Breast cancer screening at the Breast Examination Center of Harlem.

BACKGROUND: This study was designed to describe patient, disease, and treatment characteristics of women diagnosed with breast cancer at the Breast Examination Center of Harlem (BECH) and to determine whether these characteristics have changed over time. METHODS: Retrospective chart review of women diagnosed with breast cancer at BECH from 2000 to 2008 was performed. Comparisons were made to data from an earlier study period (1995-2000). RESULTS: From 2000 to 2008, 339 women were diagnosed with breast cancer following attendance at BECH-55 % were black, 39 % Hispanic, 5 % of other race/ethnicity; 52 % had no health insurance. Hispanic patients were significantly more likely to have no health insurance compared with black patients (p = 0.0091); 29 % of patients had preinvasive disease and 36.5 % had stage I disease. Almost 40 % of the entire group was followed for <1 year. Five-year overall survival for the entire group was 83 % (95 % CI, 75-89 %) and 79 % for 188 Black women (95 % CI, 68-87 %). Compared with the earlier study period (1995-2000), fewer patients presented with palpable masses (45.4 vs. 67 %), and more had either stage 0 or stage I disease (65.6 vs. 46 %). CONCLUSIONS: Women diagnosed with breast cancer at BECH are predominantly Black and Hispanic, and most of these patients do not have health insurance. An increasing proportion of women diagnosed with breast cancer are presenting with nonpalpable, early-stage disease. Despite improved access to breast cancer screening, early stage at diagnosis, and access to appropriate management, these ethnic minorities continue to have poor outcomes and are poorly compliant with follow-up.

Role of preoperative magnetic resonance imaging in the surgical management of early-stage breast cancer.

PURPOSE: To examine the role of preoperative magnetic resonance imaging (pMRI) on time to surgery and rates of reoperation and contralateral prophylactic mastectomy (CPM) using a population-based study of New Jersey breast cancer patients. METHODS: The study included 289 African-American and 320 white women who participated in the Breast Cancer Treatment Disparity Study and underwent breast surgery for newly diagnosed early-stage breast cancer between 2005 and 2010. Patients were identified through rapid case ascertainment by the New Jersey State Cancer Registry. Association between pMRI and time to surgery was examined by using linear regression and, with reoperation and CPM, by using binomial regression. RESULTS: Half (49.9 %) of the study population received pMRI, with higher use for whites compared with African-Americans (62.5 vs. 37.5 %). After adjusting for potential confounders, patients with pMRI versus those without experienced significantly longer time to initial surgery [geometric mean = 38.7 days; 95 % confidence interval (CI) 34.8-43.0; vs. 26.5 days; 95 % CI 24.3-29.0], a significantly higher rate of CPM [relative risk (RR) = 1.82; 95 % CI 1.06-3.12], and a nonsignificantly lower rate of reoperation (RR = 0.76; 95 % CI 0.54-1.08). CONCLUSIONS: Preoperative MRI was associated with significantly increased time to surgery and a higher rate of CPM, but it did not affect the rate of reoperation. Physicians and patients should consider these findings when making surgical decisions on the basis of pMRI findings.

What is an adequate margin for breast-conserving surgery? Surgeon attitudes and correlates.

BACKGROUND: Re-excision is common in breast-conserving surgery (BCS), partly due to lack of consensus on margin definitions. A population-based surgeon sample was used to determine current attitudes toward margin width and identify characteristics associated with margin choice. METHODS: Breast cancer patients treated from 2005 to 2007 were identified from Los Angeles and Detroit Surveillance, Epidemiology, and End Results (SEER) registries. Pathology reports were used to identify their surgeons, who were surveyed (n = 418). Response rate was 74.6% (n = 312). Mean surgeon age was 51.9 years, 17.8% were female, and mean number of years in practice was 18.5. RESULTS: Wide variation in margin selection was noted among surgeons, and did not differ for invasive cancer and ductal carcinoma in situ (DCIS). In a scenario of T1 invasive cancer, 11% of surgeons endorsed margins of tumor not touching ink (TNTI), 42% of 1-2 mm, 28% of > or =5 mm, and 19% >1 cm as precluding need for re-excision before radiotherapy. On multivariate analysis, having 50% or more of practice devoted to breast cancer independently predicted smaller margin choice (p = 0.03). For a patient with a 1.4-cm grade 2 estrogen receptor (ER)-positive DCIS without radiotherapy (RT) planned, 3% of surgeons chose TNTI, 12% 1-2 mm, 25% > or =5 mm, and 61% >1 cm as sufficient without re-excision. In the scenario of DCIS without RT, breast specialization independently predicted larger margin choice (p = 0.03). Gender and years in practice were not predictive of margin choice. CONCLUSIONS: Wide variation in BCS margin definition exists. Variation is similar for invasive cancer and DCIS with RT, with more specialized surgeons choosing smaller margins. In DCIS without RT, more specialized surgeons favored larger margins. A standardized margin definition may significantly affect re-excision rates.

Venous thromboembolic events in hospitalized trauma patients.

Venous thromboembolism (VTE) includes deep vein thrombosis and pulmonary embolus and is a significant cause of morbidity and mortality in injured patients. Absolute risk factors for VTE development are poorly defined. This study aimed to elucidate and evaluate risk factors in a large, population-based trauma registry. The trauma registry for a 10-year period of a single county was examined. VTE risk factors in 10,150 adult patients treated in the county's five trauma centers and seven nontrauma centers were identified. Chi2 and Student's t tests were used for statistical analysis. The incidence of VTE was low at 0.493 per cent. The rate was 0.096 per cent at nontrauma centers. Injury severity score (ISS), operative intervention, spinal cord injury, lower extremity fracture, and certain thoracic injuries were significant in VTE development. There were no differences in VTE rate by age, gender, injury mechanism, or admitting service. Hospital length of stay was doubled by VTE. The VTE rate at trauma centers was higher, which was expected, given the complexity of patients treated and higher ISS. Patients with ISS greater than 15, need for operation, spinal cord injuries, lower extremity fractures, and certain thoracic injuries are at risk for VTE.

Social media, surgeons, and the Internet: an era or an error?

According to the National Research Corporation, 1 in 5 Americans use social media sites to obtain healthcare information. Patients can easily access information on medical conditions and medical professionals; however physicians may not be aware of the nature and impact of this information. All physicians must learn to use the Internet to their advantage and be acutely aware of the disadvantages. Surgeons are in a unique position because, unlike in the primary care setting, less time is spent developing a long-term relationship with the patient. In this literature review, we discuss the impact of the Internet, social networking websites, and physician rating websites and make recommendations for surgeons about managing digital identity and maintaining professionalism.

Patterns of utilization of adjuvant radiotherapy and outcomes in black women after breast conservation at a large multidisciplinary cancer center.

PURPOSE: Population-based studies have reported that as many of 35% of black women do not undergo radiotherapy (RT) after breast conservation surgery (BCS). The objective of the present study was to determine whether this trend persisted at a large multidisciplinary cancer center, and to identify the factors that predict for noncompliance with RT and determine the outcomes for this subset of patients. METHODS AND MATERIALS: Between January 2002 and December 2007, 83 black women underwent BCS at Memorial Sloan-Kettering Cancer Center and were therefore eligible for the present study. Of the 83 women, 38 (46%) had Stage I, 38 (46%) Stage II, and 7 (8%) Stage III disease. Of the study cohort, 31 (37%) had triple hormone receptor-negative tumors. RT was recommended for 81 (98%) of the 83 patients (median dose, 60 Gy). RESULTS: Of the 81 women, 12 (15%) did not receive the recommended adjuvant breast RT. Nonreceipt of chemotherapy (p = .003) and older age (p = .009) were associated with nonreceipt of RT. With a median follow-up of 70 months, the 3-year local control, locoregional control, recurrence-free survival, disease-free survival, and overall survival rate was 99% (actuarial 5-year rate, 97%), 96% (actuarial 5-year rate, 93%), 95% (actuarial 5-year rate, 92%), 92% (actuarial 5-year rate, 89%), and 95% (actuarial 5-year rate, 91%), respectively. CONCLUSION: We found a greater rate of utilization adjuvant breast RT (85%) among black women after BCS than has been reported in recent studies, indicating that excellent outcomes are attainable for black women after BCS when care is administered in a multidisciplinary cancer center.

Randomized clinical trials in breast cancer.

Breast cancer remains the most common cancer diagnosed in women and the second leading cause of cancer-related deaths in this group. Significant advances in the treatment of breast cancer and in the ability to screen for the disease mean that it is also one of the most curable forms of cancer. Long-term updates of the trials reviewed in the previous edition of this article have demonstrated that breast-conserving therapy remains a viable option for most patients, and that local control is related to overall survival. New chemotherapeutic options and endocrine therapies are available to select subsets of patients, and the use of endocrine therapy in breast cancer prevention has been shown to be of clear benefit. The sheer number of breast cancer-related randomized, controlled trials makes it impossible to review all level Ia evidence in this article but, where possible, extensive referencing and tabular review of related trials are used to provide the reader with a clear outline of the central data dictating current standard of care.

Effective methods for disclosing breast cancer diagnosis.

BACKGROUND: The current study sought to determine effective methods for disclosing breast cancer diagnosis and to identify epidemiologic patterns in patient preference for method of information disclosure. METHODS: Surveys were sent to 691 breast cancer patients over 10 years. Questions evaluated the best methods for telling a woman of her diagnosis. The chi-square, Wilcoxon rank, and Mantel-Haenszel tests were used for statistical associations. RESULTS: Ninety percent of patients had no preference for which gender disclosed the diagnosis. Fifty-nine percent said they believe it is important to be asked how much information one would like to know when initially told the diagnosis. However, most (54%) were not asked when they were told. When asked if previous ideas about breast cancer influenced their concerns, 79% answered "yes" or "somewhat." However, only 10% knew "a great deal." CONCLUSIONS: Patients have defined preferences about breast cancer diagnosis disclosure, making effective methods of diagnosis disclosure important to identify and practice.

Venous thromboembolic events in pediatric trauma patients: is prophylaxis necessary?

BACKGROUND: Venous thromboembolic events (VTE), such as deep vein thrombosis and pulmonary embolism, are major morbidities in adult trauma patients. Invasive and noninvasive prophylactic therapies are used to prevent VTE in trauma patients. The risk of VTE in pediatric patients is not well known. Is VTE prophylaxis necessary in the pediatric trauma population? METHODS: This is a retrospective study from the trauma registry of a Level I trauma center from January 1, 1994, through December 31, 2003. Three separate age groups were reviewed: Group I, age less than 13 years; group II, age 13 to 17 years; and group III, age greater than 17 years. Group I did not receive any VTE prophylaxis. All patients in group III received invasive and noninvasive prophylaxis if not contraindicated. In group II, VTE prophylaxis was administered at the preference of the attending surgeon. All patients were assigned an Injury Severity Score at discharge. RESULTS: A total of 13,880 patients were identified. Groups I, II, and III had 1,192; 1,021; and 10,568 patients, respectively. In group I, no patient developed a VTE. Two patients in group II developed VTE. Both had an Injury Severity Score of >24 and both had contraindication to invasive prophylaxis. In group III, 59 patients developed VTE. CONCLUSION: The risk of clinically significant thromboembolic event in trauma patients under age 13 is negligible. Therefore, VTE prophylaxis is unnecessary in pediatric patients with traumatic injury.