Factors affecting the embedding of integrated primary-secondary care into a health district.

With the aging population, the tide of chronic disease is rising with attendant increases in health service need. Integrated care and patient-centred approaches, which established partnerships between a regional Hospital and health service (HHS), the local primary health network and local general practitioners (GPs), were identified as exemplars of an approach needed to support growing community health needs. This paper summarises the findings from a process evaluation of four GP-specialist care integration programs with the aim of identifying recommendations for embedding integrated GP-specialist care into routine practice within the HHS. The process evaluation of the integration programs drew on input from a multidisciplinary expert advisory group and data collected through face-to-face semi-structured interviews with key stakeholders, as well as surveys of participating GPs and patients. Overarching findings were identified and grouped under six themes: interdisciplinary teamwork; communication and information exchange; the use of shared care guidelines or pathways; training and education; access and accessibility; and funding. Within each theme, key challenges and enablers emerged. The findings of this study highlight benefits and challenges associated with the establishment of integrated care between primary and secondary care providers, leading to the development of key recommendations for routine integration.

Breast Cancer Risk and Progressive Histology in Serial Benign Biopsies.

Background: More than 1 million women per year in the United States with benign breast biopsies are known to be at elevated risk for breast cancer (BC), with risk stratified on histologic categories of epithelial proliferation. Here we assessed women who had serial benign biopsies over time and how changes in the histologic classification affected BC risk. Methods: In the Mayo Clinic Benign Breast Disease Cohort of 13 466 women, 1414 women had multiple metachronous benign biopsies (10.5%). Both initial and subsequent biopsies were assessed histologically. BC risk for clinical and prognostic factors was assessed using subdistribution models to account for competing risks, and logistic regression/Wilcoxon/chi-square tests to assess covariates. All statistical tests were two-sided. Results: Breast cancer risk for women with serial biopsies, stratified by histologic category in the later biopsies, was similar to women with a single biopsy. We found that changes in histological category between initial and subsequent biopsy statistically significantly impacted BC risk. Women with nonproliferative initial findings and subsequent proliferative findings had an increased risk (hazard ratio [HR] = 1.77, 95% confidence interval [CI] = 1.06 to 2.94, P = .03) compared with no change. Among women with proliferative disease without atypia at initial biopsy, risk decreased if later biopsy regressed to nonproliferative (HR = 0.49, 95% CI = 0.25 to 0.98) and increased if later biopsy showed progression to atypical hyperplasia (HR = 1.49, 95% CI = 0.73 to 3.05) compared with no change ( P = .04). Conclusions: We found that breast cancer risk increases in women with progressive epithelial proliferation over time and decreases in women whose biopsies show less proliferation. This finding has important implications for effective clinical management of the 100 000 women per year who have multiple benign breast biopsies.

Breast cancer after prophylactic mastectomy (bilateral or contralateral prophylactic mastectomy), a clinical entity: presentation, management, and outcomes.

Contralateral prophylactic mastectomy (CPM) and bilateral prophylactic mastectomy (BPM) markedly decrease the possibility of new breast cancer (BC) ipsilateral to the prophylactic mastectomy (PM). Given its relative infrequency, little is known about the clinical characteristics, presentation, and management of BC after PM. Between 1960 and 1993, 1065 women underwent BPM and 1643 women with unilateral BC treated with therapeutic mastectomy underwent CPM at our institution. Medical records were reviewed, and study-specific questionnaires were sent to all women. BC after PM included locoregional invasive BC or ductal carcinoma in situ ipsilateral to the PM. BC developed ipsilateral to the PM in 25 patients (13 after BPM; 12 after therapeutic mastectomy and CPM). Median follow-up after PM was 22 years (range 3-34 years). Presentations included clinically isolated local disease in 17 patients (68%); disease limited to the axilla without evidence of local primary disease in 4 (16%); synchronous local and axillary disease in 1 (4%); and synchronous local disease and distant metastases in 3 (12%). The 17 patients presenting with isolated local disease were most commonly managed with completion or redo mastectomy (65%) or local excision (29 %), followed by consideration of adjuvant therapy. The 5-year disease-free survival estimate was 69% (95% CI 52-94%) for the 22 patients who had isolated locoregional BC after PM and were treated with curative intent. Although rare, BC after PM can occur. The most common presentation, disease localized to the mastectomy site, can be managed with resection and consideration of adjuvant therapy.

Impact of reconstruction and reoperation on long-term patient-reported satisfaction after contralateral prophylactic mastectomy.

BACKGROUND: Contralateral prophylactic mastectomy (CPM) is increasingly chosen by breast cancer patients and may be related to increased use of immediate reconstruction. This study examines long-term patient satisfaction with CPM and reconstruction in a historical cohort. METHODS: 621 unilateral breast cancer patients with a family history of breast cancer who underwent CPM between 1960 and 1993 were surveyed regarding quality of life (QOL) and satisfaction with CPM at two time points (approximately 10 and 20 years after CPM). RESULTS: 583 women responded to the first follow-up questionnaire (median 10.7 years; mean 11.9 years) after CPM. There were 403 (69 %) patients who underwent reconstruction and 180 (31 %) patients who did not. Women electing reconstruction were younger [mean age 47 versus (vs.) 53 years; p = 0.01] and more likely to be married (85 vs. 78 %; p = 0.048). Most women reported satisfaction with CPM (83 %), and they would choose CPM again (84 %) and make the same choice regarding reconstruction (73 %). However, reconstruction patients demonstrated significantly lower satisfaction (p = 0.0001) and were less likely to choose CPM again (p < 0.0001). Within the reconstruction group, 39 % needed 1 + unplanned reoperation, which was strongly associated with lower satisfaction (p = 0.0001), lower likelihood of choosing CPM again (p = 0.006), and lower likelihood of choosing reconstruction again (p < 0.0001). There were 269 women who responded to the second questionnaire (median 18.4 years; mean 20.2 years after CPM). Satisfaction with CPM remained high, with 92 % of the women stating they would choose CPM again. CONCLUSIONS: Most women report stable long-term satisfaction with CPM. Women who had reconstruction and required reoperations in this historical cohort reported lower satisfaction.

Contralateral prophylactic mastectomy: long-term consistency of satisfaction and adverse effects and the significance of informed decision-making, quality of life, and personality traits.

PURPOSE: This study aims to evaluate the long-term consistency of satisfaction with contralateral prophylactic mastectomy (CPM) and adverse psychosocial effects as well as to explore the effect of informed decision-making, personality traits, and quality of life (QOL) on satisfaction. METHODS: A previously established cohort of women with unilateral breast cancer who had undergone CPM between 1960 and 1993 were surveyed using study-specific and standardized questionnaires at two follow-up time points. The first survey was a mean of 10.7 years and the second survey a mean of 20.2 years after CPM. RESULTS: 487 of the 583 women who responded to the first study were alive and resurveyed. Data from both surveys were available for 269 women. With longer follow-up, there was a small increase in the percentage of women satisfied (90%) and those who would choose CPM again (92%) (4% and 2% increase from first survey, respectively). Most adversely affected were body appearance (31%), feelings of femininity (24%), and sexual relationships (23%). Ninety-three percent of women felt they had made an informed decision. Perception of making an informed choice and current QOL were moderately associated with satisfaction with CPM (r = 0.37 and 0.37, respectively) while associations with trait anxiety and optimism were weak (r = 0.27 and 0.21, respectively). CONCLUSIONS: Long-term satisfaction and adverse effects remained remarkably stable. It is important that women fully understand the benefits and adverse effects associated with CPM.

Contralateral prophylactic mastectomy is associated with a survival advantage in high-risk women with a personal history of breast cancer.

BACKGROUND: The aim of this study was to investigate whether contralateral prophylactic mastectomy (CPM) in addition to therapeutic mastectomy (TM) is associated with a survival advantage in high-risk women with breast cancer. METHODS: A total of 385 women with stage I or II breast cancer and a family history of breast cancer who underwent TM and CPM between 1971 and 1993 were evaluated and compared to 385 patients matched on age at diagnosis, tumor stage, nodal status, and year of diagnosis who underwent TM-only. Contralateral breast cancer (CBC) events and survival outcomes were compared. RESULTS: At a median follow-up of 17.3 years, 2 CBCs (0.5%) developed in the CPM cohort and 31 (8.1%) in the TM-only cohort, representing a 95% decreased risk of CBC (hazard ratio [HR] = 0.05, 95% confidence interval [95% CI] 0.01-0.22, P < 0.0001). One hundred twenty-eight women in the CPM group and 162 women in the TM-only group have died, resulting in 10-year overall survival estimates of 83 and 74%, respectively (HR 0.68, 95% CI 0.54-0.86, P = 0.001). This difference in overall survival persisted in multivariate analysis (HR 0.77, P = 0.03). Disease-free survival (DFS) was better in the CPM cohort than the TM-only group (HR 0.66, 95% CI 0.53-0.82, P = 0.0002) and remained significant in multivariate analysis (HR 0.67, P = 0.0005). CONCLUSIONS: In this retrospective cohort study, CPM was associated with decreased CBC event and improved overall survival and disease free survival.

Satisfaction after contralateral prophylactic mastectomy: the significance of mastectomy type, reconstructive complications, and body appearance.

PURPOSE: Contralateral prophylactic mastectomy (CPM) is one option for reducing the risk of a second breast cancer in women with a personal and family history of breast cancer. Few data are available regarding satisfaction, psychological, and social function after CPM. The purpose of this research is to evaluate women's long-term satisfaction with CPM, factors influencing satisfaction, and psychological and social function after CPM. PATIENTS AND METHODS: This was a descriptive study of all women with a family history of breast cancer, known to be alive, who elected CPM at Mayo Clinic (Rochester, MN) between 1960 and 1993 (n = 621). Ninety-four percent of the women (n = 583) completed a study-specific questionnaire. RESULTS: A mean of 10.3 years after the procedure, the majority of women (83%) were satisfied with their CPM. A smaller number were neutral (8%) or dissatisfied (9%). Women who had a subcutaneous mastectomy had more problems with reconstruction, and fewer of these women were satisfied than women with simple mastectomy. Decreased satisfaction with CPM was associated with decreased satisfaction with appearance, complications with reconstruction, reconstruction after CPM, and increased level of stress in life. The majority of women experienced no change or favorable effects in self-esteem (83%), level of stress in life (83%), and emotional stability (88%). Satisfaction with body appearance, feelings of femininity, and sexual relationships were the most adversely affected with 33%, 26%, and 23% of the women responding negatively. CONCLUSION: Although most women are satisfied with CPM, each woman should weigh the benefits alongside the potential adverse effects.