Social Network, Surgeon, and Media Influence on the Decision to Undergo Contralateral Prophylactic Mastectomy.

OBJECTIVES: The rate of contralateral prophylactic mastectomy (CPM) has risen sharply in the past decade. The current study was designed to examine social network, surgeon, and media influence on patients' CPM decision-making, examining not only who influenced the decision, and to what extent, but also the type of influence exerted. METHODS: Patients (N=113) who underwent CPM at 4 Indiana University-affiliated hospitals between 2008 and 2012 completed structured telephone interviews in 2013. Questions addressed the involvement and influence of the social network (family, friends, and nonsurgeon health professionals), surgeon, and media on the CPM decision. RESULTS: Spouses, children, family, friends, and health professionals were reported as exerting a meaningful degree of influence on patients' decisions, largely in ways that were positive or neutral toward CPM. Most surgeons were regarded as providing options rather than encouraging or discouraging CPM. Media influence was present, but limited. CONCLUSIONS: Patients who choose CPM do so with influence and support from members of their social networks. Reversing the increasing choice of CPM will require educating these influential others, which can be accomplished by encouraging patients to include them in clinical consultations, and by providing patients with educational materials that can be shared with their social networks. Surgeons need to be perceived as having an opinion, specifically that CPM should be reserved for those patients for whom it is medically indicated.

Motivations for contralateral prophylactic mastectomy as a function of socioeconomic status.

BACKGROUND: Despite no demonstrated survival advantage for women at average risk of breast cancer, rates of contralateral prophylactic mastectomy (CPM) continue to increase. Research reveals women with higher socioeconomic status (SES) are more likely to select CPM. This study examines how indicators of SES, age, and disease severity affect CPM motivations. METHODS: Patients (N = 113) who underwent CPM at four Indiana University affiliated hospitals completed telephone interviews in 2013. Participants answered questions about 11 CPM motivations and provided demographic information. Responses to motivation items were factor analyzed, resulting in 4 motivational factors: reducing long-term risk, symmetry, avoiding future medical visits, and avoiding treatments. RESULTS: Across demographic differences, reducing long-term risk was the strongest CPM motivation. Lower income predicted stronger motivation to reduce long-term risk and avoid treatment. Older participants were more motivated to avoid treatment; younger and more-educated patients were more concerned about symmetry. Greater severity of diagnosis predicted avoiding treatments. CONCLUSIONS: Reducing long-term risk is the primary motivation across groups, but there are also notable differences as a function of age, education, income, and disease severity. To stop the trend of increasing CPM, physicians must tailor patient counseling to address motivations that are consistent across patient populations and those that vary between populations.

Central venous port placement: a comparison of axillary versus anterior chest wall placement.

BACKGROUND: To compare morbidity in patients with surgically implanted central venous ports that were placed in the subcutaneous tissues of the mid axillary line at the anterior border of the latissimus muscle (group A) versus the anterior chest wall (group C). METHODS: Between 2003 and 2007, a total of 183 patients with breast cancer were taken to the operating room for central venous port placement for delivery of chemotherapy. Port location was determined by patient and surgeon preference. Patient demographics were collected, and complications were evaluated by electronic medical record review. Complications identified included infection, thrombosis, port problems, and catheter problems. Basic descriptive statistics were generated. Patients with axillary ports were then compared to those with chest wall ports by appropriate t-tests or χ(2) tests. RESULTS: During this period, 137 (75%) of 183 ports were placed in the axillary position. The complication rate was 10% (9% in group A vs. 13% in group C). There were 14 catheter-related complications and 5 port-related complications. There was no statistically significant difference in complications between the two groups (P = 0.45). Patients with axillary ports weighed less (mean 75.8 kg in group A vs. 84.9 kg in group C) and were more likely to have catheters placed in the internal jugular vein (82% in group A vs. 56% in group C). CONCLUSIONS: There is no difference in rate or type of complications between axillary and chest wall port location. Subcutaneous ports can safely be placed in the mid axillary line. Axillary ports spare the patient the negative cosmetic outcomes of chest wall ports.

Can medical students achieve skills proficiency through simulation training?

BACKGROUND: The purpose of this study was to determine whether third-year medical students can become proficient in open technical skills through simulation laboratory training. METHODS: A total of 204 students participated in a structured curriculum including bladder catheterization, breast examination, and knot-tying. Proficiency was documented using global rating scales and validated, objective, model-based metrics. RESULTS: For catheterization and breast examination, all trainees showed proficiency, and self-rated comfort increased in more than 90%. For knot-tying, 83% completed the curriculum; 57% and 44% of trainees showed proficiency for 2- and 1-handed tasks, respectively. Objective performance scores improved significantly for 2- and 1-handed knot-tying (62.9-94.4 and 49.2-89.6, respectively; P < .001) and comfort rating also increased (28%-91% and 19%-80%, respectively; P < .001). CONCLUSIONS: Objective scores and trainee self-ratings suggest that this structured curriculum using simulator training allows junior medical students to achieve proficiency in basic surgical skills.

The effect of dedicated breast surgeons on the short-term outcomes in breast cancer.

OBJECTIVE: The impact of breast surgeons on short-term outcomes in breast cancer care was compared at a single institution. SUMMARY BACKGROUND DATA: Many studies have demonstrated a correlation between high procedural volume and lower mortality in technically challenging procedures. Breast cancer treatment has significant impact on patient behavior, psychology, and appearance. Therefore, evaluation of outcomes cannot be limited to only operative mortality and morbidity. We sought to determine the effect of dedicated breast cancer surgeons on short-term outcomes at a single institution. METHODS: Wishard Memorial Hospital is the county hospital affiliated with the Indiana University School of Medicine. A retrospective review was performed of all patients from January 1, 1997, to February 28, 2006. On July 1, 2003, coverage for the Breast Clinic was changed from general surgeons (G) to breast surgeons (B). There were 596 patients included in the study period. RESULTS: There were no significant differences in patient demographics or disease characteristics between the 2 time periods. For early stage (stage I and II) breast cancer, a higher percentage of patients underwent breast conservation in the breast surgeon period than in the general surgeon period (P = 0.04). Lumpectomy margins in breast conserving operations during the G period were more often positive (P = 0.025) or close (<1 mm) (P = 0.01). Similarly, the rates of re-excision lumpectomy were also significantly lower during the B period (21% vs. 39%, respectively, P = 0.01). Breast surgeons were more likely to perform the sentinel node procedure (P = 0.001). There were no differences in the use of adjuvant chemotherapy and radiation therapy. The use of hormonal manipulation, however, was significantly higher in the B group than in the G group (P < 0.0002). CONCLUSIONS: Surgeons specialized in diseases of the breast demonstrate significant improvement in short-term outcomes associated with breast cancer treatment at a single institution. The differences identified cannot be attributed to differences in institutional function, patient population, surgeon case volume, or on the influence of nonsurgeon physicians.