment-to-act statements for thematic content. PARTICIPANTS: All 32 general surgery interns participated in aspects of the coaching program. RESULTS: The end-of-program survey was completed by 19/32 (59%) interns and commitment-to-act statements were completed by 22/32 (69%). The majority (89%) of survey respondents "agreed" or "strongly agreed" that the longitudinal intern coaching program helped them reach goals they had set for themselves this academic year; 15/19 (79%) noted that the coaching experience was effective in promoting well-being practices in their life. Well-being and professional goals were identified as major themes in the end-of-the-year commitment-to-act statements. Statements specifically mentioned resources highlighted and skills taught in our coaching program such as mindfulness techniques, gratitude journals, and self-compassion strategies. CONCLUSIONS: Our study illustrates the effectiveness of a coaching pilot program on promoting well-being practices in a university-based general surgery internship and can be a roadmap with proven efficacy and measurable outcomes.

Addressing an epidemic: Improving guideline-concordant opioid prescribing in surgical patients.

BACKGROUND: Excess postoperative opioid prescribing increases the risk of opioid abuse, diversion, and addiction. Clinicians receive variable training for opioid prescribing, and despite the availability of guidelines, wide variations in prescribing practices persist. This quality improvement initiative aimed to assess and improve institutional adherence to published guidelines. METHODS: This study represented a quality improvement initiative at an academic medical center implemented over a 6-month period with data captured 1 year before and after implementation. The quality improvement initiative focused on prescribing education and monthly feedback reports for clinicians. All opioid-naïve, adult patients undergoing a reviewed procedure were included. Demographics, surgical details, hospital course, and opioid prescriptions were reviewed. Opioids prescribed on discharge were evaluated for concordance with recommendations based on published guidelines. Pre- and postimplementation cohorts were compared. RESULTS: There were 4,905 patients included: 2,343 preimplementation and 2,562 postimplementation. There were similar distributions in patient demographics between the 2 cohorts. Guideline-concordant discharge prescriptions improved from 50.3% to 72.2% after the quality improvement initiative was implemented (P < .001). Adjusted analysis controlling for sex, age, discharge clinician, length of stay, outpatient surgery, and procedure demonstrated a 190% increase in odds of receiving a guideline-concordant opioid prescription on discharge in the postimplementation cohort (adjusted odds ratio 2.90; 95% confidence interval = 2.55-3.30). CONCLUSION: This study represented a successful quality improvement initiative improving guideline-concordant opioid discharges and decreasing overprescribing. This study suggested published guidelines are insufficient without close attention to elements of effective change management including the critical importance of locally targeting educational efforts and suggested that real-time, data-driven feedback amplifies impact on prescribing behavior.

De-implementation of Axillary Dissection in Women With Breast Cancer is Largely Driven By Site-level Contextual Effects.

OBJECTIVE: To assess the contribution of unknown institutional factors (contextual effects) in the de-implementation of cALND in women with breast cancer. SUMMARY OF BACKGROUND DATA: Women included in the National Cancer Database with invasive breast carcinoma from 2012 to 2016 that underwent upfront lumpectomy and were found to have a positive sentinel node. METHODS: A multivariable mixed effects logistic regression model with a random intercept for site was used to determine the effect of patient, tumor, and institutional variables on the risk of cALND. Reference effect measureswere used to describe and compare the contribution of contextual effects to the variation in cALND use to that of measured variables. RESULTS: By 2016, cALND was still performed in at least 50% of the patients in a quarter of the institutions. Black race, younger women and those with larger or hormone negative tumors were more likely to undergo cALND. However, the width of the 90% reference effect measures range for the contextual effects exceeded that of the measured site, tumor, time, and patient demographics, suggesting institutional contextual effects were the major drivers of cALND de-implementation. For instance, a woman at an institution with low-risk of performing cALND would have 74% reduced odds of havinga cALND than if she was treated at a median-risk institution, while a patient at a high-risk institution had 3.91 times the odds. CONCLUSION: Compared to known patient, tumor, and institutional factors, contextual effects had a higher contribution to the variation in cALND use.

Patient Perceptions of Changes in Breast Cancer Care and Well-Being During COVID-19: A Mixed Methods Study.

BACKGROUND: Widespread healthcare restructuring due to the COVID-19 pandemic led to modifications in the timing and delivery of care for breast cancer patients. Our study explores patient concerns relating to COVID-19, breast cancer, and changes to breast cancer care. PATIENTS AND METHODS: Breast cancer patients who presented for surgical consultation at an academic, multidisciplinary clinic completed the electronically distributed validated COVID-19 Impact and Healthcare Related Quality of Life questionnaire between August 2020 and February 2021. This questionnaire uses Likert score responses to assess COVID-specific concerns within domains, including distress and financial hardship. Scale scores were determined by averaging items within each domain, and scores > 2 indicated greater disruption. Semistructured interviews were conducted with patients who indicated interest in participating in the questionnaire. RESULTS: Of 381 patients recruited, 133 patients completed the questionnaire and 20 patients completed interviews. Sixty-three percent of survey participants reported attending a telemedicine appointment for their cancer care, and the majority (67%) were satisfied with their experience. Half of the participants (50%) reported fear about how the COVID-19 pandemic will impact their cancer care or recovery, and 66% reported anxiety about contracting COVID-19. Twenty-two percent of participants reported decreased income due to COVID-19. Patient interviews revealed tangible changes to care and provided in-depth information on the advantages and disadvantages of telehealth. CONCLUSIONS: Breast cancer patients report anxiety about COVID-19 infection and potential care modifications. Our study identifies impacts on patients' care and quality of life. Further investigation will inform interventions to improve psychosocial outcomes for patients and the telehealth experience.

Development of a Surgical Research Program for Medical Students and its Short-Term Impact on Academic Productivity.

OBJECTIVE: To describe the development and implementation of a mentored surgical research program for medical students and its short-term impact on academic productivity. DESIGN: Description of an educational research program. SETTING: University of Colorado School of Medicine. PARTICIPANTS: Rising second-year medical students. METHODS: We piloted an 8-week mentored surgical research program with an interactive curriculum that included lectures on fundamental research skills and conferences for early clinical exposure. Each student was paired with a faculty mentor and research project and provided weekly updates at faculty led work-in-progress meetings. Students who completed the program were provided with an end-of-program evaluation of their own learning. Follow-up at 3-months and 6-months post-program completion assessed continued research engagement and productivity. RESULTS: Thirteen 1st year medical students completed the pilot program. Eleven (85%) students completed the end-of-program evaluation. All students felt the program was valuable to their future and helped develop their ability to investigate and solve new research questions. All students felt confident or very confident that they had the knowledge and resources to write and submit an abstract to a national meeting, and 10 (91%) felt similarly about writing a manuscript in the future. On 3-month follow-up, 11 (85%) of the 13 students were still engaged with their research labs; six (46%) had submitted an abstract to a national meeting, 3 (23%) of which were accepted for oral presentation. Two (15%) were in the process of drafting a manuscript; none had yet submitted one. At 6-month follow-up, 2 additional students had abstracts accepted for oral presentation. One student had submitted a manuscript, and 3 were in the process of drafting one. CONCLUSIONS: Integrating research early into the medical school curriculum helps equip students with the fundamental skills needed for early academic achievement and may help establish success in academic careers.

Early Trajectories of Patient Reported Outcomes in Breast Cancer Patients Undergoing Lumpectomy Versus Mastectomy.

PURPOSE: This study was designed to: (1) characterize longitudinal patient-reported outcomes (PROs) between breast cancer patients undergoing lumpectomy and mastectomy and (2) compare return to baseline scores at 3 months and 6 months postoperatively. METHODS: Newly diagnosed breast cancer patients seen at an academic breast center between June 2019 and February 2021 were invited to participate in longitudinal PRO surveys at their initial clinic visit. If willing to participate, patients were emailed the validated BREAST-Q™ questionnaire at the initial clinic visit (baseline), 2 weeks after surgery, and then every 3 months for the first year. We used linear mixed models to estimate the differences in slopes over time between lumpectomy and mastectomy for each PRO measure. Pearson's Chi-square tests with Yates' continuity correction were used to compare proportions of patients who return to baseline PRO scores. P < 0.05 was considered significant. RESULTS: Of 164 patients invited to participate, 100 (61%) completed a baseline survey and were included in analyses. Mastectomy patients had significantly greater decreases in breast satisfaction (P = 0.002), psychosocial well-being (P < 0.0001), and sexual well-being (P < 0.0001) over time compared with lumpectomy patients. Both surgical groups reported a decrease in physical well-being, although the decline was more significant in lumpectomy patients (P = 0.005). At 3 months and 6 months after surgery, significantly larger proportions of lumpectomy patients returned to their baseline breast satisfaction, psychosocial well-being, and physical well-being compared with mastectomy patients. CONCLUSIONS: Understanding how outcomes important to patients change over the care continuum can provide opportunities for early intervention and may prevent debilitating long-term morbidities of treatment.

Evaluation of opioid prescribing preferences among surgical residents and faculty.

BACKGROUND: Residents report that faculty preference is a significant driver of opioid prescribing practices. This study compared opioid prescribing preferences of surgical residents and faculty against published guidelines and actual practice and assessed perceptions in communication and transparency around these practices. METHODS: Surgical residents and faculty were surveyed to evaluate the number of oxycodone tablets prescribed for common procedures. Quantities were compared between residents, faculty, Opioid Prescribing Engagement Network guidelines, and actual opioids prescribed. Frequency with which faculty communicate prescribing preferences and the desire for feedback and transparency in prescription practices were assessed. RESULTS: Fifty-six (72%) residents and 57 (59%) faculty completed the survey. Overall, faculty preferred a median number of tablets greater than recommended by Opioid Prescribing Engagement Network in 5 procedures, while residents did so in 9 of 14 procedures. On average, across all operations, faculty reported prescribing practices compliant with Opioid Prescribing Engagement Network 56.1% of the time, whereas residents did so 47.6% of the time (P = .40). Interestingly, opioids actually prescribed were significantly less than recommended in 7 procedures. Among faculty, 62% reported often or always specifying prescription preferences to residents, while only 9% of residents noted that faculty often did so. Residents (80%) and faculty (75%) were amenable to seeing regular reports of personal opioid prescription practices, and 74% and 65% were amenable to seeing practices compared with peers. Only 34% of residents and 44% of faculty wanted prescription practices made public. CONCLUSION: There is a disconnect between opioid prescribing preferences and practice among surgical residents and faculty. Increased transparency through individualized reports and education regarding Opioid Prescribing Engagement Network guidelines with incorporation into the electronic medical record as practice advisories may reduce prescription variability.

Resident Opioid Prescribing Habits Do Not Reflect Best Practices in Post-Operative Pain Management: An Assessment of the Knowledge and Education Gap.

OBJECTIVE: To evaluate deficiencies in knowledge and education in opioid prescribing and to compare surgical resident opioid-prescribing practices to Opioid Prescribing Engagement Network (OPEN) procedure-specific guidelines. DESIGN: Anonymous web-based survey distributed to all general surgery residents to evaluate prior education received and confidence in knowledge in opioid prescribing. The number of 5 milligram oxycodone tablets prescribed for common procedures was assessed and compared with OPEN for significance using Wilcoxon signed rank tests. SETTING: General surgery residency program within large university-based tertiary medical center. PARTICIPANTS: Categorical general surgery residents of all postgraduate years. RESULTS: Fifty-six of 72 (78%) categorical residents completed the survey. Few reported receiving formal education in opioid prescribing in medical school (32%) or residency (16%). While 82% of residents felt confident in opioid side effects, fewer felt the same with regards to opioid pharmacokinetics (36%) or proper opioid disposal (29%). Opioids prescribed varied widely with residents prescribing significantly more than recommended by OPEN in 9 of 14 procedures. CONCLUSIONS: Tackling the evolving opioid epidemic requires a multidisciplinary approach that addresses prescribing at all steps of the process, starting with trainee education.

Biopsy Results Are Not Sufficient to Exclude Breast Implant-associated Anaplastic Large Cell Lymphoma: A Case Mistaken for Disseminated Silicosis.

We present a case report of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) that was mistaken as disseminated silicosis after multiple percutaneous biopsies. The correct diagnosis of BIA-ALCL was confirmed only after a pathologic examination of the capsulectomy specimens. A review of the literature of percutaneous biopsies of ALCL showed a diagnostic yield of only 63%. Although percutaneous biopsies may be facile to obtain and may be diagnostic, in our case, biopsies were not sufficient to exclude the diagnosis of BIA-ALCL.

Atypical ductal hyperplasia bordering on DCIS on core biopsy is associated with higher risk of upgrade than conventional atypical ductal hyperplasia.

PURPOSE: Upgrade rates of conventional ADH are reported at 10-30%; however, rates for ADH bordering on DCIS (ADH-BD) are largely unknown. We examined the upgrade rate of ADH-BD and core needle biopsy (CNB) features associated with upgrade. Surgical management in patients with concurrent ipsilateral breast cancer (BC) was also examined. METHODS: From 2000 to 2018, women with CNB diagnosis of ADH-BD were prospectively identified. Women with pure ADH-BD and concurrent ipsilateral ADH-BD/BC were analyzed separately, and upgrade rates were calculated. CNB features associated with upgrade and type of surgery were examined in women with pure ADH-BD; CNB features and concurrent pathology associated with upgrade were examined in women with ipsilateral BC. RESULTS: 108/236 (46%) patients with pure ADH-BD on CNB had DCIS (40%) or invasive carcinoma (6%) on surgical excision. DCIS or invasive carcinoma was more frequently found on excision of a mass that yielded ADH-BD on biopsy than excision of calcifications (65% vs 38%; p < 0.001). The breast conservation success rate was high (80%) in patients who upgraded, despite a high re-excision rate of 46%. The upgrade rate of ADH-BD in women with concurrent ipsilateral BC was 41%. Most women (94%) with ADH-BD in the same quadrant as the BC were candidates for breast conserving surgery, with a success rate of 89%. CONCLUSION: The upgrade rate for pure ADH-BD is significantly higher than that reported for women with conventional ADH, especially in women with a mass on imaging. The upgrade rate of concurrent ipsilateral ADH-BD and BC is similarly high. Excision with a margin of normal tissue and specimen inking should be routine to minimize the need for re-excision.