Designing and implementing a bundle of care for patients with early-stage breast cancer: lessons from a pilot program.

We present a case study on the design and implementation of a value-based bundled package of care for patients with early-stage breast cancer treated in the private health sector in Australia. Value-based healthcare is an essential change to how we deliver healthcare, shifting the focus from paying for individual services provided to a focus on the health outcomes gained over a full cycle of care. The Australian health system has unintentionally created barriers to value-based cancer care through fragmented care pathways and complex funding arrangements where patients can unexpectedly encounter high out-of-pocket costs. A team of clinicians, service providers, health systems and funding experts, private health insurers and consumers have collaborated to design and pilot a complete bundled package of care for breast cancer patients which aims to address these challenges. With 40 patients recruited to date, early evaluation results show positive patient experience of 'joined-up' care and financial transparency. This case study provides a high-level overview of the approach taken to design and implement the Breast Cancer Bundle and the lessons learned for its expansion in both public and private settings.

Alcohol and other substance use by faculty, staff, and students in a university community during two hurricanes: Lessons for preventing risky misuse.

Communities commonly warn against heavy alcohol and other substance use during natural disasters like hurricanes, because such use may produce risk for individuals and communities, with studies showing deleterious effects persisting months or even years. Examining patterns and emotional correlates of use in the immediate presence of hurricanes may identify useful risk prevention targets. We assessed self-reported substance use and emotions in a university community (faculty, staff, and students) having the unlucky fate of experiencing hurricanes in early September 2 years in a row. Participants (403 in 2018, 76.0% female; M age 28.82; SD = 12.36 and 292 in 2019, 72.6% female; M age 30.63; SD = 13.96) reported typical weekly substance use and emotions and then the same data during each hurricane day. Results showed elevated use of alcohol, caffeine and tobacco before and during each hurricane, but a rapid drop-off of alcohol and caffeine (but not tobacco) use immediately after-although anxiety remained high. Findings are interpreted using both tension-reduction and stress-coping models and suggestions are made for future risk mitigation.

Impact of same day vs day before pre-operative lymphoscintigraphy for sentinel lymph node biopsy for early breast cancer (local Australian experience).

INTRODUCTION: To assess the impact of delayed vs immediate pre-operative lymphoscintigraphy (LSG) for sentinel lymph node biopsy in a single Australian tertiary breast cancer centre. METHODS: Retrospective cohort study analysing patients with breast cancer or DCIS who underwent lumpectomy or mastectomy with pre-operative LSG and intra-operative sentinel lymph node biopsy from January 2015 to June 2016. RESULTS: A total of 182 LSG were performed. Group A patients had day before pre-operative LSG mapping (n = 79) and Group B had LSG mapping on the day of surgery (n = 103). The overall LSG localisation rate was 97.3% and no statistical difference was detected between the two groups. The overall sentinel lymph node biopsies (SLN) were identified in 99.6% of patients. The number of nodes excised was slightly higher in Group A (1.90 vs 1.72); however, this was not statistically significant. In addition, the number of nodes on histopathology and the incidence of second echelon nodal detection were also similar between the two groups without statistical significance. CONCLUSION: In conclusion, the 2-day LSG protocol had no impact on overall SLNB and LSG detection rates although slightly higher second tier nodes but this did not translate to any difference between the number of harvest nodes between the two groups. The 2-day LSG allows for greater flexibility in theatre planning and more efficient use of theatre time. We recommend a dose of 40 Mbq of Tc99 m pertechnetate-labelled colloid be given day prior to surgery within a 24-hour timeframe.

Florid pustular dermatitis of breast: A case report on a unusual complication from acellular dermal matrix use.

INTRODUCTION: Idiopathic erythematous reaction of the breast (Red breast syndrome) is a known complication following breast reconstruction with acellular dermal matrix. However pustular dermatitis like presentation is not previously known. PRESENTATION OF CASE: We present a 42-year-old lady who developed bilateral pustular dermatitis like appearance following breast reconstruction with acellular dermal matrix slings. Though surgical washout was done, both expanders and flex HD could be preserved. DISCUSSION: Acellular dermal matrix use is the only possible explanation for such a presentation and this can be considered a variant of red breast syndrome. CONCLUSION: Pustular dermatitis like presentation can be associated with acelluar dermal matrix use and should be considered in similar clinical presentations, since this can avoid unnecessary surgical procedures.

Radioactive seed localisation to guide removal of impalpable lymph nodes (radioguided occult lesion localisation using iodine-125 seeds, "ROLLIS").

Two patients with cancer requiring removal of specific impalpable lymph nodes for full pathological analysis underwent ultrasound-guided lesion localisation and marking with a low-activity I-125 seed. A gamma probe was used in theatre to localise the signal from the seed and guide excision. Successful removal of the lesions was confirmed with the probe and by specimen radiography. Radioguided Occult Lesion Localisation using I-125 Seeds ("ROLLIS") provides a method of precisely marking impalpable lesions for surgical excision.

Laparoscopic oophorectomy in the management of breast disease.

BACKGROUND: Oophorectomy is being increasingly carried out in the management of breast disease, as either adjuvant treatment for breast cancer or for prevention of ovarian and fallopian tube cancer in BRCA gene mutation carriers. The aims of this study were to determine the surgical outcome of laparoscopic oophorectomy when carried out by breast surgeons and whether laparoscopic oophorectomy can be safely carried out during the same anaesthesia as breast surgery. METHODS: Patients who had laparoscopic oophorectomy carried out by two breast surgeons were reviewed with regard to the indication, surgical outcome and concurrent procedures. Salpingectomy was also carried out when the indication was prevention. RESULTS: Seventy patients with breast disease had laparoscopic oophorectomy between January 2000 and June 2007. Forty-three patients had laparoscopic oophorectomy for adjuvant endocrine treatment of early breast cancer, 13 for prophylaxis, 7 for endocrine and prophylactic reasons and 7 for treatment of metastatic breast cancer. Sixteen patients had laparoscopic oophorectomy and breast surgery at the same time, without complication. Of note, four BRCA mutation carriers had prophylactic mastectomies, bilateral breast reconstruction and bilateral laparoscopic salpingo-oophorectomy. No patient required conversion to an open procedure, including 29 patients with previous abdominal surgery. There were no significant complications. Three patients had ovarian cancer or breast cancer detected in an ovary. CONCLUSION: Laparoscopic oophorectomy can be safely and efficiently carried out by breast surgeons with expertise in laparoscopic surgery. Previous abdominal surgery did not prevent a successful laparoscopic approach. Breast oncological and/or reconstructive surgery and laparoscopic oophorectomy can be reliably carried out as a combined procedure.

Arzoxifene: the evidence for its development in the management of breast cancer.

INTRODUCTION: Endocrine therapy is an important and integral part of breast cancer management. Selective estrogen receptor modulators (SERMs), such as tamoxifen, remain a vital component in the endocrine therapy armamentarium. However the "ideal SERM", which has antagonist effects on the breast and endometrium but beneficial agonistic effects on bone and lipid profile, remains to be found. AIM: The aim of this review is to examine the evidence for arzoxifene as the "ideal SERM." EVIDENCE REVIEW: Arzoxifene showed initial promise as the "ideal SERM" in preclinical, phase I, and phase II clinical studies. It appeared to have powerful antiestrogenic effects on breast cancer and endometrium, with equally strong favorable estrogenic effects on bone and lipid profile, minimal side effects, and good oral bioavailability. However, phase III trial data found it to be inferior to tamoxifen, bringing an apparent end to its investigation as a breast cancer treatment. CLINICAL POTENTIAL: Despite early promise as the "ideal SERM", results from a phase III trial have relegated arzoxifene to research in breast cancer prevention and osteoporosis treatment.

Multiple papillomas of the breast: is current management adequate?

Multiple papillomas (MP) are subject to debate in terms of their clinical and pathological significance and management. To date the ideal management is still not well established. The Royal Perth Hospital Multidisciplinary Breast Service has prospectively accrued clinical and pathological data on over 9000 patients since 1994. The database was interrogated and all pathology reports retrospectively reviewed. A total of 23 cases with the diagnosis of MP were retrieved from the database between 1994 and 2004. Of these 23 cases, 13 (56.5%) were diagnosed by core biopsy, nine (39.1%) on excision biopsy, and one (4.4%) on a mastectomy specimen. The average age of patients was 56.4 years (range 44-74 years). The average duration of follow up is 4.1 years (range 1-10 years). In our series a close association with malignancy was noted for MP, which was also associated with a spectrum of proliferative breast disease. Contemporary guidelines should be developed for this controversial condition. We recommend that all patients with MP, especially when associated with atypia, undergo wide excision of the lesion with clear margins of at least 10mm and that these patients be monitored closely with annual imaging.

Prospective trial of intraoperative radiation treatment for breast cancer.

BACKGROUND: A new device, Intrabeam, is available for intraoperative radiotherapy. We have prospectively examined its feasibility and tolerability in delivering adjuvant breast cancer treatment. METHODS: Thirty-five patients undergoing breast-conserving surgery received targeted tumour bed irradiation consisting of 5 Gy (at 10 mm) in a single fraction. This single intraoperative treatment was used to replace the external beam radiotherapy "boost" that would usually be given in 10 daily treatments following 5 weeks of whole breast irradiation. Patients later completed external beam radiotherapy as usual. Potential toxicities were prospectively assessed fortnightly prior to external beam radiotherapy, weekly during it, and 3 monthly subsequently. RESULTS: The intraoperative radiotherapy was able to be delivered without difficulty, either at time of initial cancer surgery or as a second procedure. When performed as a separate procedure the median operating time was 56 min. The treatment was well tolerated, with only one patient experiencing any grade 3 or 4 toxicities--this was acute grade three itch. There was an overall early breast infection rate of 17%. No unexpected toxicities were seen. CONCLUSIONS: This simple and well-tolerated treatment delivers a useful radiation dose to the area of highest risk of tumour recurrence. The early infection rate is similar to that reported in the literature, for treatments without intraoperative radiotherapy. Whether such a treatment may adequately replace the entire adjuvant radiation therapy treatment for low-risk patients is now being studied in a randomized trial.