Profiles of Burnout and Response to the COVID-19 Pandemic Among General Surgery Residents at a Large Academic Training Program.

BACKGROUND: COVID-19 has placed demands on General Surgery residents, who are already at high risk of burnout. This study examined the pandemic's impact on burnout and wellness among General Surgery residents at a large training program. METHODS: General Surgery residents at our institution completed a survey focused on self-reported burnout, mental health, perceptions of wellness resources, and changes in activities during the pandemic. Burnout was measured using the Maslach Burnout Inventory (MBI). Unsupervised machine learning (k-means clustering) was used to identify profiles of burnout and comparisons between profiles were made. RESULTS: Of 82 eligible residents, 51 completed the survey (62% response rate). During COVID-19, 63% of residents had self-described burnout, 43% had depression, 18% acknowledged binge drinking/drug use, and 8% had anxiety. There were no significant differences from pre-pandemic levels (p all >.05). Few residents perceived available wellness resources as effective (6%). Based on MBI scores, the clustering analysis identified three clusters, characterized as "overextended", "engaged", and "ineffective". Engaged residents had the least concerning MBI scores and were significantly more likely to exercise, retain social contact during the pandemic, and had less self-reported anxiety or depression. Research residents were overrepresented in the ineffective cluster (46%), which had high rates of self-reported burnout (77%) and was characterized by the lowest personal accomplishment scores. Rates of self-reported burnout for overextended and engaged residents were 73% and 48%, respectively. CONCLUSION: Surgical residents have high rates of self-reported burnout and depression during the COVID-19 pandemic. Clusters of burnout may offer targets for individualized intervention.

Axillary surgery and complication rates after mastectomy and reconstruction for breast cancer: an analysis of the NSQIP database.

PURPOSE: Some series have shown increased complications with extended nodal surgery and immediate breast reconstruction (IBR) with implants. We aim to explore complications associated with axillary dissection compared to sentinel lymph node biopsy at a population level. METHODS: American College of Surgeons National Surgical Quality Improvement Program participant user files from 2008-2018 were searched to create a cohort of female patients undergoing unilateral mastectomy with IBR and axillary surgery for non-metastatic breast cancer. Patients were classified as having sentinel lymph node biopsy (SLNB), axillary dissection (ALND), or sentinel lymph node biopsy and axillary dissection (SLNB + ALND). Baseline demographics were compared, and multivariable logistic regression was to assess for independent predictors of the primary outcome of 30-day morbidity. RESULTS: Between 2008 and 2018, 18,232 patients had mastectomy and IBR with axillary surgery; 12,632 patients underwent SLNB, 3727 had ALND and 1,873 underwent SLNB + ALND. Mean age of patients in the cohort was 52.5 (SD 11). There was no difference in 30-day morbidity between groups (SLNB: 4.3%, ALND: 4.9%, SLNB + ALND: 4.2%, p = 0.207). Multivariable regression showed that type of axillary surgery was not an independent predictor of 30-day complications (OR 0.78 (95% CI 0.52-1.15) for ALND, and OR 0.87 (95% CI 0.52-1.45) for ALND + SLNB vs SLNB alone). Significant independent predictors for complications were increased BMI (OR 1.06 (95%CI 1.04-1.08)) and increased operative time (OR 1.003 (95% CI 1.001-1.005)). CONCLUSIONS: ALND does not increase 30-day morbidity in patients undergoing IBR when compared to SLNB. This supports concurrent axillary dissection for IBR patients when indicated.

Surgical trainees achieving the CanMEDS roles in the COVID-19 era: What have we learned and where do we go?

SummaryThe COVID-19 pandemic has substantially changed the practice of medicine with a shift to virtual clinical encounters, alternative management of surgical diseases owing to restrictions on elective operations, and physician redeployment to other medical services requiring coverage. These changes may limit opportunities for trainees to gain surgical expertise and have the potential to drastically affect postgraduate surgical education. However, the pandemic has also created a number of opportunities to navigate these challenges and enhance how surgical education is delivered. For example, there are now more learning opportunities available to trainees because of virtual educational sessions. We highlight some considerations in adapting postgraduate surgical training to achieve competency in the CanMEDS roles in the COVID-19 era.

COVID-19 vaccination and breast cancer surgery timing.

There have been recent reports in the breast imaging literature of unilateral axillary lymphadenopathy following COVID-19 vaccination. It is unclear whether the reactive lymphadenopathy may impact the sentinel lymph node biopsy procedure. In this article, we provide guidelines regarding the timing of the COVID-19 vaccine and breast cancer surgery which were formulated after a review of the available literature and in consultation with infectious disease specialists.

Longitudinal Study of Psychosocial Outcomes Following Surgery in Women with Unilateral Nonhereditary Breast Cancer.

INTRODUCTION: Rates of bilateral mastectomy are rising in women with unilateral, nonhereditary breast cancer. We aim to characterize how psychosocial outcomes evolve after breast cancer surgery. PATIENTS AND METHODS: We performed a prospective cohort study of women with unilateral, sporadic stage 0-III breast cancer at University Health Network in Toronto, Canada between 2014 and 2017. Women completed validated psychosocial questionnaires (BREAST-Q, Impact of Event Scale, Hospital Anxiety & Depression Scale) preoperatively, and at 6 and 12 months following surgery. Change in psychosocial scores was assessed between surgical groups using linear mixed models, controlling for age, stage, and adjuvant treatments. P < .05 were significant. RESULTS: A total of 475 women underwent unilateral lumpectomy (42.5%), unilateral mastectomy (38.3%), and bilateral mastectomy (19.2%). There was a significant interaction (P < .0001) between procedure and time for breast satisfaction, psychosocial and physical well-being. Women having unilateral lumpectomy had higher breast satisfaction and psychosocial well-being scores at 6 and 12 months after surgery compared with either unilateral or bilateral mastectomy, with no difference between the latter two groups. Physical well-being declined in all groups over time; scores were not better in women having bilateral mastectomy. While sexual well-being scores remained stable in the unilateral lumpectomy group, scores declined similarly in both unilateral and bilateral mastectomy groups over time. Cancer-related distress, anxiety, and depression scores declined significantly after surgery, regardless of surgical procedure (P < .001). CONCLUSIONS: Psychosocial outcomes are not improved with contralateral prophylactic mastectomy in women with unilateral breast cancer. Our data may inform women considering contralateral prophylactic mastectomy.

Surgical Morbidity of Full-Thickness Chest Wall Resection for Breast Cancer: A Retrospective Study of a National Database.

BACKGROUND: Full-thickness chest wall resection (FTCWR) is an underused modality for treating locally advanced primary or recurrent breast cancer invading the chest wall, for which little data exist regarding morbidity and mortality. We examined the postoperative complication rates in breast cancer patients undergoing FTCWR using a large multinational surgical outcomes database. METHODS: A retrospective cohort analysis was conducted using the American College of Surgeons National Surgical Quality Improvement Program database. All patients undergoing FTCWR for breast cancer between 2007 and 2016 were identified (n = 137). Primary outcome measures included 30-d postoperative morbidity, composite respiratory complications, and hospital length of stay (LOS). The secondary aim was to compare the postoperative morbidity of FTCWR to those of patients undergoing mastectomy. One-to-one coarsened exact matching was conducted between two groups, which were then compared with respect to morbidity, mortality, reoperations, readmissions, and LOS. RESULTS: The overall rate of postoperative morbidity was 11.7%. Two patients (1.5%) had respiratory complications requiring intubation. Median hospital LOS was 2 d. In the coarsened exact matching analysis, 122 patients were included in each of the two groups. Comparison of matched cohorts demonstrated an overall morbidity for the FTCWR group of 11.5% compared with 8.2% for the mastectomy group (8.2%) (P = 0.52). CONCLUSIONS: FTCWR for the local treatment of breast cancer can be performed with relatively low morbidity and respiratory complications. This is the largest study looking at postoperative complications for FTCWR in the treatment of breast cancer. Future studies are needed to determine the long-term outcomes of FTCWR in this patient population.

Early Postoperative Complications From National Surgical Quality Improvement Program: A Closer Examination of Timing and Technique of Breast Reconstruction.

BACKGROUND: Despite the recent surge in rates of immediate breast reconstruction, there is a paucity of large multicenter studies to compare differences in morbidity after immediate versus delayed breast reconstruction. This study used the National Surgical Quality Improvement Program (NSQIP) to study the association between timing of breast reconstruction and complication rates, stratified by reconstructive modality. STUDY DESIGN: The NSQIP database was used to identify breast reconstructions from 2005 to 2012. Rates of major complications were compared by timing within each reconstructive modality (implant vs autologous). Cohort differences in baseline characteristics and variables associated with increased complication rates were identified in bivariate analyses. A multivariable model was created to compare the association between the timing of reconstruction and major complications. RESULTS: Of 24,506 postmastectomy reconstructions, 85.8% were immediate, 14.2% were delayed, 84% were implant, and 16% were autologous reconstructions. Overall, 10.0% of patients suffered a major complication. After stratification, only implant reconstructions showed a statistically higher complication rate with immediate (8.8%) reconstruction compared with delayed (5.3%) (odds ratio, 1.7, P < 0.01). There was no significant difference in complication rates between autologous immediate (18.4%) or delayed (19.0%) reconstructions. After controlling for baseline cohort differences and other risk factors, immediate reconstruction remained as an independent significant predictor of major complications in implant reconstructions (odds ratio, 1.8, P < 0.01). CONCLUSIONS: Immediate rather than delayed breast reconstruction is associated with a significantly higher rate of major complications in implant reconstruction but not in autologous reconstruction. It is important to include these findings in the routine preoperative surgeon-patient discussion of reconstructive options.

Preconsultation Educational Group Intervention Can Address the Knowledge Gap in Postmastectomy Breast Reconstruction.

BACKGROUND: Whether to undergo postmastectomy breast reconstruction (PMBR) is a challenging, preference-sensitive decision. It is therefore paramount to optimize decision quality through ensuring patients' knowledge and aligning treatments with their personal preferences. This study assessed the effects of a preconsultation educational group intervention (PEGI) on patient knowledge, state-trait anxiety, and decisional conflict (patient uncertainty in decision making) during the decision-making process. METHODS: This phase 3 randomized controlled trial assessed effects of a PEGI in women without active breast cancer undergoing delayed PMBR, or prophylactic mastectomy with immediate PMBR. Both groups underwent routine education before consultation. In addition, the intervention group underwent a PEGI composed of presentations from a plastic surgeon and nurse, a value clarification exercise, and shared experiences from PMBR patients before the consultation with the plastic surgeon. Before and 1-week after consultation, outcome measures were assessed using the Decisional Conflict Scale, State-Trait Anxiety Inventory, and the BREAST-Q. RESULTS: Of the 219 women deemed eligible, a total of 156 women were recruited and randomized. Treatment fidelity was 96% and retention was 88%. At baseline, there were no significant differences in terms of demographic or clinical status, knowledge, state-trait anxiety, and decisional conflict. Patient knowledge about PMBR improved in both groups; however, the degree of knowledge attainment was significantly greater in the PEGI group (24.5% improvement in the intervention group compared with 13.5% in the routine education group, P < 0.001). The reduction in decisional conflict from baseline to follow-up was greater in the intervention group compared with the routine education; however, the difference only approached significance (P = 0.09). CONCLUSIONS: The provision of a preconsultation educational group intervention has been shown to significantly close the knowledge gap on PMBR in patients seeking delayed breast reconstruction or prophylactic mastectomy with immediate breast reconstruction compared with routine education alone.

Does oncoplastic surgery increase immediate (30-day) postoperative complications? An analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database.

PURPOSE: Although there has been a significant increase in the use of oncoplastic surgery (OPS), data on the postoperative safety of this approach are limited compared to traditional lumpectomy. This study aimed to compare the immediate (30-day) postoperative complications associated with OPS and traditional lumpectomy. METHODS: An analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was performed on women with breast cancer who underwent OPS or traditional lumpectomy. Logistic regression was used to explore the effect of type of surgery on the outcome of interest. RESULTS: A total of 109,487 women were analyzed of whom 8.3% underwent OPS. OPS had a longer median operative time than traditional lumpectomy. The unadjusted immediate (30-day) overall complication rate was significantly higher with OPS than traditional lumpectomy (3.8% versus 2.6%, p < 0.001). After adjusting for baseline differences, overall 30-day postoperative complications were significantly higher amongst women undergoing OPS compared with traditional lumpectomy (OR 1.41, 95%CI 1.24-1.59). Factors that were independent predictors of overall 30-day complications included higher age, higher BMI, race, smoking status, lymph node surgery, neoadjuvant chemotherapy, ASA class ≥ 3, in situ disease, and year of operation. The interaction term between type of surgery and operative time was not statistically significant, indicating that operative time did not modify the effect of type of surgery on immediate postoperative complications. CONCLUSIONS: Although there were slightly higher overall complication rates with OPS, the absolute rates remained quite low for both groups. Therefore, OPS may be performed in women with breast cancer who are suitable candidates.

Screening women at high risk for breast cancer: one program fits all? : Subgroup analysis of a large population high risk breast screening program.

INTRODUCTION: The Ontario High Risk Breast Screening program follows women aged 30-69 at an increased risk of breast cancer, using a yearly mammography and breast MRI. The aim of this study is to determine the clinical outcomes for the enrolled women. METHODS: Observational cohort study following 2081 participants in the high-risk screening program 2011-2017. The participants were divided into three subgroup according to their risk criteria: (a) known carriers of pathogenic variants (PV) in hereditary breast cancer genes. (b) Previous chest radiotherapy. (c) Estimated life time risk (ELR) ≥ 25%, calculated using the International Breast Cancer Intervention Study (IBIS) tool, with no known mutation or previous radiation. All Breast Cancer (BC) diagnosed during the follow-up time were recorded. RESULTS: 673 women carried PVs in hereditary breast cancer genes, 159 had a history of chest radiotherapy, and 1249 had an ELR ≥ 25%. The total cohort of screening years was 8126. Median age at BC diagnosis was 41 for the first group, 47 for the second group and 51 for the third. BC incidence rate was 18.2 for PV mutation carriers, 17.9 for the chest radiotherapy group and 6.2 for ELR ≥ 25%. Hazard ratio was similar for the first two groups, but significantly lower for the ELR ≥ 25% group. When stratifying by age, the incidence rate in the ELR ≥ 25% increased over time, until it became similar to that of the other subgroups after age 50. CONCLUSION: Our findings question the need to screen women with an elevated lifetime risk using the same screening practices used for women who are PV mutation carriers, or with a history of chest radiation, prior to the age of 50.

Is immediate breast reconstruction safe in women over 70? An analysis of the National Surgical Quality Improvement Program (NSQIP) database.

PURPOSE: The safety of immediate breast reconstruction (IBR) in older women is largely unknown. This study aimed to determine the 30-day postoperative complication rates following IBR (implant-based or autologous) in older women (≥ 70 years) with breast cancer and to compare them to younger women (18-69 years). METHODS: The National Surgical Quality Improvement Program (NSQIP) database was used to identify women with in situ or invasive breast cancer who underwent IBR (2005-2016). Outcomes included 30-day postoperative morbidity and mortality, which were compared across age groups stratified by type of reconstruction. RESULTS: Of 28,850 women who underwent implant-based and 9123 who underwent autologous reconstruction, older women comprised 6.5% and 5.7% of the sample, respectively. Compared to younger women, older women had more comorbidities, shorter operative times, and longer length of hospital stay. In the implant-based reconstruction group, the 30-day morbidity rate was significantly higher in older women (7.5% vs 5.3%, p < 0.0001) due to higher rates of infectious, pulmonary, and venous thromboembolic events. Wound morbidity and prosthesis failure occurred equally among age groups. In the autologous reconstruction group, there was no statistically significant difference in the 30-day morbidity rates (older 9.5% vs younger 11.6%, p = 0.15). Both wound morbidity and flap failure rates were similar between the two age groups. For both reconstruction techniques, mortality within 30 days of breast surgery was rare. CONCLUSION: Immediate breast reconstruction is safe in older women. These data support the notion that surgeons should discuss IBR as a safe and integral part of cancer treatment in well-selected older women.

Concurrent risk-reduction surgery in patients with increased lifetime risk for breast and ovarian cancer: an analysis of the National Surgical Quality Improvement Program (NSQIP) database.

BACKGROUND: Patients with genetic susceptibility to breast and ovarian cancer are eligible for risk-reduction surgery. Surgical morbidity of risk-reduction mastectomy (RRM) with concurrent bilateral salpingo-oophorectomy (BSO) is unknown. Outcomes in these patients were compared to patients undergoing RRM without BSO using a large multi-institutional database. METHODS: A retrospective cohort analysis was conducted using the American College of Surgeon's National Surgical Quality Improvement Program (NSQIP) 2007-2016 datasets, comparing postoperative morbidity between patients undergoing RRM with patients undergoing RRM with concurrent BSO. Patients with genetic susceptibility to breast/ovarian cancer undergoing risk-reduction surgery were identified. The primary outcome was 30-day postoperative major morbidity. Secondary outcomes included surgical site infections, reoperations, readmissions, length of stay, and venous thromboembolic events. A multivariate analysis was performed to determine predictors of postoperative morbidity and the adjusted effect of concurrent BSO on morbidity. RESULTS: Of the 5470 patients undergoing RRM, 149 (2.7%) underwent concurrent BSO. The overall rate of major morbidity and postoperative infections was 4.5% and 4.6%, respectively. There was no significant difference in the rate of postoperative major morbidity (4.5% vs 4.7%, p = 0.91) or any of the secondary outcomes between patients undergoing RRM without BSO vs. those undergoing RRM with concurrent BSO. Multivariable analysis showed Body Mass Index (OR 1.05; p < 0.001) and smoking (OR 1.78; p = 0.003) to be the only predictors associated with major morbidity. Neither immediate breast reconstruction (OR 1.02; p = 0.93) nor concurrent BSO (OR 0.94; p = 0.89) were associated with increased postoperative major morbidity. CONCLUSION: This study demonstrated that RRM with concurrent BSO was not associated with significant additional morbidity when compared to RRM without BSO. Therefore, this joint approach may be considered for select patients at risk for both breast and ovarian cancer.

Evolving surgical treatment decisions for male breast cancer: an analysis of the National Surgical Quality Improvement Program (NSQIP) database.

BACKGROUND: Male breast cancer (MBC) is a rare malignancy, and gender-specific treatment outcomes are currently lacking. The use of a large, multi-national surgical-outcomes database may provide a better understanding of treatment patterns and postoperative morbidity in men who undergo oncological breast surgery. METHODS: A retrospective cohort analysis was conducted between 2007 and 2016 using the American College of Surgeons National Surgical Quality Improvement Program database (NSQIP), examining MBC treatment patterns and postoperative complication rates. All men undergoing surgery for the treatment of invasive or in situ carcinoma of the breast were identified. Clinical characteristics, demographics, and surgical treatment options most frequently used for this population were described. In addition, the 30-day postoperative complication rates in the surgical treatment of male breast cancer were evaluated. RESULTS: A total of 1773 MBC patients with a median age of 65 years (IQR 56-74 years) were included in this analysis. Mean body mass index (BMI) was 29.1 (IQR 25.4-33.8). In this study population, 177 (10.0%) had a diagnosis of in situ breast cancer, while the remaining 1596 (90.0%) had invasive disease. While most men underwent mastectomy, 282 (15.9%) had breast-conserving surgery. There were 74 (4.2%) patients who underwent immediate breast reconstruction. In addition, 118 (6.7%) patients elected to have a contralateral prophylactic mastectomy. Overall, the rate of morbidity was 4.6%, comprising mostly of wound complications (3.2%). CONCLUSION: Analysis of this large, prospective multi-institutional cohort revealed that complication rates are low and comparable to reported rates in the female breast cancer population. What is also significant about this analysis is that the cohort demonstrated the importance of cosmetic considerations in MBC patients, as some men decide to undergo breast-conserving surgery or immediate breast reconstruction. Contralateral prophylactic mastectomy in the treatment of MBC is also performed.

Thirty-day postoperative morbidity and mortality in elderly women with breast cancer: an analysis of the NSQIP database.

PURPOSE: Postoperative complication rates for elderly women undergoing breast cancer surgery have not been well studied. We describe the postoperative complication rates of elderly (≥ 70 years) women with breast cancer and compare them with young (40-69 years) women. METHODS: Data were extracted from the National Surgical Quality Improvement Program database (2004-2014). We included women with invasive breast cancer who underwent surgery. Outcomes were 30-day postoperative morbidity and mortality (complications), which were compared between young and elderly women. Morbidity was categorized using the Surgical Risk Preoperative Assessment System (SURPAS) clusters. RESULTS: We identified 100,037 women of which 26.7% were elderly. Compared to young women, elderly women were more likely to have more comorbidities and undergo breast-conserving surgery, but less likely to undergo lymph node surgery, breast reconstruction, and neoadjuvant chemotherapy. While the 30-day overall morbidity rate was not significantly different between young and elderly women (3.9 vs. 3.8%, p = 0.2), elderly women did have significantly higher rates of pulmonary, cardiac (arrest and myocardial infarction), venous thromboembolic, and neurological morbidity. Specific morbidities that showed significantly lower rates among elderly women included wound disruption and deep and organ space surgical site infection. Any cause death was significantly higher in elderly compared to young women (0.2 vs. 0.05%, p < 0.001). CONCLUSIONS: While some specific 30-day postoperative morbidities were more often seen in elderly women, the overall 30-day postoperative complication rate was very low. These data support the safety of breast cancer surgery in well-selected elderly patients.

Using Texting for Clinical Communication in Surgery: A Survey of Academic Staff Surgeons.

BACKGROUND: Text messaging has become ubiquitous and is being increasingly used within the health care system. The purpose of this study was to understand texting practices for clinical communication among staff surgeons at a large academic institution. METHODS: Staff surgeons in 4 subspecialties (vascular, plastics, urology, and general surgery) were surveyed electronically. RESULTS: A total of 62 surgeons from general surgery (n = 33), vascular surgery (n = 6), plastic surgery (n = 13), and urology (n = 10) completed the study (response rate 30%). When conveying urgent patient-related information, staff surgeons preferred directly calling other staff surgeons (61.5%) and trainees (58.8%). When discussing routine patient information, staff surgeons used email to reach other staff surgeons (54.9%) but preferred texting (62.7%) for trainees. The majority of participants used texting because it is fast (65.4%), convenient (69.2%) and allows transmitting information to multiple recipients simultaneously (63.5%). Most felt that texting enhances patient care (71.5%); however, only half believed that it enhanced trainees' educational experiences. The majority believed that texting identifiable patient information breaches patient confidentiality. CONCLUSIONS: Our data showed high adoption of text messaging for clinical communication among surgeons, particularly with trainees. The majority of surgeons acknowledge security concerns inherent in texting for patient care. Existing mobile communication platforms fail to meet the needs of academic surgeons. Further research should include guidelines related to texting in clinical practice, educational implications of texting, and technologies to better meet the needs of clinicians working in an academic surgical settings.

Complications of Oncoplastic Breast Surgery Involving Soft Tissue Transfer Versus Breast-Conserving Surgery: An Analysis of the NSQIP Database.

BACKGROUND: Oncoplastic breast surgery (OBS) aims to provide breast cancer patients with optimum oncologic outcomes and excellent cosmesis. We sought to determine if there is a difference in complications associated with OBS involving soft tissue transfer compared with the traditional breast-conserving surgical (BCS) approach. METHODS: Analysis of the American College of Surgeons National Surgical Quality Improvement Program database was performed. Patients with breast cancer who underwent BCS from 2005 to 2014 were included in the study cohort, while patients undergoing concurrent high-risk non-breast surgery, male patients, and those with metastatic disease were excluded. Patients with concomitant current procedural terminology codes identifying soft tissue transfer were categorized as having OBS. Multivariable analysis was performed to determine the independent effect of OBS on postoperative morbidity. RESULTS: We identified 75,972 patients who underwent BCS for breast cancer between 2005 and 2014, of whom 1363 (1.8 %) underwent OBS with soft tissue transfer. Compared with the standard lumpectomy group, patients undergoing OBS were more likely to be younger, had a lower body mass index, were less likely to be smokers, and more often received neoadjuvant chemotherapy. OBS with soft tissue transfer also had a significantly longer operative time (83 vs. 59 min; p < 0.001). The multivariable analysis confirmed that soft tissue transfer OBS was not an independent predictor of overall complications (odds ratio 0.78; 95 % confidence interval 0.50-1.19). CONCLUSIONS: These data confirm that the use of OBS with soft tissue transfer for breast cancer treatment does not confer an increased risk of surgical complications, despite the longer operative time. This is important given the increasing use of oncoplastic surgery techniques within North America.

Smartphones and Patient Care: Exploring the Use of Text-Based Messaging for Patient-Related Communication.

Background Text messaging (texting) has become a routine medium of communication in society. However, its use among clinicians has not been fully characterized. We explored general surgery residents' practices and views on texting for patient-related communication. Methods An email survey was distributed to all general surgery residents at a large Canadian medical school. Results Overall, 46 (57%) of those surveyed responded. All used texting for patient-related communication. Eleven percent of residents did not have a password on their cell phone and 89% did not have encrypted phones. Texting was the most common way (41%) by which residents communicated routine patient-related information with staff physicians. Most (85%) residents agreed that texting enhances patient care. The majority (66%) did not know if their hospital had a policy on texting and were unaware of legislation surrounding texting in patient care (89%). Conclusions Most general surgery residents use texting for communication of routine patient-related care issues. However, they acknowledge concerns regarding the security of this medium.

Long-Term Psychosocial Functioning in Women with Bilateral Prophylactic Mastectomy: Does Preservation of the Nipple-Areolar Complex Make a Difference?

INTRODUCTION: Nipple-sparing prophylactic mastectomy (PM) is an option for women at high-risk for breast cancer, and may offer better cosmetic results than a skin-sparing PM where the nipple-areolar complex (NAC) is removed. However, there may be residual breast cancer risk due to the maintained NAC. It is unclear if sparing the NAC with PM impacts on psychosocial functioning, including cancer-related distress and body image after PM. METHODS: This was a cross-sectional survey study of women who had undergone bilateral PM (no previous breast cancer) recruited through surgical or cancer genetics clinics. All women completed standardized questionnaires assessing cancer-related distress, anxiety, depression, satisfaction with decision, decision regret, and health-related quality of life related to breast surgery. Outcomes were compared between women with nipple-areola-sparing PM (NAC-PM) and skin-sparing PM (SS-PM). RESULTS: Overall, 137 women completed the study; 53 (39%) had NAC-PM and 84 (61%) had SS-PM. The mean age of the study population was 41.5 years [standard deviation (SD) 8.8] and the mean time between PM and questionnaire completion was 50 months (SD 31). On the BREAST-Q, we found that women with NAC-PM had significantly higher levels of satisfaction with breasts (p = 0.01), satisfaction with outcome (p = 0.02), and sexual well-being (p < 0.001) compared with SS-PM. No statistically significant differences in total cancer-related distress (p = 0.89), anxiety (p = 0.86), or depression (p = 0.93) were observed between the two groups. CONCLUSIONS: Overall, women with NAC-PM had better body image and sexual functioning compared with women with SS-PM, while both groups had comparable levels of cancer-related distress and perception of breast cancer risk.

The Impact of COVID-19 on Breast Cancer Care: A Qualitative Analysis of Surgeons' Perspectives.

INTRODUCTION: While studies have documented delays in breast cancer (BC) care during the COVID-19 pandemic due to healthcare restrictions, there have been no studies on the experiences, and, particularly, the challenges with providing care faced by breast surgeons during this unprecedented time. This paper aims to understand the perspectives of breast surgeons regarding the impact of the COVID-19 pandemic on BC care. METHODS: We used purposeful and snowball sampling to identify breast surgeons in Ontario, Canada. One-on-one qualitative semi-structured interviews were conducted exploring the impact of the pandemic on BC treatment, psychosocial well-being of patients and providers, and the future state of BC care. Audio-recorded interviews were transcribed verbatim and analyzed using Thematic Analysis. RESULTS: A total of 10 breast surgeons (5 community and 5 academic) were interviewed. Breast surgeons reported that the pandemic led to increased multidisciplinary collaboration and innovations in delivery of BC surgery (e.g., increased use of regional anesthesia). Multiple surgeons identified that the pandemic created disparities in BC care based geographic location and that existing disparities in care based on ethnicity or marginalization were exacerbated. Last, surgeons identified that virtual care improved, but also created some challenges to how BC care was delivered, with many hoping for this to be continued after the pandemic was over. CONCLUSIONS: In this study, breast surgeons identified unique challenges and solutions to BC care delivery during the pandemic. Concerns regarding disparities in care based on geographic location and marginalized patients require further study to improve future BC care.