Extramammary findings in diagnostic breast magnetic resonance imaging among patients with known breast cancer: incidence and cost analysis.

BACKGROUND: Extramammary findings (EMFs) are common on breast magnetic resonance imaging (MRI). METHODS: A retrospective review of breast MRIs in breast cancer patients between January 2009 and December 2014 was performed to identify EMF occurrences, resultant evaluation, and added cost. RESULTS: EMFs were noted in 185 (59%) of 316 MRIs. Overall, 201 new EMFs were identified with 178 (89%) benign and 23 (11%) malignant. New malignant findings included 19 metastatic nodes (18 axillary, 1 internal mammary) and 4 primary malignancies (2 thyroid, 2 lung). New malignant nonaxillary EMFs occurred at a rate of 1.6% (5/316). EMFs resulted in 65 patients undergoing 98 imaging studies, 37 procedures, and 10 consultations with a median (range) total charge of $3,491 ($222 to $29,076] and out of pocket cost of $2,206 ($44 to $12,780) per patient. CONCLUSIONS: EMFs occurred in more than half of our patients, were usually benign, and frequently led to additional testing and costs.

Are Cure Rates for Breast Cancer Improved by Local and Regional Anesthesia?

BACKGROUND AND OBJECTIVES: Recent preclinical basic science studies suggest that patient tumor immunity is altered by general anesthesia (GA), potentially worsening cancer outcomes. A single retrospective review concluded that breast cancer patients receiving paravertebral block and GA had better cancer outcomes compared with patients receiving GA alone. This study has not been validated. We hypothesized that local or regional anesthesia (LRA) would be associated with better cancer outcomes compared with GA. METHODS: We retrospectively reviewed a prospectively collected database to identify all stage 0-III breast cancer patients undergoing surgery in a single center during a 9-year period ending January 1, 2010. Patients were divided into 2 groups: those who received only LRA and those who received GA. Overall survival (OS), disease-free survival (DFS), and local regional recurrence (LRR) were calculated using the Kaplan-Meier method with log-rank comparison before and after propensity score matching. RESULTS: Median age of the 1107 patients who met study criteria was 64 years (range, 24-97 years). Median and longest follow-up were 5.5 and 12.5 years, respectively. General anesthesia was used for 461 patients (42%), and 646 (58%) received LRA. The point estimates of cumulative OS, DFS, and LRR "free" rates at 5 years for the GA and LRA groups were 85.5% and 87.1%, 94.2% and 96.1%, and 96.3% and 95.8%, respectively. Cox regression showed no significant differences between the 2 groups (GA and LRA) for the 3 outcomes: OS (hazard ratio [HR], 0.81; 95% confidence interval [CI], 0.59-1.10; P = 0.17), DFS (HR, 0.91; 95% CI, 0.55-1.76; P = 0.87), and LRR (HR, 1.73; 95% CI, 0.83-3.63; P = 0.15). CONCLUSIONS: Breast cancer OS, DFS, and LRR were not affected by type of anesthesia in our institution. This result differs from that of the only prior published clinical report on this topic and does not provide clinical corroboration of the basic science studies that suggest oncologic benefits to LRA.

Is the American College of Surgeons National Surgical Quality Improvement Program surgical risk calculator applicable for breast cancer patients undergoing breast-conserving surgery?

BACKGROUND: We aimed to analyze the applicability of the National Surgical Quality Improvement Program (NSQIP) calculator to patients undergoing breast-conserving surgery. METHODS: A total of 287 consecutive patients treated with breast-conserving surgery from 2010 to 2012 were identified retrospectively. The risk calculator was applied to each patient to generate an individual risk profile. Risk calculations were then compared with actual outcomes. The performance of the risk calculator was evaluated using 2 metrics: the Brier score and c statistic. RESULTS: The NSQIP calculator performed adequately for all complications, with Brier scores less than .05. However, 37 patients (12.9%) returned to the operating room for oncologic indications. Twenty-nine patients (10.1%) had positive margins, whereas 8 patients (2.8%) returned due to an upgrade in diagnosis. CONCLUSIONS: When considering return to the operating room for oncologic management, the observed rate of 13.9% is significantly higher than the NSQIP prediction. This deviation must be addressed when using the NSQIP risk calculator model during preoperative risk discussion.

Are Breast Cancer Outcomes Compromised by General Surgical Resident Participation in the Operation?

OBJECTIVE: The effect of surgery resident participation on breast cancer recurrence has not been previously reported. The objectives of this study were to determine if resident participation was associated with either immediate postoperative or long-term breast cancer outcomes. DESIGN: We retrospectively reviewed a prospectively collected breast center database to identify all patients with breast cancer undergoing surgery in a single center during a 9-year period ending 1 January 2010. Patients were divided into 2 groups based on whether surgery residents completed more than 50% of the critical portions of the case (Resident group) or not. The outcomes of operation length, reoperative rates, morbidity, and the long-term outcomes of cancer recurrence were compared by group. Comparisons of immediate postoperative outcomes were made with chi-square and Fisher exact tests. Comparisons of operation length were analyzed by Wilcoxon rank-sum testing. Survival analyses were calculated using the Kaplan-Meier method with log-rank comparison. Multivariate analysis with Cox regression was also performed. SETTING: The study occurred at a community-based hospital that has an accredited general surgery training program. PARTICIPANTS: In all, 1107 consecutive patients with stage 0-3 breast cancer undergoing breast cancer operations were included. RESULTS: Median age of patients was 64 years (range: 24-97). Median and longest follow-up were 5.5 and 12.5 years, respectively. Initial operation was breast conserving in 796 (72%) and mastectomy in 311 (28%). Of the 1107 patients, 887 (80.1%) had resident participation. The Resident group was associated with longer operative times. We identified no differences in operative morbidity, reoperations, overall survival, disease-free survival, or local-regional recurrence in the Resident and No Resident groups. CONCLUSIONS: Resident involvement in breast cancer operations was associated with longer operative times but did not affect any other perioperative or cancer outcome in our institution. This information can be used to reassure program directors, attending surgeons, and patients if they have questions or concerns about the safety or effectiveness of cancer surgery when there is surgical resident participation.

Institutional review of compliance with NCCN guidelines for breast cancer: lessons learned from real-time multidimensional synoptic reporting.

BACKGROUND: Variations exist in compliance with NCCN Guidelines. Prior reports of adherence to NCCN Guidelines contain limitations because of lack of contemporary review and incomplete listing of reasons for noncompliance. PURPOSE: To assess institutional compliance and assist national quality improvement strategies through identifying valid reasons for noncompliance. METHODS: Compliance with NCCN Guidelines was recorded prospectively using electronic synoptic templates for patients with newly diagnosed breast cancer treated at a single institution between January 2010 and December 2011. Compliance with NCCN Guidelines was recorded. The accuracy of real-time synoptic auditing methods compared with retrospective chart review and reasons for noncompliance was assessed. SAS 9.3 software was used for data analysis. RESULTS: Compliance with NCCN Guidelines among 395 patients was 94% for initial staging evaluation, 97% for surgery, 91% for chemotherapy, 89% for hormone therapy, 91% for radiation therapy, 85% for follow-up, and 100% for determination of estrogen receptor/progesterone receptor and HER2 status. Age, comorbidities, and stage influenced guideline compliance. The most common reasons for noncompliance were patient refusal, patient choice after shared decision-making, and overuse of testing. Synoptic templated reporting was accurate in 97% patients. CONCLUSIONS: High compliance with NCCN Guidelines was demonstrated. Reasons for noncompliance were identifiable. Compliance and nonadherence can be evaluated quickly with electronic synoptic reporting. This allows real-time action plans to address quality concerns and aids national risk adjustment for comparison and benchmarking.

Determining whether excision of all fibroepithelial lesions of the breast is needed to exclude phyllodes tumor: upgrade rate of fibroepithelial lesions of the breast to phyllodes tumor.

Fibroepithelial lesions (FELs) are a common histologic finding on core needle biopsy (CNB) of the breast. Fibroepithelial lesions include fibroadenoma and phyllodes tumor, which can be difficult to distinguish with an initial CNB. An institutional experience was reviewed from February 12, 2001, to January 4, 2007, to determine the safety of selective rather than routine excision of FELs and to determine the factors associated with upgrading diagnosis of FELs to phyllodes tumors without definitive phyllodes tumor diagnosis by CNB. Of 313 patients, 261 (83%) with FELs diagnosed by CNB received observation with long-term follow-up (mean, 8 years). Of the observed patients, 3 (1%) were diagnosed with phyllodes tumor on follow-up. Eighteen of 52 patients (35%) who received excision had an upgrade of diagnosis to phyllodes tumor. Sensitivity and specificity of the pathologist's comment of concern for phyllodes tumor on a CNB demonstrating FELs without definitive phyllodes tumor diagnosis were 82% and 93%, respectively. Our policy of selective excision of FELs without definitive phyllodes tumor diagnosis resulted in safe avoidance of many surgical procedures.

A community breast center report card determined by participation in the national quality measures for breast centers program.

Measurement of quality indicators and peer comparison has been demonstrated to improve quality of care. The goal of this study was to determine whether a community breast center, in collaboration with the National Consortium of Breast Centers (NCBC), could voluntarily audit the quality of breast cancer care, confidentially transmit quality information to the NCBC, and receive peer performance comparisons. Quality indicator metrics from consecutive breast cancer patients undergoing care at a community interdisciplinary breast center were entered into a prospective database of quality measures that were defined by the NCBC. Retrospective review of patients from 2004 to 2006 was performed and subsequent quality indicator data was submitted electronically to the NCBC National Quality Measures for Breast Centers (NQMBC(TM) ) program. The percentage of new cancer diagnoses made by needle biopsy techniques was 94%, 95% and 96% from 2004 to 2006. Sentinel lymph node utilization in eligible patients was 93%, 96% and 91% from 2004 to 2006 and the immediate intraoperative pathologic frozen section false negative rate of the sentinel lymph node was 6.5%, 4.7% and 4%. Chart documentation of "patient participation in shared decision making for breast conserving therapy versus mastectomy" improved from 74% to 99% (p<0.05) from 2004 to 2006. Adjuvant systemic treatment for stage 2 breast cancer occurred in 76%, 89% and 77% of patients from 2004 to 2006. Neutropenia requiring hospital admission occurred in no patients in 2004 but in 4.8% and 2.9% in 2005 and 2006. The re-excision lumpectomy rates for stage 0, 1, 2, and 3 breast cancer patients from 2004 to 2006 was 14.2%, 22% and 24.8%. Quality indicator data was submitted to the NQMBC(TM) with successful confidential receipt of peer performance comparisons. Voluntary interdisciplinary institutional audits of breast cancer quality can be successfully submitted to the NQMBC(TM) with confidential peer performance comparison.

Perioperative quality metrics for one step breast cancer surgery: a patient-centered approach.

BACKGROUND AND OBJECTIVES: Patient-centered care is recommended by the Institute of Medicine to build a better healthcare system. The aim of this study was to audit patient-centered quality measures (QM) to create a breast center report card that could be provided to patients for education and informed consent. METHODS: An IRB approved retrospective review of 695 patients undergoing sentinel lymph node biopsy for breast cancer was conducted to audit the components of one step surgery and other QM. RESULTS: The intraoperative sensitivity to detect node positive patients was 25% (2/8), 27% (9/34), and 87% (68/78) for pN0(i+), pN1mi, pN1 patients, respectively. The re-excision lumpectomy rate was 15% (72/471) and the one step surgery success rate, which included lumpectomy and mastectomy patients, was 86% (598/695). Patient self-assessment of "very good to excellent" cosmesis and pain control were 77% (103/134) and 83% (60/72). Local recurrence rate was 2% (12/695) at a mean 3.1-year follow-up. CONCLUSIONS: The components of care that contribute to a patient-centered assessment of breast cancer surgery are measurable. "Bundling" of QM creates a perioperative report card that aids patients' informed consent and provides a framework for future comparative effectiveness studies.

Local and paravertebral block anesthesia for outpatient elective breast cancer surgery.

Most breast cancer operations in the United States are performed with the patient given general anesthesia. We retrospectively reviewed our prospective breast cancer database to determine the percentage of patients who underwent breast cancer operations with either local or paravertebral block regional anesthesia from January 1 through June 30, 2008. Fifty-two of 70 patients (74%) were able to undergo breast cancer surgery with local or paravertebral block regional anesthesia. Operations included mastectomy, full axillary dissections, and expander or implant reconstruction. There were no conversions to general anesthesia and no unplanned overnight admissions. Only 5 of 52 patients (10%) undergoing surgery with local or paravertebral block regional anesthesia developed postoperative nausea or vomiting. We conclude that most elective outpatient breast cancer surgery operations can be performed with the patients given local or regional anesthesia.

A quality review of the timeliness of breast cancer diagnosis and treatment in an integrated breast center.

BACKGROUND: The National Consortium of Breast Centers defines "quality" of breast cancer care as "accurate evaluation and appropriate services ... in a timely manner." We sought to determine timeliness of care and relationship to patient satisfaction. STUDY DESIGN: The electronic medical records of breast cancer patients seen at a breast center from 2004 through 2007 were retrospectively reviewed. Dates of patient service were audited. A postal survey was then conducted to determine patient satisfaction with timeliness. RESULTS: Median time interval in business days from abnormal screening mammogram to diagnostic evaluation and core needle biopsy was 6 days. Median time intervals from core needle biopsy to core needle biopsy pathology report and then subsequent surgical consultation and breast cancer operation were 1, 3, and 7 days, respectively. Breast MRI, systemic imaging, plastic surgery consultation, type of surgery, and patient choice prolonged time to treatment. More than 90% of breast cancer patients who responded to our postal survey had their expectations met or exceeded for the dates of service provided for diagnostic evaluation and treatment. CONCLUSIONS: Evaluation of timeliness as a quality indicator for breast cancer care is complex and requires an assessment of whether patient expectations were met for dates of service. Factors that prolong time to treatment, such as additional imaging, should be considered for risk adjustment for peer performance comparison and compliance with published timeliness target goals.

Tumoral pseudoangiomatous stromal hyperplasia of the breast.

Tumoral pseudoangiomatous stromal hyperplasia (PASH) is a rare benign proliferative disease of the breast. The majority of the literature reports of PASH have not contained detailed descriptions of the imaging characteristics of PASH. A 10-year retrospective study of patients with tumoral PASH and a 20-year Ovid MEDLINE search were performed to determine whether specific imaging and needle biopsy results could characterize PASH preoperatively. We identified 22 patients with tumoral PASH. Seventeen (77%) of 22 women had a palpable lump and 14 (72%) of 21 had a density on mammography. Ultrasound (US) findings included mixed or hypoechoic echogenicity in 83 per cent and ill-defined borders in 62 per cent. Eight (36%) patients had lesions with a Breast Imaging Reporting and Data System (BI-RADS) classification of 4 or 5. The sensitivity of preoperative core needle biopsy (CNB) to identify PASH was 83 per cent. A review of the literature revealed that 90 per cent of patients with PASH had some malignant imaging characteristics and 95 per cent had a mass on mammography. The imaging characteristics of PASH exhibited marked variability. Excision of PASH after CNB may be considered for patients with symptoms, enlarging lesions, or lesions classified as BI-RADS 4 or 5. PASH diagnosed by CNB allows selected patients to avoid excision.

A breast center review of compliance with National Comprehensive Cancer Network Breast Cancer guidelines.

BACKGROUND: National Comprehensive Cancer Network (NCCN) guideline compliance for breast cancer was determined in a breast center. METHODS: A retrospective study of 200 new breast cancer patients seen in 2004 was performed. RESULTS: NCCN guideline compliance rates for preoperative evaluation, breast surgery, lymph node surgery, radiation treatment, and systemic adjuvant therapy were 87%, 97%, 97%, 77%, and 63%, respectively. The most common reasons for noncompliance were partial breast radiation, no radiation, limited life expectancy, and patient choice to defer systemic treatment. CONCLUSIONS: The investigation of quality of breast cancer care requires measurement of compliance and reasons for noncompliance with established guidelines. A review that focuses only on percentage compliance has the potential to penalize institutions that (1) practice informed consent detailing absolute risks of survival with and without systemic therapy, (2) practice evidence-based medicine before the standardized guideline is changed to reflect it, and (3) serve populations with limited life expectancy.

Paravertebral block: an alternative to general anesthesia in breast cancer surgery.

Alternative forms of anesthesia in breast cancer patients have been sought to reduce the untoward effects of general anesthesia. The purpose of this study was to compare paravertebral block (PVB) and general anesthesia (GA) in terms of pain control, postoperative nausea and vomiting, and resumption of diet in patients undergoing operations for breast cancer. A retrospective chart review was performed on all patients (289) undergoing breast cancer surgery from May 1, 1999 through December 31, 2000 with PVB or GA. The PVB (n = 128) and GA (n = 100) groups had similar demographics. Postoperative narcotics were given to 80.8 and 93 per cent of PVB and GA patients, respectively (P < 0.01), after an average of 216 and 122 minutes from the end of surgery (P = 0.028). The PVB group received 6.2 narcotic units compared with 10.1 in the GA group (P = 0.04). Postoperative nausea and vomiting was present in 16.8 and 24 per cent of patients in the PVB and GA groups, respectively (P = 0.12). A diet was tolerated on the same day of surgery by 98.4 and 82 per cent of PVB and GA patients, respectively (P < 0.01). The complication rate of PVB was 1.8 per cent. PVB resulted in better postoperative pain control and earlier resumption of diet compared with GA. The good success rate and low complication rate of PVB make it well suited for breast cancer surgery and can eliminate the need for GA in patients with serious comorbidities.