Whither surgical quality assurance of breast cancer surgery (surgical margins and local recurrence) after paterson.

PURPOSE: The Kennedy report into the actions of the disgraced Breast Surgeon, Paterson focussed on issues of informed consent for mastectomy, management of surgical margins and raised concerns about local recurrence rates and the increasing emphasis on cosmesis after mastectomy for breast cancer. This article assesses whether Kennedy's recommendations apply to the UK as a whole and how to address these issues. New GMC advice on consent and newer nonevidenced innovations in immediate reconstruction have altered the level of informed consent required. Patients deserve a better understanding of the issues of oncological versus cosmetic outcomes on which to base their decisions. Involvement of the whole multidisciplinary team including Oncologists is necessary in surgical planning. Failure to obtain clear microscopic margins at mastectomy leads to an increased local recurrence, yet has received little attention in the UK. Whereas, other countries have used surgical quality assurance audits to reduce local recurrence; local recurrence rates are not available and the extent of variation across the UK in margin involvement after surgery, its management and relationship to local recurrence needs auditing prospectively to reduce unnecessary morbidity. To reassure public, patients and the NHS management, an accreditation system with more rigour than NHSBSP QA and peer review is now required. Resource and efforts to support its introduction will be necessary from the Royal College of Surgeons and the Association of Breast Surgeons. New innovations require careful evaluation before their backdoor introduction to the NHS. Private Hospitals need to have the same standards imposed.

Making decisions about breast reconstruction: A systematic review of patient-reported factors influencing choice.

PURPOSE: Many studies have explored women's reasons for choosing or declining a particular type of breast reconstruction (BR) following mastectomy for breast cancer. This systematic review synthesises women's reasons for choosing a range of BR options, including no BR, in different settings and across time. METHODS: Thirteen databases were systematically searched, with 30 studies (4269 participants), meeting the selection criteria. Information on study aim and time frame, participation rate, design/methods, limitations/bias, reasons and conclusions, as well as participant clinical and demographic information, was reported. An overall quality score was generated for each study. Reasons were grouped into eight domains. RESULTS: While study methodology and results were heterogeneous, all reported reasons were covered by the eight domains: Feeling/looking normal; Feeling/looking good; Being practical; Influence of others; Relationship expectations; Fear; Timing; and Unnecessary. We found a strong consistency in reasons across studies, ranging from 52% of relevant publications citing relationship expectations as a reason for choosing BR, up to 91% citing fear as a reason for delaying or declining BR. Major thematic findings were a lack of adequate information about BR, lack of genuine choice for women and additional access limitations due to health system barriers. CONCLUSIONS: Understanding women's reasons for wanting or not wanting BR can assist clinicians to help women make choices most aligned with their individual values and needs. Our thematic findings have equity implications and illustrate the need for surgeons to discuss all clinically appropriate BR options with mastectomy patients, even if some options are not available locally.

Parental reasoning about growth attenuation therapy: report of a single-case study.

In 2006 a case report was published about a 6-year-old girl, Ashley, who has profound developmental disabilities and was treated with oestrogen patches to limit her final height, along with a hysterectomy and the removal of her breast buds. Ashley's parents claimed that attenuating her growth would make it possible for them to lift and move her more easily, facilitating greater involvement in family activities and making routine care more straightforward. The 'Ashley treatment' provoked public comment and academic debate and remains ethically controversial. As more children are being referred for such treatment, there is an urgent need to clarify how clinicians and ethics committees should respond to such requests. The controversy surrounding the Ashley treatment exists, at least in part, because of gaps in the literature, including a lack of empirical data about the outcomes for children who do and do not receive such treatment. However, we suggest in this paper that there is also merit in examining the parental decision-making process itself, and provide empirical data about the reasoning of one set of parents who ultimately chose part of this treatment for their child. Using the interview data, we illuminate some important points regarding how these parents characterise benefits and harms and their responsibilities as surrogate decision-makers. This analysis could inform decision-making about future requests for growth attenuation and might also have wider relevance to healthcare decision-making for children with profound cognitive impairment.

Ashley revisited: a response to the critics.

The case of Ashley X involved a young girl with profound and permanent developmental disability who underwent growth attenuation using high-dose estrogen, a hysterectomy, and surgical removal of her breast buds. Many individuals and groups have been critical of the decisions made by Ashley's parents, physicians, and the hospital ethics committee that supported the decision. While some of the opposition has been grounded in distorted facts and misunderstandings, others have raised important concerns. The purpose of this paper is to provide a brief review of the case and the issues it raised, then address 25 distinct substantive arguments that have been proposed as reasons that Ashley's treatment might be unethical. We conclude that while some important concerns have been raised, the weight of these concerns is not sufficient to consider the interventions used in Ashley's case to be contrary to her best interests, nor are they sufficient to preclude similar use of these interventions in the future for carefully selected patients who might also benefit from them.

Agency, duties and the "Ashley treatment".

In 2006, a paper in the journal Archives of Pediatric and Adolescent Medicine described a novel case of growth attenuation therapy and other treatments carried out on Ashley, a severely cognitively, neurologically and physically disabled 6-year-old girl. Some of the moral arguments that have sprung up in respect of the so-called "Ashley treatment" are considered, and it is suggested that they all miss something-that the proper treatment of Ashley may have as much to do with doctors' duties to themselves as with their duties to her. It is suggested that the Ashley treatment may have been in violation of doctors' self-regarding duties and that this possibility is worthy of further investigation.

Revisiting the legal standards that govern requests to sterilize profoundly incompetent children: in light of the "Ashley Treatment," is a new standard appropriate?

This Note discusses the recent controversy surrounding a six-year-old girl named Ashley, whose parents chose to purposefully stunt her growth and remove her reproductive organs for nonmedical reasons. A federal investigation determined that Ashley's rights had been violated because doctors performed the procedure, now referred to as the "Ashley Treatment," without first obtaining a court order. However, the investigation did not make any conclusions regarding whether the "Ashley Treatment" could present a legally permissible treatment option in the future. After discussing the constitutional rights that the "Ashley Treatment" implicates and the current legal standards in place, this Note examines how courts have applied these legal standards to cases involving extreme requests. Drawing upon legal commentators, this Note concludes that a court could approve a request for the "Ashley Treatment" in appropriate and limited cases where the parents have presented clear and convincing evidence before a court that the benefits that the "Ashley Treatment" would provide to the child and her family outweigh the risks associated with the procedure. This Note argues that those benefits may include extrinsic considerations, but courts should remain cautious when considering such evidence and be sure that the evidence as a whole supports their conclusions.