Primary Care Physicians' Perspectives in Leading Breast Cancer Follow-Up Care.

INTRODUCTION: Limited data exist on the barriers associated with transitioning breast cancer follow-up care to primary care physicians (PCPs). This study aimed to describe the current perspectives of PCPs in managing breast cancer follow-up. METHOD: An online survey was distributed to PCPs in Toronto, ON, Canada. Questions examined PCPs' view of transitioning breast cancer follow-up care to their practices. RESULTS: Of 800 PCPs invited, 126 responded (response rate: 15.7%). The types of practice models amongst respondents included blended capitation (42.9%), blended salary (27%), and fee-for-service (17.5%). Seventy-seven percent of respondents stated they provided follow-up care. Approximately half of the respondents stated they were somewhat comfortable providing follow-up care. PCP-led follow-up care was considered either very (49.2%) or somewhat appropriate (30.2%). When asked about financial remuneration, 43.7% of respondents stated it was somewhat important. The factors that influenced the feasibility of PCP-led follow-up care included receipt of a detailed follow-up care plan provided by the specialist after discharge (81%), the ability to re-refer to specialists rapidly (56.3%), and the ability to obtain regular updates of best practice changes (59.5%). The preferred means of educational updates included E-mail (40.5%), continuing medical education events (30.2%), and electronic medical records (19.8%). When the fee model was taken into consideration there was no significant difference in opinions regarding follow-up care. CONCLUSIONS: Transitioning to a PCP-led model was supported by most of the PCPs who participated in this study. Their perspective on PCP-led follow up care and barriers associated with implementation of this model of care needs to be further explored with future studies that include larger sample size and a more diverse PCP population.

Assessing the effect of a hands-on oncoplastic surgery training course: A survey of Canadian surgeons.

BACKGROUND: The adoption of oncoplastic surgery in North America is poor despite evidence supporting the benefits. Surgeons take courses to acquire oncoplastic techniques, however, the effect of these courses is unknown. This study aimed to assess the impact of a hands-on oncoplastic course on surgeons' comfort with oncoplastic techniques and rate of adoption of these techniques in their practice. MATERIAL AND METHODS: An online 10-question survey was developed and distributed to surgeons who had participated in a hands-on oncoplastic course offered in Ontario, Canada. Categorical data were reported using frequencies and percentages. RESULTS: A total of 105 surveys were sent out of which 69 attending surgeons responded (response rate: 65.7%). All respondents stated cosmesis was of the utmost importance in breast conserving surgery. The most common oncoplastic techniques they currently use included glandular re-approximation (98.4%), undermining of skin (93.6%), undermining of the nipple areolar complex (63.4%), and de-epithelialization and repositioning of the nipple areola complex (49.2%). Only 26% of respondnets stated they used more advanced techniques such as mammoplasty. Sixty percent of surgeons reported they used oncoplastic techniques in at least half of their cases. Ninety-two percent of respondents stated that the hands-on course increased the amount of oncoplastic techniques in their practice. At least 70% of respondents stated they would do another hands-on course. The main factor that facilitated the uptake of oncoplastic techniques was a better understanding of surgical techniques and planning. CONCLUSION: A hands-on oncoplastic course helps surgeons adopt oncoplastic surgery techniques into their clinical practice. This teaching model allows surgeons to become comfortable with a variety of techniques. This study supports the relevance of a hands-on oncoplastic course to enhance the availability of safe oncoplastic surgery for breast cancer patients.

Comparison of Radioactive Seed Localized Excision and Wire Localized Excision of Breast Lesions: A Community Hospital's Experience.

BACKGROUND: Most data comparing wire localized excision (WLE) and radioactive seed localized excision (RSLE) derive from academic institutions with limited data from community hospitals. This study aimed to compare positive margin rates between WLE and RSLE and to determine if there were any differences in specimen volume and operation time. PATIENTS AND METHODS: A retrospective cohort study was conducted on patients who underwent WLE or RSLE at a Canadian community hospital. Group characteristics were compared as appropriate. Multivariable logistic regression was used determine if the localization techniques were independently associated with having a positive margin. Statistical significance was set as P < .05. RESULTS: The cohort consisted of 747 (WLE) and 577 (RSLE) patients. Both groups had similar mean age, mean tumor (invasive and ductal carcinoma-in-situ) size, histologic grade distribution, presence of lymphovascular invasion, and extensive intraductal component, nodal status, and hormone receptor and HER2 status. Compared to WLE, patients who underwent RSLE had significantly lower invasive positive margin rates (8.1% vs. 12.3%, P = .03), shorter operation time (39.5 minutes vs. 68.7 minutes, P = .0001), and smaller surgical specimens (21.4 cm³ vs. 30.2 cm³, P = .008). Ductal carcinoma-in-situ positive margin rates were not different between the groups. However, the localization technique was not independently associated with having a positive margin (odds ratio = 1.55; 95% confidence interval, 0.99-2.44). CONCLUSION: RSLE led to a shorter operation time and smaller surgical specimens compared to WLE, but there was no difference in positive margin rates. RSLE is an effective technique to excise nonpalpable breast lesions in the community setting.

Breast reconstruction: Updated overview for primary care physicians.

OBJECTIVE: To offer primary care providers a comprehensive summary of breast reconstruction options and complications. QUALITY OF EVIDENCE: A literature search was conducted in PubMed with no time restriction using the search terms breast reconstruction, summary, review, complications, and options. Levels of evidence range from I to III. MAIN MESSAGE: As breast cancer survival rates increase, the focus of breast cancer management must shift to include the restoration of a patient's quality of life after cancer. Breast reconstruction plays a crucial role in the restoration of normality for these women. Women who undergo mastectomy often suffer from challenges related to body image, self-esteem, and a decrease in quality of life scores. Cancer Care Ontario's Breast Cancer Treatment Pathway Map mandates that all women diagnosed with breast cancer who might require mastectomy be referred to a plastic surgeon to discuss reconstructive options before surgery. CONCLUSION: The knowledge and guidance of primary care providers is critical to effectively guiding and supporting patients who might undergo breast reconstruction in their decision-making processes. A thorough understanding of patient selection factors, modern options for breast reconstruction, and expected outcomes is essential.

Reconstruction mammaire: Aperçu actualisé à l'intention des médecins de soins primaires.

OBJECTIF: Présenter aux prestataires de soins primaires un résumé complet des options en matière de reconstruction mammaire et de leurs complications. SOURCES DE L'INFORMATION: Une recherche documentaire a été effectuée dans PubMed, sans restrictions relatives à la date de publication, à l'aide des expressions de recherche en anglais breast reconstruction, summary, review, complications et options. Les niveaux des données probantes varient de I à III. MESSAGE PRINCIPAL: Étant donné la hausse des taux de survie au cancer du sein, la prise en charge doit changer de cap pour inclure aussi la restauration de la qualité de vie de la patiente après le cancer. La reconstruction mammaire joue un rôle majeur pour un retour à la normale chez ces femmes. Les femmes qui subissent une mastectomie éprouvent souvent des difficultés quant à leur image corporelle et à leur estime de soi, et elles évaluent leur qualité de vie à la baisse. La carte des voies pathologiques d'Action Cancer Ontario préconise que toutes les femmes ayant reçu un diagnostic de cancer du sein qui pourraient avoir besoin d'une mastectomie soient envoyées en consultation en chirurgie plastique pour discuter des options de reconstruction avant l'opération. CONCLUSION: Les connaissances et les conseils des médecins de soins primaires sont essentiels pour bien orienter et appuyer les patientes dans leur processus décisionnel quant à la reconstruction mammaire. Il est nécessaire de bien comprendre les facteurs de sélection des patientes, les options contemporaines de reconstruction mammaire et les résultats attendus.

Current Practices and Barriers to the Integration of Oncoplastic Breast Surgery: A Canadian Perspective.

BACKGROUND: Despite the safety and popularity of oncoplastic surgery, there is limited data examining utilization and barriers associated with its incorporation into practice. This study examines the use of oncoplastic techniques in breast conserving surgery and determines the barriers associated with their implementation. METHODS: A 13-item survey was mailed to all registered general surgeons in Ontario, Canada. The survey assessed surgeon demographics, utilization of specific oncoplastic techniques, and perceived barriers. RESULTS: A total of 234 survey responses were received, representing a response rate of 32.2 % (234 of 725). Of the respondents, 166 surgeons (70.9 %) reported a practice volume of at least 25 % breast surgery. Comparison was made between general surgeons performing oncoplastic breast surgery (N = 79) and those who did not use these techniques (N = 87). Surgeon gender, years in practice, fellowship training, and access to plastic surgery were similar across groups. Both groups rated the importance of breast cosmesis similarly. General surgeons with a practice volume involving >50 % breast surgery were more likely to use oncoplastic techniques (OR 8.82, p < .001) and involve plastic surgeons in breast conserving surgery (OR 2.21, p = .02). For surgeons not performing oncoplastic surgery, a lack of training and access to plastic surgeons were identified as significant barriers. For those using oncoplastic techniques, the absence of specific billing codes was identified as a limiting factor. CONCLUSIONS: Lack of training, access to plastic surgeons, and absence of appropriate reimbursement for these cases are significant barriers to the adoption of oncoplastic techniques.

Postmastectomy radiation and recurrence patterns in breast cancer patients younger than age 35 years: a population-based cohort.

BACKGROUND: The utility of post mastectomy radiotherapy in very young women is understudied. The objective of this study was to evaluate the use of PMRT in very young women to determine the effect on recurrence and survival. METHODS: All women aged ≤35 years diagnosed with invasive breast cancer from 1994 to 2003 were identified from the Ontario Cancer Registry. Patient, tumour, treatment and outcome data were abstracted from primary chart review. Local or regional recurrence was the primary endpoint with contralateral, distant recurrence/death treated as competing risks. Propensity score methods were incorporated into multivariable Cox proportional hazards models to evaluate the effect of radiation therapy on the time to local/regional, distant recurrence or death. RESULTS: 588 patients were identified during the study period, of which 382 were eligible for analysis. Overall, 182 (48%) of patients sustained a recurrence after a median follow-up of 2.72 years. The use of PMRT significantly reduced locoregional recurrence (HR 0.54, 95% CI 0.29-0.996) compared with those who did not receive PMRT. There was no significant effect of PMRT on contralateral, distant recurrences, or death without recurrence (HR 0.98, 95% CI 0.66-1.47). Of the patients with known node status (N = 451), isolated local recurrence occurred in 5, 2.5, and 8.5% in patients with N0, N1-3, and N4 positive nodes respectively. CONCLUSIONS: We have found a significant reduction in locoregional recurrence with PMRT but no survival benefit in very young women with breast cancer.

Increased postoperative complications in bilateral mastectomy patients compared to unilateral mastectomy: an analysis of the NSQIP database.

BACKGROUND: Recent studies indicate that women with unilateral breast cancer are choosing contralateral prophylactic mastectomy (CPM) at an increasing rate. There is limited literature evaluating the postoperative complication rates associated with CPM without breast reconstruction. The objective of this study was to compare postoperative complications in women undergoing unilateral mastectomy (UM) and sentinel lymph node biopsy (SLNB) to those undergoing bilateral mastectomy (BM) and SLNB for the treatment of their breast cancer. METHODS: The American College of Surgeons National Surgery Quality Improvement Program (ACS NSQIP) Participant Use Files between 2007 and 2010 were used to identify women with breast cancer undergoing UM or BM with SLNB. Individual and composite end points of 30-day complications were used to compare both groups by univariate and multivariate analyses. RESULTS: We identified 4,219 breast cancer patients who had a SLNB: 3,722 (88.2 %) had UM and 497 (11.8 %) had BM. The wound complication rate was significantly higher in the BM group versus the UM group, 5.8 % versus 2.9 % [unadjusted odds ratio (OR) 2.1, 95 % confidence interval (CI) 1.3-3.3, P < 0.01]. The overall 30-day complication rate in UM patients was 4.2 % versus 7.6 % in the BM group (unadjusted OR 1.9, 95 % CI 1.3-2.7, P < 0.01). The adjusted OR for overall complications adjusting for important patient characteristics was 1.9 (95 % CI 1.3-2.8, P < 0.01). Independent predictors of overall postoperative complications were body mass index (OR 1.1, P < 0.01) and smoking (OR 2.2, P < 0.01). CONCLUSIONS: For patients with breast cancer, bilateral mastectomy is associated with an increased risk of wound and overall postoperative complications. Discussion of these outcomes is imperative when counseling women contemplating CPM.

Development of a standardized definition for Hirschsprung's-associated enterocolitis: a Delphi analysis.

PURPOSE: The reported incidence of Hirschsprung's-associated enterocolitis (HAEC) is extremely variable. A standardized definition would permit comparison of different studies and provide an interpretable outcome measure for future prospective studies in patients with Hirschsprung's disease. METHODS: The Delphi method is a technique for achieving consensus among a panel of experts. A list of 38 potential criteria from the history, physical examination, radiologic studies, and pathologic specimens was made available to pediatric surgeons and gastroenterologists who have contributed to the literature on Hirschsprung's disease. Each expert ranked the diagnostic importance of each item using a Likert scale. In subsequent surveys, the same process was used, but the means and SDs from previous rounds were included as a way of influencing the experts toward consensus. Cronbach's alpha was used after each round to measure variability among the experts. Once consensus was reached, an overall "HAEC score" was developed by assigning a value of 1 or 2 to each item that was considered important by the expert panel. The score was then validated by circulating 10 clinical cases to the panel and asking if each represented HAEC or not. RESULTS: Twenty-seven experts completed the survey. Cronbach's alpha increased from 0.93 after the first round to 0.97 after the second. Criteria receiving the highest scores were diarrhea, explosive stools, abdominal distension, and radiologic evidence of bowel obstruction or mucosal edema. Eighteen items were included in the score. During the validation process, the score agreed with the experts in 9 of the 10 case scenarios. CONCLUSION: The most important clinical diagnostic criteria for HAEC were identified from a larger pool of potential diagnostic items through a consensus approach using the Delphi method. A score was developed and validated and can now be used as a standardized and reproducible outcome measure for future studies in children with Hirschsprung's disease.

Recombinant activated coagulation factor VII and bleeding trauma patients.

BACKGROUND: Recombinant activated coagulation factor VII (rFVIIa) is increasingly being administered to massively bleeding trauma patients. rFVIIa has been shown to correct coagulopathy and to decrease transfusion requirements. However, there is no conclusive evidence to suggest that rFVIIa improves the survival of these patients. The purpose of this study was to determine whether or not rFVIIa has an effect on the in-hospital survival of massively bleeding trauma patients. METHODS: A retrospective cohort study was conducted from January 1, 2000 to January 31, 2005, at a Level I trauma center in Toronto, Canada. Inclusion criteria included trauma patients requiring transfusion of 8 or more units of packed red cells within the first 12 hours of admission. The primary exposure of interest was the administration of rFVIIa. Primary outcome was a 24-hour survival and secondary outcome was overall in-hospital survival. RESULTS: There were 242 trauma patients identified who met inclusion criteria; 38 received rFVIIa. rFVIIa patients were younger, had more penetrating injuries, and fewer head injuries. However, rFVIIa patients required more red cell transfusions initially, and were more acidotic. Administering rFVIIa was associated with improved 24-hour survival, after adjusting for baseline demographics and injury factors. The odds ratio (OR) for survival was 3.4 (1.2-9.8). Furthermore, there was a strong trend toward increased overall in-hospital survival. The OR of in-hospital survival was 2.5 (0.8-7.6). Also, subgroup analysis of rFVIIa patients showed that 24-hour survivors required a slower initial rate of red cell transfusion (4.5 vs. 2.9 units/hr, p = 0.002), had higher platelet counts (175 vs. 121 [x10(-9)/L], p = 0.05) and smaller base deficits (7.1 vs. 14.3, p = 0.001) compared with rFVIIa patients who died during the first 24 hours. CONCLUSION: rFVIIa may be able to improve the early survival of massively bleeding trauma patients. However, surgical control of massive hemorrhage still has primacy, as rFVIIa did not appear efficacious if extremely high red cell transfusion rates were required. Also, correction of acidosis and thrombocytopenia may be important for rFVIIa efficacy. Prospective studies are required.