Missed Appointments in a Breast Clinic: Patient-Related Factors.

BACKGROUND: Missed appointments are problematic because they occupy an appointment that could have been used by another patient and represent lost resources for the hospital system. The objective of this study was to determine patient-related factors associated with missed appointments. METHODS: Totally, 1,624 patients were seen from January 14, 2010 to January 16, 2012. Sociodemographic variables were collected including health literacy assessment, electronic medical record system-collected scheduled appointments and missed appointments for each patient. Patients were also asked for their preferred method of contact. RESULTS: From January 1, 2009 to January 16, 2012 the 1,624 patients had 21,648 scheduled appointments in the hospital system. Overall 3,633 (16.8%) of the appointments were missed. Insurance status, income, education and primary language were not significant predictors for missed appointments. Limited health literacy was associated with increased rate of missed appointments (adequate health literacy 13.4% versus limited health literacy 17.2%, P = 0.0009). Current smokers had higher rates of missed appointments than nonsmokers (18.5% versus 16.1%, P = 0.025). Patients who underwent screening mammography were also less likely to miss appointments (odds ratio = 0.78, P < 0.0001). The preferred method of contact was via mobile phone; however, this was only 42%. CONCLUSIONS: Patients with limited health literacy and current smokers had higher rates of missed appointments. In addition, patients who were compliant with screening mammography were also more likely to be compliant with appointments. Appointment reminders should be kept simple to accommodate the rapidly growing population with limited health literacy.

Factors associated with surgical management in an underinsured, safety net population.

BACKGROUND: Few studies include significant numbers of racial and ethnic minority patients. The current study was performed to examine factors that affect breast cancer operations in an underinsured population. METHODS: We performed a retrospective review of all breast cancer patients from January 2010 to May 2012. Patients with American Joint Committee on Cancer clinical stage 0-IIIA breast cancer underwent evaluation for type of operation: breast conservation, mastectomy alone, and reconstruction after mastectomy. RESULTS: The population included 403 patients with mean age 53 years. Twelve of the 50 patients (24%) diagnosed at stage IIIB presented with synchronous metastatic disease. Of the remaining patients, only 2 presented with metastatic disease (0.6%). The initial operation was 65% breast conservation, 26% mastectomy alone, and 10% reconstruction after mastectomy. Multivariate analysis revealed that Hispanic ethnicity (odds ratio [OR], 0.38; 95% CI, 0.19-0.73; P = .004), presentation with palpable mass (OR, 0.34; 95% CI, 0.13-0.90; P = .03), preoperative chemotherapy (OR, 0.25; 95% CI, 0.10-0.62; P = .003) were associated with a lesser likelihood of mastectomy. Multivariate analysis of factors associated with reconstruction after mastectomy showed that operation with Breast surgical oncologist (OR, 18.4; 95% CI, 2.18-155.14; P < .001) and adequate health literacy (OR, 3.13; 95% CI, 0.95-10.30; P = .06) were associated with reconstruction. CONCLUSION: The majority of safety net patients can undergo breast conservation despite delayed presentation and poor use of screening mammography. Preoperative chemotherapy increased the likelihood of breast conservation. Routine systemic workup in patients with operable breast cancer is not indicated.

Solitary liver metastasis from follicular variant papillary thyroid carcinoma: A case report and literature review.

INTRODUCTION: Papillary (PTC) and follicular (FTC) thyroid carcinomas, together known as differentiated thyroid carcinomas (DTC), are among the most curable of cancers. Sites of metastases from FTC are usually osseous and those from PTC are in regional nodal basins and the lungs. Visceral metastases are rare and when they do occur, they tend do so in multiple sites. We present the case of a patient with a follicular variant of PTC and a solitary metastasis to the liver then review the relevant literature. PRESENTATION OF CASE: An otherwise healthy 68-year-old woman was diagnosed with follicular variant papillary thyroid cancer in 2003 and subsequently underwent thyroidectomy. The patient's endocrinologist conducted surveillance of her thyroid cancer. In 2012, due to rise in thyroglobulin, a whole body radioiodine scan was obtained which revealed an iodine-avid left liver lobe mass. Three cycles of radioiodine ablation therapy were unsuccessful and eventually the patient was referred for surgical resection. Metastatic evaluation including a PET scan was negative with the exception of an isolated enhancing 4cm mass in segment 4B of the liver. Anatomic segmental resection of liver was performed without complications. Intraoperative ultrasonography was used to guide resection of the liver mass. Pathology reports confirmed metastatic follicular variant of PTC. Surgical margins were free of tumor. Patient was discharged home and is doing well one year after surgery. The latest thyroglobulin level was undetectable. DISCUSSION: Post-operative surveillance by PCP, endocrinologist or surgeon for patients with thyroid carcinoma should be performed routinely. If identified, a solitary liver metastasis from primary thyroid carcinoma should be considered for surgical resection. Due to sparse data available in literature, collecting more data to establish algorithms for treatment of such rare metastatic cancers may be able to aid physicians to achieve better outcomes. CONCLUSION: Rare distant sites of metastases from DTC include eyes, pharynx, skin, muscle, ovaries, adrenal glands, kidneys, esophagus, pancreas and liver. Isolated, resectable liver metastases from PTC are exceedingly rare. Literature review revealed only 10 reported cases of liver metastases from DTC. As in our patient, solitary liver metastasis from PTC should be considered for surgical resection which offers the best chance for prolonged survival.

Factors which affect the use of lumpectomy and mastectomy in an underinsured, safety net hospital population.

BACKGROUND: This study was performed to evaluate variables that affect the use of mastectomy and lumpectomy in an underinsured population. METHODS: A retrospective review of all patients who underwent breast cancer operations from July 2001 to February 2011 at a safety net hospital was performed. Univariate and multivariate analyses were performed to identify variables, which were associated with the type of operation. RESULTS: Of the 412 patients, 81% of the patients were underinsured or uninsured. Most patients (58%) presented with clinical stage 2A/B disease. Mastectomy was performed in 37% of patients and lumpectomy in 63%. In multivariate analysis, clinical tumor size (P = .035) and pathologic stage (P = .003) remained associated with mastectomy, while use of preoperative chemotherapy (P = .004) and type of surgeon (P = .001) was associated with lumpectomy. CONCLUSIONS: Most patients underwent lumpectomy despite later stage at presentation. Preoperative chemotherapy was associated with increased likelihood of lumpectomy.