Expanding Access to Immediate Lymphatic Reconstruction Through an Axillary Surgery Referral Program: A 6-Year Single-Center Experience.

BACKGROUND: Recent advances in breast cancer have progressed toward less aggressive axillary surgery. However, axillary lymph node dissection (ALND) remains necessary in specific cases and can increase the risk of lymphedema. Performing ALND with immediate lymphatic reconstruction (ILR) can help lower this risk. This report outlines the implementation of an Axillary Surgery Referral Program (ASRP) to broaden access to ILR, providing insights for institutions considering similar initiatives. METHODS: A retrospective study analyzed patients referred to the ASRP at Beth Israel Deaconess Medical Center (BIDMC) between 6 January 2017 and 10 December 2022. Patients were identified from a prospective registry, with data subsequently extracted from electronic medical records. This analysis specifically centered on patients referred from external institutions to undergo ALND with ILR. RESULTS: The program received referrals for 131 patients from institutions across five different states. Annual referrals steadily increased over time. The primary indication for referral was residual axillary disease after neoadjuvant chemotherapy (41.2%). Among the referrals, 20 patients (15.3%) no longer required ALND due to axillary pathologic complete response to neoadjuvant therapy. Care coordination played a crucial role in streamlining the patient care process for both efficiency and effectiveness. CONCLUSION: The ASRP expands access to ILR for patients with breast cancer, the majority referred for surgical management of residual disease after chemotherapy. The program provides a model for health care institutions aiming to establish similar specialized referral services. Continued program evaluation will be instrumental in refining axillary surgery referral practices and ensuring optimal patient care.

Reliability of artificial intelligence chatbot responses to frequently asked questions in breast surgical oncology.

INTRODUCTION: Artificial intelligence (AI)-driven chatbots, capable of simulating human-like conversations, are becoming more prevalent in healthcare. While this technology offers potential benefits in patient engagement and information accessibility, it raises concerns about potential misuse, misinformation, inaccuracies, and ethical challenges. METHODS: This study evaluated a publicly available AI chatbot, ChatGPT, in its responses to nine questions related to breast cancer surgery selected from the American Society of Breast Surgeons' frequently asked questions (FAQ) patient education website. Four breast surgical oncologists assessed the responses for accuracy and reliability using a five-point Likert scale and the Patient Education Materials Assessment (PEMAT) Tool. RESULTS: The average reliability score for ChatGPT in answering breast cancer surgery questions was 3.98 out of 5.00. Surgeons unanimously found the responses understandable and actionable per the PEMAT criteria. The consensus found ChatGPT's overall performance was appropriate, with minor or no inaccuracies. CONCLUSION: ChatGPT demonstrates good reliability in responding to breast cancer surgery queries, with minor, nonharmful inaccuracies. Its answers are accurate, clear, and easy to comprehend. Notably, ChatGPT acknowledged its informational role and did not attempt to replace medical advice or discourage users from seeking input from a healthcare professional.

Evaluating Axillary Lymph Node Yield After Neoadjuvant Chemotherapy.

INTRODUCTION: The benefits that neoadjuvant chemotherapy (NAC) provides in treating patients with breast cancer are well known. However, its effects on axillary lymph nodes and lymph node yield (LNY) following axillary lymph node dissection (ALND) remain unclear. Given the importance of LNY for accurate axillary staging in patients with breast cancer, we retrospectively reviewed a large national cancer database to determine if NAC has an effect on LNY following axillary surgery. METHODS: A retrospective review of the National Cancer Database was performed. Patients diagnosed from 2010 to 2015 with T0-T4, clinical N0-3, and M0 breast cancer who underwent ALND were included. Patients were categorized by NAC and primary surgery (PS). A descriptive analysis of patient and tumor characteristics, as well as extrinsic factors, was performed. A univariate analysis using Student's t-test was performed to evaluate LNY between the two groups. RESULTS: A total of 118,108 patients were included in our study. We found that 29,066 (24.6%) patients underwent NAC, and 89,042 (75.4%) had surgery as initial treatment (PS group). The median LNY by ALND in the NAC group was 11 (Q1, Q3: 6, 16). The median LNY in the PS group was 11 (Q1, Q3: 6, 17), p < 0.001. CONCLUSION: Despite differences in patient characteristics and external factors, we found no difference in LNY following ALND between patients who underwent NAC and those who had initial surgery. Efforts should be made to achieve equivalent LNY whether or not patients receive NAC.

Discordant Breast and Axillary Pathologic Response to Neoadjuvant Chemotherapy.

INTRODUCTION: Neoadjuvant chemotherapy (NAC) for breast cancer has the advantage of determining in vivo response to treatment, enabling more conservative surgery, and facilitating the understanding of tumor biology. Pathologic complete response (pCR) after NAC is a predictor of improved overall survival. However, some patients demonstrate a discordant response to NAC between the breast and axillary nodes. This study was designed to identify factors that correlate to achieving a breast pCR without an axillary node pCR following NAC and explore the potential clinical implications. METHODS: The National Cancer Database was used to identify patients diagnosed with clinical T1-4, N1-3 breast cancer between 2004 and 2017. Patients underwent NAC followed surgical resection of the breast cancer and axillary node surgery. Multivariable analyses were used to identify clinical and pathologic factors associated with discordant pathologic response. RESULTS: In total, 13,934 patients met the inclusion criteria. Of these, 4292 (30.8%) patients demonstrated a breast pCR without a corresponding axillary pCR on final pathology. After adjusting for covariates, factors associated with higher discordance between axillary response in our cohort of breast pCR patients included older age (≥ 54), treatment at a community facility, T1 tumors, HR-positive, HER2 negative, low-grade tumors, and cN2/3 disease. CONCLUSIONS: Discordance between breast and axillary pCR is not infrequent and may be related to a number of patient-related factors and tumor characteristics impacting nodal response to NAC. Further investigation into differing responses to NAC is warranted to better understand the mechanism of this phenomenon and to determine how these findings may influence treatment.

Home Recovery After Mastectomy: Review of Literature and Strategies for Implementation American Society of Breast Surgeons Working Group.

BACKGROUND: Practices regarding recovery after mastectomy vary significantly, including overnight stay versus discharge same day. Expanded use of Enhanced Recovery After Surgery (ERAS) algorithms and the recent COVID pandemic have led to increased number of patients who undergo home recovery after mastectomy (HRAM). METHODS: The Patient Safety Quality Committee of the American Society of Breast Surgeons created a multispecialty working group to review the literature evaluating HRAM after mastectomy with and without implant-based reconstruction. A literature review was performed regarding this topic; the group then developed guidance for patient selection and tools for implementation. RESULTS: Multiple, retrospective series have reported that patients discharged day of mastectomy have similar risk of complications compared with those kept overnight, including risk of hematoma (0-5.1%). Multimodal strategies that improve nausea and analgesia improve likelihood of HRAM. Patients who undergo surgery in ambulatory surgery centers and by high-volume breast surgeons are more likely to be discharged day of surgery. When evaluating unplanned return to care, the only significant factors are African American race and increased comorbidities. CONCLUSIONS: Review of current literature demonstrates that HRAM is a safe option in appropriate patients. Choice of method of recovery should consider patient factors, such as comorbidities and social situation, and requires input from the multidisciplinary team. Preoperative education regarding pain management, drain care, and after-hour access to medical care are crucial components to a successful program. Additional investigation is needed as these programs become more prevalent to assess quality measures such as unplanned return to care, complications, and patient satisfaction.

Oncology team perspectives on distress screening: a multisite study of a well-established use of patient-reported outcomes for clinical assessment.

PURPOSE: Cancer care team attitudes towards distress screening are key to its success and sustainability. Previous qualitative research has interviewed staff mostly around the startup phase. We evaluate oncology teams' perspectives on psychosocial distress screening, including perceived strengths and challenges, in settings where it has been operational for years. METHODS: We conducted, transcribed, and analyzed semi-structured interviews with 71 cancer care team members (e.g., MDs, RNs, MSWs) at 18 Commission on Cancer-accredited cancer programs including those serving underrepresented populations. RESULTS: Strengths of distress screening identified by participants included identifying patient needs and testing provider assumptions. Staff indicated it improved patient-provider communication and other aspects of care. Challenges to distress screening included patient barriers (e.g., respondent burden) and lack of electronic system interoperability. Participants expressed the strengths of distress screening (n = 291) more than challenges (n = 86). Suggested improvements included use of technology to collect data, report results, and make referrals; complete screenings prior to appointments; longitudinal assessment; additional staff training; and improve resources to address patient needs. CONCLUSION: Cancer care team members' perspectives on well-established distress screening programs largely replicate findings of previous studies focusing on the startup phase, but there are important differences: team members expressed more strengths than challenges, suggesting a positive attitude. While our sample described many challenges described previously, they did not indicate challenges with scoring and interpreting the distress screening questionnaire. The differences in attitudes expressed in response to mature versus startup implementations provide important insights to inform efforts to sustain and optimize distress screening.

Evaluation of online Spanish and English health materials for preventive mastectomy. are we providing adequate information?

PURPOSE: Breast cancer remains the leading cause of cancer-related death in US Hispanic women. When present, lower health literacy levels potentially within this patient population require tailored materials to address health disparities. We aim to evaluate and compare Spanish and English online health care informative resources on preventive mastectomy. METHODS: A Google web search using "preventive mastectomy" and "mastectomía preventiva" was conducted. The first ten institutional/organizational websites in each language were selected. Assessment of mean reading grade level, cultural sensitivity, understandability, and actionability was carried out utilizing validated tools. RESULTS: The mean reading grade level for English materials was 14.69 compared with 11.3 for Spanish, both exceeding the recommended grade level established by the AMA and NIH. The mean cultural sensitivity score for English information was 2.20 compared with 1.88 for Spanish information, both below the acceptability benchmark of 2.5. English webpages scored 65% and 35% for understandability and actionability, respectively, while Spanish webpages scored 47% and 18%. CONCLUSIONS: Online English and Spanish preventive mastectomy materials were written at an elevated reading level and lacked cultural sensitivity. Spanish language information demonstrated inferior understandability, actionability, and cultural sensitivity. Addressing these issues provides an opportunity to help resolve health literature disparities regarding preventive mastectomy for US Hispanic women.

Burnout and Professional Fulfillment in Early and Early-Mid-Career Breast Surgeons.

BACKGROUND: Prior work has shown that burnout among breast surgeons is prevalent and highest in those earlier in their clinical practice career. Therefore, we sought to better understand and identify specific contributors to early-career breast surgeon burnout. METHODS: We analyzed data from our 2017 survey of members of the American Society of Breast Surgeons. The 16-items of the Professional Fulfillment Index were used in determining overall burnout and professional fulfillment scores. Multivariable regressions were performed to evaluate factors related to overall burnout and professional fulfillment. RESULTS: The mean overall burnout score was 1.23 (0-4 scale; higher score unfavorable) for surgeons in practice < 5 years, compared with 1.39 for surgeons in practice 5-9 years and 1.22 for those in practice ≥ 10 years. The mean professional fulfillment score was 2.71 (0-4 scale; higher score favorable) for surgeons in practice < 5 years, 2.66 for surgeons in practice 5-9 years, and 2.67 for surgeons in practice ≥ 10 years. Multivariable analysis showed that burnout was positively correlated with ≥ 60 work hours per week in the group practicing for < 5 years, and dedicating less than full time to breast surgery in the group in practice 5-9 years. Professional fulfillment was negatively associated with single relationship status in surgeons practicing < 5 years, and dedicating less than full time to breast surgery for those in practice 5-9 years. CONCLUSION: Our study suggests that breast surgeons who have been in practice for 5-9 years have particularly high overall burnout rates and additional support focused on this group of breast surgeons may be needed.

The Role of Oncotype DX® Recurrence Score in Predicting Axillary Response After Neoadjuvant Chemotherapy in Breast Cancer.

INTRODUCTION: Oncotype DX® recurrence score (RS) is well-recognized for guiding decision making in adjuvant chemotherapy; however, the predictive capability of this genomic assay in determining axillary response to neoadjuvant chemotherapy (NCT) has not been established. METHODS: Using the National Cancer Data Base (NCDB), we identified patients diagnosed with T1-T2, clinically N1/N2, estrogen receptor-positive/human epidermal growth factor receptor 2-negative (ER +/HER2 -) invasive ductal carcinoma of the breast between 2010 and 2015. Patients with an Oncotype DX® RS who received NCT were included. RS was defined as low (< 18), intermediate (18-30), or high (> 30). Unadjusted and adjusted analyses were performed to determine the association between axillary pathologic complete response (pCR) and RS. RESULTS: This study included a total of 158 women. RS was low in 56 (35.4%) patients, intermediate in 62 (39.2%) patients, and high in 40 (25.3%) patients. The majority of patients presented with clinical N1 disease (89.2%). Axillary pCR was achieved in 23 (14.6%) patients. When stratifying patients with axillary pCR by RS, 11 (47.8%) patients had a high RS, 6 (26.1%) patients had an intermediate RS, and 6 (26.1%) patients had a low RS. Comparing cohorts by RS, 27.5% of patients with high RS tumors had an axillary pCR, compared with only 9.7% in the intermediate RS group, and 10.7% in the low RS group (p = 0.0268). CONCLUSION: Our findings demonstrate that Oncotype DX® RS is an independent predictor of axillary pCR in patients with ER +/HER2 - breast cancers receiving NCT. A greater proportion of patients with a high RS achieved axillary pCR. These results support Oncotype DX® as a tool to improve clinical decision making in axillary management.

Malpractice Cases in Breast Surgery: An Assessment of Litigation Involving Surgeons.

INTRODUCTION: Improving patient safety and quality are priorities in health care. The study of malpractice cases provides an opportunity to identify areas for quality improvement. While the issues surrounding malpractice cases in breast cancer are often multifactorial, there are few studies providing insight into malpractice cases specifically related to common breast cancer surgical procedures. We sought to characterize the factors in liability cases involving breast cancer surgery. METHODS: Closed cases from 2008 to 2019 involving a breast cancer diagnosis, a primary responsible service of general surgery, surgical oncology, or plastic surgery, and a breast cancer procedure were reviewed using data from the Controlled Risk Insurance Company (CRICO) Strategies Comparative Benchmarking System database, a national repository of professional liability data. RESULTS: A total of 174 malpractice cases were reviewed, of which 41 cases were closed with payment. Plastic surgeons were most commonly named (64%, 111/174), followed by general surgeons (30%, 53/174), and surgical oncologists (6%, 10/174). The most common allegation was error in surgical treatment (87%, 152/174), and infection, cosmetic injury, emotional trauma, foreign body, and nosocomial infections represented the top five injury descriptions. On average, indemnity payments were larger for high clinical severity cases. Technical skills, followed by clinical judgment, were the most commonly named contributing factors. The average payment per case was $130,422. CONCLUSION: Malpractice cases predominantly involve technical complications related to plastic surgery procedures. Better understanding of the malpractice environment involving surgical procedures performed for breast cancer may provide practical insight to guide initiatives aimed at improving patient outcomes.

Implementing radar reflector-guided localization of nonpalpable breast lesions: Feasibility, challenges, outcomes, and lessons learned.

Reflector-guided localization uses a nonradioactive radar implant for wire-free presurgical breast lesion localization. A single-institution retrospective evaluation found lower rates of positive margins and of close margins for reflector-guided localizations compared with wire localizations, resulting in a statistically significant decrease in the re-excision rates (p = 0.015). The two approaches did not show statistically significant difference in localization time and OR time. Technical challenges included particulars inherent in reflector placement, while patient factors included special considerations for reflector placement in the postsurgical breast. Despite novel challenges, we found reflector-guided localization to be accurate and efficient.

Socioeconomic Status and Melanoma in Canada: A Systematic Review.

As melanoma is one of the leading cancers in average years of life lost per death from disease, screening and early diagnosis are imperative to decrease morbidity and mortality. Socioeconomic status (SES) has been shown to be associated with melanoma incidence. However, it is unclear if this association holds true in universal healthcare systems where screening, diagnostic, and treatment services are available to all patients. The objective of this systematic review was to evaluate the evidence on the association of SES and melanoma incidence in Canada. A comprehensive search of PubMed and EMBASE yielded 7 studies reporting on melanoma incidence or outcomes with respect to SES in Canada. High SES was associated with increased melanoma incidence across all studies, which encompassed all Canadian provinces, and time periods spanning from 1979 to 2012. Studies also reported an increasing incidence of melanoma over time. There were substantial discrepancies in melanoma incidence across Canadian provinces, after controlling for SES and demographic characteristics. Populations of lower SES and living within certain healthcare regions had increased risks of advanced melanoma at diagnosis. This review highlights the potential for inequities in access to care even within a universal healthcare system. Future research is needed to characterize specific risk factors within different patient groups and within the universal health system context in order to implement targeted strategies to lower melanoma incidence, morbidity, and mortality.

Role of Sentinel Lymph Node Biopsy in Microinvasive Breast Cancer.

BACKGROUND: Microinvasive ductal carcinoma (DCISM), defined as DCIS with a focus of invasive carcinoma ≤ 1 mm, can be managed similarly to pure DCIS; however, management of the axilla in DCISM has been a subject of debate. Reports in the literature differ on the utility and necessity of sentinel lymph node biopsy (SLNB) for DCISM. The aim of the present study was to identify risk factors for nodal disease in patients with DCISM, which can help develop a selective approach to SLNB in this patient population. METHODS: The National Cancer Database was used to select patients with DCISM (pT1mi), diagnosed from 2012 to 2015, who underwent SLNB. Multivariable regression analysis was performed to determine associations between sentinel lymph node metastasis and relevant clinical variables. RESULTS: Our cohort comprised of 2609 patients with pT1mi who underwent SLNB. Of these, 76 (2.9%) were found to have sentinel lymph node metastases on final pathology. Low/intermediate grade tumors were associated with decreased SLN metastasis (OR 0.50, CI 0.28-0.92). Age and receptor status of the tumor did not have a clear association in predicting SLN metastases. CONCLUSIONS: The rate of sentinel node metastases in DCISM is low at only 2.9% in this national study. Tumor grade was identified as influencing the risk of SLN metastases. This information can factor into shared decision-making for SLNB in patients with DCISM.

Pain Control in Breast Surgery: Survey of Current Practice and Recommendations for Optimizing Management-American Society of Breast Surgeons Opioid/Pain Control Workgroup.

INTRODUCTION: The opioid epidemic in the United States is a public health crisis. Breast surgeons are obligated to provide good pain control for their patients after surgery but also must minimize administration of narcotics to prevent a surgical episode of care from becoming a patient's gateway into opioid dependence. METHODS: A survey to ascertain pain management practice patterns after breast surgery was performed. A review of currently available literature that was specific to breast surgery was performed to create recommendations regarding pain management strategies. RESULTS: A total of 609 surgeons completed the survey and demonstrated significant variations in pain management practices, specifically within regards to utilization of regional anesthesia (e.g., nerve blocks), and quantity of prescribed narcotics. There is excellent data to guide the use of local and regional anesthesia. There are, however, fewer studies to guide narcotic recommendations; thus, these recommendations were guided by prevailing practice patterns. CONCLUSIONS: Pain management practices after breast surgery have significant variation and represent an opportunity to improve patient safety and quality of care. Multimodality approaches in conjunction with standardized quantities of narcotics are recommended.

Analysis of active surveillance as a treatment modality in ductal carcinoma in situ.

Ductal carcinoma in situ (DCIS) is a nonobligate precursor of invasive breast cancer. Current clinical trials are exploring active surveillance (AS) of DCIS. The purpose of this study is to characterize current practice trends in the use of AS. The findings may inform clinical trials and provide insight into factors influencing adoption into practice. The National Cancer Database was used to identify women diagnosed with DCIS from 2004 to 2015. Management with AS was defined as any patient not undergoing surgery, chemotherapy, or radiation therapy. Multivariable logistic regression was used to assess patterns of AS. Of 84 281 women with DCIS, 342 (0.4%) underwent AS. Increased age (OR 1.16, CI 1.15-1.17), Hispanic or non-Hispanic black ethnicities (OR 1.91 CI 1.42-2.56; 1.54 CI 1.13-2.10), treatment at an academic facility (OR 1.64 CI 1.31-2.10), and low-volume facilities (OR 1.60 CI 1.06-2.42) were associated with an increased use of AS. Patients with ≥1 comorbidities (OR 0.70 CI 0.49-0.98), high-grade tumors (OR 0.671 CI 0.51-0.89), and private insurance (OR 0.69 CI 0.53-0.89) less frequently underwent AS. Of all patients undergoing AS, 11% received endocrine therapy. Active surveillance is currently an infrequently used treatment modality for patients with DCIS. We observed variations in AS based on age, ethnicity, comorbidities, facility type, facility volume, insurance status, and tumor grade. Most patients managed with AS did not receive hormone therapy. This information may further inform strategies for clinical trials, as well as guide quality of care in the adoption of future management options for DCIS.

Delayed adjuvant hormonal therapy and its impact on mortality in women with breast cancer.

Adjuvant hormonal therapy (HT) is important for the management of hormone-sensitive breast cancer. However, the timeliness for adjuvant HT and the consequences of delayed initiation of treatment have not been analyzed. The purpose of this study was to characterize delays to HT and assess the impact on clinical outcomes. The study cohort consisted of female patients with invasive ductal and/or lobular, hormone receptor-positive breast cancer diagnosed between 2010 and 2015. Initiation of HT >6 months (180 days) after surgery was defined as delayed. Patients receiving chemotherapy were excluded from the study cohort. Multivariable logistic regression modeling was performed to establish associations between delayed HT and demographic, facility, and clinical factors. Survival analysis was performed using the Kaplan-Meier estimation and Cox proportional hazards regression to evaluate overall survival. Of 179 590 women assessed in the National Cancer Database, 3.2% had a delay in the initiation of adjuvant HT. Positive demographic-related risk factors were younger age, ethnic minority groups, and multiple comorbidities. Clinical factors significantly associated with delayed initiation of adjuvant HT were high-grade tumor, larger tumor size, greater lymph node involvement, having an unplanned readmission within 30 days of surgery, and positive final surgical margins. Adjusted survival analysis showed a survival disadvantage of delayed initiation of HT. Risk factors for delayed initiation of HT specific to demographic and clinical characteristics were identified. Delayed initiation of HT was associated with a survival detriment.

Impact of geographic distribution of accredited breast centers.

The National Accreditation Program for Breast Centers (NAPBCs) is dedicated to improving the quality of care in patients with breast disease. Geographic distribution of health care resources is an important measure of quality, yet little is known regarding breast center allocation patterns concerning population demand and impact on health outcomes. The purpose of this study was to analyze the distribution of NAPBC programs in the United States (USA) and evaluate the impact on breast cancer survival. Using the Centers for Disease Control and Prevention 2014 data base, we identified the incidence and mortality rates for breast cancer by state. We also determined the concentration of NAPBC programs in each state (ie, the number of centers per 1000 cases of breast cancer). Data were analyzed using Spearman's (nonparametric) rank correlation coefficients. Five hundred and seventy NAPBC programs were identified. Across the United States, there was a mean of 2.8 programs/1000 breast cancer diagnoses. A positive correlation (r = .45) between breast cancer incidence and the number of programs was identified (P = .0009). There was no statistically significant correlation between mortality and NAPBC program concentration (r = -0.20, P = .16). NAPBC-accredited program distribution within the United States correlates with breast cancer incidence per state. However, the number of NAPBC programs per state did not alter overall mortality rates. Added measures beyond survival, as well as further insight into referral patterns to NAPBC programs, may be required to demonstrate the value and impact of NAPBC accreditation.

The All but Forgotten Mascagni-Sappey Pathway: Learning from Immediate Lymphatic Reconstruction.

BACKGROUND: Upper extremity lymphedema occurs in 25 to 40% of patients after axillary lymph node dissection (ALND). Immediate lymphatic reconstruction (ILR) or the lymphatic micro- surgical preventative healing approach has demonstrated a significant decrease in postoperative rates of lymphedema (LE) from 4 to 12%. Our objective was to map the Mascagni -Sappey pathway, the lateral upper arm draining lymphatics, in patients undergoing ILR to better characterize the drainage pattern of this lymphosome to the axilla. METHODS: A retrospective review of our institutional lymphatic database was conducted and consecutive breast cancer patients undergoing ILR were identified from November 2017 through June 2018. Patient demographics, clinical characteristics, and intraoperative records were retrieved and analyzed. RESULTS: Twenty-nine consecutive breast cancer patients who underwent ILR after ALND were identified. Patients had a mean age of 54.6years and body mass index (BMI) of 26.6 kg/m2. Fluorescein isothiocyanate (FITC) was injected at the medial upper arm and isosulfan blue was injected at the cephalic vein, or lateral upper arm, prior to ALND. After ALND, an average 2.5 divided lymphatics were identified, and a mean 1.2 lymphatics were bypassed. In all patients, divided FITC lymphatics were identified. However, in only three patients (10%), divided blue lymphatics were identified after ALND. CONCLUSION: In this study, variable drainage of the lateral upper arm to the axillary bed was noted. This study is the first to provide a description of intraoperative findings, demonstrating variable drainage patterns of upper extremity lymphatics to the axilla. Moreover, we noted that the lateral- and medial-upper arm lymphosomes have mutually exclusive pathways draining to the axilla. Further study of lymphatic anatomy variability may elucidate the pathophysiology of lymphedema development and influence approaches to immediate lymphatic reconstruction.

Standardized activities for lay patient navigators in breast cancer care: Recommendations from a citywide implementation study.

BACKGROUND: There is a need for guidelines on patient navigation activities to promote both the quality of patient navigation and the standards of reimbursement for these services because a lack of reimbursement is a major barrier to the implementation, maintenance, and sustainability of these programs. METHODS: A broad community-based participatory research process was used to identify the needs of patients for navigation. A panel of stakeholders of clinical providers was convened to identify specific activities for navigators to address the needs of patients and providers with the explicit goal of reducing delays in the initiation of cancer treatment and improving adherence to the care plan. RESULTS: Specific activities were identified that could be generalized to all patient navigation programs for care during active cancer management to address the needs of vulnerable communities. CONCLUSIONS: Oncology programs that seek to implement lay patient navigation may benefit from the adoption of these activities for quality monitoring. Such activities are necessary as we consider reimbursement strategies for navigators without clinical training or licensure.

Time-varying risks of second events following a DCIS diagnosis in the population-based Vermont DCIS cohort.

PURPOSE: Long-term disease-free survival patterns following surgical, radiation, and endocrine therapy treatments for ductal carcinoma in situ (DCIS) are not well characterized in general US practice. METHODS: We identified 1252 women diagnosed with DCIS in Vermont during 1994-2012 using data from the Vermont Breast Cancer Surveillance System, a statewide registry of breast imaging and pathology records. Poisson regression and Cox regression with time-varying hazards were used to evaluate disease-free survival among self-selected treatment groups. RESULTS: With 7.8 years median follow-up, 192 cases experienced a second breast cancer diagnosis. For women treated with breast-conserving surgery (BCS) alone, the annual rate of second events decreased from 3.1% (95% CI 2.2-4.2%) during follow-up years 1-5 to 1.7% (95% CI 0.7-3.5%) after 10 years. In contrast, the annual rate of second events among women treated with BCS plus adjuvant radiation therapy increased from 1.8% (95% CI 1.1-2.6%) during years 1-5 to 2.8% (95% CI 1.6-4.7%) after 10 years (P < 0.05 for difference in trend compared to BCS alone). Annual rates of second events also increased over time among women treated with BCS plus adjuvant radiation and endocrine therapy (P = 0.01 for difference in trend compared to BCS alone). The rate of contralateral events increased after 10 years for all groups with adjuvant treatments. The rate of second events did not vary over time among women who underwent ipsilateral mastectomy (P = 0.62). CONCLUSIONS: Long-term risk of a second event after DCIS varies over time in a manner dependent on initial treatment.