Relation between socioeconomic variables and surgical, systemic and radiation treatment in a cohort of patients with breast cancer in an urban Canadian centre

Background: Studies have shown an association between socioeconomic status and breast cancer treatment. We examined the relation between socioeconomic status and the treatment of breast cancer (surgical, systemic and radiation) in a universal health care system. Methods: Data from a single urban Canadian centre were collected for consecutive patients who received a diagnosis of breast cancer from January 2010 to December 2011. Variables included patient and disease factors, surgery type, systemic and radiation treatment, and breast reconstruction. Socioeconomic variables were obtained from 2006 Canadian census data. We used multivariable logistic regression to identify predictors of breast cancer treatment. Results: A total of 721 patients were treated for breast cancer during the study period. Socioeconomic variables were not related to type of breast surgery for breast cancer. Age less than 50 years, having a first-degree relative with breast cancer and income status were predictors of breast reconstruction. Employment status was a consistent predictor of systemic and radiation treatment. Conclusion: Employment consistently predicted systemic and radiation treatment, and age and income were predictors of breast reconstruction in a universal health care system. Further research is required to determine precisely how socioeconomic factors affect care and to minimize possible disparities in delivery of health care services.

Contexte: Des études ont montré un lien entre la situation socio-économique et le traitement du cancer du sein. Nous avons analysé ce lien entre la situation socioéconomique et le traitement (chirurgie, chimiothérapie, radiothérapie) du cancer du sein dans un système de santé universel. Méthodes: Les données d'un seul centre urbain canadien ont été compilées pour les patientes consécutives ayant reçu un diagnostic de cancer du sein entre janvier 2010 et décembre 2011. Les variables incluaient des facteurs propres aux patientes et à la maladie, le type de chirurgie, la chimiothérapie, la radiothérapie et la reconstruction mammaire. Les variables socio-économiques proviennent des données du recensement canadien de 2006. Nous avons utilisé la régression logistique multivariée pour identifier les prédicteurs du traitement du cancer du sein. Résultats: En tout, 721 patientes ont été traitées pour un cancer du sein durant la période de l'étude. Les variables socio-économiques n'ont pas influé sur le type de chirurgie mammaire pour cancer du sein. L'âge inférieur à 50 ans, un cancer du sein chez une parente au premier degré et le revenu ont été des prédicteurs de la reconstruction mammaire. La situation professionnelle a été un prédicteur fiable du traitement systémique et de la radiothérapie. Conclusion: L'emploi a été un prédicteur fiable du traitement systémique et de la radiothérapie, et l'âge et le revenu ont été des prédicteurs de la reconstruction mammaire, dans un système de santé universel. Il faudra approfondir la recherche pour déterminer plus précisément l'influence des facteurs socio-économiques sur les soins et pour réduire les possibles disparités dans leur prestation.

Time-resolved fluorescence (TRF) and diffuse reflectance spectroscopy (DRS) for margin analysis in breast cancer.

PURPOSE: One of the major problems in breast cancer surgery is defining surgical margins and establishing complete tumor excision within a single surgical procedure. The goal of this work is to establish instrumentation that can differentiate between tumor and normal breast tissue with the potential to be implemented in vivo during a surgical procedure. METHODS: A time-resolved fluorescence and reflectance spectroscopy (tr-FRS) system is used to measure fluorescence intensity and lifetime as well as collect diffuse reflectance (DR) of breast tissue, which can subsequently be used to extract optical properties (absorption and reduced scatter coefficient) of the tissue. The tr-FRS data obtained from patients with Invasive Ductal Carcinoma (IDC) whom have undergone lumpectomy and mastectomy surgeries is presented. A preliminary study was conducted to determine the validity of using banked pre-frozen breast tissue samples to study the fluorescence response and optical properties. Once the validity was established, the tr-FRS system was used on a data-set of 40 pre-frozen matched pair cases to differentiate between tumor and normal breast tissue. All measurements have been conducted on excised normal and tumor breast samples post surgery. RESULTS: Our results showed the process of freezing and thawing did not cause any significant differences between fresh and pre-frozen normal or tumor breast tissue. The tr-FRS optical data obtained from 40 banked matched pairs showed significant differences between normal and tumor breast tissue. CONCLUSION: The work detailed in the main study showed the tr-FRS system has the potential to differentiate malignant from normal breast tissue in women undergoing surgery for known invasive ductal carcinoma. With further work, this successful outcome may result in the development of an accurate intraoperative real-time margin assessment system. Lasers Surg. Med. 50:236-245, 2018. © 2018 Wiley Periodicals, Inc.

Are testers also admitters? Comparing emergency physician resource utilization and admitting practices.

OBJECTIVE: To describe the relationship between emergency department resource utilization and admission rate at the level of the individual physician. METHODS: Retrospective observational study of physician resource utilization and admitting data at two emergency departments. We calculated observed to expected (O/E) ratios for four measures of resource utilization (intravenous medications and fluids, laboratory testing, plain radiographs, and advanced imaging studies) as well as for admission rate. Expected values reflect adjustment for patient- and time-based variables. We compared O/E ratios for each type of resource utilization to the O/E ratio for admission for each provider. We report degree of correlation (slope of the trendline) and strength of correlation (adjusted R2 value) for each association, as well as categorical results after clustering physicians based on the relationship of resource utilization to admission rate. RESULTS: There were statistically significant positive correlations between resource utilization and physician admission rate. Physicians with lower resource utilization rates were more likely to have lower admission rates, and those with higher resource utilization rates were more likely to have higher admission rates. CONCLUSIONS: In a two-facility study, emergency physician resource utilization and admission rate were positively correlated: those who used more ED resources also tended to admit more patients. These results add to a growing understanding of emergency physician variability.

The effect of surgery type on survival and recurrence in very young women with breast cancer.

BACKGROUND: The impact of surgical treatment on outcomes in breast cacner in very young women remains unclear. We sought to determine the effect of surgery type on risk of recurrence and survival in a population-based cohort. METHODS: All women diagnosed with breast cancer aged ≤35 (1994-2003) were identified from the Ontario Cancer Registry. Patient, tumor, and treatment variables, including primary surgery, recurrences, and death were abstracted from chart review. Cox regression models were fit to determine the effect of surgery type on recurrence and overall survival. RESULTS: We identified 1,381 patients with 11-year median follow-up of which 793 (57%) had BCS. Of the remaining mastectomy patients, 52% had postmastectomy radiation. Overall, 41% of patients sustained a recurrence of any type and 31% died. Controlling for known confounders, there was no association between type of surgery and death from any cause (HR = 0.98, 95% CI = 0.78, 1.25) or first recurrence (HR = 0.93, 95% CI = 0.75, 1.14). Distant recurrence was most common (13% in BCS; 25.3% in mastectomy) with local recurrence 12.4% after BCS and 7.5% after mastectomy. CONCLUSIONS: In this cohort of very young women who were selected for treatment with BCS and mastectomy, we found similar oncologic outcomes. J. Surg. Oncol. 2017;115:122-130. © 2017 Wiley Periodicals, Inc.

A Population-Based Study of the Effects of a Regional Guideline for Completion Axillary Lymph Node Dissection on Axillary Surgery in Patients with Breast Cancer.

INTRODUCTION: Evidence from the American College of Surgeons Oncology Group (ACOSOG) Z0011 trial suggests completion axillary lymph node dissection (cALND) after positive sentinel lymph node biopsy (+SLNB) does not improve outcomes in select patients, leading to practice variation. A multidisciplinary group of surgeons, oncologists, and pathologists developed a regional guideline for cALND which was disseminated in August 2012. We assessed the impact of Z0011 and the regional guideline on cALND rates. METHODS: Consecutive invasive breast cancer cases undergoing SLNB were reviewed at 12 hospitals. Patient, tumor, and process measures were collected for three time periods: TP1, before publication of Z0011 (May 2009-August 2010); TP2, after publication of Z0011 (March 2011-June 2012); and TP3, after guideline dissemination (January 2013-April 2014). Cases were categorized by whether they met the guideline criteria for cALND (i.e. ≤50 years, mastectomy, T3 tumor, three or more positive sentinel lymph nodes [SLNs]) or not (e.g. age > 50 years, breast-conserving surgery, T1/T2 tumor, and one to two positive SLNs). RESULTS: The SLNB rate increased from 56 % (n = 620), to 70 % (n = 774), to 78 % (n = 844) in TP1, TP2, and TP3, respectively. Among cases not recommended for cALND using the guideline criteria, cALND rates decreased significantly over time (TP1, 71 %; TP2, 43 %; TP3, 17 %) [p < 0.001]. The cALND rate also decreased over time among cases recommended to have cALND using the guideline criteria (TP1, 92 %; TP2, 69 %; TP3, 58 %) [p < 0.001]. Based on multivariable analysis, age and nodal factors appeared to be significant factors for cALND decision making. CONCLUSION: Publication of ACOSOG Z0011 and regional guideline dissemination were associated with a marked decrease in cALND after +SLNB, even among several cases in which the guideline recommended cALND.

Geolocalization of Influenza Outbreak Within an Acute Care Population: A Layered-Surveillance Approach.

STUDY OBJECTIVE: We seek to use a novel layered-surveillance approach to localize influenza clusters within an acute care population. The first layer of this system is a syndromic surveillance screen to guide rapid polymerase chain reaction testing. The second layer is geolocalization and cluster analysis of these patients. We posit that any identified clusters could represent at-risk populations who could serve as high-yield targets for preventive medical interventions. METHODS: This was a prospective observational surveillance study. Patients were screened with a previously derived clinical decision guideline that has a 90% sensitivity and 30% specificity for influenza. Patients received points for the following signs and symptoms within the past 7 days: cough (2 points), headache (1 point), subjective fever (1 point), and documented fever at triage (temperature >38°C [100.4°F]) (1 point). Patients scoring 3 points or higher were indicated for influenza testing. Patients were tested with Xpert Flu (Cepheid, Sunnyvale, CA), a rapid polymerase chain reaction test. Positive results were mapped with ArcGIS (ESRI, Redlands, CA) and analyzed with kernel density estimation to create heat maps. RESULTS: There were 1,360 patients tested with Xpert Flu with retrievable addresses within the greater Phoenix metro area. One hundred sixty-seven (12%) of them tested positive for influenza A and 23 (2%) tested positive for influenza B. The influenza A virus exhibited a clear cluster pattern within this patient population. The densest cluster was located in an approximately 1-square-mile region southeast of our hospital. CONCLUSION: Our layered-surveillance approach was effective in localizing a cluster of influenza A outbreak. This region may house a high-yield target population for public health intervention. Further collaborative efforts will be made between our hospital and the Maricopa County Department of Public Health to perform a series of community vaccination events before the next influenza season. We hope these efforts will ultimately serve to reduce the burden of this disease on our patient population, and that this system will serve as a framework for future investigations locating at-risk populations.

Results of a surgeon-directed quality improvement project on breast cancer surgery outcomes in South-Central Ontario.

BACKGROUND: Gaps in breast cancer (BC) surgical care have been identified. We have completed a surgeon-directed, iterative project to improve the quality of BC surgery in South-Central Ontario. METHODS: Surgeons performing BC surgery in a single Ontario health region were invited to participate. Interventions included: audit and feedback (A&F) of surgeon-selected quality indicators (QIs), workshops, and tailoring interviews. Workshops and A&F occurred yearly from 2005-2012. QIs included: preoperative imaging; preoperative core biopsy; positive margin rates; specimen orientation labeling; intraoperative specimen radiography of nonpalpable lesions; T1/T2 mastectomy rates; reoperation for positive margins; sentinel lymph node biopsy (SLNB) rates, number of sentinel lymph nodes; and days to receive pathology report. Semistructured tailoring interviews were conducted to identify facilitators and barriers to improved quality. All results were disseminated to all surgeons performing breast surgery in the study region. RESULTS: Over 6 time periods, 1,828 BC charts were reviewed from 12 hospitals (8 community and 4 academic). Twenty-two to 40 participants attended each workshop. Sustained improvement in rates of positive margins, preoperative core biopsies, specimen orientation labeling, and SLNB were seen. Mastectomy rates and overall axillary staging rates did not change, whereas time to receive pathology report increased. The tailoring interviews concerning positive margins, SLNB, and reoperation for positive margins identified facilitators and barriers relevant to surgeons. CONCLUSIONS: This surgeon-directed, regional project resulted in meaningful improvement in numerous QIs. There was consistent and sustained participation by surgeons, highlighting the importance of integrating the clinicians in a long-term, iterative quality improvement strategy in BC surgery.

Survey of American and Canadian general surgeons' perceptions of margin status and practice patterns for breast conserving surgery.

Although breast conservation surgery (BCS) is commonly performed, several aspects of the procedure remain controversial. We undertook a cross-sectional survey to compare Canadian (CDN) and American (AM) general surgeons' reported BCS practice patterns to better understand the cross-border differences in early-stage breast cancer surgery care. A modified Dillman Method survey was mailed to 1,447 AM and 1,443 CDN surgeons. Factors evaluated included preoperative assessment, margin definition, surgical techniques, and re-excision practices. The response rate was 26% and 51% for AM and CDN surgeons, respectively. There was variation in use of preoperative core biopsies. American surgeons required wider margins for invasive cancer and ductal carcinoma in situ, and more often recommend re-excision for invasive cancer with 1 and 2 mm margins (p < 0.05). There was also variability in surgical techniques used for intraoperative margin assessment. Wide variation in BCS practice was observed, with some of this variability related to surgeon country.

Retrospective Cohort Analysis of the Relationship Between Emergency Department Length of Stay and Timing of First Laboratory Orders.

Background The efficiency of patient management in the Emergency Department (ED) is critical for optimizing healthcare delivery. Provider in triage (PIT) and similar ED flow models attempt to expedite throughput by decreasing the amount of time between patient arrival and initial order placement. The exact relationship between ED length of stay (LOS) and the timing of the first laboratory order, however, is unclear. The varying speed at which clinicians of different ages place laboratory orders and move patients through an ED also is understudied.  Methods A retrospective analysis was conducted using SQL from the Clarity data archive to pull all patient encounters in 2023. Linear regression models using Analysis ToolPak in Microsoft Excel were used to create and examine the relationship between LOS and the timing of the first laboratory order. Secondary outcomes using the same models were created to analyze the impact of clinician age on LOS and the relationship between clinician age and the timing of first laboratory orders.  Results Two hundred sixty-nine thousand eight hundred and eight ED visits were reviewed across three academic and 17 community emergency departments. We report a weak but statistically significant positive relationship between the timing of the first laboratory order and LOS (R² = 0.0378, p < 0.001). Secondary outcomes indicated a very weak negative correlation between clinician age and LOS (R² ≈ 0, p < 0.001) and no significant relationship between clinician age and the timing of the first laboratory order (R² ≈ 0, p > 0.05). Conclusion The timing of the first laboratory order is a significant, albeit weak, predictor of LOS in the ED. Clinician age has minimal impact on LOS and does not significantly influence the timing of the first laboratory order.

Association Between Sexually Transmitted Infections and the Urine Culture.

Introduction: Bacterial urinary tract infections (UTI) and some sexually transmitted infections (STI) can have overlapping signs and symptoms or nonspecific findings, such as pyuria on urinalysis. Furthermore, results from the urine culture and the nucleic acid amplification test for an STI may not be available during the clinical encounter. We sought to determine whether gonorrhea, chlamydia, and trichomoniasis are associated with bacteriuria, information that might aid in the differentiation of STIs and UTIs. Methods: We used multinomial logistic regression to analyze 9,650 encounters of female patients who were aged ≥18 years and who underwent testing for STIs. The ED encounters took place from April 18, 2014-March 7, 2017. We used a multivariable regression analysis to account for patient demographics, urinalysis findings, vaginal wet-mount results, and positive or negative (or no) findings from the urine culture and testing for Neisseria gonorrhoeae, Chlamydia trachomatis, or Trichomonas vaginalis. Results: In multivariable analysis, infection with T vaginalis, N gonorrhoeae, or C trachomatis was not associated with having a urine culture yielding 10,000 or more colony-forming units per mililiter (CFU/mL) of bacteria compared with a urine culture yielding less than 10,000 CFU/mL or no urine culture obtained. The diagnosis of a UTI in the ED was not associated with having a urine culture yielding 10,000 or more CFU/mL compared with a urine culture yielding less than 10,000 CFU/mL. Conclusion: After adjusting for covariates, no association was observed between urine culture results and testing positive for trichomoniasis, gonorrhea, or chlamydia. Our results suggest that having a concurrent STI and bacterial UTI is unlikely.

Acute Renal Failure and Generalized Weakness in a 75-Year-Old Male With Pauci-Immune Necrotizing Antineutrophil Cytoplasmic Antibody (ANCA)-Associated Vasculitis: A Case Report.

We describe a 75-year-old male who presented to the emergency department with generalized weakness and was ultimately diagnosed with acute renal failure secondary to pauci-immune necrotizing antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis. The patient's clinical course was complicated by a perforated gastric ulcer and severe malnutrition, necessitating involvement from multiple specialists. The case highlights the challenges of this rare vasculitis and the complications that can arise from the disease and its treatment. .

Perforated Peptic Ulcer: A Case Report of a Dreaded Complication of an Insidious Disease.

Perforated peptic ulcers, though relatively rare, represent critical surgical emergencies with potentially life-threatening consequences. Their significance lies not only in their acute presentation but also in the diagnostic challenges they pose, particularly in patients with complex medical histories. Here we present a case of a 71-year-old female with a complex medical history, including insulin-dependent type 2 diabetes mellitus, hypertension, hyperlipidemia, hypothyroidism, dementia, diverticulitis, and chronic back pain, who initially were unresponsive and cyanotic. Despite challenges in diagnosis due to her medical complexity and opioid use, she was ultimately diagnosed with a perforated duodenal ulcer. Tragically, despite immediate surgical intervention, she succumbed to her illness, highlighting the complexities involved in managing perforated peptic ulcers, especially in patients with multiple chronic medical conditions. Peptic ulcer disease (PUD) can often remain asymptomatic, leading to delayed diagnosis and potentially life-threatening complications like perforation. Mortality rates associated with perforated peptic ulcers vary widely, ranging from 1.3% to 20%, with risk factors including nonsteroidal anti-inflammatory drug (NSAID) use, Helicobacter pylori infection, smoking, and corticosteroid use. Diagnosis necessitates a high index of suspicion, thorough clinical examination, and imaging modalities such as computed tomography (CT) scans with oral contrast. Treatment strategies range from nonoperative management with intravenous (IV) histamine H2-receptor blockers or proton pump inhibitors (PPIs) to surgical intervention, depending on the patient's hemodynamic stability. However, the case presented underscores the challenges in timely diagnosis and intervention, particularly in patients with complex medical histories, where symptoms may be masked or attributed to other comorbidities. Recent studies indicate a demographic shift toward older age and a higher prevalence among females, emphasizing the importance of increased awareness and vigilance among healthcare providers. Early recognition of symptoms, prompt investigation, and interdisciplinary collaboration are crucial in optimizing outcomes for patients presenting with perforated peptic ulcers, especially in the context of their underlying medical conditions.

Imaging in a Pandemic: How Lack of Intravenous Contrast for Computed Tomography Affects Emergency Department Throughput.

Introduction: During the coronavirus 2019 pandemic, hospitals in the United States experienced a shortage of contrast agent, much of which is manufactured in China. As a result, there was a significantly decreased amount of intravenous (IV) contrast available. We sought to determine the effect of restricting the use of IV contrast on emergency department (ED) length of stay (LOS). Methods: We conducted a single-institution, retrospective cohort study on adult patients presenting with abdominal pain to the ED from March 7-July 5, 2022. Of 26,122 patient encounters reviewed, 3,028 (11.6%) included abdominopelvic CT with a complaint including "abdominal pain." We excluded patients with outside imaging and non-ED scans. Routine IV contrast agent was administered to approximately 74.6% of patients between March 7-May 6, 2022, when we altered usage guidelines due to a nationwide shortage. Between May 6-July 5, 2022, 32.8% of patients received IV contrast after institutional recommendations were made to limit contrast use. We compared patient demographics and clinical characteristics between groups with chi-square test for frequency data. We analyzed ED LOS with nonparametric Wilcoxon rank-sum test for continuous measures with focus before and after new ED protocols. We also used statistical process control charts and plotted the 1, 2 and 3 sigma control limits to visualize the variation in ED LOS over time. The charts include the average (mean) of the data and upper and lower control limits, corresponding to the number of standard deviations away from the mean. Results: After use of routine IV contrast was discontinued, ED LOS (229.0 vs 212.5 minutes, P = <0.001) declined by 16.5 minutes (95% confidence interval -10, -22). Conclusion: Intravenous contrast adds significantly to ED LOS. Decreased use of routine IV contrast in the ED accelerates time to CT completion. A policy change to limit IV contrast during a national shortage significantly decreased ED LOS.

Emergency department responses to nursing shortages.

BACKGROUND: The COVID-19 pandemic exacerbated the nursing shortage, which is predicted to continue to worsen with significant numbers of nurses planning to retire within the next 5 years. There remains a lack of published information regarding recommended interventions for emergency departments (EDs) facing a sudden nursing shortage. METHODS: We queried emergency department leaders from the American College of Emergency Physicians to examine the impact of nursing shortages on EDs and to gather real-world interventions employed to mitigate the effects of the shortage. RESULTS: Most respondents (98.5%) reported nursing shortages, with 83.3% describing prolonged shortages lasting more than 12 months, with negative impacts such as misses/near-misses (93.9%) and increasing left without being seen rates (90.9%). ED leaders reported a range of interventions, including operational flow changes, utilizing alternative staff to fill nurse roles, recruitment of new nurses, and retention strategies for existing nurses. They employed temporary and permanent pay increases as well as efforts to improve the ED work environment and techniques to hire new nurses from atypical pipelines. CONCLUSION: We report a patchwork of solutions ED leaders utilized which may have variable efficacy among different EDs; personalization is essential when selecting interventions during a sudden nursing shortage.

Adult Congenital Heart Disease in the Emergency Department.

While congenital heart disease historically was a pathology primarily restricted to specialized pediatric centers, advances in technology have dramatically increased the number of people living into adulthood, the number of complications faced by these patients, and the number of patients visiting non-specialized emergency departments for these concerns. Clinicians need to be aware of the issues specific to patients' individual congenital defects but also have an understanding of how typical cardiac pathology may manifest in this special group of patients. This manuscript attempts to provide an overview of this diverse but increasingly common group of adult patients with congenital heart diseases, including a review of their anatomical variants, the complications they face at the highest rates, and ways that emergency physicians may need to manage these patients differently to avoid causing harm.

Challenges and Successes in Introducing Coronary CT Angiography in an Emergency Medicine-Run Observation Unit.

This study was designed to analyze the departmental changes in transitioning the Emergency Department (ED)-run Observation Medicine Unit's routine noninvasive cardiac evaluation from the traditional standard-of-care procedures to coronary computed tomography angiography (CCTA).  While the routine use of CCTA for the evaluation of chest pain has been deemed feasible and safe, provider confidence appears apprehensive, and ordering patterns appear reluctant to change.  We conducted a retrospective analysis of data from two risk-matched cohorts of ED patients who presented with symptoms suggestive of acute coronary syndrome (ACS) but without ischemic electrocardiogram (ECG) changes or positive troponin. Endpoints included length of stay, major adverse cardiovascular event (MACE) rates at 28 days, recidivism rate, and downstream findings on coronary catheterization.  The adoption of CCTA led to a significant reduction in the length of stay for patients in the ED-run Observation Medicine Unit. Provider and nursing education initiatives were crucial in overcoming initial resistance and improving the implementation of CCTA. Post-education, there was a marked increase in the volume of CCTA performed and a decrease in the length of stay, enhancing overall departmental throughput.  The results suggest that CCTA offers a reliable and efficient diagnostic alternative to traditional noninvasive tests, with high diagnostic accuracy contributing to faster decision-making and reduced need for invasive procedures. Continuous education for providers and nursing staff was essential to ensure adherence to the new protocol and improve clinical outcomes.  Transitioning to CCTA for routine noninvasive cardiac evaluation in the ED-run Observation Medicine Unit demonstrated significant efficiency and diagnostic accuracy benefits. Successful implementation requires targeted educational efforts to ensure competency and confidence among healthcare providers. The findings support the integration of CCTA into standard clinical practice for the evaluation of chest pain in the emergency setting, with future research needed to validate these results in broader patient populations and assess long-term outcomes.

Prevention of persistent pain with lidocaine infusions in breast cancer surgery (PLAN): study protocol for a multicenter randomized controlled trial.

BACKGROUND: Persistent pain is a common yet debilitating complication after breast cancer surgery. Given the pervasive effects of this pain disorder on the patient and healthcare system, post-mastectomy pain syndrome (PMPS) is becoming a larger population health problem, especially as the prognosis and survivorship of breast cancer increases. Interventions that prevent persistent pain after breast surgery are needed to improve the quality of life of breast cancer survivors. An intraoperative intravenous lidocaine infusion has emerged as a potential intervention to decrease the incidence of PMPS. We aim to determine the definitive effects of this intervention in patients undergoing breast cancer surgery. METHODS: PLAN will be a multicenter, parallel-group, blinded, 1:1 randomized, placebo-controlled trial of 1,602 patients undergoing breast cancer surgery. Adult patients scheduled for a lumpectomy or mastectomy will be randomized to receive an intravenous 2% lidocaine bolus of 1.5 mg/kg with induction of anesthesia, followed by a 2.0 mg/kg/h infusion until the end of surgery, or placebo solution (normal saline) at the same volume. The primary outcome will be the incidence of persistent pain at 3 months. Secondary outcomes include the incidence of pain and opioid consumption at 1 h, 1-3 days, and 12 months after surgery, as well as emotional, physical, and functional parameters, and cost-effectiveness. DISCUSSION: This trial aims to provide definitive evidence on an intervention that could potentially prevent persistent pain after breast cancer surgery. If this trial is successful, lidocaine infusion would be integrated as standard of care in breast cancer management. This inexpensive, widely available, and easily administered intervention has the potential to reduce pain and suffering in an already afflicted patient population, decrease the substantial costs of chronic pain management, potentially decrease opioid use, and improve the quality of life in patients. TRIAL REGISTRATION: This trial has been registered on clinicaltrials.gov (NCT04874038, Dr. James Khan. Date of registration: May 5, 2021).

Physician-related facilitators and barriers to patient involvement in treatment decision making in early stage breast cancer: perspectives of physicians and patients.

OBJECTIVE: To identify patients' and physicians' perceptions of physician-related verbal and nonverbal facilitators and barriers to patient involvement in treatment decision making (TDM) occurring during clinical encounters for women with early stage breast cancer (ESBC). METHODS: Eligible women were offered treatment options including surgery and adjuvant therapy. Eligible physicians provided care for women with ESBC in either a teaching hospital or an academic cancer centre. In Phase 1, women were interviewed 1-2 weeks after their initial consultation. In Phase 2, women and their physicians were interviewed separately while watching their own consultation on a digital video disk. All interviews were audiotaped, transcribed and analysed. RESULTS: Forty women with ESBC and six physicians participated. Patients and physicians identified thirteen categories of physician facilitators of women's involvement. Of these, seven categories were frequently identified by women: conveyed a rationale for patient involvement in TDM; explained the risk of cancer recurrence; explained treatment options; enhanced patient understanding of information; gave time for TDM; offered a treatment recommendation; and made women feel comfortable. Physicians described similar information-giving facilitators but less often mentioned other facilitators. Few physician barriers to women's involvement in TDM were identified. CONCLUSIONS: Women with ESBC and cancer physicians shared some views of how physicians involve patients in TDM, although there were important differences. Physicians may underestimate the importance that women's place on understanding the rationale for their involvement in TDM and on feeling comfortable during the consultation.

Impact of 18F-Labeled Fluorodeoxyglucose Positron Emission Tomography-Computed Tomography Versus Conventional Staging in Patients With Locally Advanced Breast Cancer.

PURPOSE: Patients with locally advanced breast cancer (LABC) typically undergo staging tests at presentation. If staging does not detect metastases, treatment consists of curative intent combined modality therapy (neoadjuvant chemotherapy, surgery, and regional radiation). Positron emission tomography-computed tomography (PET-CT) may detect more asymptomatic distant metastases, but the evidence is based on uncontrolled studies. METHODS: For inclusion, patients had histological evidence of invasive ductal carcinoma of the breast and TNM stage III or IIb (T3N0, but not T2N1). Consenting patients from six regional cancer centers in Ontario were randomly assigned to 18F-labeled fluorodeoxyglucose PET-CT or conventional staging (bone scan, CT of the chest/abdomen and pelvis). The primary end point was upstaging to stage IV. A key secondary outcome was receiving curative intent combined modality therapy (ClinicalTrials.gov identifier: NCT02751710). RESULTS: Between December 2016 and April 2022, 184 patients were randomly assigned to whole-body PET-CT and 185 patients to conventional staging. Forty-three (23%) PET-CT patients were upstaged to stage IV compared with 21 (11%) conventional staged patients (absolute difference, 12.3% [95% CI, 3.9 to 19.9]; P = .002). Consequently, treatment was changed in 35 (81.3%) of 43 upstaged PET-CT patients and 20 (95.2%) of the 21 upstaged conventional patients. Subsequently, 149 (81%) patients in the PET-CT group received combined modality treatment versus 165 (89.2%) patients in the conventional staging group (absolute difference, 8.2% [95% CI, 0.1 to 15.4]; P = .03). CONCLUSION: In patients with LABC, PET-CT detected more distant metastases than conventional staging, and fewer PET-CT patients received combined modality therapy. Our randomized trial demonstrates the utility of the PET-CT staging strategy.