Outcomes after Surgery for Early Stage Breast Cancer in Women Staged With Preoperative Breast Magnetic Resonance Imaging According to Breast Tissue Density.

PURPOSE: To determine surgical outcomes and breast cancer disease-free survival outcomes of women with early stage breast cancer with and without use of preoperative breast MRI according to breast tissue density. METHODS: Women with early stage breast cancer diagnosed from 2004 to 2009 were classified into 2 groups: 1) those with dense and heterogeneously dense breasts (DB); 2) those with nondense breasts (NDB) (scattered fibroglandular and fatty replaced tissue). The 2 groups were reviewed to determine who underwent preoperative MRI. Breast tissue density was determined with mammography according to ACR BI-RADS. Patients were compared according to tumor size, grade, stage, and treatment. Survival analysis was performed using Kaplan-Meier estimates. RESULTS: In total, 261 patients with mean follow-up of 85 months (25-133) were included: 156 DB and 105 NDB. Disease-free survival outcomes were better in the DB group in patients with MRI than in those without MRI: patients with MRI had significantly fewer local recurrences (P < 0.016) and metachronous contralateral breast cancers (P < 0.001), but this was not the case in the NDB group. Mastectomies were higher in the DB group with preoperative MRI than in those without MRI (P < 0.01), as it was in the NDB group (P > 0.05). CONCLUSIONS: Preoperative breast MRI was associated with reduced local recurrence and metachronous contralateral cancers in the DB group, but not in the NDB group; however, the DB patients with MRI had higher mastectomy rates.

Reducing persistent postoperative pain and disability 1 year after breast cancer surgery: a randomized, controlled trial comparing thoracic paravertebral block to local anesthetic infiltration.

BACKGROUND: The objective of this study was to compare the effect of thoracic paravertebral block (TPVB) and local anesthetic (LA) on persistent postoperative pain (PPP) 1 year following breast cancer surgery. Secondary objectives were to compare the effect on arm morbidity and quality of life. METHODS: Women scheduled for elective breast cancer surgery were randomly assigned to either TPVB or LA followed by general anesthesia. An NRS value of >3 at rest or with movement 1 year following surgery defined PPP. Blinded interim analysis suggested rates of PPP much lower than anticipated, making detection of the specified 20 % absolute reduction in the primary outcome impossible. Recruitment was stopped, and all enrolled patients were followed to 1 year. RESULTS: A total of 145 participants were recruited; 65 were randomized to TPVB and 64 to LA. Groups were similar with respect to demographic and treatment characteristics. Only 9 patients (8 %; 95 % CI 4-14 %) met criteria for PPP 1 year following surgery; 5 were in the TPVB and 4 in the LA group. Brief Pain Inventory severity and interference scores were low in both groups. Arm morbidity and quality of life were similar in both groups. The 9 patients with PPP reported shoulder-arm morbidity and reduced quality of life. CONCLUSIONS: This study reports a low incidence of chronic pain 1 year following major breast cancer surgery. Although PPP was uncommon at 1 year, it had a large impact on the affected patients' arm morbidity and quality of life.

Perioperative myocardial ischemia and isolated systolic hypertension in non-cardiac surgery.

PURPOSE: To determine whether patients with isolated systolic hypertension (ISH) undergoing non-cardiac surgery have a higher incidence of perioperative myocardial ischemia than normotensive patients and hence a greater risk for perioperative adverse events. METHODS: After obtaining Research Ethics Board approval, patients were recruited to either an ISH group (systolic blood pressure [SBP] > 140 mmHg with diastolic blood pressure [DBP] < 90 mmHg) or a normotensive group (SBP < 140 mmHg and DBP < 90 mmHg), according to their resting preoperative blood pressure. The primary outcome was the overall incidence of perioperative myocardial ischemia (PMI) as determined by 48-hr ambulatory Holter monitoring. P values ≤ 0.05 were considered to be statistically significant. RESULTS: A total of 312 (150 ISH and 162 normotensive) patients completed the study. Orthopedic surgery was the most frequent surgical procedure in both groups. The overall incidence of PMI was 19.7% in the ISH group compared with 18.8% in the normotensive group (difference 0.9%; 95% confidence interval [CI], -7.9% to 9.8%). The overall incidence of adverse events was 4.0% in the ISH group compared with 1.9% in the normotensive group (difference 2.2%; 95% CI, -1.6% to 5.9%). CONCLUSION: In this study, we chose to examine ISH as potential cardiac risk factor for patients undergoing non-cardiac surgery. The incidence of myocardial ischemia, a surrogate outcome, was similar in the two groups. The relatively high incidence of myocardial ischemia (19.2%) was of particular interest in this relatively low cardiac risk surgical population. (ClinicalTrials.gov number, NCT01237652).

Predictors of referral for adjuvant therapy for colorectal cancer.

OBJECTIVE: We carried out a retrospective cohort study at the Ottawa Hospital-Civic Campus to determine the proportions of patients referred for and provided adjuvant therapy for colorectal cancer (CRC) among those eligible according to published clinical practice guidelines. METHOD: Patients with stage III colon or stage II or stage III rectal cancer who had had potentially curative surgical resection for CRC and were seen at the Ottawa Hospital during 1999 and 2000 were eligible. We noted the number of medical or radiation oncology consultations, or both, and the subsequent receipt of adjuvant chemotherapy or radiotherapy, or both. RESULTS: Of 158 eligible patients, 135 (85%) had medical or radiation oncology consultations, or both. Of the total, 104 were less than 75 years of age and of these 99 (95%) were referred; of the 54 patients 75 years of age or older, 36 (67%) were referred. Of the 158 patients, 113 (72%) received adjuvant therapy, 90 (87%) eligible patients aged less than 75 years and 23 (43%) older patients. Increasing age and the presence of comorbidity were independent predictors of nonreferral and nontreatment. Gender and cancer site (colon or rectum) were not significant predictors of referral for, or receipt of, adjuvant therapy in general. CONCLUSIONS: The observed rates of referral for and receipt of adjuvant therapy for CRC are greater than generally published and appear reasonably concordant with current clinical practice guidelines, but optimal rates are undefined. Older patients and those with comorbidity were less likely to be referred and treated. However, our knowledge of the factors important to the process of clinical decision-making about adjuvant therapy for CRC is incomplete, and there may be patients, especially older ones, for whom adjuvant therapy would be appropriate but who are not being referred or treated.

Insulin responses to glucose and isoproterenol decrease with age.

BACKGROUND: Older trauma patients are less tolerant of glucose loads than are young patients, in part as a result of diminished insulin response. We hypothesized that diminished insulin responses result from reduced pancreatic sensitivity to beta-adrenergic stimulation. METHODS: We studied healthy subjects prospectively at a clinical investigation unit, to compare young (n = 6, mean age 21 [standard deviation {SD} 2] yr) and older people (n = 6, mean 63 [SD 2] yr). Paired studies of isoproterenol infusion, alone and in conjunction with a 2-hour hyperglycemic glucose clamp, were conducted in each subject. Heart rate, serum insulin concentration and other hemodynamic, biochemical, and physiologic variables were measured. RESULTS: Heart rate increased less markedly in response to isoproterenol in older than in young subjects (p < 0.01). Serum insulin during infusion accompanied by hyperglycemic clamp was also lower (467 [SD 135] pmol/L in older v. 755 [SD 284] pmol/L in young subjects, p < 0.05), despite similar hyperglycemia. Whole-body disposal of exogenous glucose was lower in older (5.8 [SD 1.7] mg/kg/min) than in young subjects (9.6 [SD 3.9], p < 0.05). CONCLUSIONS: Heart rate and serum insulin responses to combined isoproterenol infusion and glucose loading were both lower in healthy older subjects than in the young. Diminished tissue sensitivity to beta-adrenergic signals may contribute to the impaired insulin response and exaggerated glucose intolerance displayed by older patients after injury and during acute illness.

Limited effects of micronutrient supplementation on strength and physical function after abdominal aortic aneurysmectomy.

BACKGROUND: Tissue injury following ischemia-reperfusion is mediated in part by free oxygen radicals. We hypothesized that perioperative micronutrient supplementation would augment antioxidant defenses, minimize muscle injury, and minimize postoperative decreases in muscle strength and physical function following abdominal aortic aneurysmectomy. SETTING: A university-affiliated hospital and regional referral center. DESIGN: A randomized, double-blind, placebo-controlled trial of supplementation with beta-carotene, vitamins C and E, zinc, and selenium for a period of 2-3 weeks prior to surgery and 1 week thereafter. STUDY POPULATION: Patients undergoing elective abdominal aortic aneurysmectomy (n=18 per group). PRINCIPAL MEASUREMENTS: Handgrip and other measures of strength and physical function. RESULTS: Handgrip and quadriceps strength decreased following surgery, but not to a significantly different extent in the placebo and supplemented groups. Self-rated physical function decreased following surgery in the placebo group and was preserved in the supplemented group. CONCLUSIONS: Perioperative supplementation with micronutrients with antioxidant properties has limited effects on strength and physical function following major elective surgery.

Surgery in the elderly.

The elderly (those 75 years of age or older) are a heterogeneous group. They present with both elective and urgent surgical problems, and risk assessment, decision-making and perioperative care are typically more challenging than in younger patients. An appreciation for this heterogeneity and an understanding of how physiologic changes of aging affect surgical care are essential if the best outcomes are to be achieved.