Factors leading to the late diagnosis and poor outcomes of breast cancer in Matabeleland South and the Bulawayo Metropolitan Provinces in Zimbabwe.

INTRODUCTION: Breast cancer (BC) is the leading cause of female cancer deaths in Africa, and in Zimbabwe, >80% present with advanced disease. A Needs Project (NP) was carried out to determine the key factors responsible for delayed diagnosis and poor BC outcomes and to investigate possible solutions in 6 rural and urban districts of Matabeleland South and Bulawayo Metropolitan Provinces. METHODS: A mixed method approach was used to collect data in 2 phases. Phase 1: an exploration of key factors leading to poor BC outcomes with >50 professional stakeholders and patient representatives. Phase 2: (i) Quantitative arm; validated questionnaires recording breast cancer knowledge, demographic information and perceived barriers to care administered to women and their relatives (Group 1) and health professionals (HPs) (Group 2). (ii) Qualitative arm; 10 focus group discussions with medical specialists and interested lay representatives (Group 3). The Cochran sample size formulae technique was used to determine the quantitative sample size and data was aggregated and analysed using SPSS Version 23™. Purposive sampling for the qualitative study selected participants with an understanding of BC and the NP. Focus group discussions were recorded and a thematic analysis of the transcriptions was conducted using NVivo9™. RESULTS: Quantitative analysis of Group 1 data (n = 1107) confirmed that younger women (<30years) had the least knowledge of breast cancer (p<0.001). Just under half of all those surveyed regarded breast cancer as incurable. In Group 2 (n = 298) the largest group of health workers represented were general nurses and midwives (74.2%) in keeping with the structure of health provision in Zimbabwe. Analysis confirmed a strong association between age and awareness of BC incidence (p = 0.002) with respondents aged 30-39 years being both the largest group represented and the least knowledgeable, independent of speciality. Nearly all respondents (90%) supported decentralisation of appropriate breast surgical services to provincial and district hospitals backed up by specialist training. Thematic analysis of focus group discussions (Group 3) identified the following as important contributors to late BC diagnosis and poor outcomes: (i) presentation is delayed by poorly educated women and their families who fear BC and high treatment costs (ii) referral is delayed by health professionals with no access to training, skills or diagnostic equipment (iii), treatment is delayed by a disorganised, over-centralized patient pathway, and a lack of specialist care and inter-disciplinary communication. CONCLUSION: This study confirms that the reasons for poor BC outcomes in Zimbabwe are complex and multi-factorial. All stakeholders support better user and provider education, diagnostic service reconfiguration, targeted funding, and specialist training.

Impact of oncoplasty in increasing breast conservation rates Post neo-adjuvant chemotherapy.

Introduction: The essential goal of neoadjuvant chemotherapy (NACT) is to downstage the primary tumor making it amenable for breast conservation surgery (BCS). However, since the safety of this surgery is paramount, post-NACT breast conservation rates remain low. As per the recommendation of the 2018 Early Breast Cancer Trialists' Collaborative Group (EBCTCG) overview of long-term post-NACT follow-up, we have devised a protocol for imaging, localization, rad-path analysis, and documentation of radiotherapy techniques to ensure the safety of post-NACT breast conservation. Methods: This is a retrospective cohort of 180 breast cancer patients who received NACT and were operated on by a single surgical oncologist from 2015 to 2020. After selection based on published guidelines, patients were treated with neoadjuvant systemic (chemo or hormone) therapy. In cases where primary tumors responded and reduced to 1-2 cm in size mid-NACT, the residual tumors were localized by clips under ultrasound guidance and calcification was wire localized. All patients were treated using appropriate surgical and oncoplastic techniques where indicated. Negative margins were ensured by intra-operative rad-path analysis. Adjuvant chemotherapy and radiotherapy were given as per protocol. Results: In 81 cases that required mastectomy at presentation, we were able to achieve a 72.8% post-NACT BCS rate with the help of oncoplasty. Overall, 142 of 180 (80%) patients were treated with breast conserving surgery of which 80% (121 of 142) were oncoplasty. Margins were assessed on intra-operative frozen and re-excised in the same setting. No positive margins were reported in final histopath of 142 breast conservation procedures. Post-operative complication rates after breast conservation in the first year were at 17% (24 of 142 including two major complications). Patient reported outcomes were satisfactory with increased satisfaction for breast conservation compared with immediate breast reconstruction. Discussion: Employing oncoplastic breast surgery (OBS) techniques following stringent protocols for accurate localization of the residual tumor, intra-operative rad-path analysis, and adjuvant treatments, we show successful breast conservation in 72.8% of our mastectomy-qualified patients after downstaging by NACT. We also report satisfactory outcomes for post-NACT surgery, patient-reported satisfaction, and survival.

Patients' satisfaction with the reconstructive options provided to them measured 18 months after mastectomy surgery for breast cancer.

INTRODUCTION: Mastectomy patients' satisfaction with reconstructive options has not been examined. METHODS: A national study measured 18-month satisfaction with reconstructive options and collected case-mix and reconstructive offer and uptake data on breast cancer patients having mastectomy with or without immediate reconstruction (IR) in England between January 2008 and March 2009. Multivariable logistic regression examined the relationship between satisfaction, age, IR offer and uptake, and clinical suitability. RESULTS: Of 4796 patients, 1889 were not offered IR, 1489 declined an offer and 1418 underwent it. Women not offered IR were more likely older, obese or smokers and had higher ASA grades, ECOG scores, tumour burdens and adjuvant chemotherapy and radiotherapy likelihoods (9% of lowest suitability group offered IR; 81% in highest suitability group). 83.7% were satisfied with their reconstructive options, varying significantly by IR offer and uptake (76.1% for those not offered IR; 85.8% for those who declined IR; 91.7% following IR). Older women and women deemed more suitable for IR were more often satisfied (p-values <0.001). CONCLUSIONS: Satisfaction varied by offer and uptake status, age and suitability score. Clinicians should target equity for women deemed unsuitable by exploring their needs and desired outcomes, standardising operative fitness assessments and utilising shared decision-making aids.

Measuring the patient perspective on latissimus dorsi donor site outcomes following breast reconstruction.

BACKGROUND: There is little evidence about the long-term donor site outcome of latissimus dorsi breast reconstruction and no patient-reported outcome measures designed specifically for the procedure. METHODS: A prospective cohort of breast cancer patients having latissimus dorsi reconstruction after a mastectomy was recruited from 270 hospitals in the United Kingdom. An 18-month follow up questionnaire containing two novel scales was sent to consenting patients. The prevalence of aesthetic and functional morbidity at the donor site was described. The two new scales were refined using the Rasch measurement model and subsequently validated. RESULTS: 1,096 women completed the new scales. 78% of patients reported that no back appearance issues had bothered them "most of the time" or "all of the time" in the past two weeks. The equivalent figure for functional morbidity was 60%. Four items were eliminated following initial psychometric testing. This produced an 8-item Back Appearance scale and an 11-item Back and Shoulder Function scale. Both scales showed adequate fit to the Rasch measurement model. Higher levels of aesthetic and functional bother were observed for completely autologous procedures versus those where latissimus dorsi reconstruction was used to cover an implant (p <0.05). Higher levels of aesthetic bother were observed in women who had suffered a perioperative complication at the donor site (p = 0.003). CONCLUSION: These results can inform patients of the morbidity associated with latissimus dorsi reconstruction. The new scales can be used to compare groups undergoing different variations of the procedure and to monitor individual patients.

The association between complications and quality of life after mastectomy and breast reconstruction for breast cancer.

BACKGROUND: Medical treatment for breast cancer is associated with substantial toxicity and patient burden. There is less known about the impact of surgical complications. Understanding this impact could provide important information for patients when they are considering surgical options. METHODS: Between 2008 and 2009, the UK National Mastectomy and Breast Reconstruction Audit recorded surgical complications for a prospective cohort of 17,844 women treated for breast cancer at 270 hospitals; 6405 of these women were surveyed about their quality of life 18 months after surgery. Breast appearance, emotional well-being, and physical well-being were quantified on 0- to 100-point scales. Linear multiple regression models, controlling for a range of baseline prognostic factors, were used to compare the scores of patients who had complications with the scores of those who did not. RESULTS: The overall complication rate was 10.2%. Complications were associated with little or no impairment in women undergoing mastectomy without reconstruction or with delayed reconstruction. The association was much larger for flap-related complications suffered during immediate reconstruction. The breast-appearance scores (adjusted mean difference, -23.8; 95% confidence interval [CI], -31.0 to -16.6) and emotional well-being scores (adjusted mean difference, -14.0; 95% CI, -22.0 to -6.0) of these patients were much lower than those of any other patient group. Implant-related complications were not associated with a lower quality of life in any surgical group. CONCLUSIONS: There is a strong case for prospectively collecting flap-complication rates at the surgeon and surgical unit level and for allowing patients to access these data when they make choices about their breast cancer surgery. Cancer 2017;123:3460-7. © 2017 American Cancer Society.

Surgical Determinants of Patient-Reported Outcomes following Postmastectomy Reconstruction in Women with Breast Cancer.

BACKGROUND: This national prospective cohort study compared the patient-reported outcomes of breast cancer patients undergoing postmastectomy autologous reconstruction to those who had breast implants, in terms of aesthetic appearance; levels of psychological, physical, and sexual well-being; and overall satisfaction. METHODS: Of 5063 women who underwent immediate reconstruction (n = 3349) or delayed reconstruction (n = 1714) between January 1, 2008, and March 31, 2009, in England, 2923 women who gave informed consent were sent validated, procedure-specific, 18-month follow-up questionnaires. Outcome scale scores ranged from 0 (poor) to 100 (excellent); multiple linear regression was used to adjust scores for patient and treatment characteristics. RESULTS: Two thousand two hundred eighty-nine women (78 percent) returned completed questionnaires (immediate reconstruction, n = 1528; delayed reconstruction, n = 761). For immediate reconstruction, mean overall satisfaction scores for the various techniques ranged from 67 to 85 (median, 67 to 93). For delayed reconstruction, mean overall satisfaction scores ranged from 70 to 85 (median, 75 to 100). For both groups, similar gradients were observed for the other outcome scales across techniques. Reconstruction using patients' own tissues tended to have higher mean adjusted scores compared with those techniques using implants alone (p < 0.0001 for aesthetic appearance, psychological well-being, sexual well-being, and satisfaction with outcomes for immediate and delayed reconstruction groups). CONCLUSIONS: Women who underwent autologous reconstruction tended to report greater satisfaction than those who underwent implant reconstruction. These results can inform patients of the anticipated outcomes of their selected surgery, but further research is required to confirm whether autologous reconstruction is superior in general. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Findings of a national comparative audit of mastectomy and breast reconstruction surgery in England.

OBJECTIVES: This paper summarises the findings of a national audit of mastectomy and breast reconstruction surgery carried out in England. It describes patterns of treatment, and the clinical and patient-reported quality of life outcomes associated with these types of procedure. DESIGN: Prospective cohort study. SETTING: All 150 National Health Service hospital groups (NHS trusts) in England that provided mastectomy or breast reconstruction surgery, along with six NHS trusts in Wales and Scotland and 114 independent hospitals. PARTICIPANTS: Women aged 16 years and over undergoing mastectomy with or without immediate breast reconstruction, or primary delayed breast reconstruction, between 1st January 2008 and 31st March 2009. MAIN OUTCOME MEASURES: Reconstructive utilisation, post-operative complications and sequelae, and patient-reported satisfaction and quality of life. RESULTS: Overall, 21% of the 16,485 women who had mastectomy underwent immediate reconstruction. However, the proportion varied between regions from 9% to 43% (p < 0.001). Levels of patient satisfaction with information, choice and the quality of care were high. The proportion of women who experienced local complications was 10.30% (95% CI 9.78-10.84) for mastectomy surgery, ranged from 11.02% (9.31-12.92) to 18.24% (14.80-22.10) for different immediate reconstructive procedures, and from 5.00% (2.76-8.25) to 19.86% (16.21-23.94) for types of delayed reconstruction. Breast appearance and overall well-being scores reported 18 months after surgery were higher among women having immediate breast reconstruction compared to mastectomy only. Postoperative outcomes were similar across providers.. CONCLUSIONS: The Audit found women were highly satisfied with their peri-operative care, with hospital providers achieving similar outcomes. English providers should examine how to reduce the variation in rates of immediate reconstruction.

E learning in surgery.

E learning means use of electronic media and information technologies in education. Virtual learning environment (VLE) provides learning platforms consisting of online tools, databases and managed resources. This article is a review of use of E learning in medical and surgical education including available evidence favouring this approach. E learning has been shown to be more effective, less costly and more satisfying to the students than the traditional methods. E learning cannot however replace direct consultant supervision at their place of work in surgical trainees and a combination of both called blended learning has been shown to be most useful. As an example of university-based qualification, one such programme is presented to clarify the components and the process of E learning. Increasing use of E learning and occasional face to face focussed supervision by the teacher is likely to enhance surgical training in the future.

Training the oncoplastic breast surgeon-current and future perspectives.

Oncoplastic breast surgery has evolved to become a distinct subspecialty within the field of general surgery. The oncoplastic breast surgeon requires comprehensive knowledge and understanding of all aspects of breast oncology, in addition to technical proficiency in operative procedures to remodel and reconstruct the breast. This article describes current educational resources available for the training of oncoplastic breast surgeons both within the UK and internationally. A recent development is the online Master of Surgery degree in Oncoplastic Breast Surgery, based at the University of East Anglia in the UK. This innovative course combines delivery of clinical knowledge using interactive problem-based forum discussions with assessment of operative and decision making skills. The degree is facilitated and assessed by an expert specialist breast faculty, and requires students to achieve standards expected of a first year practising UK oncoplastic breast consultant. Future international developments using this blended educational model are discussed.

'Surgical cure' for non-parathyroid hypercalcemia.

BACKGROUND: Sarcoidosis is a granulomatous disease of unknown aetiology. Over 90% patients of sarcoidosis present with pulmonary findings. Other organs such as lymph nodes, skin, and joints may be involved. Isolated granulomatous disease confined to the spleen is rare. CASE PRESENTATION: This report documents a rare case of isolated granulomatous disease of spleen presenting as hypercalcemia. After all possible causes for hypercalcemia were ruled out, splenectomy was done which proved diagnostic and therapeutic, as calcium levels returned to normal. CONCLUSION: We propose that sarcoidosis should be kept in mind as a cause of unexplained hypercalcemia. Increased awareness of radiological features of splenic involvement in sarcoidosis, would help in diagnosis. We believe that we are reporting 9th case in the literature while writing this report.

Randomized clinical trial comparing two mastectomy techniques.

BACKGROUND: The unit was considering the routine use of diathermy scissors for standard mastectomy surgery. We therefore aimed to assess scientifically the outcome of patients following the use of this instrument in their operation before accepting it as a routine procedure. METHODS: A single blind randomized control trial compared the outcome of patients undergoing simple mastectomy using either the standard scalpel blade technique or the bipolar cutting scissors technique. Each arm of the trial contained 30 patients. RESULTS: The two primary outcome measures were blood loss intraoperatively and the operating time. There was a significant difference between the two groups, with a statistically significant benefit in the scissors group in terms of the secondary outcome measures of chest wall clearance and skin flap development as assessments of surgical completeness of mastectomy. There is no evidence of any other secondary outcome measures differing between the treatment groups. CONCLUSION: There is strong evidence that using electric scissors reduces intraoperative blood loss and operating time. There is some evidence that the scissors may provide better surgical completeness of mastectomy.