Importance of attachment to place in growing a sustainable Australian Rural Health Workforce: A rapid review.

INTRODUCTION: Personal, community, and environmental factors can influence the attraction and retention of regional, rural, and remote health workers. However, the concept of place attachment needs further attention as a factor affecting the sustainability of the rural health workforce. OBJECTIVE: The purpose of this rapid review was to explore the influence of a sense of place in attracting and retaining health professionals in rural and remote areas. DESIGN: A systematic rapid review was conducted based on an empirical model using four dimensions: place dependence, place identity, social bonding and nature bonding. English-language publications between 2011 and 2021 were sought from academic databases, including studies relevant to Australian health professionals. FINDINGS: A total of 348 articles were screened and 52 included in the review. Place attachment factors varied across disciplines and included (a) intrinsic place-based personal factors; (b) learning experiences enhancing self-efficacy and rural health work interest; (c) relational, social and community integration; and (d) connection to place with lifestyle aspirations. DISCUSSION: This rapid review provides insight into the role of relational connections in building a health workforce and suggests that community factors are important in building attachment through social bonding and place identity. Results indicate that future health workforce research should focus on career decision-making and psychological appraisals including place attachment. CONCLUSION: An attachment to place might develop through placement experiences or from a strong rural upbringing. The importance of the relational interactions within a work community and the broader community is seen as an important factor in attracting, recruiting, and sustaining a rural health workforce.

TARGIT-R (Retrospective): North American Experience with Intraoperative Radiation Using Low-Kilovoltage X-Rays for Breast Cancer.

BACKGROUND: Single-dose intraoperative radiotherapy (IORT) is an emerging treatment for women with early stage breast cancer. The objective of this study was to define the frequency of IORT use, patient selection, and outcomes of patients treated in North America. METHODS: A multi-institutional retrospective registry was created, and 19 institutions using low-kilovoltage IORT for the treatment of breast cancer entered data on patients treated at their institution before July 31, 2013. Patient selection, IORT treatment details, complications, and recurrences were analyzed. RESULTS: From 2007 to July 31, 2013, a total of 935 women were identified and treated with lumpectomy and IORT. A total of 822 patients had at least 6 months' follow-up documented and were included in the analysis. The number of IORT cases performed increased significantly over time (p < 0.001). The median patient age was 66.8 years. Most patients had disease that was <2 cm in size (90 %) and was estrogen positive (91 %); most patients had invasive ductal cancer (68 %). Of those who had a sentinel lymph node procedure performed, 89 % had negative sentinel lymph nodes. The types of IORT performed were primary IORT in 79 %, secondary IORT in 7 %, or planned boost in 14 %. Complications were low. At a median follow-up of 23.3 months, crude in-breast recurrence was 2.3 % for all patients treated. CONCLUSIONS: IORT use for the treatment of breast cancer is significantly increasing in North America, and physicians are selecting low-risk patients for this treatment option. Low complication and local recurrence rates support IORT as a treatment option for selected women with early stage breast cancer.

Shared decision making in breast cancer: national practice patterns of surgeons.

BACKGROUND: The purpose of this study was to assess national practices of surgeons who treat breast cancer in order to identify opportunities to improve patient education. METHODS: In June 2012, the membership of the American Society of Breast Surgeons (ASBrS) (n = 2,818) was surveyed via email questionnaire to evaluate their current practice of shared decision making and informed consent for breast cancer patients. RESULTS: A total of 737 members (26 %) responded, including 384 breast surgeons and 306 general surgeons, 13 midlevel providers, and 25 other specialists. It was found that 90 % of surgeons spent more than 30 min meeting with a new cancer patient, and of these, 30 % spent more than an hour. Surgeons who spent more than 1 h face-to-face with a new cancer patient reported higher levels of overall patient knowledge compared with those who spent less (mean = 3.80 vs. 3.64 of 5; p = 0.001). Also, 89 % of respondents reported using educational tools, of whom more than 90 % used written tools. In addition, 65 % of members stated an interest in a free online educational tool if available and indicated a preference for a flexible tool that could be used by the patient alone or with a nurse. CONCLUSIONS: While practice patterns may vary, our results reveal that one-third of surgeons spend at least 1 h in consultation with a new breast cancer patient. More time spent translated to a higher perceived patient understanding of their disease and treatment options. Although the majority of surgeons currently use written materials, there was clear support for a free online educational tool.

Training a new generation of breast surgeons: are we succeeding?

BACKGROUND: Society of Surgical Oncology (SSO)-approved fellowships in Breast Oncology began training fellows in 2004. Here we ascertain methods of evaluating and improving the fellowship experience through fellowship alumni experience. METHODS: We conducted an electronic survey of fellowship graduates to learn perceived successes and weaknesses of their fellowship training, as well as their current practice experiences. Our electronic survey focused on their preparedness for practice, their job opportunities, and their use of image-guided biopsies in practice. RESULTS: Between 2005 and 2009, 142 fellows graduated and received our survey; 85 (60%) responded. Although 98% of graduates though that they were well prepared by their fellowship for performing breast cancer surgery, fewer thought that they were well prepared to perform oncoplastic techniques (53%), ultrasound (39%), and ultrasound-guided biopsies (28%). Nevertheless, many acquired additional training, and 63% were performing ultrasound-guided biopsies in practice. The majority (76%) were performing breast surgery exclusively, with 14% identifying themselves as director of a breast center and only 29% describing themselves as being in private practice-the rest being employed at a hospital or university. Only 8% of respondents were disappointed with the job market, and 67% stated they had received at least three job offers; 82% were satisfied in their current job. CONCLUSIONS: SSO breast oncology fellowships appear to be training confident, well-prepared graduates with good job outlooks, and many are achieving leadership positions. Deficiencies in sonography training, some advanced surgical techniques, and administrative experiences should be addressed by program directors as graduates do perceive the need for such training.

Breast-specific gamma imaging as an adjunct imaging modality for the diagnosis of breast cancer.

PURPOSE: To retrospectively determine the sensitivity and specificity of breast-specific gamma imaging (BSGI) for the detection of breast cancer by using pathologic results as the reference standard. MATERIALS AND METHODS: This study was Institutional Review Board approved and Health Insurance Portability and Accountability Act compliant. Informed consent was obtained for participants who were not imaged as part of their clinical protocol but were participating in other Institutional Review Board-approved studies that used BSGI. A retrospective review of 146 women (aged 32-98 years) undergoing BSGI and breast biopsy was performed. Patients underwent BSGI with intravenous injection of 30 mCi (1110 MBq) of technetium 99 ((99m)Tc)-sestamibi and were imaged in craniocaudal and mediolateral oblique projections. Study images were assigned scores, and scores were classified as positive (focal increased radiotracer uptake) or negative (no uptake or scattered heterogeneous physiologic uptake) and compared with biopsy results. The sensitivity, specificity, and positive and negative predictive values were determined. RESULTS: In 146 patients, 167 lesions underwent biopsy, of which 83 (16 ductal carcinoma in situ [DCIS] and 67 invasive cancers) were malignant. Of 84 nonmalignant lesions, 82 were benign and two showed atypical histologic results (one atypical lobular hyperplasia and one lobular carcinoma in situ). BSGI helped detect cancer in 80 of 83 malignant lesions with a sensitivity of 96.4% (95% confidence interval [CI]: 92%, 99%) and correctly identified 50 of 84 nonmalignant lesions as negative for cancer with a specificity of 59.5% (95% CI: 49%, 70%). The positive predictive value for 80 of 114 malignant lesions with a BSGI examination with findings positive for cancer was 68.8% (95% CI: 60%, 78%) and the negative predictive value for 50 of 53 nonmalignant lesions was 94.3% (95% CI: 88%, 99%). The smallest invasive cancer and DCIS detected were both 1 mm. BSGI helped detect occult cancer not visualized at mammography or ultrasonography in six patients. CONCLUSION: BSIG has high sensitivity (96.4%) and moderate specificity (59.5%) helping detect breast cancers.

Breast-specific gamma imaging with 99mTc-Sestamibi and magnetic resonance imaging in the diagnosis of breast cancer--a comparative study.

The purpose of this study was to compare the sensitivity and specificity of breast-specific gamma imaging (BSGI) using a high-resolution breast-specific gamma camera and magnetic resonance imaging (MRI) in patients with indeterminate breast findings. Twenty-three women with an indeterminate breast finding that required BSGI and MRI as deemed necessary by the interpreting radiologist or referring physician were included. MRI was performed on a GE 1.5T scanner and BSGI was performed on a Dilon high-resolution breast-specific gamma camera. All imaging findings were correlated with pathologic diagnosis. Thirty-three indeterminate lesions were evaluated in the study. There were a total of nine pathologically confirmed cancers. There was no statistically significant difference in sensitivity of cancer detection between BSGI and MRI. BSGI demonstrated a greater specificity than MRI, 71% and 25%, respectively. BSGI has equal sensitivity and greater specificity than MRI for the detection of breast cancer.

Evaluation of intraoperative scrape cytology for sentinel lymph node biopsy in patients with breast cancer.

The techniques for intraoperative evaluation of sentinel lymph nodes (SLNs) vary. The most common methods include frozen section, imprint cytology/touch preparation cytology, and scrape cytology (SC). The purpose of this study was to evaluate whether there is concordance between the intraoperative SC and the final pathology of SLNs in patients with breast cancer. From October 2001 to June 2005, sentinel lymph node biopsies were attempted in 181 patients with breast cancer using a combination of blue dye and radioisotope. A lymph node was considered an SLN when it was stained with blue dye, had a blue lymphatic afferent, had increased radioactivity, or was abnormal by palpation. SLNs were successfully identified in 180 patients, for an identification rate of 99.4%. Forty-five patients had positive SLNs. In 16 (35%) of those patients, the SLNs were negative intraoperatively by SC. All of the false negatives occurred in SLNs with micrometastases. Thus, SC is an excellent method for identifying macrometastases intraoperatively, but less successful for micrometastases.

Correlation of lymphoscintigraphy with the number of sentinel lymph nodes identified intraoperatively in patients with breast cancer.

BACKGROUND: Numerous studies have evaluated the benefit of performing lymphoscintigraphy for the sentinel lymph node procedure in breast cancer patients. The purpose of this study is to determine if lymphoscintigraphy accurately predicts the number of radioactive sentinel lymph nodes (SLNs) identified during surgery for breast cancer patients. METHODS: From October 2001 to June 2004, SLN biopsy was attempted in 112 patients with breast cancer using a combination of blue dye and radioisotope. Lymphoscintigraphy was performed in 98 of the patients. A lymph node was considered an SLN when it was stained with blue dye, had a blue lymphatic afferent, had increased radioactivity, or was abnormal by palpation. RESULTS: Lymphoscintigraphy accurately predicted the number of radioactive SLN identified intraoperatively in 47 patients. In 44 of the patients who did not have concordance, there were more SLN identified intraoperatively than were seen on lymphoscintigraphy. In the other 8 patients, there were fewer SLN identified intraoperatively than seen on lymphoscintigraphy. CONCLUSIONS: Lymphoscintigraphy accurately predicted the number of SLN identified intraoperatively in only 47% of the patients in this study. In a majority of the patients in whom the lymphoscintigraphy was not concordant, the number of SLN identified intraoperatively was underestimated. Thus, although lymphoscintigraphy is beneficial in showing that at least 1 radioactive SLN will be identified intraoperatively, it does not accurately predict the number.

Prospective study of intraoperative mammary ductoscopy in patients undergoing partial mastectomy for breast cancer.

BACKGROUND: The purpose of this study was to critically evaluate the added benefit of intraoperative mammary ductoscopy on margin assessment and identification of occult intraductal pathology in patients undergoing therapeutic partial mastectomy for in-situ and invasive breast carcinoma. METHODS: Eligible patients underwent intraoperative mammary ductoscopy before partial mastectomy. In patients where an intraductal abnormality was identified and the mammary ductoscope was not within the partial mastectomy cavity, an additional ductoscopy-directed margin of tissue was analyzed. RESULTS: Nineteen of 30 (63%) patients yielded nipple aspirate fluid and were able to undergo mammary ductoscopy; an intraductal abnormality was identified in 15 of 19 (79%) patients. Only 1 patient had an occult infiltrating carcinoma, which was outside of the resection cavity and identified by ductoscopy. CONCLUSIONS: Although mammary ductoscopy can identify intraductal abnormalities during partial mastectomy in a significant number of patients, many of these findings may be either benign or within the standard field of resection, thus adding no benefit to the patient.

Axillary lymph node metastases in patients with a final diagnosis of ductal carcinoma in situ.

BACKGROUND: Recent studies report the incidence of axillary metastases in patients with ductal carcinoma in-situ (DCIS) approaches 13%. The purpose of this study was to define the incidence of axillary micrometastases in patients with pure DCIS before and after the introduction of sentinel lymph node biopsy. METHODS: Patients with a final diagnosis of DCIS form the basis of this study. Data were entered prospectively into an Institutional Review Board approved Oracle database from January 1997 through July 2002. RESULTS: One hundred and thirty-four patients had lymph nodes evaluated. Ninety-eight percent of patients had no evidence of metastatic disease and 2% were found to have micrometastases. This was consistent in those who had level I or II lymph node sampling or both and those who had lymphatic mapping and a sentinel lymph node biopsy procedure. CONCLUSIONS: These data do not support axillary lymph node removal of any type in patients with pure DCIS.