Breast-Conserving Therapy Versus Postmastectomy Breast Reconstruction: Propensity Score-Matched Analysis.

BACKGROUND: Although studies have compared patient-reported outcomes (PROs) after breast conserving-therapy (BCT) and postmastectomy breast reconstruction (PMBR), they often have been confounded by treatment or other factors that complicate a direct comparison. This study aimed to compare PROs after BCT and PMBR by using propensity score-matching analysis. METHODS: Patients who underwent BCT or PMBR between 2010 and 2022 and completed the BREAST-Q were identified. Each BCT patient was matched to a PMBR patient using nearest-neighbor 1:1 matching with replacement for each BREAST-Q time point. Outcomes included all prospectively collected BREAST-Q domains preoperatively, at 6 months, and at 1, 2, and 3 years postoperatively. A 4-point difference was considered clinically meaningful. RESULTS: For this study, 6215 patients (2501 BCT [40.2%] and 3714 PMBR [59.8%] patients) were eligible, and 2616 unique patients were matched. Preoperatively, 463 BCT and 463 PMBR patients were matched for analysis (6 months [443 matched pairs], 1 year [639 matched pairs], 2 years [421 matched pairs], 3 years [254 matched pairs]). At 6 months postoperatively, the BCT patients scored higher on all BREAST-Q domains than the PMBR patients (p < 0.05; differences > 4 points). At 1, 2, and 3 years, the patients who underwent BCT consistently had superior Satisfaction With Breasts, Psychosocial Well-Being, and Sexual Well-Being (p < 0.05), and the differences were clinically meaningful. CONCLUSION: In this statistically powered study, the BCT patients reported higher quality of life than the PMBR patients in early assessment and also through 3 years of follow-up evaluation. Given the equivalency in survival and recurrence outcomes between BCT and PMBR, patients eligible for either surgery should be counseled regarding the superiority of BCT in terms of PROs.

Race and Ethnicity Impacts Patient-Reported Outcomes in Implant-Based Breast Reconstruction.

BACKGROUND: Addressing social determinants of health is critical in achieving health equity, and of the many determinants, race and ethnicity are key contributors in postmastectomy breast reconstruction. The purpose of this study was to investigate the impact of race and ethnicity on patient-reported outcomes (PROs) after implant-based breast reconstruction (IBBR) and to provide reference values for each cohort. METHODS: We identified all patients who underwent IBBR between January 2017 and August 2022 and completed the BREAST-Q longitudinally. Race and ethnicity were self-categorized as White, Asian, Black, or Hispanic. Reference values were established. Outcomes of interest were BREAST-Q scores preoperatively, and 6 months, 1 year, and 2 years postoperatively. Generalized estimating equation (GEE) modeling was performed to assess race and ethnicity as independent predictors of BREAST-Q scores. RESULTS: Overall, 3281 patients were included, of whom 2479 (75.6%) were White, 296 (9.0%) were Asian, 239 (7.3%) were Black, and 267 (8.1%) were Hispanic. There were significant differences in Physical Well-being of the Chest at all timepoints; Satisfaction with Breasts and Psychosocial Well-being at preoperative, 6 months, and 1 year; and in Sexual Well-being at 1 year. GEE modeling showed that relative to White patients, Asian subjects scored significantly lower on all BREAST-Q domains, while Black and Hispanic patients scored significantly lower on the Physical Well-being of the Chest domain. CONCLUSION: Racial and ethnic disparities persist within IBBR, with minority patients scoring lower on the BREAST-Q than White patients. This study suggests that more work is needed to understand and improve these PROs in minority patient populations. Individualized reference values may prove beneficial in assessing outcomes over time.

Predicting Postoperative Satisfaction with Breasts: How Important is the Preoperative BREAST-Q Score?

BACKGROUND: The role that preoperative Satisfaction with Breast plays in a patient's postoperative course after postmastectomy breast reconstruction (PMBR) is not understood. The aim of this study is to understand the impact of the preoperative score on postoperative outcome as an independent variable. METHODS: We examined patients who underwent PMBR between 2017 and 2021 and who completed the BREAST-Q Satisfaction with Breasts at 1 year postoperatively. Two multiple linear regression models (Model 1 with the preoperative Satisfaction with Breasts score and Model 2 without the preoperative score), likelihood ratio tests, simple t-statistics, and sample patient dataset to predict the 1 year score were performed. Multiple imputation was used to account for missing preoperative scores. RESULTS: Overall, 2324 patients were included. Model 1 showed that the preoperative score is significantly associated with the postoperative score (ß = 0.09, 95% confidence interval 0.04-0.14; p < 0.001). Comparing Model 1 and Model 2 demonstrated that including preoperative Satisfaction with Breasts in a regression significantly improves model fit (test statistic = 10.04; p = 0.0021). Using the absolute value of the t-statistics as a measure of variable importance in linear regression, the importance of the preoperative score was quantified as 3.39-more important than neoadjuvant radiation, mastectomy weight, body mass index, bilateral prophylactic mastectomy, and race, but less than adjuvant radiation, reconstruction type, and psychiatric diagnoses. CONCLUSION: Preoperative Satisfaction with Breasts scores are an important independent predictor of postoperative satisfaction after PMBR. Just as vital sign and work-up are carefully documented before surgery, preoperative scores should be collected to pre-emptively gauge patients' satisfaction and optimize postoperative outcomes.

Defining the Genomic Landscape of Diffuse Sclerosing Papillary Thyroid Carcinoma: Prognostic Implications of RET Fusions.

BACKGROUND: Diffuse sclerosing papillary thyroid carcinoma (DSPTC) is an aggressive histopathologic subtype of papillary thyroid carcinoma. Correlation between genotype and phenotype has not been comprehensively described. This study aimed to describe the genomic landscape of DSPTC comprehensively using next-generation sequencing (NGS), analyze the prognostic implications of different mutations, and identify potential molecular treatment targets. METHODS: Tumor tissue was available for 41 DSPTC patients treated at Memorial Sloan Kettering Cancer Center between 2004 and 2021. After DNA extraction, NGS was performed using the Memorial Sloan Kettering Integrated Mutation Profiling of Actionable Cancer Targets platform, which sequences 505 critical cancer genes. Clinicopathologic characteristics were compared using the chi-square test. The Kaplan-Meier method and log-rank statistics were used to compare outcomes. RESULTS: The most common mutation was RET fusion, occurring in 32% (13/41) of the patients. Other oncologic drivers occurred in 68% (28/41) of the patients, including 8 BRAFV600E mutations (20%) and 4 USP8 mutations (10%), which have not been described in thyroid malignancy previously. Patients experienced RET fusion-positive tumors at a younger age than other drivers, with more aggressive histopathologic features and more advanced T stage (p = 0.019). Patients who were RET fusion-positive had a significantly poorer 5-year recurrence-free survival probability than those with other drivers (46% vs 84%; p = 0.003; median follow-up period, 45 months). In multivariable analysis, RET fusion was the only independent risk factor for recurrence (hazard ratio [HR], 7.69; p = 0.017). CONCLUSION: Gene-sequencing should be strongly considered for recurrent DSPTC due to significant prognostic and treatment implications of RET fusion identification. The novel finding of USP8 mutation in DSPTC requires further investigation into its potential as a driver mutation.

Nonresponse data in sexual well-being among breast reconstruction patients-who are we overlooking?

BACKGROUND: Missing data can affect the representativeness and accuracy of survey results, and sexual health-related surveys are especially at a higher risk of nonresponse due to their sensitive nature and stigma. The purpose of this study was to evaluate the proportion of patients who do not complete the BREAST-Q Sexual Well-being relative to other BREAST-Q modules and compare responders versus nonresponders of Sexual Well-being. We secondarily examined variables associated with Sexual Well-being at 1-year. METHODS: A retrospective analysis of patients who underwent breast reconstruction from January 2018 to December 2021 and completed any of the BREAST-Q modules postoperatively at 1-year was performed. RESULTS: The 2941 patients were included. Of the four BREAST-Q domains, Sexual Well-being had the highest rate of nonresponse (47%). Patients who were separated (vs. married, OR = 0.69), whose primary language was not English (vs. English, OR = 0.60), and had Medicaid insurance (vs. commercial, OR = 0.67) were significantly less likely to complete the Sexual Well-being. Postmenopausal patients were significantly more likely to complete the survey than premenopausal patients. Lastly, autologous reconstruction patients were 2.93 times more likely to respond than implant-based reconstruction patients (p < 0.001) while delayed (vs. immediate, OR = 0.70, p = 0.022) and unilateral (vs. bilateral, OR = 0.80, p = 0.008) reconstruction patients were less likely to respond. History of psychiatric diagnosis, aromatase inhibitors, and immediate breast reconstruction were significantly associated with lower Sexual Well-being at 1-year. CONCLUSION: Sexual Well-being is the least frequently completed BREAST-Q domain, and there are demographic and clinical differences between responders and nonresponders. We encourage providers to recognize patterns in nonresponse data for Sexual-Well-being to ensure that certain patient population's sexual health concerns are not overlooked.

Analyzing mastectomy and reconstruction weight in immediate autologous breast reconstruction: A preliminary study.

BACKGROUND: This study aims to explore the ideal breast size by assessing the relationship between mastectomy to free flap weight ratio and complications as well as patient-reported outcomes in autologous breast reconstruction (ABR). METHOD: A retrospective review of patients undergoing bilateral immediate ABR with mastectomy and flap weights available was completed. Patients were divided into three groups based on the ratio of mastectomy to flap weights. The patients were grouped as "maintained" if the flap weight was within 10% of the mastectomy weight. Patients with a weight difference greater than 10% were used to declare "downsized" or "upsized." Outcomes included complications and four domains of the BREAST-Q at 1-year postoperatively. RESULTS: Three hundred and fifty-nine patients were included in the analysis, of which 112 were downsized, 91 maintained, and 156 upsized, respectively. Presence of complications did not significantly differ among the groups. At 1-year postoperatively, Sexual Well-being significantly differed (p = 0.033). Between preoperative and 1 year, patients who upsized experienced an improvement in Satisfaction with Breasts by 16 points (p < 0.001), while patients who downsized experienced a decline in Physical Well-being of the Chest by 7 points (p = 0.016). Multivariable linear regression model showed that Sexual Well-being was 13 points lower in the downsized cohort than in the maintained cohort (ß = -13, 95% confidence interval: -21 to -5.4; p = 0.001). CONCLUSION: Although complication rates do not significantly differ between the three cohorts, patients who downsize may have lower Sexual Well-being postoperatively. Surgeons should consider our preliminary findings to counsel patients preoperatively about the predicted breast size and the impact of downsizing on sexual health.

Social Determinants of Health and Patient-reported Outcomes Following Autologous Breast Reconstruction, Using Insurance as a Proxy.

BACKGROUND: Insurance type can serve as a surrogate marker for social determinants of health and can influence many aspects of the breast reconstruction experience. We aimed to examine the impact of insurance coverage on patients reported outcomes with the BREAST-Q (patient reported outcome measure for breast reconstruction patients, in patients receiving) in patients receiving deep inferior epigastric artery perforator (DIEP) flap breast reconstruction. METHODS: We retrospectively examined patients who received DIEP flaps at our institution from 2010 to 2019. Patients were divided into categories by insurance: commercial, Medicaid, or Medicare. Demographic factors, surgical factors, and complication data were recorded. Descriptive statistics, Fisher's exact, Kruskal-Wallis rank sum tests, and generalized estimating equations were performed to identify associations between insurance status and five domains of the BREAST-Q Reconstructive module. RESULTS: A total of 1,285 patients were included, of which 1,011 (78.7%) had commercial, 89 (6.9%) had Medicaid, and 185 (14.4%) had Medicare insurances. Total flap loss rates were significantly higher in the Medicare and Medicaid patients as compared to commercial patients; however, commercial patients had a higher rate of wound dehiscence as compared to Medicare patients. With all other factors controlled for, patients with Medicare had lower Physical Well-being of the Chest (PWBC) than patients with commercial insurance (ß = - 3.1, 95% confidence interval (CI): -5.0, -1.2, p = 0.002). There were no significant associations between insurance classification and other domains of the BREAST-Q. CONCLUSION: Patients with government-issued insurance had lower success rates of autologous breast reconstruction. Further, patients with Medicare had lower PWBC than patients with commercial insurance regardless of other factors, while other BREAST-Q metrics did not differ. Further investigation as to the causes of such variation is warranted in larger, more diverse cohorts.

Practical considerations for sandwich variance estimation in two-stage regression settings.

We present a practical approach for computing the sandwich variance estimator in two-stage regression model settings. As a motivating example for two-stage regression, we consider regression calibration, a popular approach for addressing covariate measurement error. The sandwich variance approach has been rarely applied in regression calibration, despite it requiring less computation time than popular resampling approaches for variance estimation, specifically the bootstrap. This is likely due to requiring specialized statistical coding. We first outline the steps needed to compute the sandwich variance estimator. We then develop a convenient method of computation in R for sandwich variance estimation, which leverages standard regression model outputs and existing R functions and can be applied in the case of a simple random sample or complex survey design. We use a simulation study to compare the sandwich to a resampling variance approach for both settings. Finally, we further compare these two variance estimation approaches for data examples from the Women's Health Initiative (WHI) and Hispanic Community Health Study/Study of Latinos (HCHS/SOL). The sandwich variance estimator typically had good numerical performance, but simple Wald bootstrap confidence intervals were unstable or over-covered in certain settings, particularly when there was high correlation between covariates or large measurement error.

Nutritional Blood Concentration Biomarkers in the Hispanic Community Health Study/Study of Latinos: Measurement Characteristics and Power.

Measurement error is a major issue in self-reported diet that can distort diet-disease relationships. Use of blood concentration biomarkers has the potential to mitigate the subjective bias inherent in self-reporting. As part of the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) baseline visit (2008-2011), self-reported information on diet was collected from all participants (n = 16,415). The HCHS/SOL also included annual telephone follow-up, as well as a second (2014-2017) and third (2020-2023) clinic visit. Blood concentration biomarkers for carotenoids, tocopherols, retinol, vitamin B12, and folate were measured in a subset of participants (n = 476) as part of the Study of Latinos: Nutrition and Physical Activity Assessment Study (SOLNAS) (2010-2012). We examined the relationships among biomarker levels, self-reported intake, Hispanic/Latino background (Central American, Cuban, Dominican, Mexican, Puerto Rican, or South American), and other participant characteristics in this diverse cohort. We built regression calibration-based prediction equations for 10 nutritional biomarkers and used a simulation to study the power of detecting a diet-disease association in a multivariable Cox model using a predicted concentration level. Good statistical power was observed for some nutrients with high prediction model R2 values, but further research is needed to understand how best to realize the potential of these dietary biomarkers. This study provides a comprehensive examination of several nutritional biomarkers within the HCHS/SOL, characterizing their associations with subject characteristics and the influence of the measurement characteristics on the power to detect associations with health outcomes.

Issues in Implementing Regression Calibration Analyses.

Regression calibration is a popular approach for correcting biases in estimated regression parameters when exposure variables are measured with error. This approach involves building a calibration equation to estimate the value of the unknown true exposure given the error-prone measurement and other covariates. The estimated, or calibrated, exposure is then substituted for the unknown true exposure in the health outcome regression model. When used properly, regression calibration can greatly reduce the bias induced by exposure measurement error. Here, we first provide an overview of the statistical framework for regression calibration, specifically discussing how a special type of error, called Berkson error, arises in the estimated exposure. We then present practical issues to consider when applying regression calibration, including: 1) how to develop the calibration equation and which covariates to include; 2) valid ways to calculate standard errors of estimated regression coefficients; and 3) problems arising if one of the covariates in the calibration model is a mediator of the relationship between the exposure and outcome. Throughout, we provide illustrative examples using data from the Hispanic Community Health Study/Study of Latinos (United States, 2008-2011) and simulations. We conclude with recommendations for how to perform regression calibration.

An approximate quasi-likelihood approach for error-prone failure time outcomes and exposures.

Measurement error arises commonly in clinical research settings that rely on data from electronic health records or large observational cohorts. In particular, self-reported outcomes are typical in cohort studies for chronic diseases such as diabetes in order to avoid the burden of expensive diagnostic tests. Dietary intake, which is also commonly collected by self-report and subject to measurement error, is a major factor linked to diabetes and other chronic diseases. These errors can bias exposure-disease associations that ultimately can mislead clinical decision-making. We have extended an existing semiparametric likelihood-based method for handling error-prone, discrete failure time outcomes to also address covariate error. We conduct an extensive numerical study to compare the proposed method to the naive approach that ignores measurement error in terms of bias and efficiency in the estimation of the regression parameter of interest. In all settings considered, the proposed method showed minimal bias and maintained coverage probability, thus outperforming the naive analysis which showed extreme bias and low coverage. This method is applied to data from the Women's Health Initiative to assess the association between energy and protein intake and the risk of incident diabetes mellitus. Our results show that correcting for errors in both the self-reported outcome and dietary exposures leads to considerably different hazard ratio estimates than those from analyses that ignore measurement error, which demonstrates the importance of correcting for both outcome and covariate error.

Reconstructing Failure: Assessing Surgical and Patient Reported Outcomes Following Loss of Initial Breast Reconstruction.

BACKGROUND: Breast reconstruction failure, defined as the removal of a prosthetic device or flap without immediate replacement, can be traumatic for patients. We aim to describe the progression of patients who experience tissue expander (TE), implant, or autologous breast reconstructive failure and assess the patient reported outcomes (PROs) among patients who undergo additional reconstruction. METHOD: Patients undergoing TE, implant, or autologous breast reconstruction between 2017 and 2022 were included, and patients with reconstructive failures were identified. Outcomes of interests included (1) receipt of additional reconstruction and (2) BREAST-Q scores 1-year after reconstructive failure. We also performed a propensity-matched analysis between patients who undergo secondary reconstruction and patients who had an uncomplicated reconstruction. RESULTS: 4,258 TE, 4,420 implant, and 1,545 autologous breast reconstruction patients were included. Of patients who experienced reconstructive failures, 49.5% of TE, 4.8% of implant, and 53.8% of autologous patients underwent secondary reconstruction. Age, psychiatric diagnosis, chemotherapy, radiation, and mastectomy type were associated with increased likelihood of secondary reconstruction. Between patients with and without additional reconstruction, higher Psychosocial Well-being trended towards the former cohort (61 [Interquartile Range: 56, 80] vs 50 [46, 65], p=0.085). Propensity-matched analysis demonstrated comparable PROs at 1-year after definite reconstruction. CONCLUSION: Less than half of reconstructive failure patients undergo an additional reconstruction. Patients with secondary reconstruction may have improved Psychosocial Well-being than those who do not and comparable PROs to those who had uncomplicated initial reconstruction. Surgeons should counsel patients with reconstructive failures that although traumatizing, secondary reconstruction may be beneficial.

Inpatient Care and Outcomes Among People With Cancer Experiencing Homelessness.

Importance: Cancer is a leading cause of death among people experiencing homelessness (PEH) in the US. Acute care settings are important sources of care for PEH; however, the association of housing status with inpatient care remains understudied, particularly in the context of cancer. Objective: To assess whether housing status is associated with differences in the inpatient care of hospitalized adults with cancer. Design, Setting, and Participants: This cross-sectional study included hospitalized inpatient adults aged 18 years or older diagnosed with cancer who were identified using data from the 2016 to 2020 National Inpatient Sample. Propensity score matching was used to create a cohort of PEH and housed individuals matched according to age, sex, race and ethnicity, insurance type, cancer diagnosis, number of comorbidities, substance use disorder, severity of illness, year of admission, hospital location, hospital ownership, region, and hospital bed size. Matched pairs were identified using a 1:1 nearest neighbor matching algorithm without replacement, accounting for survey weights. Data were analyzed from August 1, 2022, to April 30, 2024. Exposure: Housing status. Main Outcomes and Measures: The associations of receipt of invasive procedures, systemic therapy, or radiotherapy during hospitalization (primary outcomes) as well as inpatient death, high cost of stay, and discharge against medical advice (AMA) (secondary outcomes) with housing status. Odds ratios and 95% CIs were estimated with multivariable logistic regression, with adjustment for patient, disease, and hospital characteristics of the matched cohort. Results: The unmatched cohort comprised 13 838 612 individuals (median [IQR] age, 67 [57-76] years; 7 329 473 males [53.0%]) and included 13 793 462 housed individuals (median [IQR] age, 68 [58-77] years) and 45 150 (median [IQR] age, 58 [52-64] years) individuals who were experiencing homelessness after accounting for survey weights. The PEH cohort had a higher prevalence of lung (17.3% vs 14.5%) and upper gastrointestinal (15.2% vs 10.5%) cancers, comorbid substance use disorder (70.2% vs 15.3%), and HIV (5.3% vs 0.5%). Despite having higher rates of moderate or major illness severity (80.1% vs 74.0%) and longer length of stay (≥5 days: 62.2% vs 49.1%), PEH were less likely to receive invasive procedures (adjusted odds ratio [AOR], 0.53; 95% CI, 0.49-0.56), receive systemic therapy (AOR, 0.73; 95% CI, 0.63-0.85), or have a higher-than-median cost of stay (AOR, 0.71; 95% CI, 0.65-0.77). Although PEH had lower rates of inpatient death (AOR, 0.79; 95% CI, 0.68-0.92), they were 4 times more likely to be discharged AMA (AOR, 4.29; 95% CI, 3.63-5.06). Conclusions and Relevance: In this nationally representative cross-sectional study of hospitalized adults with cancer, disparities in inpatient care of PEH highlight opportunities to promote equitable cancer care in this socioeconomically vulnerable population.

Satisfaction with Breasts Following Autologous Reconstruction: Assessing Associated Factors and the Impact of Revisions.

BACKGROUND: Autologous breast reconstruction (ABR) may confer higher patient reported outcomes than implant breast reconstruction, but an in-depth examination of factors associated with satisfaction after ABR is lacking. We aimed to determine independent predictors of 1-year Satisfaction with Breasts after ABR and assess the importance of elective procedures on satisfaction. METHODS: A retrospective analysis of patients who underwent abdominal-based ABR between 2010 and 2021 and completed the BREAST-Q Satisfaction with Breasts module at 1-year was performed. Elective procedures comprised of breast revision and nipple areolar complex (NAC) reconstruction. RESULTS: 959 patients were included. Satisfaction with Breasts score improved from 53 (IQR: 44 to 64) preoperatively to 64 (53 to 78) at 1-year postoperatively (p<0.001). Factors significantly associated with decreased postoperative score included lower preoperative scores (ß=0.19 [95% CI: 0.08, 0.31], p=0.001), older age (ß=-0.17 [-0.34, -0.01], p=0.042), Asian race (versus White, ß=-6.7 [-12, -1.7], p=0.008), and a history of psychiatric diagnoses (ß=-3.4 [-6.2, -0.66], p=0.015). Patients who received radiation (ß=-5.6 [-9.0, -2.3], p=0.001) or had mastectomy skin flap/nipple necrosis (ß=-3.8 [-7.6, -0.06], p=0.046) also had significantly decreased scores. Satisfaction with Breasts significantly improved after breast revision procedures (54 [42 to 65] to 65 [54 to 78], p<0.001) and NAC reconstruction (58 [47 to 71] to 67 [57 to 82], p<0.001). CONCLUSION: Multiple independent patient and treatment level factors are associated with lower 1-year Satisfaction with Breasts following ABR. Elective procedures have the potential to improve satisfaction. Understanding these findings is imperative for optimizing clinical decision making and managing expectations.

Disparity Reduction in United States Breast Reconstruction: An Analysis From 2005-2017 Using 3 Nationwide Data Sets.

BACKGROUND: Following passage of the Women's Health and Cancer Rights Act (WHCRA), a steady rise in breast reconstruction rates was reported; however, a recent update is lacking. This study aimed to evaluate longitudinal trends in breast reconstruction (BR) rates in the U.S. and relevant sociodemographic factors. METHODS: Mastectomy cases with/without BR from 2005 through 2017 were abstracted from the National Surgical Quality Improvement Program (NSQIP), Surveillance, Epidemiology, and End Results (SEER) Program, and National Cancer Database (NCDB). BR rates were examined using Poisson regression. Multivariable logistic regression analysis of NCDB data was used to identify predictors of reconstruction. Race and insurance distributions were evaluated over time. RESULTS: Of 1,554,381 mastectomy patients, 507,631 (32.7%) received BR. Annual reconstruction rates per 1000 mastectomies increased from 2005 to 2012 (NSQIP: Incidence Rate Ratio (IRR) 1.077; SEER: 1.090; NCDB: 1.092) and stabilized from 2013 to 2017. NCDB data showed that patients who were younger (≤59 years), privately insured, had fewer comorbidities, and underwent contralateral prophylactic mastectomy were more likely to undergo BR (all p<0.001). Over time, the increase in BR rates was higher among Black (252.3%) and Asian (366.4%) patients than White patients (137.3%). BR rates increased more among Medicaid (418.6%) and Medicare (302.8%) patients than privately insured (125.3%) patients. CONCLUSIONS: This analysis demonstrates stabilization in immediate BR rates over the last decade; reasons behind this stabilization are likely multifactorial. Disparities based on race and insurance type have decreased, with a more equitable distribution of BR rates.

Management of the Infected Tissue Expander.

BACKGROUND: Tissue expander (TE) infection is a critical postoperative complication in two-stage implant-based breast reconstruction (IBBR). We assessed risk factors associated with TE infection and reconstructive loss and examined reconstructive salvage rates. METHODS: We retrospectively reviewed patients who underwent IBBR with TE placement from 2017 to 2022. Included were patients with TE infection treated with admission and IV antibiotics, interventional radiology (IR) drainage, and/or operative management (washout with or without TE removal and TE replacement, TE removal and replacement with implant, and/or TE removal without replacement). Reconstructive success was defined as maintenance of breast reconstruction for 1 year after TE placement. RESULTS: Of 4,498 patients who underwent IBBR, 305 (338 TEs) met the inclusion criteria. Cox modeling showed higher body mass index, hypertension, radiation, bilateral TEs, acellular dermal matrix use, increasing mastectomy weight, and nipple sparing mastectomy were associated with increased hazard of TE infection. Patients with TE infection had a 54% reconstructive failure rate within 1 year; Cox modeling showed Black race and gram-negative cultures were associated with increased hazard of reconstructive failure within 1 year. Patients who underwent TE replacement with an implant had the most favorable success rate following infection. CONCLUSION: Overall, 46% of patients admitted with a periprosthetic infection had successful salvage. Patients with TE infection should be started on IV antibiotics with a low threshold for operative intervention based on exam and culture data. While IR can guide operative intervention of periprosthetic infections, our practice has shifted away from IR drainage towards definitive operative management.

Breast Conserving Therapy Preserves Sexual Well-Being More Than Postmastectomy Breast Reconstruction: Trends, Factors, and Interventions.

BACKGROUND: Up to 85% of breast cancer patients report sexual health concerns, but their concerns are not adequately addressed by providers. Sexual dysfunction among breast cancer patients remains understudied. We aimed to investigate the impact of breast-conserving therapy (BCT) and postmastectomy breast reconstruction (PMBR) on the sexual health of breast cancer patients and frequency of sexual medicine consultation in postoperative care. METHODS: We conducted a retrospective analysis of patients who underwent BCT or PMBR and completed the Sexual Well-being of the BREAST-Q BCT and Reconstruction modules from January 2010 to October 2022. We compared Sexual Well-being scores between BCT and PMBR patients overtime up to 5-years postoperatively, delineated associated demographic and clinical factors with Sexual Well-being, and evaluated the frequency of sexual medicine consultations. RESULTS: Of 15,857 patients, 8,510 (53.7%) underwent BCT and 7,347 (46.3%) underwent PMBR. PMBR patients had significantly lower Sexual Well-being scores than BCT patients from preoperative to 5-year postoperative. Regression analyses showed that PMBR patients scored 7.6 points lower at 1-year than BCT patients. Separated marital status, higher body mass index, cardiovascular disease, hyperlipidemia, psychiatric diagnosis, and neoadjuvant chemotherapy were associated with significantly lower Sexual Well-being. 299 (3.5%) of BCT and 400 (5.4%) of PMBR patients received sexual medicine consultations. CONCLUSION: Sexual health concerns must be considered in breast cancer care, particularly among patients who undergo PMBR. Although many patients experience sexual dysfunction, most do not receive a sexual medicine consultation, suggesting an opportunity for providers to improve breast cancer patients' sexual health.

Outcomes of Conversion Surgery for Patients With Low-Risk Papillary Thyroid Carcinoma.

Importance: The outcomes of patients with low-risk thyroid cancer who undergo surgery following a period of active surveillance (AS) are not well-defined. Objective: To evaluate surgical, pathologic, and oncologic outcomes among patients undergoing conversion surgery (CS) following AS for low-risk papillary thyroid carcinoma. Design, Setting, and Participants: In this cohort study, patients who underwent CS for disease progression were compared with patients who underwent CS without disease progression and with a propensity score-matched cohort of patients who underwent initial surgery (IS). The median (IQR) postsurgical follow-up time was 40.3 (18.0-59.0) months. Patients were treated at a quaternary cancer referral center in the United States. Exposures: Surgery. Main Outcomes and Measures: Surgical complications, pathologic characteristics, overall survival (OS), and recurrence-free survival (RFS). Results: Of 550 patients who underwent AS, 55 (10.0%) had CS, of whom 39 (7.1%) had surgery due to suspected disease progression (median [IQR] age, 48 [39-56] years; 32 [82.1%] female). There were no clinically meaningful differences in rates of surgical sequalae between the progression CS group (12 of 39 [30.7%]) and the nonprogression CS group (7 of 16 [43.8%]) (Cramer V, 0.2; 95% CI, 0.01-0.5). The 5-year OS was 100% (95% CI, 100%-100%) in both the disease-progression CS cohort and the IS cohort. Although the cohort of patients undergoing CS after disease progression was by definition a subset with more aggressive tumor behavior, no clinically meaningful differences were observed in the rates of regional recurrence (2 of 39 [5.1%] vs 0 of 39 patients with IS), local recurrence (0 patients), distant metastasis (0 patients), or disease-specific mortality (0 patients) when compared with the matched IS group. Five-year RFS rates were similar: 100% in the IS group and 86% (95% CI, 70%-100%) in the CS group. Conclusions and Relevance: In this cohort study, CS for suspected disease progression was associated with surgical and oncologic outcomes similar to IS, supporting the feasibility and safety of AS for patients with low-risk papillary thyroid carcinoma.

Clinicogenomic predictors of survival and intracranial progression after stereotactic radiosurgery for colorectal cancer brain metastases.

OBJECTIVE: Brain metastases (BM) from colorectal cancer (CRC) are associated with dismal prognosis. When BM-directed therapy is considered, better methods are needed to identify patients at risk of poor oncological outcomes in order to optimize patient selection for closer surveillance or escalated therapy. The authors sought to identify clinicogenomic predictors of survival and intracranial disease progression after CRC BM have been treated with stereotactic radiosurgery (SRS). METHODS: Patients with newly diagnosed CRC BM treated with SRS between 2009 and 2022 who had next-generation genomic sequencing data available were included. Frameless SRS was delivered in 1-5 fractions, alone or after neurosurgical resection. Outcomes included overall survival (OS) and intracranial progression (IP), evaluated per patient treated with SRS, and local progression (LP), evaluated per BM. Associations between baseline clinicogenomic features and outcomes were evaluated with Cox regression and competing risk regression, with death as a competing risk. RESULTS: This analysis included 123 patients with 299 BM. At BM diagnosis, 111 patients (90%) had progressive extracranial disease, and 79 patients (64%) had ≥ 3 sites of extracranial metastasis. The median (IQR) number of BM was 2 (1-3) per patient. The median (IQR) biologically effective dose (BED) was 51.3 (51.3-65.1) Gy, corresponding to a prescription of 27 Gy in 3 fractions. OS, IP, and LP estimates at 1 year after SRS were 36%, 55%, and 12%, respectively. OS was independently associated with progressive extracranial disease (HR 4.26, 95% CI 1.63-11.2, p = 0.003) and ≥ 3 extracranial metastatic sites (HR 1.84, 95% CI 1.12-3.01, p = 0.02). LP was less likely when BM received BED ≥ 51.3 Gy (HR 0.24, 95% CI 0.07-0.78, p = 0.02), independent of BM diameter (HR 1.21/cm, 95% CI 0.8-1.84, p = 0.4). IP was independently associated with genomic alterations; TP53 driver alterations were associated with higher risk of IP (HR 2.71, 95% CI 1.26-5.79, p = 0.01), whereas MYC pathway alterations were associated with lower risk (HR 0.15, 95% CI 0.03-0.68, p = 0.01). CONCLUSIONS: The authors identified clinicogenomic features associated with adverse outcomes after SRS for CRC BM. Progressive and extensive extracranial metastases predicted worse OS. Insufficient SRS doses predicted greater risk of LP. Wild-type TP53 and alterations in the MYC pathway were independently associated with lower risk of IP. Patients at high risk of IP may be considered for closer surveillance or escalated therapy.