Assessment of Oncologists' Perspectives on Omission of Sentinel Lymph Node Biopsy in Women 70 Years and Older With Early-Stage Hormone Receptor-Positive Breast Cancer.

Importance: Randomized clinical trial data have demonstrated that omission of surgical axillary evaluation does not affect overall survival in women 70 years and older with early-stage (clinical tumor category 1 [cT1] with node-negative [N0] disease) hormone receptor (HR)-positive and erb-B2 receptor tyrosine kinase 2 (ERBB2; formerly HER2)-negative breast cancer. Therefore, the Choosing Wisely initiative has recommended against routine use of sentinel lymph node biopsy (SLNB) in this population; however, retrospective data have revealed that more than 80% of patients eligible for SLNB omission still undergo the procedure. Multidisciplinary factors involved in these patterns remain unclear. Objective: To describe surgical, medical, and radiation oncologists' perspectives on omission of SLNB in women 70 years and older with cT1N0 HR-positive, ERBB2-negative breast cancer. Design, Setting, and Participants: This qualitative study used in-depth semi-structured interviews to explore the factors involved in oncologists' perspectives on providing care to older women who were eligible for SLNB omission. Purposive snowball sampling was used to recruit a sample of surgical, medical, and radiation oncologists representing a wide range of practice types and number of years in practice in the US and Canada. A total of 29 oncologists who finished training and were actively treating patients with breast cancer were interviewed. Interviews were conducted between March 1, 2020, and January 17, 2021. Main Outcomes and Measures: Recordings from semi-structured interviews were transcribed and deidentified. Thematic analysis was used to identify emergent themes. Results: Among 29 physicians (16 women [55.2%] and 13 men [44.8%]) who participated in interviews, 16 were surgical oncologists, 6 were medical oncologists, and 7 were radiation oncologists. Data on race and ethnicity were not collected. Participants had a range of experience (median [range] years in practice, 12.0 [0.5-30.0]) and practice types (14 academic [48.3%], 7 community [24.1%], and 8 hybrid [27.6%]). Interviews revealed that the decision to omit SLNB was based on nuanced patient- and disease-level factors. Wide variation was observed in oncologists' perspectives on SLNB omission recommendations and supporting data. In addition, participants' statements suggested that the multidisciplinary nature of cancer care may increase oncologists' anxiety regarding SLNB omission. Conclusions and Relevance: In this study, findings from interviews revealed that oncologists' perspectives may have implications for the largely unsuccessful deimplementation of SLNB in women 70 years and older with cT1N0 HR-positive, ERBB2-negative breast cancer. Interventions aimed at educating physicians, improving patient-physician communication, and facilitating preoperative multidisciplinary conversations may help to successfully decrease SLNB rates in this patient population.

Autologous Posterior Rectus Sheath as a Vascularized Onlay Flap: a Novel Approach to Hiatal Hernia Repair.

INTRODUCTION: Complex and recurrent paraesophageal hernia repairs are a challenge for surgeons due to their high recurrence rates despite the use of various prosthetic and suturing techniques. METHODS: Here we describe the use of vascularized fascia harvested from the posterior rectus sheath with peritoneum during robotic hiatal hernia repair in two patients with large complex diaphragmatic defects. RESULTS: Successful harvesting and onlay of the right posterior rectus sheath based on a falciform vascular pedicle was achieved robotically by rotating and securing the flap to the diaphragmatic hiatus as an onlay flap following cruroplasty of the hiatal defect. CONCLUSIONS: In patients with difficult to repair large paraesophageal hernias, we demonstrate a promising new technique to restore the dynamic hiatal complex with the tensile strength of autologous vascularized fascia and peritoneum.

Factors Influencing Adolescent and Young Adults' First Pelvic Examination Experiences: A Qualitative Study.

STUDY OBJECTIVE: To understand the factors that influence individuals' experiences during their first pelvic examination. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: We conducted semistructured interviews with adolescents and young adults, aged 18-24, who had received at least 1 pelvic examination. Interviews explored contextual factors of the first pelvic examination, including visit acuity and clinical setting and individuals' experiences with the pelvic examination itself and elicited recommendations on how to improve the examination experience. Interviews were transcribed and computer-assisted content analysis was performed; salient themes are presented. RESULTS: Thirty participants completed interviews. Nineteen participants described their first pelvic examination experience as positive; 11 described this examination as a negative or neutral experience. Factors influencing the experience include the examination indication and acuity, examination location and physical space, provider features, relational and interpersonal features, and procedural aspects. Recommendations included: (1) establish rapport and educate before the examination; (2) establish practices to orient patients; (3) make no assumptions about identity; and (4) elicit continuous feedback. CONCLUSION: Individuals' first pelvic examination experiences are influenced by a variety of factors. Although some factors are directly modifiable by providers, other factors that might not be modifiable are important to elicit to optimize the examination experience. These findings call for best practice guidelines and educational interventions to prepare providers to perform the first pelvic examination.