RESUMO
BACKGROUND: More than 20% of patients undergoing initial breast-conserving surgery (BCS) for cancer require reoperation. To address this concern, the American Society of Breast Surgeons (ASBrS) endorsed 10 processes of care (tools) in 2015 to be considered by surgeons to de-escalate reoperations. In a planned follow-up, we sought to determine which tools were associated with fewer reoperations. METHODS: A cohort of ASBrS member surgeons prospectively entered data into the ASBrS Mastery® registry on consecutive patients undergoing BCS in 2017. The association between tools and reoperations was estimated via multivariate and hierarchical ranking analyses. RESULTS: Seventy-one surgeons reported reoperations in 486 (12.3%) of 3954 cases (mean 12.7% [standard deviation (SD) 7.7%], median 11.5% [range 0-32%]). There was an eightfold difference between surgeons in the 10th and 90th percentile performance groups. Actionable factors associated with fewer reoperations included routine planned cavity side-wall shaves, surgeon use of ultrasound (US), neoadjuvant chemotherapy, intra-operative pathologic margin assessment, and use of a pre-operative diagnostic imaging modality beyond conventional 2D mammography. For patients with invasive cancer, ≥ 24% of those who underwent reexcision did so for reported margins of < 1 or 2 mm, representing noncompliance with the SSO-ASTRO margin guideline. CONCLUSIONS: Although ASBrS member surgeons had some of the lowest rates of reoperation reported in any registry, significant intersurgeon variability persisted. Further efforts to lower rates are therefore warranted. Opportunities to do so were identified by adopting those processes of care, including improved compliance with the SSO-ASTRO margin guideline, which were associated with fewer reoperations.
Assuntos
Neoplasias da Mama/cirurgia , Mastectomia Segmentar/normas , Guias de Prática Clínica como Assunto/normas , Padrões de Prática Médica/normas , Reoperação , Cirurgiões/normas , Idoso , Idoso de 80 Anos ou mais , Neoplasias da Mama/patologia , Carcinoma Ductal de Mama/patologia , Carcinoma Ductal de Mama/cirurgia , Carcinoma Lobular/patologia , Carcinoma Lobular/cirurgia , Feminino , Seguimentos , Humanos , Margens de Excisão , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Sociedades MédicasRESUMO
The Disclosures in the original article are incomplete. Not included is the following information.
RESUMO
BACKGROUND: Patients want information to search for destination of care for breast-conserving surgery (BCS). To inform patients wanting a lumpectomy, we aimed to develop a pilot project that communicated composite quality measure (QM) results using a '4-star' rating system. Two patient-centered QMs were included in the model-reoperation rate (ROR) and cosmetic outcome (COSM). METHODS: A prospective database was reviewed for stage 0-3 patients undergoing initial lumpectomy by three surgeons from 2010 to 2015. Self-reported COSM was assessed by survey. Multivariate analyses were used to test for interactions between surgeon and other variables known to influence RORs and COSMs. Models of surgeon profiling were developed that summed the ROR and COSM performance scores, then reported results using a Centers for Medicare and Medicaid Services (CMS) star-type system. Functionality for a patient to 'weight' the importance of the ratio of ROR:COSM before profiling was introduced. RESULTS: The unadjusted ROR for stage 1-3 patients for three surgeons was 9.5, 13.0, and 16.3%, respectively (p = 0.179) [overall rate 10.4% (38/366)]. After risk adjustment, differences between surgeons were observed for RORs, but not COSMs. Overall, patients reported excellent, good, fair, and poor COSMs of 55, 30, 11 and 4%, respectively. Composite star scores reflected differences in performance by surgeon, which could increase, or even disappear, dependent on the patient's weighting of the ROR:COSM ratio. CONCLUSION: Composite measures of performance can be developed that allow patients to input their weighted preferences and values into surgeon profiling before they consider a destination of care for BCS.
Assuntos
Neoplasias da Mama/patologia , Neoplasias da Mama/cirurgia , Cosméticos , Mastectomia Segmentar , Preferência do Paciente , Reoperação/estatística & dados numéricos , Cirurgiões/normas , Idoso , Carcinoma Ductal de Mama/patologia , Carcinoma Ductal de Mama/cirurgia , Carcinoma Intraductal não Infiltrante/patologia , Carcinoma Intraductal não Infiltrante/cirurgia , Carcinoma Lobular/patologia , Carcinoma Lobular/cirurgia , Competência Clínica , Feminino , Seguimentos , Humanos , Pessoa de Meia-Idade , Invasividade Neoplásica , Avaliação de Resultados em Cuidados de Saúde , Prognóstico , Estudos ProspectivosRESUMO
INTRODUCTION: Past studies indicate delays in adoption of consensus-based guideline updates. In June 2016, the National Comprehensive Cancer Network changed its guidelines from routine testing to omission of ordering complete blood cell count (CBC) and liver function tests (LFT) in patients with early breast cancer. In response, we developed an implementation strategy to discontinue our historical practice of routine ordering of these tests in asymptomatic patients. METHODS: The ordering of CBC and LFT for clinical stage I-IIIA breast cancer patients was audited in 2016. In June 2016, we utilized the levers of the National Quality Strategy implementation methodology to enact a system-wide change to omit routine ordering. To measure the plan's effectiveness, guideline compliance for ordering was tracked continually. RESULTS: Of 92 patients with early stage cancer in 2016, the overall rate of compliance with guidelines for ordering a CBC and LFT was 82% (88/107) and 87% (93/107), respectively. Segregated by the pre- and post-guideline change time period, the compliance rates for ordering a CBC and LFT were 78% and 87% (P = 0.076). CONCLUSION: In contrast to historical reports of delays in adoption of new evidence-based guideline changes, we were able to quickly change provider practice during the transition from routine ordering to omission of ordering screening blood tests in newly diagnosed patients with early breast cancer.
Assuntos
Neoplasias da Mama/diagnóstico , Neoplasias da Mama/economia , Testes Diagnósticos de Rotina/economia , Testes Diagnósticos de Rotina/normas , Fidelidade a Diretrizes , Programas de Rastreamento/economia , Programas de Rastreamento/normas , Padrões de Prática Médica/economia , Padrões de Prática Médica/estatística & dados numéricos , Adulto , Idoso , Neoplasias da Mama/patologia , Análise Custo-Benefício , Medicina Baseada em Evidências , Feminino , Humanos , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Estados UnidosRESUMO
BACKGROUND: Reoperations occur frequently after initial lumpectomy for breast cancer. The authors hypothesized that the receipt of neoadjuvant chemotherapy (NAC) is associated with fewer reoperations. METHODS: The association between timing of chemotherapy and reoperation rates (ROR) after lumpectomy was investigated for patients with stages 1-3 breast cancer in the National Cancer Database (NCDB) from 2010 to 2013 by multivariable logistic regression modeling. Then propensity score-matching was performed. RESULTS: The unadjusted ROR for 71,627 stages 1-3 patients was 11.4% for those who had NAC compared with 20.3% for those who had postoperative chemotherapy (p < 0.001) (odds ratio [OR] 0.53; 95% confidence interval [CI] 0.49-0.57; p < 0.001). The ORs for the reoperations performed for patients with stages 1, 2, and 3 cancers who received NAC were respectively 0.65 (95% CI 0.56-0.75), 0.50 (95% CI 0.45-0.56), and 0.27 (95% CI 0.19-0.38) The p values for all were lower than 0.001. CONCLUSION: For a population of patients receiving chemotherapy, the receipt of chemotherapy before instead of after surgery was associated with fewer reoperations after initial lumpectomy for breast cancer.
Assuntos
Neoplasias da Mama/cirurgia , Quimioterapia Adjuvante/estatística & dados numéricos , Bases de Dados Factuais , Mastectomia , Terapia Neoadjuvante/estatística & dados numéricos , Reoperação/estatística & dados numéricos , Cirurgia de Second-Look/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias da Mama/tratamento farmacológico , Neoplasias da Mama/patologia , Feminino , Seguimentos , Humanos , Pessoa de Meia-Idade , Prognóstico , Taxa de Sobrevida , Adulto JovemRESUMO
BACKGROUND: Margin status is an important prognostic factor for local recurrence after breast conserving surgery (BCS) for breast cancer. We designed a prospective randomized trial to evaluate the effect of shave margins on positive margins and locoregional recurrence (LRR). METHODS: Patients were randomized to BCS or BCS with resection of 5 additional margins (BCS + M). Tumor margins were classified as negative [>2 mm for ductal carcinoma in situ (DCIS); >1 mm for invasive carcinoma] based on guidelines at the time of accrual. RESULTS: A total of 75 patients with stage 0-III breast cancer (76 samples) were randomized, mean age 59.6 years with median follow-up 39.5 months. Overall, 21 patients (27.6 %) had positive margins: 14 had undergone BCS and 7 BCS + M (p = 0.005). Of the 21 patients with positive margins, 19 had DCIS on final pathology (OR 7.56; 95 % CI 1.52-37.51).All patients with positive margins were offered re-excision; 11 had negative final margins after re-excision surgery. Overall, 6 patients (8.3 %) developed LRR with recurrence being more common in the BCS group when compared with the BCS + M group (17.2 vs 2.3 %; p = 0.025). CONCLUSIONS: Taking additional cavity shave margins at the time of initial excision resulted in a reduction in positive margin rate, a decrease in return to operating room for re-excision, and lower LRR.
Assuntos
Negro ou Afro-Americano/estatística & dados numéricos , Neoplasias da Mama/cirurgia , Carcinoma Ductal de Mama/cirurgia , Carcinoma Intraductal não Infiltrante/cirurgia , Mastectomia Segmentar , Recidiva Local de Neoplasia/diagnóstico , Neoplasia Residual/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias da Mama/etnologia , Neoplasias da Mama/patologia , Carcinoma Ductal de Mama/etnologia , Carcinoma Ductal de Mama/patologia , Carcinoma Intraductal não Infiltrante/etnologia , Carcinoma Intraductal não Infiltrante/patologia , Feminino , Seguimentos , Hospitais Públicos , Humanos , Pessoa de Meia-Idade , Invasividade Neoplásica , Estadiamento de Neoplasias , Neoplasia Residual/etnologia , Neoplasia Residual/patologia , Prognóstico , Estudos ProspectivosRESUMO
BACKGROUND: Variations exist in compliance with NCCN Guidelines. Prior reports of adherence to NCCN Guidelines contain limitations because of lack of contemporary review and incomplete listing of reasons for noncompliance. PURPOSE: To assess institutional compliance and assist national quality improvement strategies through identifying valid reasons for noncompliance. METHODS: Compliance with NCCN Guidelines was recorded prospectively using electronic synoptic templates for patients with newly diagnosed breast cancer treated at a single institution between January 2010 and December 2011. Compliance with NCCN Guidelines was recorded. The accuracy of real-time synoptic auditing methods compared with retrospective chart review and reasons for noncompliance was assessed. SAS 9.3 software was used for data analysis. RESULTS: Compliance with NCCN Guidelines among 395 patients was 94% for initial staging evaluation, 97% for surgery, 91% for chemotherapy, 89% for hormone therapy, 91% for radiation therapy, 85% for follow-up, and 100% for determination of estrogen receptor/progesterone receptor and HER2 status. Age, comorbidities, and stage influenced guideline compliance. The most common reasons for noncompliance were patient refusal, patient choice after shared decision-making, and overuse of testing. Synoptic templated reporting was accurate in 97% patients. CONCLUSIONS: High compliance with NCCN Guidelines was demonstrated. Reasons for noncompliance were identifiable. Compliance and nonadherence can be evaluated quickly with electronic synoptic reporting. This allows real-time action plans to address quality concerns and aids national risk adjustment for comparison and benchmarking.
Assuntos
Neoplasias da Mama/diagnóstico , Neoplasias da Mama/terapia , Fidelidade a Diretrizes , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias da Mama Masculina/diagnóstico , Neoplasias da Mama Masculina/terapia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como AssuntoRESUMO
BACKGROUND: A patient navigation process is required for accreditation by the National Accreditation Program for Breast Centers (NAPBC). Patient navigation has previously been shown to improve timely diagnosis in patients with breast cancer. This study sought to assess the effect of nurse navigation on timeliness of care following the diagnosis of breast cancer by comparing patients who were treated in a comprehensive cancer center with and without the assistance of nurse navigation. METHODS: Navigation services were initiated at an NAPBC-accredited comprehensive breast center in July 2010. Two 9-month study intervals were chosen for comparison of timeliness of care: October 2009 through June 2010 and October 2010 through June 2011. All patients with breast cancer diagnosed in the cancer center with stage 0 to III disease during the 2 study periods were identified by retrospective cancer registry review. Time from diagnosis to initial oncology consultation was measured in business days, excluding holidays and weekends. RESULTS: Overall, 176 patients met inclusion criteria: 100 patients prior to and 76 patients following nurse navigation implementation. Nurse navigation was found to significantly shorten time to consultation for patients older than 60 years (B = -4.90, P = .0002). There was no change in timeliness for patients 31 to 60 years of age. CONCLUSIONS: Short-term analysis following navigation implementation showed decreased time to consultation for older patients, but not younger patients. Further studies are indicated to assess the long-term effects and durability of this quality improvement initiative.
Assuntos
Neoplasias da Mama/diagnóstico , Neoplasias da Mama/terapia , Acessibilidade aos Serviços de Saúde , Papel do Profissional de Enfermagem , Navegação de Pacientes/normas , Encaminhamento e Consulta , Tempo para o Tratamento/normas , Centros Médicos Acadêmicos , Adulto , Fatores Etários , Idoso , Gerenciamento Clínico , Feminino , Georgia , Humanos , Seguro Saúde , Modelos Lineares , Pessoa de Meia-Idade , Gradação de Tumores , Estadiamento de Neoplasias , Sistema de Registros , Estudos Retrospectivos , Estações do Ano , Classe Social , Tempo para o Tratamento/organização & administraçãoRESUMO
OBJECTIVE: The purpose of this study is to evaluate the rate of minimally invasive biopsy for diagnosis of breast cancer at an interdisciplinary breast center. BACKGROUND: Percutaneous core needle biopsy (CNB) is optimal for minimizing surgery for the diagnosis of benign and malignant lesions of the breast while preserving surgery for definitive resection. Core needle biopsy increases patient satisfaction and reduces the cost of diagnosis and treatment. Despite the endorsement of CNB by many professional organizations, the literature documents underutilization. METHODS: Institutional review board approval was obtained. An audit of a single institution's prospectively maintained cancer databases was performed for all breast cancers diagnosed in 2007 and 2008. Methods of diagnosis included image-guided and freehand-guided CNB, image-guided vacuum assisted needle biopsy, image-guided fine needle aspiration, punch biopsy, and open surgical biopsy. RESULTS: Three hundred sixty new breast cancers were diagnosed in 2007 and 2008. Malignancy was diagnosed by minimally invasive techniques in 350/360 (97%) cancers. CONCLUSION: A very high rate of accurate tissue diagnosis of breast cancer by minimally invasive techniques is achievable.
Assuntos
Biópsia por Agulha Fina/estatística & dados numéricos , Biópsia por Agulha/estatística & dados numéricos , Neoplasias da Mama/patologia , Carcinoma Ductal de Mama/patologia , Carcinoma Intraductal não Infiltrante/patologia , Comportamento Cooperativo , Comunicação Interdisciplinar , Qualidade da Assistência à Saúde , Cirurgia Assistida por Computador/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Mama/patologia , Neoplasias da Mama/diagnóstico , Carcinoma Ductal de Mama/diagnóstico , Carcinoma Intraductal não Infiltrante/diagnóstico , Feminino , Hospitais Especializados/estatística & dados numéricos , Humanos , Auditoria Médica , Pessoa de Meia-Idade , Satisfação do Paciente , Garantia da Qualidade dos Cuidados de Saúde , Sistema de Registros , Estudos Retrospectivos , Revisão da Utilização de Recursos de SaúdeRESUMO
Vitamin D receptor (VDR) ligands are therapeutic agents for the treatment of psoriasis, osteoporosis, and secondary hyperparathyroidism. VDR ligands also show immense potential as therapeutic agents for autoimmune diseases and cancers of skin, prostate, colon, and breast as well as leukemia. However, the major side effect of VDR ligands that limits their expanded use and clinical development is hypercalcemia that develops as a result of the action of these compounds mainly on intestine. In order to discover VDR ligands with less hypercalcemia liability, we sought to identify tissue-selective VDR modulators (VDRMs) that act as agonists in some cell types and lack activity in others. Here, we describe LY2108491 and LY2109866 as nonsecosteroidal VDRMs that function as potent agonists in keratinocytes, osteoblasts, and peripheral blood mononuclear cells but show poor activity in intestinal cells. Finally, these nonsecosteroidal VDRMs were less calcemic in vivo, and LY2108491 exhibited more than 270-fold improved therapeutic index over the naturally occurring VDR ligand 1,25-dihydroxyvitamin D3 [1,25-(OH)2D3] in an in vivo preclinical surrogate model of psoriasis.
Assuntos
Acetatos/farmacologia , Sulfonatos de Arila/farmacologia , Receptores de Calcitriol/metabolismo , Tiofenos/farmacologia , Vitamina D/análogos & derivados , Vitamina D/farmacologia , Acetatos/síntese química , Acetatos/metabolismo , Animais , Sulfonatos de Arila/síntese química , Sulfonatos de Arila/metabolismo , Células CACO-2 , Calcitriol/metabolismo , Calcitriol/farmacologia , Proliferação de Células , Células Cultivadas , Neoplasias do Colo/metabolismo , Relação Dose-Resposta a Droga , Avaliação Pré-Clínica de Medicamentos , Feminino , Humanos , Hipercalcemia/metabolismo , Intestinos , Queratinócitos/efeitos dos fármacos , Queratinócitos/metabolismo , Ligantes , Camundongos , Camundongos Pelados , Camundongos Endogâmicos C57BL , Camundongos Endogâmicos , Modelos Biológicos , Osteoblastos/efeitos dos fármacos , Osteoblastos/metabolismo , Psoríase/tratamento farmacológico , Ratos , Receptores de Calcitriol/agonistas , Transdução de Sinais , Especificidade da Espécie , Tiofenos/síntese química , Tiofenos/metabolismo , Transcrição Gênica , Células Tumorais Cultivadas , Vitamina D/síntese química , Vitamina D/metabolismoRESUMO
BACKGROUND: Repeat operations after breast-conserving surgery (BCS) for cancer have been termed "epidemic." To aid improvement activities, we sought to identify those National Cancer Data Base (NCDB) characteristics that were associated with reoperations. METHODS: A retrospective cohort of patients with invasive breast cancer undergoing initial BCS in the NCDB from 2004 to 2015 were identified. Univariate, multivariate, ranking (effect size and R2), and time-trend methods were used to assess associations between patient, facility, tumor, treatment, and calendar-year characteristics with reoperation. RESULTS: In 1226 facilities, 84,462 (16.1%) of 524,594 patients underwent reoperations after BCS [range 0-75%; 10th/90th performance percentilesâ¯=â¯6.6%/25%]. Of 18 factors associated with reoperations, facility ID was the highest-ranked. Its estimated impact on the odds of reoperation was more than 10 times greater than any other factor considered, followed by tumor size, neo-adjuvant chemotherapy receipt, patient age, cancer histology, and nodal status. Reoperations after the year of the SSO-ASTRO margin guideline declined significantly compared with prior years. Significant inter-facility reoperation variability persisted after risk adjustment for more than a dozen distinct patient, facility, tumor, and treatment characteristics. CONCLUSION: In the NCDB, significant inter-facility variability exists regardless of case volume, case mix, and risk adjustment. There were fewer reoperations after the SSO-ASTRO guideline. An endorsed target rate of 10% was achieved by only 1 in 4 facilities. The most impactful determinant of reoperation was the facility itself. Thus, all stakeholders should consider participation in improvement activities. Such activities will benefit from risk-adjusted profiling; the relevant adjustors were identified.
Assuntos
Neoplasias da Mama/cirurgia , Carcinoma Ductal de Mama/cirurgia , Carcinoma Lobular/cirurgia , Hospitais/estatística & dados numéricos , Mastectomia Segmentar , Reoperação/estatística & dados numéricos , Centros Médicos Acadêmicos , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Antineoplásicos/uso terapêutico , Antineoplásicos Hormonais/uso terapêutico , Neoplasias da Mama/metabolismo , Neoplasias da Mama/patologia , Institutos de Câncer , Carcinoma Ductal de Mama/metabolismo , Carcinoma Ductal de Mama/patologia , Carcinoma Lobular/metabolismo , Carcinoma Lobular/patologia , Feminino , Hospitais Comunitários , Hospitais com Alto Volume de Atendimentos , Hospitais com Baixo Volume de Atendimentos , Humanos , Linfonodos/patologia , Pessoa de Meia-Idade , Terapia Neoadjuvante/estatística & dados numéricos , Estadiamento de Neoplasias , Guias de Prática Clínica como Assunto , Receptor ErbB-2/metabolismo , Receptores de Estrogênio/metabolismo , Receptores de Progesterona/metabolismo , Estudos Retrospectivos , Fatores de Risco , Carga TumoralRESUMO
BACKGROUND: Recent observational studies are concerning because they document rising mastectomy rates coinciding with more than a dozen reports that lumpectomy has better overall survival (OS) than mastectomy. Our aim was to determine if there were differences in OS of matched breast cancer patients undergoing lumpectomy versus mastectomy in the National Cancer Database (NCDB). PATIENTS AND METHODS: A retrospective cohort of patients with stage I-III breast cancer in the NCDB (2004-2013) was identified. Propensity score matching (PSM), Kaplan-Meier, and multivariate Cox proportional hazards models were used to examine OS by type of surgery. RESULTS: Of 845,136 patients, 464,052 (54.9%) underwent lumpectomy and 381,084 (45.1%) underwent mastectomy. After PSM, the hazard ratio (HR) and confidence interval (CI) for OS in all patients comparing lumpectomy with mastectomy was 1.02 (CI, 1.00-1.04; P = .002). In patients with stage I, II, and III, they were HR 1.27 (CI, 1.23-1.36; P < .001), HR 0.98 (CI, 0.95-1.01; P = .21), and HR 0.83 (CI, 0.80-0.86; P < .001), respectively. In subgroup analyses of all patients by estrogen receptor (ER) status, they were HR 1.05 (CI, 1.03-1.07; P < .001) and HR 1.00 (CI, 0.96-1.03; P = .65) in ER+ and ER- patients. CONCLUSION: In our primary model of all stage I-III matched patients, using the most recent NCDB data and the largest observational sample size to date, the OS after mastectomy was not inferior to lumpectomy. This finding can be reassuring to patients and providers. In subgroup analyses, the association between type of surgery and OS differed by cancer stage and hormone receptor status.
Assuntos
Neoplasias da Mama/mortalidade , Bases de Dados Factuais , Mastectomia Segmentar/mortalidade , Mastectomia/mortalidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias da Mama/patologia , Neoplasias da Mama/cirurgia , Feminino , Seguimentos , Humanos , Pessoa de Meia-Idade , Prognóstico , Pontuação de Propensão , Estudos Retrospectivos , Taxa de SobrevidaRESUMO
BACKGROUND: The influence of neoadjuvant chemotherapy (NAC) prior to breast cancer surgery on postoperative complications is unclear. Our objective was to determine whether NAC was associated with postoperative outcomes in patients undergoing lumpectomy or mastectomy without reconstruction. METHODS: Patients meeting inclusion criteria were identified from the National Surgical Quality Improvement Program (NSQIP) database participant user files from 2005 through 2012, after which NSQIP discontinued the NAC variable. Primary outcome measures included a composite measure of morbidity and mortality (M&M) and reoperations and readmissions within 30 days of the index procedure. Rates of postoperative complications stratified by receipt of NAC were compared by χ2. A logistic regression model was then built that included confounding factors for M&M. RESULTS: There were 30,309 patients meeting inclusion criteria. NAC was not associated with any postoperative outcomes from 2005 through 2012, but it was associated with higher M&M in lumpectomy patients during 2011 to 2012 [P=0.011, odds ratio (OR) 2.579; 95% confidence interval (CI), 1.239-5.368]. CONCLUSIONS: The finding that NAC was associated with higher M&M in lumpectomy patients during 2011 to 2012 warrants further investigation. Therefore, we recommend that the NSQIP database reinstitute the NAC variable to allow monitoring during anticipated changes in chemotherapy agents and protocols.
RESUMO
BACKGROUND: We aimed to analyze the applicability of the National Surgical Quality Improvement Program (NSQIP) calculator to patients undergoing breast-conserving surgery. METHODS: A total of 287 consecutive patients treated with breast-conserving surgery from 2010 to 2012 were identified retrospectively. The risk calculator was applied to each patient to generate an individual risk profile. Risk calculations were then compared with actual outcomes. The performance of the risk calculator was evaluated using 2 metrics: the Brier score and c statistic. RESULTS: The NSQIP calculator performed adequately for all complications, with Brier scores less than .05. However, 37 patients (12.9%) returned to the operating room for oncologic indications. Twenty-nine patients (10.1%) had positive margins, whereas 8 patients (2.8%) returned due to an upgrade in diagnosis. CONCLUSIONS: When considering return to the operating room for oncologic management, the observed rate of 13.9% is significantly higher than the NSQIP prediction. This deviation must be addressed when using the NSQIP risk calculator model during preoperative risk discussion.
Assuntos
Neoplasias da Mama/cirurgia , Mastectomia Segmentar , Garantia da Qualidade dos Cuidados de Saúde/métodos , Medição de Risco , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Pessoa de Meia-Idade , Melhoria de Qualidade , Sistema de Registros , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Sociedades Médicas , Estados UnidosRESUMO
BACKGROUND: Extramammary findings (EMFs) are common on breast magnetic resonance imaging (MRI). METHODS: A retrospective review of breast MRIs in breast cancer patients between January 2009 and December 2014 was performed to identify EMF occurrences, resultant evaluation, and added cost. RESULTS: EMFs were noted in 185 (59%) of 316 MRIs. Overall, 201 new EMFs were identified with 178 (89%) benign and 23 (11%) malignant. New malignant findings included 19 metastatic nodes (18 axillary, 1 internal mammary) and 4 primary malignancies (2 thyroid, 2 lung). New malignant nonaxillary EMFs occurred at a rate of 1.6% (5/316). EMFs resulted in 65 patients undergoing 98 imaging studies, 37 procedures, and 10 consultations with a median (range) total charge of $3,491 ($222 to $29,076] and out of pocket cost of $2,206 ($44 to $12,780) per patient. CONCLUSIONS: EMFs occurred in more than half of our patients, were usually benign, and frequently led to additional testing and costs.
Assuntos
Neoplasias da Mama/diagnóstico por imagem , Carcinoma/diagnóstico por imagem , Achados Incidentais , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias da Mama/economia , Neoplasias da Mama/patologia , Carcinoma/economia , Carcinoma/patologia , Custos e Análise de Custo , Feminino , Humanos , Incidência , Imageamento por Ressonância Magnética , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
BACKGROUND AND OBJECTIVES: Recent preclinical basic science studies suggest that patient tumor immunity is altered by general anesthesia (GA), potentially worsening cancer outcomes. A single retrospective review concluded that breast cancer patients receiving paravertebral block and GA had better cancer outcomes compared with patients receiving GA alone. This study has not been validated. We hypothesized that local or regional anesthesia (LRA) would be associated with better cancer outcomes compared with GA. METHODS: We retrospectively reviewed a prospectively collected database to identify all stage 0-III breast cancer patients undergoing surgery in a single center during a 9-year period ending January 1, 2010. Patients were divided into 2 groups: those who received only LRA and those who received GA. Overall survival (OS), disease-free survival (DFS), and local regional recurrence (LRR) were calculated using the Kaplan-Meier method with log-rank comparison before and after propensity score matching. RESULTS: Median age of the 1107 patients who met study criteria was 64 years (range, 24-97 years). Median and longest follow-up were 5.5 and 12.5 years, respectively. General anesthesia was used for 461 patients (42%), and 646 (58%) received LRA. The point estimates of cumulative OS, DFS, and LRR "free" rates at 5 years for the GA and LRA groups were 85.5% and 87.1%, 94.2% and 96.1%, and 96.3% and 95.8%, respectively. Cox regression showed no significant differences between the 2 groups (GA and LRA) for the 3 outcomes: OS (hazard ratio [HR], 0.81; 95% confidence interval [CI], 0.59-1.10; P = 0.17), DFS (HR, 0.91; 95% CI, 0.55-1.76; P = 0.87), and LRR (HR, 1.73; 95% CI, 0.83-3.63; P = 0.15). CONCLUSIONS: Breast cancer OS, DFS, and LRR were not affected by type of anesthesia in our institution. This result differs from that of the only prior published clinical report on this topic and does not provide clinical corroboration of the basic science studies that suggest oncologic benefits to LRA.
Assuntos
Anestesia por Condução , Anestesia Local , Neoplasias da Mama/cirurgia , Mastectomia , Adulto , Idoso , Idoso de 80 Anos ou mais , Anestesia por Condução/efeitos adversos , Anestesia por Condução/mortalidade , Anestesia Local/efeitos adversos , Anestesia Local/mortalidade , Neoplasias da Mama/mortalidade , Neoplasias da Mama/patologia , Distribuição de Qui-Quadrado , Bases de Dados Factuais , Intervalo Livre de Doença , Feminino , Humanos , Estimativa de Kaplan-Meier , Modelos Logísticos , Mastectomia/efeitos adversos , Mastectomia/mortalidade , Pessoa de Meia-Idade , Análise Multivariada , Recidiva Local de Neoplasia , Estadiamento de Neoplasias , Pontuação de Propensão , Modelos de Riscos Proporcionais , Indução de Remissão , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Adulto JovemRESUMO
OBJECTIVE: The effect of surgery resident participation on breast cancer recurrence has not been previously reported. The objectives of this study were to determine if resident participation was associated with either immediate postoperative or long-term breast cancer outcomes. DESIGN: We retrospectively reviewed a prospectively collected breast center database to identify all patients with breast cancer undergoing surgery in a single center during a 9-year period ending 1 January 2010. Patients were divided into 2 groups based on whether surgery residents completed more than 50% of the critical portions of the case (Resident group) or not. The outcomes of operation length, reoperative rates, morbidity, and the long-term outcomes of cancer recurrence were compared by group. Comparisons of immediate postoperative outcomes were made with chi-square and Fisher exact tests. Comparisons of operation length were analyzed by Wilcoxon rank-sum testing. Survival analyses were calculated using the Kaplan-Meier method with log-rank comparison. Multivariate analysis with Cox regression was also performed. SETTING: The study occurred at a community-based hospital that has an accredited general surgery training program. PARTICIPANTS: In all, 1107 consecutive patients with stage 0-3 breast cancer undergoing breast cancer operations were included. RESULTS: Median age of patients was 64 years (range: 24-97). Median and longest follow-up were 5.5 and 12.5 years, respectively. Initial operation was breast conserving in 796 (72%) and mastectomy in 311 (28%). Of the 1107 patients, 887 (80.1%) had resident participation. The Resident group was associated with longer operative times. We identified no differences in operative morbidity, reoperations, overall survival, disease-free survival, or local-regional recurrence in the Resident and No Resident groups. CONCLUSIONS: Resident involvement in breast cancer operations was associated with longer operative times but did not affect any other perioperative or cancer outcome in our institution. This information can be used to reassure program directors, attending surgeons, and patients if they have questions or concerns about the safety or effectiveness of cancer surgery when there is surgical resident participation.
Assuntos
Neoplasias da Mama/cirurgia , Cirurgia Geral/educação , Internato e Residência , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: Clinical management of papillary breast lesions (PBLs) remains controversial. The objective of this study was to identify pathologic and radiologic predictors of malignancy from a large cohort of PBLs diagnosed on core-needle biopsy (CNB). STUDY DESIGN: Retrospective review of the institutional pathology database identified all PBLs diagnosed from 2001 to 2009 and surgically excised within 6 months of diagnosis. PBLs were divided into intraductal papilloma (IDP) and IDP associated with atypical ductal or lobular hyperplasia (ADH/ALH). Surgical pathology of all lesions was reviewed and upgrade was defined as a change to a lesion of greater clinical significance, including ALH, ADH, lobular, or ductal carcinoma in situ (LCIS or DCIS), and invasive ducal carcinoma (IDC). RESULTS: We identified 276 patients (mean age 56 years; range 23 to 88 years) with PBLs on CNB. Seventy-nine patients (28.6%) upgraded to a lesion of greater clinical significance. Of the 234 (84.7%) had IDP only, 42 (17.9%) upgraded to ADH, and 21 (8.9%) to DCIS or IDC. Of the 42 (15.3%) patients with associated ADH or ALH on CNB, 16 (38.0%) upgraded to DCIS or IDC. The majority of patients (n = 173, 62.6%) had no breast symptoms. All patients had an abnormal mammogram and/or ultrasound that prompted the CNB. Among all clinical and radiographic variables analyzed, older age alone was predictive of upgrade. CONCLUSIONS: Frequent upgrade to a high-risk lesion or cancer is observed with IDPs diagnosed on CNB without adequate identifiable clinical and radiographic risk factors. Surgical excision should be performed for all IDPs to delineate subsequent clinical management.
Assuntos
Biópsia por Agulha , Neoplasias da Mama/diagnóstico por imagem , Neoplasias da Mama/patologia , Papiloma/diagnóstico por imagem , Papiloma/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias da Mama/cirurgia , Carcinoma in Situ/patologia , Carcinoma Ductal de Mama/patologia , Feminino , Seguimentos , Humanos , Hiperplasia , Pessoa de Meia-Idade , Gradação de Tumores , Papiloma/cirurgia , Radiografia , Estudos RetrospectivosRESUMO
Disease conditions of the breast are very common. Patients with such conditions often present to surgeons for both diagnostic evaluation and treatment. Nearly all of them will require breast imaging. This article summarizes the use, applicability, and concordance assessment of mammography, ultrasonography, and magnetic resonance imaging in patients who have breast complaints or abnormalities on clinical examination or imaging.
Assuntos
Neoplasias da Mama/diagnóstico , Imageamento por Ressonância Magnética , Mamografia , Ultrassonografia Mamária , Neoplasias da Mama/cirurgia , Feminino , HumanosRESUMO
BACKGROUND: Evaluation of lymph nodes is important for the optimal treatment of colon adenocarcinoma. Few studies have assessed whether lymph node harvest is compromised by obesity. We hypothesized that lymph node retrieval in colon cancer resection would be reduced in obese patients. METHODS: Patients undergoing resection for colon adenocarcinoma diagnosed from 2000 to 2007 were reviewed retrospectively and stratified by body mass index (BMI). Lymph node harvest was evaluated. RESULTS: A total of 401 patients were included. Their mean age was 72.8 years, and 44% were men. Their mean BMI was 28.2 kg/m(2). Mean lymph node recovery among BMI groups was as follows: BMI less than 18.5 was 20.6; BMI of 18.5 to 24.9 was 25.1; BMI of 25 to 29.9 was 23.1; BMI of 30 to 34.9 was 22.4; BMI of 35 to 39.9 was 19.0; and BMI of 40 or greater was 21.1 nodes (P = .321). Surgical time increased with increasing BMI (P = .005). Adequacy of node harvest differed by stage (P = .007), left-sided versus right-sided resections (P = .001), and pathology technician (P = .001). CONCLUSIONS: Lymph node retrieval was not affected by BMI.