Determination of Factors Associated with Upstage in Atypical Ductal Hyperplasia to Identify Low-Risk Patients Where Active Surveillance May be an Alternative.

BACKGROUND: Excision is routinely recommended for atypical ductal hyperplasia (ADH) found on core biopsy given cancer upstage rates of near 20%. Identifying a cohort at low-risk for upstage may avoid low-value surgery. Objectives were to elucidate factors predictive of upstage in ADH, specifically near-complete core sampling, to potentially define a group at low upstage risk. PATIENTS AND METHODS: This retrospective, cross-sectional, multi-institutional study from 2015 to 2019 of 221 ADH lesions in 216 patients who underwent excision or active observation (≥ 12 months imaging surveillance, mean follow-up 32.6 months) evaluated clinical, radiologic, pathologic, and procedural factors for association with upstage. Radiologists prospectively examined imaging for lesional size and sampling proportion. RESULTS: Upstage occurred in 37 (16.7%) lesions, 25 (67.6%) to ductal carcinoma in situ (DCIS) and 12 (32.4%) to invasive cancer. Factors independently predictive of upstage were lesion size ≥ 10 mm (OR 5.47, 95% CI 2.03-14.77, p < 0.001), pathologic suspicion for DCIS (OR 12.29, 95% CI 3.24-46.56, p < 0.001), and calcification distribution pattern (OR 8.08, 95% CI 2.04-32.00, p = 0.003, "regional"; OR 19.28, 95% CI 3.47-106.97, p < 0.001, "linear"). Near-complete sampling was not correlated with upstage (p = 0.64). All three significant predictors were absent in 65 (29.4%) cases, with a 1.5% upstage rate. CONCLUSIONS: The upstage rate among 221 ADH lesions was 16.7%, highest in lesions ≥ 10 mm, with pathologic suspicion of DCIS, and linear/regional calcifications on mammography. Conversely, 30% of the cohort exhibited all low-risk factors, with an upstage rate < 2%, suggesting that active surveillance may be permissible in lieu of surgery.

Post-Mastectomy Patients in an Urban Safety-Net Hospital: How Do Safety-Net Hospital Breast Reconstruction Rates Compare to National Breast Reconstruction Rates?

BACKGROUND: Breast reconstruction (BR) has documented psychological benefits following mastectomy. Yet, racial/ethnic minority groups have lower reported rates of BR. We sought to evaluate the rate, type, and outcome of BR in a racially and ethnically diverse population within a safety-net hospital system. METHODS: All patients who underwent mastectomy between October 2015 and July 2019 at Harbor-UCLA Medical Center were retrospectively examined. Rates and type of BR were analyzed according to patient characteristics (race/ethnicity, age, and body mass index), smoking status, cancer stage, and presence of diabetes mellitus. Breast reconstruction outcomes were also assessed. RESULTS: Of the 259 patients that underwent mastectomy, 87 (33.6%) received BR. Immediate BR was performed in 79 (30.5%) patients and delayed BR in 8 (3.1%). Of the 79 patients with immediate BR, 58 (73.4%) received implant-based BR and 21 (26.5%) autologous tissue. The BR failure rate was 10%, all implant-based. Increasing age and smoking negatively impacted BR rates. Black (P =.331) and Hispanic (P =.132) ethnicity were not independent predictors of decreased breast reconstruction. CONCLUSION: This study demonstrated that the rate, type, and quality of BR in this integrated safety-net hospital within a diverse population are comparable to national rates. When made available, historically underrepresented minority patients of Black and Hispanic ethnicity utilize BR.

Characteristics Associated With Outstanding General Surgery Residency Graduate Performance, as Rated by Surgical Educators.

Importance: Characteristics of outstanding graduating surgical residents are currently undefined. Identifying these qualities may be important in guiding resident selection and resident education. Objective: To determine characteristics that are most strongly associated with being rated as an outstanding graduating surgical resident. Design, Setting, and Participants: The multi-institutional study had 3 phases. First, an expert panel developed a list of characteristics embodied by top graduating surgical residents. Second, groups of faculty from 14 US general-surgery residency programs ranked 2017 through 2020 graduates into quartiles of overall performance. Third, faculty evaluated their graduates on each characteristic using a 5-point Likert scale. Data were analyzed using Spearman rank-order correlation to identify which individual characteristics were associated with overall graduate performance. A least absolute shrinkage and selection operator (LASSO) ordinal regression was performed to select a parsimonious model to predict the outcome of overall performance rating from individual characteristic scores. Main Outcome and Measures: Surgical educators' rankings of general surgery residency graduates' overall performance. Results: Fifty faculty from 14 US residency programs with a median of 13 (range, 5-30) years of surgical education experience evaluated 297 general surgery residency graduates. Surgical educators identified 21 characteristics that they believed outstanding graduating surgical residents possessed. Two hundred ninety-seven surgical residency graduates were evaluated. Higher scores in every characteristic correlated with better overall performance. Characteristics most strongly associated with higher overall performance scores were surgical judgment (r = 0.728; P < .001), leadership (r = 0.726; P < .001), postoperative clinical skills (r = 0.715; P < .001), and preoperative clinical skills (r = 0.707; P < .001). The remainder of the characteristics were moderately associated with overall performance. The LASSO regression model identified 3 characteristics from which overall resident performance could be accurately predicted without measuring other qualities: surgical judgment (odds ratio [OR] per 1 level of 5-level Likert scale OR, 1.27; 95% CI, 1.03-1.51), leadership (OR, 1.27; 95% CI, 1.06-1.48), and medical knowledge (OR, 1.16; 95% CI, 1.01-1.33). Conclusions and Relevance: All individual characteristics identified by surgical educators as being qualities of outstanding graduating surgical residents were positively associated with overall graduate performance. Surgical judgment and leadership skills had the strongest individual associations. Assessment of only 3 qualities (surgical judgment, leadership, and medical knowledge) were required to predict overall resident performance ratings. These findings highlight the importance of developing specific surgical judgment and leadership skills curricula and assessments during surgical residency.

Nipple Adenoma: A Benign Disease With a Suspicious Presentation.

Nipple adenoma is a rare proliferative lesion that originates from the lactiferous ducts of the nipple. Though it is benign, the typical presentation includes suspicious symptoms-a firm nodule, crusting erosion, and/or discharge from the nipple. These findings can raise concern for malignancy and in particular, Paget's disease. We report two cases of this uncommon entity, highlighting the variable clinical presentation and keys to the diagnostic evaluation and management.

Should Robotic Surgery Training Become a General Surgery Residency Requirement? A National Survey of Program Directors in Surgery.

OBJECTIVE: Robotic-assisted surgery (RAS) accounts for 15% of general surgery (GS) operations performed and is set to grow in prevalence. Currently, there are no training requirements or standard robotic curricula for GS residents. This study aimed to query GS program directors (PDs) on the necessity, extent, and potential impact of including RAS as a required component of residency training. DESIGN: Analysis of responses to a 14-question web-based survey. SETTING: Survey was distributed to PDs via the Association of Program Directors in Surgery listserv in April and May 2021. PARTICIPANTS: General surgery program directors RESULTS: Among 140 respondents, 110 (78.6%) agreed that operating at the robotic console should be a GS residency requirement, yet 93 (66.4%) indicated that RAS exposure negatively impacts the acquisition of other necessary skills. Still, 116 (82.9%) agreed that RAS training provided a net benefit to GS residents, PDs at academic programs were more supportive than those at independent programs of RAS console training requirements (68.2% versus 46.7%, p = 0.048). The median response to the ideal proportion of abdominopelvic cases performed by graduation was 20% robotic, 40% laparoscopic, and 35% open. The suggested minimum number of robotic cases that should be performed by graduation was indicated to be 30 cases by 26% of respondents, 20 by 23%, 10 by 12%, 5 by 4%, and "no minimum" by 36%. CONCLUSIONS: There is strong interest among PDs to institute RAS training requirements for GS residents. This study provides PD perspectives to help inform national conversations on whether and to what extent RAS requirements should be included in GS residency training.

Current status of robotic surgery in colorectal residency training programs.

BACKGROUND: Robotic surgery (RS) has been increasingly incorporated into colorectal surgery (CRS) training. The degree to which RS has been integrated into CRS residency training is not well described. METHODS: A web-based survey was sent to all 2019 accredited CRS residency programs within the United States and Canada. Program directors (PDs) were queried on how robotic surgery had been integrated into their program, specifics on RS curriculum and opinions on RS training during general surgery residency. We compared survey responses by program type (university-based, university-affiliated programs, or independent programs) and by geographic region. In addition, a chi-square test was used to evaluate differences in survey responses with respect to robotic curriculum components. RESULTS: Of 66 programs, 42 (64%) responded to the survey. Of the responding programs, 35 (83%) were university-based or university-affiliated, while 7 (17%) were independent. Most programs were in the Midwest (33%). Forty-one (98%) reported having a surgical robot in use at their institution, with 95% reporting active participation of CRS residents in RS. While 74% of programs have a formal RS training curriculum for CRS residents, there was considerable variability in the curriculum elements employed by each institution, and the differences in proportions of these elements were significant (χ2 99.8, p < 0.001). The median operative approach to abdominopelvic cases was estimated to be 33% robotic, 40% laparoscopic and 20% open. There were no significant differences in the survey responses between university/university-affiliated and independent programs (p > 0.05) or among the different regions (p > 0.05). CONCLUSIONS: This study demonstrated that almost all CRS residencies have integrated RS and have trainees operating at the robotic console. Most programs have a robotics curriculum and there are expanding indications for RS within CRS. This expansion calls for discussion on implementation of training standards such as curricular requisites, baseline competency assessments, and definitions of minimum case requirements to ensure adequate training.

Determinants of Psychosocial Distress in Breast Cancer Patients at a Safety Net Hospital.

INTRODUCTION: Psychosocial distress screening of cancer patients is an American College of Surgeons Commission on Cancer mandate for accredited cancer programs. We evaluated psychosocial distress in breast cancer patients to characterize risk factors for high distress scores at a safety net hospital. MATERIALS AND METHODS: The psychosocial distress screening form includes a list of potential issues and a distress score scaled from 1 through 10. Psychosocial distress screening results were retrospectively analyzed, along with patient demographics and clinical data. Cochran-Mantel-Haenszel test was applied to identify predictors for high distress scores, which were defined as a score of 5 and greater. RESULTS: 775 distress screens were completed by 171 breast cancer patients. High distress scores were reported in 21.3%. Patients who had no evidence of disease at time of screening were less likely to report a high distress score compared to those who were newly diagnosed or in active treatment (odds ratio 0.51, 95% CI, 0.38-0.68, P< .0001). Patients with high distress scores were more likely to report concerns with insurance (29.1% vs. 7.6%, P< .0001), transportation (16.4% vs. 4.6%, P< .0001), housing (15.2% vs 2.1%, P< .0001), sadness/depression (63.6% vs. 14.1, P< .0001), and physical issues (89.1% vs. 52.8%, P< .0001). CONCLUSION: Status of cancer at time of screening, particularly newly diagnosed cancer and active treatment of cancer were associated with high distress scores in this patient group. While there should be an emphasis to ensure patients with these risk factors receive psychosocial distress screening, routine periodic screening for all patients should continue to be implemented to ensure quality cancer care.

A Microcosm of Disparities in Breast Cancer: Comparison Between a Private Hospital and a Safety-Net County Hospital Within Los Angeles County.

BACKGROUND: Breast cancer survival is improving due to early detection and treatment advances. However, racial/ethnic differences in tumor biology, stage, and mortality remain. The objective of this study was to analyze presumed disparities at a local level. METHODS: Breast cancer patients at a county hospital and private hospital from 2010 to 2012 were retrospectively reviewed. Demographic, clinical, pathologic, and surgical data were collected. Comparisons were made between hospital cohorts and between racial/ethnic groups from both hospitals combined. RESULTS: 754 patients were included (322 from county hospital and 432 from private hospital). All patients were female. The median age was 54 years at county hospital and 60 years at private hospital (P < .0001). Racial/ethnic minorities comprised 85% of county hospital patients vs. 12% of private hospital patients (P < .0001). County hospital patients had a higher grade, clinical/pathologic stage, HER2-positive rate, and mastectomy rate. Compared to other racial/ethnic groups, non-Hispanic white women were more likely to have lower grade and ER-positive tumors. Hispanic/Latina women were younger and were more likely to have HER2-positive tumors. Both Hispanic/Latina and non-Hispanic black women presented at higher clinical stages and were more likely to undergo neoadjuvant chemotherapy and mastectomy. DISCUSSION: At county hospital compared to private hospital, the proportion of racial/ethnic minorities was higher, and patients presented at younger ages with more aggressive tumors and more advanced disease. The racial/ethnic disparities that were identified locally are largely consistent with those identified in national database studies. These marked differences at hospitals within a diverse city highlight the need for further research into the disparities.

Lower lymph node yield in axillary lymph node dissection specimens in breast cancer patients receiving neoadjuvant chemotherapy: Quality concern or treatment effect?

Axillary lymph node dissection (ALND) specimens should have at least ten-lymph nodes for examination according to established guidelines. Nonetheless, recent evidence suggests that neoadjuvant chemotherapy (NAC) results in fewer nodes in the specimen. We sought to examine if NAC patients have lower lymph node yield from ALND specimens and whether the number of lymph nodes in the specimen is correlated with pathologic complete response (pCR). Using the National Cancer Database (NCDB), a study cohort of female patients with node-positive, non-metastatic invasive breast cancer diagnosed from 2012 to 2015 was identified. The axillary lymph node retrieval count was compared in NAC and non-NAC patients and then correlated with pCR. A multivariable analysis was performed to identify factors that were associated with less than ten-lymph nodes in the ALND pathologic specimen. Of 56,976 patients identified, 27,197 (48%) received neoadjuvant chemotherapy; 29,779 (52%) did not. NAC patients failed to meet the ten-lymph node minimum in the ALND specimen more often than non-NAC patients (35% vs. 27%, p < 0.001). NAC patients with fewer than ten-lymph nodes were more likely to have a pCR than those with ten or more (22% vs. 16%, p < 0.001). On multivariable analysis, pCR of the primary tumor and receptor status were found to be independent predictors of having fewer than ten-lymph nodes in the ALND specimen. Node-positive breast cancer patients that underwent NAC were more likely to not meet the ten-lymph node standard. However, NAC patients who did not meet the minimum were also more likely to have a pCR compared to NAC patients who did. This suggests lower lymph node yield may not truly be a marker of lower quality surgery but rather a potential marker of NAC treatment effect.

Patients With Invasive Breast Cancer Who Refuse Treatment: An Analysis of Associated Factors and Impact on Survival.

BACKGROUND: Completion of surgical resection and adjuvant/neoadjuvant treatments (chemotherapy, radiation, and endocrine therapy) is necessary to achieve optimal outcomes in invasive breast cancer. The objective of this study was to determine the characteristics of patients refusing treatment and to analyze the impact of refusal on survival. STUDY DESIGN: A retrospective cohort study of invasive breast cancer cases diagnosed 2004-2016 was performed utilizing the National Cancer Database. RESULTS: Of 2 058 568 cases comprising the study cohort, .6% refused recommended surgery, 14.1% refused chemotherapy, 5.5% refused radiation, and 6.3% refused endocrine therapy. Patients refusing therapy were older and more likely uninsured; they did not live farther from the treating hospital. Racial disparities were also associated with refusal. Surgery refusal had the highest hazard ratio for mortality (2.7; 95% CI: 2.5-3.0, P < .001) compared to chemotherapy (1.3; 95% CI: 1.3-1.4, P < .001), radiation (1.8; 95% CI: 1.7-1.9, P < .001), and endocrine therapy (1.5; 95% CI: 1.4-1.6, P < .001) independent of race, insurance, receptor status, and stage. CONCLUSION: This study demonstrates significant associations with refusal of breast cancer treatment and quantifies the impact on mortality, which may help to identify at-risk groups for whom interventions could prevent increases in mortality associated with declining treatment.

Evaluation of Patterns in Access to Breast Cancer Care and Breast Cancer Presentation in a Safety Net Patient Population.

BACKGROUND: While prior studies have shown the apparent health disparities in breast cancer diagnosis and treatment, there is a gap in knowledge with respect to access to breast cancer care among minority women. METHODS: We performed a retrospective analysis of patients with newly diagnosed breast cancer from 2014 to 2016 to evaluate how patients presented and accessed cancer care services in our urban safety net hospital. Patient demographics, cancer stage, history of breast cancer screening, and process of referral to cancer care were collected and analyzed. RESULTS: Of the 202 patients identified, 61 (30%) patients were younger than the age of 50 and 75 (63%) were of racial minority background. Only 39% of patients with a new breast cancer were diagnosed on screening mammogram. Women younger than the age of 50 (P < .001) and minority women (P < .001) were significantly less likely to have had any prior screening mammograms. Furthermore, in patients who met the screening guideline age, more than half did not have prior screening mammograms. DISCUSSION: Future research should explore how to improve breast cancer screening rates within our county patient population and the potential need for revision of screening guidelines for minority patients.

Does diagnostic mammography need to be a routine component of the initial evaluation of a breast symptom in women 30-39 years of age?

Diagnostic mammography is routinely ordered, along with targeted breast ultrasound, to evaluate breast symptoms in women 30-39 years of age. However, in this age group, mammography is often limited by breast density and the probability of detecting an occult malignancy is low. We sought to evaluate whether diagnostic mammography detected any new incidental malignancies in women aged 30-39 years presenting with focal breast symptoms. This retrospective study included women 30-39 years of age who had a diagnostic mammogram performed for focal breast symptoms at a single institution from 2002 to 2017. Descriptive analyses were performed to determine the rate of incidental mammographic findings outside of the region of the presenting symptom that 1) led to additional imaging and/or biopsies and 2) were found to be malignant. During the 16-year study period, 1770 evaluations were performed, of which 249 (14.1%) were found to have an additional incidental mammographic abnormality. Further diagnostic imaging was required in 211 (11.3%), core biopsy in 67 (3.8%), and excisional biopsy in 8 (0.5%). None of the mammographically detected incidental findings resulted in a new diagnosis of breast cancer. In the evaluation of focal benign breast symptoms in women 30-39 years of age, diagnostic mammography did not detect any new incidental malignancies outside of the area of interest, but instead led to additional unavailing imaging and biopsy procedures. The mammography component of the diagnostic evaluation of younger average-risk women may potentially be omitted if the presenting symptom is determined to be benign with ultrasound alone.

Squamous Cell Carcinoma Arising in Breast Implant Capsules.

ABSTRACT: Breast augmentation and reconstruction utilizing implants are among the most common plastic surgery procedures performed in the United States. A small proportion of these implants are removed each year. We report 2 cases where routine pathologic evaluation of capsulectomy specimens revealed squamous cell carcinoma associated with the breast implant capsule and discuss the possible pathogenesis of this unusual entity. Both patients had long-standing implants (>10 years) and presented with acute unilateral breast erythema and swelling. Intraoperatively, the capsules for both cases appeared thickened and calcified, containing extensive granulomatosis and keratinaceous debris invading into the chest wall. Extensive workup failed to find an occult primary. One patient died from a malignant pleural effusion secondary to tumor invasion during chemotherapy, and the second patient obtained stabilization of the mass after 5 weeks of chemotherapy but subsequently declined further surgical intervention. A thorough literature review was performed, and 5 similar reports were identified, involving 6 patients. All patients presented with similar clinical presentations as ours and had poor outcomes. The mean reporting age at diagnosis was 60 years, and the average time from initial implant to diagnosis was 25 years. Due to the small numbers of squamous cell carcinomas associated with breast implant capsules, the true association between the 2 is unknown. It is postulated that chronic inflammation/irritation from the breast implant and epithelialization of the capsule play a significant role in the disease process. This may represent a new entity of "chronic inflammatory capsular malignancies." Increased awareness of this entity may allow for earlier suspicion, diagnosis, and management.

A Randomized Prospective Blinded Study Evaluating the Effect of Music on Novice Surgical Trainees' Ability to Perform a Simulated Surgical Task.

OBJECTIVE: To determine if playing music would affect novice surgical trainees' ability to perform a complex surgical task. BACKGROUND: The effect of music in the operating room (OR) is controversial. Some studies from the anesthesiology literature suggest that OR music is distracting and should be banned. Other nonblinded studies have indicated that music improves surgeons' efficiency with simple tasks. DESIGN/METHODS: A prospective, blinded, randomized trial of 19 novice surgical trainees was conducted using an in vitro model. Each trainee performed a baseline vascular anastomosis (VA) without music. Subsequently, they performed one VA with music (song validated to reduce anxiety) and one without, in random order and without prior knowledge of the study's purpose. The primary endpoint was a difference in differences from baseline with and without music with respect to time to completion, acceleration/deceleration (using a previously validated hand-tracking motion device), and video performance scoring (3 blinded experts using a validated scale). The participants completed a poststudy survey to gauge their opinions regarding music during tasks. RESULTS: Overall, 57 VAs by 19 trainees were evaluated. Average time to completion was 11.6 minutes. When compared to baseline, time to completion improved for both the music group (p = 0.01) and no-music group (p = 0.001). When comparing music to no music, there was no difference in time to completion (p = 0.7), acceleration/deceleration (p = 0.3), or video performance scorings (p = NS). Among participants, 89% responded that they enjoy listening to music while performing tasks. CONCLUSIONS: Using three outcome measures, relaxing music did not improve the performance of novice surgical trainees performing a complex surgical task, and the music did not make their performance worse. However, nearly all trainees reported enjoying listening to music while performing tasks.

Initiation of an Intraoperative Radiotherapy Program at a Safety net Hospital: What Is the Impact of an Intraoperative Radiotherapy Program in Underserved Patients With Early Breast Cancer?

BACKGROUND: Intraoperative radiotherapy (IORT) can allow for single-dose radiation treatment following breast conservation therapy in low-risk patients with early breast cancer, in lieu of a traditional 6-week course of whole breast radiotherapy (WBRT). The objective of this study was to analyze the uptake and utilization of an IORT program in a safety-net hospital. MATERIALS AND METHODS: A retrospective review was conducted for all patients who underwent IORT from September 2014 to June 2018. Patient demographics, tumor characteristics, and IORT outcomes were analyzed. The proportion of patients undergoing IORT were determined to assess utilization and uptake. RESULTS: There were 27 female patients that received IORT, 23 (85.2%) of which required no further radiotherapy. Three (7.4%) patients had positive axillary lymph nodes and/or positive margins requiring subsequent WBRT. One patient (3.7%) developed an in-breast recurrence distant from the lumpectomy site 23 months after IORT. Ten patients (37.0%) developed a postoperative complication, including 5 seromas and 6 wound complications (superficial infections and/or wound necrosis). Overall, in the 46-month study period, IORT accounted for only 6.4% of 423 operations. Still, 27 of 29 (93.1%) patients who met eligibility criteria for IORT underwent the procedure. DISCUSSION: Although IORT comprised only 6.4% of all cases due to higher rates of mastectomy rates and advanced disease in our population, there was a high uptake of IORT among patients who met eligibility criteria for the procedure. Major complication rates of IORT were low, and most patients successfully completed radiotherapy in 1 intraoperative dose.

Are Nomograms Useful in Predicting Upstage From Ductal Carcinoma In Situ to Invasive Carcinoma Requiring Sentinel Lymph Node Biopsy?

The upstage rate from ductal carcinoma in situ (DCIS) on core biopsy to invasive carcinoma at definitive excision ranges from 20 to 30%. Nomograms have been developed to aid in the prediction of upstaging so as to guide surgical planning with respect to performance of sentinel lymph node biopsy (SLNB). The aim of this study was to evaluate the ability of these nomograms to predict upstaging within our public hospital population. A retrospective review of patients with DCIS from 2013 to 2018 at a single institution was performed. Individualized probability of upstage was calculated using the Samsung Medical Center (SMC) and Annals of Surgical Oncology (ASO) nomograms. Areas under the receiver operating characteristic curves were calculated to assess the discriminative power of each. Of 105 patients with DCIS, 31 (29.5%) were upstaged to invasive disease. The SMC and ASO nomograms demonstrated area under the curves (AUCs) of .65 (OR = 1.023, 95% CI 1.004-1.042, P = .02) and .60 (OR = 1.035, 95% CI 1.003-1.068, P = .03), respectively. While SMC provided greater discrimination in our cohort, the performance of these nomograms as reliable clinical adjuncts to guide SLNB decision-making in this cohort was less than optimal and thus should not be the sole factor in determining individual upstage risk.

Can Oncotype DX testing be omitted in invasive breast cancer patients with clinicopathologic factors predicting very high pretest probability of a concordant result?

OBJECTIVE: To determine if clinicopathologic (CP) factors could identify patients at "very low" and/or "very high" pretest probability of a high Oncotype DX (ODX) score. METHODS: A retrospective analysis of all patients that had ODX testing 2008-2018 at a single institution. RESULTS: Of 215 patients, all 16 (7.4%) with "all high" risk CP factors had high ODX scores, and all 45 (20.9%) over age 50 with "all low" risk CP factors had ODX recommendations for no chemotherapy. CONCLUSIONS: Oncotype DX results did not change chemotherapy recommendations in those with "very low" or "very high" pretest probability of high ODX scores.

Should Robotic Surgery Training Be Prioritized in General Surgery Residency? A Survey of Fellowship Program Director Perspectives.

OBJECTIVE: Robotic surgery has been increasingly incorporated into the subspecialties of colorectal (CRS), minimally invasive/bariatric (MIS/Bar), and surgical oncology/hepatobiliary (SO/HPB) surgery, yet its impact on fellowship applicant evaluation and contribution to postresidency training remains undefined. The aim of our study was to evaluate how robotic training during General Surgery (GS) residency affects an applicant's competitiveness from the perspective of fellowship programs. DESIGN: A web-based survey was sent to all 235 accredited fellowship programs in CRS (n = 66), MIS/Bar (n = 122), and SO/HPB (n = 47) within the United States and Canada. Fellowship programs were queried on the import of robotic surgery training during GS residency and its impact on an applicant's match potential. RESULTS: Of 235 programs, 155 (66%) responded to the survey - 42 (63.6%) CRS, 87 (71.3%) MIS/Bar, and 26 (55.3%) SO/HPB. Of responding programs, 147 (94.8%) have a surgical robot at their institution, and 131 (84.5%) have fellows actively operating at the console. Overall, 107 (69%) fellowship program directors rated robotic training during surgery residency as "somewhat" or "very" important for residents seeking fellowship. While 95 (61.3%) programs said GS residents should not prioritize robotic training, 60 (38.7%) felt they should, and 38 (24.5%) were more likely to rank an applicant higher if they had some console exposure. Still, 69.7% (n = 108) of programs expect no robotic experience for incoming fellows. CONCLUSIONS: This study demonstrates that most fellowship programs have low expectations of robotic experience for incoming fellows. Still, it is notable that nearly a quarter of programs would rank an applicant more highly if they had robotic console exposure. While these findings appear reassuring to residents with limited access to robotic training, residency programs should be alerted to the growing importance of robotic exposure.

Single Hormone Receptor-Positive Breast Cancers Have Distinct Characteristics and Survival.

BACKGROUND: Estrogen receptor (ER) and progesterone receptor (PR) status is pivotal to determining the prognosis and treatment of human epidermal growth factor 2 (HER2) receptor-negative invasive breast cancer. Frequently ER-positive (ER+) and/or PR-positive (PR+) cancers are labeled nonspecifically as "hormone receptor-positive" although only one is positive. This study aimed to evaluate and characterize the ER+PR- and ER-PR+ breast cancer phenotypes in reference to ER+PR+ cancers. METHODS: A retrospective cohort study of female patients with HER2-negative (HER2-) invasive breast cancer diagnosed in 2010-2015 was performed using the National Cancer Database. Cases were grouped into ER+PR+, ER-PR+, ER+PR-, and ER-PR- phenotypes to determine differences in patient demographics, tumor characteristics, and overall survival. RESULTS: Of 823,969 cases, 619,050 (75.1%) were ER+PR+, 79,777 (9.7%) were ER+PR-, 7006 (0.9%) were ER-PR+, and 118,136 (14.3%) were ER-PR-. Compared with the ER+PR+ group, the ER+PR- and ER-PR+ groups were more likely to be high-grade cancer (16.0% vs. 34.2% and 80.0%, respectively; p < 0.001), to have lymphovascular invasion (17.9% vs. 19.6% and 23.0%; p < 0.001), to be node-positive (13.5% vs. 19.7% and 26.3%; p < 0.001), to be stage 4 cancer (3.6% vs. 5.9% and 6.7%; p < 0.001), to have a higher multigene assay score (mean, 16.0 vs. 27.8 and 38.1; p < 0.001), and to have a worse survival (90.6% vs. 83.8% and 78.1%; p < 0.001). CONCLUSION: Single hormone receptor-positive breast cancer subtypes (ER+PR- and ER-PR+) are more likely to have unfavorable characteristics and worse survival than the ER+PR+ subtype, with the ER-PR+ subtype having outcomes similar to those for ER-PR- cancers. The single hormone receptor-positive subtypes, representing 10% of HER2- cancers, should be considered clinically distinct from ER+PR+ disease.