The association of race/ethnicity in male breast cancer survival within similar comorbidity cohorts.

BACKGROUND: Concomitant disease is associated with poor breast cancer survival in women and is more prevalent in racial/ethnic minority groups than individuals who are non-Hispanic White. The purpose of this study was to determine if race/ethnicity is associated with survival among men with breast cancer when stratifying analyses by level of comorbidity. METHODS: We used the California Cancer Registry to identify 1730 cases of men and 259,828 cases of women with breast cancer and documented Charlson Comorbidity Index (CCI). Kaplan-Meier survival and Cox regression analyses were used to compare breast cancer-specific survival and risk of mortality for African American/Black, Hispanic, and Asian/Pacific Islander men with White women and White men. RESULTS: When compared with White women, Black men with a CCI of 0 (hazard ratio [HR], 3.09; 95% CI, 1.10-1.16) and a CCI of 2+, (HR, 2.51; 95% CI, 1.42-4.42) had an increased risk of mortality when compared with White women. When compared with White men, African American men with a CCI of 0 (HR, 2.36; 95% CI, 1.45-3.85) and 2+ (HR, 2.44; 95% CI, 1.26-4.74) had an increased unadjusted risk of mortality, but these disparities were neutralized when controlling for sociodemographic and clinical factors. CONCLUSIONS: Black men with both low and high levels of concomitant disease have an increased risk of mortality when compared with both White men and women, but demographic and clinical factors are contributors to this disparity.

The influence of comorbidity on treatment and survival of triple-negative breast cancer.

Concomitant comorbidity is a key factor in treatment decision-making for breast cancer. The aim of this study was to determine how the Charlson Comorbidity Index (CCI) affected treatment and risk of mortality of women with TNBC, the subtype with the poorest prognosis. We accessed 20 177 cases of TNBC from the California Cancer Registry 2000-2015 with documented Charlson Comorbidity Index (CCI). Cox Regression was used to compute the adjusted risk of breast cancer-specific mortality for a CCI of 1 (low comorbidity) and 2+ (high comorbidity) vs a CCI of 0 (no comorbidity). Logistic regression was used to compute the association of CCI with treatment of mastectomy, lumpectomy + radiation, and chemotherapy. Analyses were conducted separately for each stage. Patients with high comorbidity CCI (2+) were less likely to receive systemic chemotherapy irrespective of Stage. High comorbidity was associated with higher breast-specific mortality in all stages of disease. High comorbidity did not have an effect on the use of lumpectomy and radiation of stage 1 breast cancer but was associated with reduced use in stages 2-4. Comorbidity was not associated with decreased risk of mastectomy except for patients with high comorbidity in stage 3. Concomitant comorbidity influences treatment decisions and breast cancer-specific mortality in patients with TNBC.

Differences in clinicopatholgic characteristics and risk of mortality between the triple positive and ER+/PR+/HER2- breast cancer subtypes.

PURPOSE: This study compared the demographic and clinicopathologic characteristics and risk of mortality between the triple positive (TP) and ER+/PR+/HER2- breast cancer subtypes. METHODS: Cases of first primary female invasive TP and ER+/PR+/HER2- breast cancer were obtained from the California Cancer Registry. Logistic regression analysis was used to compare differences in factors associated with the TP versus the ER+/PR+/HER2- subtype. Cox regression was used to compute the adjusted risk of breast cancer-specific mortality of the TP versus ER+/PR+/HER2-. RESULTS: The odds of TP versus ER+/PR+/HER2- were higher with advanced stage, high grade, low SES, ≤ 45 years of age (OR 1.48; CI 1.40-1.55), black (OR 1.11; CI 1.02-1.21), Asian/Pacific Islander (OR 1.15; CI 1.09-1.22), and uninsured (OR 1.42; CI 1.15-1.73). Unadjusted survival analysis indicated worse survival for the TP when compared with the ER+/PR+/HER2- subtype. However, adjusted risk of mortality for the TP subtype was not statistically significantly worse than the ER+/PR+/HER2- subtype. CONCLUSIONS: Young age, advanced stage and grade, low SES, black and API race, and lack of health insurance are more common in the TP subtype than in the ER+/PR+/HER2- subtype. However the risk of mortality between these two subtypes is similar.

Assessing the Recall Rate for Screening Mammography: Comparing the Medicare Hospital Compare Dataset With the National Mammography Database.

OBJECTIVE: High-quality screening mammography has been shown to substantially reduce mortality from breast cancer. Recall rate is a principal performance metric for screening mammography because it directly relates to the rate of false-positive examinations. This study aims to compare the recall rate derived using two sources-the claims-based Hospital Compare (HC) dataset from the Centers for Medicare & Medicaid Services versus the National Mammography Database (NMD) from the American College of Radiology-to understand the implications in pay-for-performance and quality improvement activities. MATERIALS AND METHODS: This study retrospectively compared the recall rate reported by NMD facilities with that reported in the HC dataset. Site matching was performed by facility name and zip code, followed by manual verification. Scatterplots, correlations, a paired t test, and Bland-Altman analysis were performed to assess association between the two measures. RESULTS: During the period from October 1 to December 1, 2016, 92 facilities were unambiguously matched using 2014-2015 records in both datasets. The recall rates were positively correlated (r = 0.428, p < 0.001), but the mean HC recall rate (8.5% ± 2.86% [SD]) was significantly (p < 0.001) lower than the mean NMD recall rate (10.6% ± 3.90%). CONCLUSION: The NMD and HC are two commonly used datasets for measuring screening mammography recall rate. Although recall rates are correlated at the individual facility level, there are important differences that have implications for quality improvement and pay-for-performance.

The influence of marital status and race/ethnicity on risk of mortality for triple negative breast cancer.

PURPOSE: To assess the effect of marital status and the role of race/ethnicity on breast cancer specific mortality in women with triple negative breast cancer (TNBC). METHODS: The study utilized the California Cancer Registry to identify 22,812 cases of first primary female TNBC. Unadjusted Kaplan-Meier breast cancer specific survival was computed. Cox Proportional Hazards modeling was used to compute the adjusted risk of breast cancer specific mortality for women who were single, separated, divorced, and widowed when compared with women who were married. Models were adjusted for age, stage, tumor grade, SES, and treatment with surgery, chemotherapy, hormone therapy, and radiation therapy. Hazard ratios (HR) and 95% confidence intervals (CI) were reported. RESULTS: Separated (HR: 1.45; 95% CI: 1.14-2.01) and widowed (HR: 1.39; 95%CI: 1.23-1.57) white women had a higher risk of mortality than white married women whereas single and divorced white women had the same risk of mortality. For Asian/Pacific Islanders (API), only single (HR: 1.55; 95% CI: 1.17-2.06) and divorced (HR:1.81; 95% CI:1.26-2.60) women had a higher risk of mortality than married women. Marital status had no influence on risk of mortality for either black or Hispanic women. CONCLUSIONS: The risk of mortality associated with marital status is dependent on race/ethnicity. Only white and API women with TNBC have a marital advantage.

Fourteen Year Follow-Up of Randomized Clinical Trials of Active Robotic-Assisted Total Hip Arthroplasty.

BACKGROUND: Active robotic total hip arthroplasty (THA) has been used clinically for over 20 years, but long-term results have never been studied. The aims of this study are to determine whether active robotic THA improves clinical outcomes and results in fewer revisions over a long-term follow-up. METHODS: Patients from 2 US Food and Drug Administration clinical trials (1994-1998 and 2001-2006) who had undergone THA using either an active robotic system or a traditional manual technique were examined to determine if any differences existed in radiographic analysis and patient pain and function using the University of California, Los Angeles; visual analog scale; Health Status Questionnaire (HSQ) pain; HSQ role physical; HSQ physical functioning; Harris pain scores; and the total Western Ontario and McMaster Universities Osteoarthritis Index scores at a mean follow-up of 14 years. RESULTS: The ROBODOC group had statistically significant higher HSQ pain and Harris pain scores and lower Western Ontario and McMaster Universities Osteoarthritis Index scores. There was no statistically significant difference in probability of a revision for wear between the groups (χ2 = 1.80; P = .179), and no revisions for loosening in either group. CONCLUSION: Prior studies have demonstrated improved implant fit and alignment with the use of this active robot system. This long-term study now shows no failures for stem loosening at a mean follow-up of 14 years and small but potentially important improvements in clinical outcomes in the robot group.

Risk of mortality of node-negative, ER/PR/HER2 breast cancer subtypes in T1, T2, and T3 tumors.

PURPOSE: The purpose of this study was to assess differences in breast cancer-specific mortality within tumors of the same size when breast cancer was defined using the three tumor markers estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2). METHODS: We identified 104,499 cases of node-negative primary female invasive breast cancer from the California Cancer Registry. Tumor size was categorized as T1a, T1b, T1c, T2, and T3. Breast cancer was defined using ER, PR, and HER2. Kaplan-Meier Survival analysis was conducted and Cox Regression was used to compute the adjusted risk of mortality for the ER+/PR+/HER2+, ER-/PR-/HER2- (TNBC), and ER-/PR-/HER2+ (HER2-overexpressing) subtypes when compared with the ER+/PR+/HER2-. Separate models were computed for each tumor size. RESULTS: Unadjusted survival analysis showed that for all tumor sizes, the ER+/PR+ subtypes regardless of HER status have better breast cancer-specific survival than ER-/PR- subtypes. Subtype was not an important factor for risk of mortality for T1a tumors. The ER+/PR+/HER2+ subtype was only a risk for mortality in T1b tumors that were unadjusted for treatment. For all other tumor sizes, the ER+/PR+/HER2+ had the same mortality as the ER+/PR+/HER2- subtype regardless of adjustment for treatment. The HER2-overexpressing subtype had a higher risk of mortality than the ER+/PR+/HER2- subtype except for T1b tumors that were adjusted for treatment. For all tumor sizes, the TNBC had higher hazard ratios than all other subtypes. CONCLUSIONS: T1a tumors have the same risk of mortality regardless of ER/PR/HER2 subtype, and ER and PR negativity plays a stronger role in survival than HER2 positivity for tumors of all size.

Do small changes in rotation affect measurements of lower extremity limb alignment?

BACKGROUND: The alignment of the lower extremity has important implications in the development of knee arthritis. The effect of incremental rotations of the limb on common parameters of alignment has not been studied. The purpose of the study was to (1) determine the standardized neutral position measurements of alignment and (2) determine the effect of rotation on commonly used measurements of alignment. METHODS: Eighty-seven full length CT angiography studies (49 males and 38 females, average age 66 years old) were included. Three-dimensional models were created using a rendering software program and placed on a virtual plane. An image of the extremity was obtained. Thirty scans were randomly selected, and those models were rotated in 3° intervals around the longitudinal axis and additional images were obtained. RESULTS: In the neutral position, the mechanical lateral distal femoral articular angle (mLDFA) was 85.6 ± 2.3°, medial proximal tibial angle (MPTA) was 86.1 ± 2.8°, and mechanical tibiofemoral angle (mTFA) was -0.7 ± 3.1°. Females had a more valgus alignment with a mTFA of 0.5 ± 2.9° while males had a more varus alignment with a mTFA of -1.7 ± 2.9°. The anatomic tibiofemoral angle (aTFA) was 4.8 ± 2.6°, the anatomic lateral distal femoral angle (aLDFA) measured 80.2 ± 2.2°, and the anatomical-mechanical angle (AMA) was 5.4 ± 0.7°. The prevalence of constitutional varus was 18%. The effect of rotation on the rotated scans led to statistically significant differences relative to the 0° measurement for all measurements. These effects may be small, and their clinical importance is unknown. CONCLUSIONS: This study provides new information on standardized measures of lower extremity alignment and the relationship between discreet axial rotations of the entire lower extremity and these parameters.

Risk factors associated with the triple-negative breast cancer subtype within four race/ethnicities.

PURPOSE: The ER-/PR-/HER2- or triple-negative (TNBC) subtype is more prevalent among women who are young, black, Hispanic, and of lower SES. The purpose of this study is to determine if young age and low SES are associated with TNBC within four mutually exclusive race/ethnicities. METHODS: The study identified 19,283 cases of TNBC and 89,089 of ER+/PR+/HER2- from the California Cancer Registry. Logistic regression analyses were conducted separately for whites, blacks, Hispanics, and Asian/Pacific Islanders (API) to compute the adjusted odds ratios (OR) for age and SES for the TNBC versus the ER+/PR+/HER2- subtype. RESULTS: White (OR=1.37;1.23-1.53) and Hispanic and women (OR=1.35;1.17-1.56) 30-39 had increased odds of the TNBC when compared with women 50-59 of the same race/ethnicity. Black women under 40 had the same odds, and black women 40-49 had lower odds of the TNBC as black women 50-59. White, black, and Hispanic women 70 and older had decreased or the same odds of the TNBC as 50 to 59-year-old women. API women had a similar risk of TNBC at all ages. Lower SES was associated with increased risk of TNBC only for white and Hispanic women. The odds of TNBC were no worse for API women with lower SES than API women with higher SES. SES was not statistically significant for black women. CONCLUSIONS: When assessing the odds of TNBC within a single race/ethnicity, young age and low SES are risk factors only for white and Hispanic women, but not for black and API women.

Regional Variation in Disparities in Breast Cancer Specific Mortality Due to Race/Ethnicity, Socioeconomic Status, and Urbanization.

PURPOSE: Disparities in breast cancer mortality due to race/ethnicity, area socioeconomic status (SES), and urbanization have been documented. This study examined if disparities in the risk of breast cancer specific mortality due to race/ethnicity, SES, and urbanization varied within diverse regions of California. METHODS: We identified 163,569 cases of first primary female invasive breast cancer from the California Cancer Registry diagnosed between January, 2000 and December, 2013. Cox regression was used to compute hazard ratios (HR) and 95 % confidence intervals for race/ethnicity, SES, and urbanization within eight regions of California. RESULTS: Blacks had an increased risk of mortality in the San Francisco Bay Area (SFBA) (HR = 1.37; 1.22-1.55), Desert Sierra (HR = 1.27; 1.08-1.49), San Diego/Orange (HR = 1.43; 1.19-1.71), and Los Angeles (LA) (HR = 1.31; 1.20-1.44). Japanese (HR = 0.62; 0.47-0.81), Chinese (HR = 0.71; 0.58-0.87), and Filipino (HR = 0.81; 0.69-0.95) women had a decreased risk of mortality in LA. Southeast Asians had a decreased risk in San Diego/Orange (HR = 0.72; 0.57-0.90) and in the SFBA (HR = 0.81; 0.67-0.98). Hispanics had a decreased risk (HR = 0.73; 0.57-0.93) and American Indians had an increased risk (HR = 2.32; 1.08-4.98) in the Tri-County region. SES was a significant risk factor for mortality in all regions except the North and Tri-County. Urbanization was a statistically significant factor for mortality only in LA (HR = 1.32; 1.08-1.60). CONCLUSIONS: Disparities in breast cancer mortality, due to race/ethnicity, SES, and urbanization vary by region which suggests that further research is warranted concerning the role of geographic regions and neighborhoods in cancer outcomes.

Breast Cancer Mortality among Asian-American Women in California: Variation according to Ethnicity and Tumor Subtype.

PURPOSE: Asian-American women have equal or better breast cancer survival rates than non-Hispanic white women, but many studies use the aggregate term "Asian/Pacific Islander" (API) or consider breast cancer as a single disease. The purpose of this study was to assess the risk of mortality in seven subgroups of Asian-Americans expressing the estrogen receptor (ER), progesterone receptor (PR), or human epidermal growth factor receptor 2 (HER2) tumor marker subtypes and determine whether the risk of mortality for the aggregate API category is reflective of the risk in all Asian ethnicities. METHODS: The study included data for 110,120 Asian and white women with stage 1 to 4 first primary invasive breast cancer from the California Cancer Registry. The Asian ethnicities identified were Pacific Islander, Southeast Asian (SEA), Indian Subcontinent, Chinese, Japanese, Filipino, and Korean. A Cox regression analysis was used to compute the risk of breast cancer-specific mortality in seven Asian ethnicities and the combined API category versus white women within each of the ER/PR/HER2 subtypes. Hazard ratios (HRs) and 95% confidence intervals (CIs) were computed. RESULTS: For the ER+/PR+/HER2- subtype, the combined API category showed a 17% (HR, 0.83; 95% CI, 0.76-0.91) lower mortality risk. This was true only for SEA (HR, 0.75; 95% CI, 0.61-0.91) and Japanese women (HR, 0.60; 95% CI, 0.45-0.81). In the ER+/PR-/HER2- subtype, SEA (HR, 0.57; 95% CI, 0.38-0.84) and Filipino women (HR, 0.71; 95% CI, 0.51-0.97) had a lower risk of mortality. Japanese (HR, 0.49; 95% CI, 0.25-0.99) and Filipino women (HR, 0.74; 95% CI, 0.58-0.94) had a lower HR for the ER-/PR-/HER2+ subtype. For triple-positive, ER+/PR+/HER2+ (HR, 0.84; 95% CI, 0.71-0.98) and triple-negative, ER-/PR-/HER2- (HR, 0.84; 95% CI, 0.74-0.94) subtypes, only the API category showed a lower risk of mortality. CONCLUSION: Breast cancer-specific mortality among Asian-American women varies according to their specific Asian ethnicity and breast cancer subtype.

The Influence of Socioeconomic Status on Racial/Ethnic Disparities among the ER/PR/HER2 Breast Cancer Subtypes.

Background. The eight ER/PR/HER2 breast cancer subtypes vary widely in demographic and clinicopathologic characteristics and survival. This study assesses the contribution of SES to the risk of mortality for blacks, Hispanics, Asian/Pacific Islanders, and American Indians when compared with white women for each ER/PR/HER2 subtype. Methods. We identified 143,184 cases of first primary female invasive breast cancer from the California Cancer Registry between 2000 and 2012. The risk of mortality was computed for each race/ethnicity within each ER/PR/HER2 subtype. Models were adjusted for tumor grade, year of diagnosis, and age. SES was added to a second set of models. Analyses were conducted separately for each stage. Results. Race/ethnicity did not contribute to the risk of mortality for any subtype in stage 1 when adjusted for SES. In stages 2, 3, and 4, race/ethnicity was associated with risk of mortality and adjustment for SES changed the risk only in some subtypes. SES reduced the risk of mortality by over 45% for American Indians with stage 2 ER+/PR+/HER2- cancer, but it decreased the risk of mortality for blacks with stage 2 triple negative cancer by less than 4%. Conclusions. Racial/ethnic disparities do not exist in all ER/PR/HER2 subtypes and, in general, SES modestly alters these disparities.

Disparities in the risk of the ER/PR/HER2 breast cancer subtypes among Asian Americans in California.

BACKGROUND: Population-based studies of breast cancer often aggregate all Asians into a single category termed Asian/Pacific Islander (API). PURPOSE: (1) Describe the demographic and clinicopathologic features of early breast cancer utilizing all eight ER/PR/HER2 subtypes among white, black, Hispanic, American Indian, seven Asian ethnicities, and the aggregate API category; (2) ascertain the risk of the ER+/PR+/HER2+, ER-/PR-/HER2-, and ER-/PR-/HER2+ subtypes when compared with the ER+/PR+/HER2- subtype, among seven Asian ethnicities versus non-Hispanic white women and (3) contrast the results with the risk of these same subtypes when using the aggregate API category. METHODS: Using the California Cancer Registry, we identified 225,441 cases of stages 1-4 first primary female invasive breast cancer. Logistic regression was used to assess the association of race with the ER+/PR+/HER2+, ER-/PR-/HER2- (triple-negative), and the ER-/PR-/HER2+ subtypes versus the ER+/PR+/HER2- when adjusted for stage, age, tumor grade, and socioeconomic status. Models were fit separately for each subtype. Odds ratios for the seven Asian ethnicities and the aggregate API category using non-Hispanic white women as the reference category were computed. RESULTS: There was an increased risk of the ER+/PR+/HER2+ subtype for the combined API category (OR=1.16; 95% CI=1.09-1.23). But only Southeast Asians (OR=1.17; 95% CI=1.04-1.31), Filipino (OR=1.23; 95% CI=1.12-1.36), and Korean (OR=1.63; 95% CI=1.38-1.99) women had an increased risk of this subtype. The reduced risk of the triple-negative subtype seen in APIs (OR=0.84; 95% CI=0.79-0.90) was only noted in Chinese (OR=0.80; 95% CI=0.70-0.91) and Filipino (OR=0.65; 95% CI=0.58-0.73) women whereas Indian Continent (OR=1.25; 95% CI=1.01-1.53) women had an increased risk of the triple-negative subtype. The race×stage interaction was statistically significant for the ER-/PR-/HER2+ subtype (p<0.05). When stratified by stage, there was no statistically significant association of race with subtype in stages 3 and 4. APIs had an increased risk of the ER-/PR-/HER2+ subtype in stage 1 (OR=1.59; 95% CI=1.37-1.75) and stage 2 (OR=1.42; 95% CI=1.28-1.58) but this risk was not seen in Pacific Islander, Indian Continent, and Japanese women for either stage. CONCLUSIONS: Among the Asian ethnicities, there is marked variability in the demographic and clinicopathologic features of breast cancer. Use of the ER/PR/HER2 subtypes reveals that the risk of the ER-/PR-/HER2-, ER+/PR+/HER2+, and ER-/PR-/HER2+ subtypes varies among the Asian population. The API category, is sometimes, but not always reflective of all Asian women.

Breast Cancer Survival Defined by the ER/PR/HER2 Subtypes and a Surrogate Classification according to Tumor Grade and Immunohistochemical Biomarkers.

Introduction. ER, PR, and HER2 are routinely available in breast cancer specimens. The purpose of this study is to contrast breast cancer-specific survival for the eight ER/PR/HER2 subtypes with survival of an immunohistochemical surrogate for the molecular subtype based on the ER/PR/HER2 subtypes and tumor grade. Methods. We identified 123,780 cases of stages 1-3 primary female invasive breast cancer from California Cancer Registry. The surrogate classification was derived using ER/PR/HER2 and tumor grade. Kaplan-Meier survival analysis and Cox proportional hazards modeling were used to assess differences in survival and risk of mortality for the ER/PR/HER2 subtypes and surrogate classification within each stage. Results. The luminal B/HER2- surrogate classification had a higher risk of mortality than the luminal B/HER2+ for all stages of disease. There was no difference in risk of mortality between the ER+/PR+/HER2- and ER+/PR+/HER2+ in stage 3. With one exception in stage 3, the ER-negative subtypes all had an increased risk of mortality when compared with the ER-positive subtypes. Conclusions. Assessment of survival using ER/PR/HER2 illustrates the heterogeneity of HER2+ subtypes. The surrogate classification provides clear separation in survival and adjusted mortality but underestimates the wide variability within the subtypes that make up the classification.

Disparities in race/ethnicity and socioeconomic status: risk of mortality of breast cancer patients in the California Cancer Registry, 2000-2010.

BACKGROUND: Racial disparities in breast cancer survival have been well documented. This study examines the association of race/ethnicity and socioeconomic status (SES) on breast cancer-specific mortality in a large population of women with invasive breast cancer. METHODS: We identified 179,143 cases of stages 1-3 first primary female invasive breast cancer from the California Cancer Registry from January, 2000 through December, 2010. Cox regression, adjusted for age, year of diagnosis, grade, and ER/PR/HER2 subtype, was used to assess the association of race/ethnicity on breast cancer-specific mortality within strata of stage and SES. Hazard ratios (HR) and 95% confidence intervals were reported. RESULTS: Stage 1: There was no increased risk of mortality for any race/ethnicity when compared with whites within all SES strata. Stage 2: Hispanics (HR = 0.85; 0.75, 0.97) in the lowest SES category had a reduced risk of mortality.. Blacks had the same risk of mortality as whites in the lowest SES category but an increased risk of mortality in the intermediate (HR = 1.66; 1.34, 2.06) and highest (HR = 1.41; 1.15, 1.73) SES categories. Stage 3: Hispanics (HR = 0.74; 0.64, 0.85) and APIs (HR = 0.64; 0.50, 0.82) in the lowest SES category had a reduced risk while blacks had similar mortality as whites. Blacks had an increased risk of mortality in the intermediate (HR = 1.52; 1.20, 1.92) and highest (HR = 1.53; 1.22, 1.92) SES categories. CONCLUSIONS: When analysis of breast cancer-specific mortality is adjusted for age and year of diagnosis, ER/PR/HER2 subtype, and tumor grade and cases compared within stage and SES strata, much of the black/white disparity disappears. SES plays a prominent role in breast cancer-specific mortality but it does not fully explain the racial/ethnic disparities and continued research in genetic, societal, and lifestyle factors is warranted.

Platelet-rich fibrin matrix in the management of arthroscopic repair of the rotator cuff: a prospective, randomized, double-blinded study.

BACKGROUND: Arthroscopic rotator cuff repair has a high rate of patient satisfaction. However, multiple studies have shown significant rates of anatomic failure. Biological augmentation would seem to be a reasonable technique to improve clinical outcomes and healing rates. PURPOSE: To represent a prospective, double-blinded, randomized study to assess the use of platelet-rich fibrin matrix (PRFM) in rotator cuff surgery. STUDY DESIGN: Randomized controlled trial; level of evidence, 1. METHODS: Prestudy power analysis demonstrated that a sample size of 30 patients in each group (PRFM vs control) would allow recognition of a 20% difference in perioperative pain scores. Sixty consecutive patients were randomized to either receive a commercially available PRFM product or not. Preoperative and postoperative range of motion (ROM), University of California-Los Angeles (UCLA), and simple shoulder test (SST) scores were recorded. Surgery was performed using an arthroscopic single-row technique. Visual analog scale (VAS) pain scores were obtained upon arrival to the recovery room and 1 hour postoperatively, and narcotic consumption was recorded and converted to standard narcotic equivalents. The SST and ROM measurements were taken at 3, 6, 9, and 12 weeks postoperatively, and final (1 year) American shoulder and elbow surgeons (ASES) shoulder and UCLA shoulder scores were assessed. RESULTS: There were no complications. Randomization created comparable groups except that the PRFM group was younger than the control group (mean ± SD, 59.67 ± 8.16 y vs 64.50 ± 8.59 y, respectively; P < .05). Mean surgery time was longer for the PRFM group than for the control group (83.28 ± 17.13 min vs 73.28 ± 17.18 min, respectively; P < .02). There was no significant difference in VAS scores or narcotic use between groups and no statistically significant differences in recovery of motion, SST, or ASES scores. Mean ASES scores were 82.48 ± 8.77 (PRFM group) and 82.52 ± 12.45 (controls) (F(1,56) = 0.00, P > .98). Mean UCLA shoulder scores were 27.94 ± 4.98 for the PRFM group versus 29.59 ± 1.68 for the controls (P < .046). Structural results correlated with age and size of the tear and did not differ between the groups. CONCLUSION: Platelet-rich fibrin matrix was not shown to significantly improve perioperative morbidity, clinical outcomes, or structural integrity. While longer term follow-up or different platelet-rich plasma formulations may show differences, early follow-up does not show significant improvement in perioperative morbidity, structural integrity, or clinical outcome.

Utilizing clinical support staff and electronic health records to increase tobacco use documentation and referrals to a state quitline.

The purpose of this study was to determine if incorporation of a workflow in the electronic health record (EHR) that empowered medical assistants (MA) to become tobacco-cessation promoters, would increase tobacco documentation and referral for cessation counseling. MAs in three primary care centers were trained to ask every patient, at every visit, about tobacco use then document this status in the EHR. Patients ready to quit were electronically referred to the quitline for tobacco cessation counseling. Documentation of tobacco status, ongoing verification of tobacco use, and chief complaint recording was compared before and after the intervention. Logistic regression analysis indicated that after adjusting for differences between care centers, there were increased odds in initial documentation (OR = 1.52; 95% CI = 1.42 - 1.62) and ongoing verification (OR = 2.86; 95% CI = 1.42 - 1.62) in 2010 in comparison with 2009. Recording of tobacco cessation as the chief complaint in current smokers increased 91% (OR = 1.91; 95% CI = 1.56 - 2.34). Documentation and referrals for smoking cessation can be increased in organizations using EHR by empowering MAs to promote tobacco cessation and providing electronic referral options.

Disparities in receipt of adjuvant radiation therapy after breast-conserving surgery among the cancer-reporting regions of California.

BACKGROUND: Incidence and mortality of breast cancer vary according to demographic factors such as age, race/ethnicity, socioeconomic status (SES), and geographic region. This study assesses the variation of these factors in the use of adjuvant radiation therapy (RT) after breast-conserving surgery (BCS) among 8 regions of California. METHODS: The authors identified 85,574 cases of first primary female invasive breast cancer with complete data diagnosed between January 1, 2000 and December 31, 2007. Logistic regression was used to determine the association between race/ethnicity, age, SES, and receipt of RT after BCS within each of the regions of California. Odds ratios (ORs) and 95% confidence intervals (CIs) were computed. RESULTS: Age was a significant predictor of receipt of RT after BCS in all regions. In Los Angeles (LA), lower SES was associated with decreasing odds of RT. Racial disparities were evident only in LA, where black (OR, 0.85; 95% CI, 0.74-0.97) and Hispanic (OR, 0.86; 95% CI, 0.78-0.96) women were about 15% less likely to receive RT than white women. CONCLUSIONS: Racial disparities in the receipt of RT after BCS exist only in LA, where African American and Hispanic women are less likely to receive this form of adjuvant treatment. Lower SES was also associated with a reduced likelihood of receipt of RT in LA. Women age 70 years and older are less likely to receive RT after BCS in all regions of California.

Use of ER/PR/HER2 subtypes in conjunction with the 2007 St Gallen Consensus Statement for early breast cancer.

BACKGROUND: The 2007 St Gallen international expert consensus statement describes three risk categories and provides recommendations for treatment of early breast cancer. The set of recommendations on how to best treat primary breast cancer is recognized and used by clinicians worldwide. We now examine the variability of five-year survival of the 2007 St Gallen Risk Classifications utilizing the ER/PR/HER2 subtypes. METHODS: Using the population-based California Cancer Registry, 114,786 incident cases of Stages 1-3 invasive breast cancer diagnosed between 2000 and 2006 were identified. Cases were assigned to Low, Intermediate, or High Risk categories. Five-year-relative survival was computed for the three St Gallen risk categories and for the ER/PR/HER2 subtypes for further differentiation. RESULTS AND DISCUSSION: There were 9,124 (13%) cases classified as Low Risk, 44,234 (65%) cases as Intermediate Risk, and 14,340 (21%) as High Risk. Within the Intermediate Risk group, 33,735 (76%) were node-negative (Intermediate Risk 2) and 10,499 (24%) were node-positive (Intermediate Risk 3). For the High Risk group, 6,149 (43%) had 1 to 3 positive axillary lymph nodes (High Risk 4) and 8,191 (57%) had four or more positive lymph nodes (High Risk 5). Using five-year relative survival as the principal criterion, we found the following: a) There was very little difference between the Low Risk and Intermediate Risk categories; b) Use of the ER/PR/HER2 subtypes within the Intermediate and High Risk categories separated each into a group with better five-year survival (ER-positive) and a group with worse survival (ER-negative), irrespective of HER2-status; c) The heterogeneity of the High Risk category was most evident when one examined the ER/PR/HER2 subtypes with four or more positive axillary lymph nodes; (d) HER2-positivity did not always translate to worse survival, as noted when one compared the triple positive subtype (ER+/PR+/HER2+) to the triple negative subtype (ER-/PR-/HER2-); and (e) ER-negativity appeared to be a stronger predictor of poor survival than HER2-positivity. CONCLUSION: The use of ER/PR/HER2 subtype highlights the marked heterogeneity of the Intermediate and High Risk categories of the 2007 St Gallen statements. The use of ER/PR/HER2 subtypes and correlation with molecular classification of breast cancer is recommended.