Association between Care-need Level after Discharge and Long-term Outcomes in 7491 Patients Requiring Rehabilitation for Stroke.

Introduction: Stroke is a major cause of disability and mortality worldwide and requires long-term care, including rehabilitation. This study aims to elucidate the association between care-need levels after discharge and long-term outcomes in patients with stroke. Methods: We used a Japanese administrative database that covers both medical and long-term care insurance systems to retrospectively identify 7491 patients who underwent acute-phase in-hospital rehabilitation for stroke between June 2014 and February 2019. We investigated the association between nationally standardized care-need levels (support levels 1-2 and care-need levels 1-3) 6 months after discharge and long-term outcomes. Using the Fine-Gray model, we conducted multivariable survival analysis with adjustment for patient backgrounds and treatment courses to estimate hazard ratios (HR) for mortality and the incidence of being bedridden. Results: The median age was 82 (interquartile range [IQR], 76-87) years, 5418 patients (72%) had cerebral infarction, and 4009 patients (54%) had partial dependence after discharge. During a median follow-up of 580 (IQR, 189-925) days, 1668 patients (22%) became bedridden, and 2174 patients (29%) died. Compared with patients with support level 1, those with higher care-need levels showed significantly higher proportions of being bedridden-the subdistribution HR [95% confidence interval] were 1.52 [1.10-2.12], 2.85 [2.09-3.88], and 3.79 [2.79-5.15] in those with care-need levels 1, 2, and 3, respectively. Higher care-need levels were also significantly associated with higher mortality. Conclusions: This large-scale observational study demonstrated that a higher level of care-need after discharge was significantly associated with poorer functional outcomes and higher mortality.

Patient survey on cancer genomic medicine in Japan under the national health insurance system.

In Japan, comprehensive genomic profiling (CGP) tests have been reimbursed under the national health care system for solid cancer patients who have finished standard treatment. More than 50,000 patients have taken the test since June 2019. We performed a nation-wide questionnaire survey between March 2021 and July 2022. Questionnaires were sent to 80 designated Cancer Genomic Medicine Hospitals. Of the 933 responses received, 370 (39.7%) were web based and 563 (60.3%) were paper based. Most patients (784, 84%) first learned about CGP tests from healthcare professionals, and 775 (83.1%) gave informed consent to their treating physician. At the time of informed consent, they were most worried about test results not leading to novel treatment (536, 57.4%). On a scale of 0-10, 702 respondents (75.2%) felt that the explanations of the test result were easy to understand (7 or higher). Ninety-one patients (9.8%) started their recommended treatment. Many patients could not receive recommended treatment because no approved drugs or clinical trials were available (102/177, 57.6%). Ninety-eight patients (10.5%) did not wish their findings to be disclosed. Overall satisfaction with the CGP test process was high, with 602 respondents (64.5%) giving a score of 7-10. The major reason for choosing 0-6 was that the CGP test result did not lead to new treatment (217/277, 78.3%). In conclusion, satisfaction with the CGP test process was high. Patients and family members need better access to information. More patients need to be treated with genomically matched therapy.

FXYD3 functionally demarcates an ancestral breast cancer stem cell subpopulation with features of drug-tolerant persisters.

The heterogeneity of cancer stem cells (CSCs) within tumors presents a challenge in therapeutic targeting. To decipher the cellular plasticity that fuels phenotypic heterogeneity, we undertook single-cell transcriptomics analysis in triple-negative breast cancer (TNBC) to identify subpopulations in CSCs. We found a subpopulation of CSCs with ancestral features that is marked by FXYD domain-containing ion transport regulator 3 (FXYD3), a component of the Na+/K+ pump. Accordingly, FXYD3+ CSCs evolve and proliferate, while displaying traits of alveolar progenitors that are normally induced during pregnancy. Clinically, FXYD3+ CSCs were persistent during neoadjuvant chemotherapy, hence linking them to drug-tolerant persisters (DTPs) and identifying them as crucial therapeutic targets. Importantly, FXYD3+ CSCs were sensitive to senolytic Na+/K+ pump inhibitors, such as cardiac glycosides. Together, our data indicate that FXYD3+ CSCs with ancestral features are drivers of plasticity and chemoresistance in TNBC. Targeting the Na+/K+ pump could be an effective strategy to eliminate CSCs with ancestral and DTP features that could improve TNBC prognosis.

Predicting Breast Cancer Risk Using Radiomics Features of Mammography Images.

Mammography images contain a lot of information about not only the mammary glands but also the skin, adipose tissue, and stroma, which may reflect the risk of developing breast cancer. We aimed to establish a method to predict breast cancer risk using radiomics features of mammography images and to enable further examinations and prophylactic treatment to reduce breast cancer mortality. We used mammography images of 4000 women with breast cancer and 1000 healthy women from the 'starting point set' of the OPTIMAM dataset, a public dataset. We trained a Light Gradient Boosting Machine using radiomics features extracted from mammography images of women with breast cancer (only the healthy side) and healthy women. This model was a binary classifier that could discriminate whether a given mammography image was of the contralateral side of women with breast cancer or not, and its performance was evaluated using five-fold cross-validation. The average area under the curve for five folds was 0.60122. Some radiomics features, such as 'wavelet-H_glcm_Correlation' and 'wavelet-H_firstorder_Maximum', showed distribution differences between the malignant and normal groups. Therefore, a single radiomics feature might reflect the breast cancer risk. The odds ratio of breast cancer incidence was 7.38 in women whose estimated malignancy probability was ≥0.95. Radiomics features from mammography images can help predict breast cancer risk.

Post-traumatic growth and cancer-related communication among adolescents having mothers with breast cancer.

PURPOSE: This study aimed to clarify the characteristics of post-traumatic growth (PTG) among adolescents having mothers diagnosed with breast cancer and the relationship between PTG and cancer-related communication with breast cancer survivors. METHODS: A cross-sectional study was conducted using anonymous self-report questionnaires with breast cancer survivors and adolescent children. PTG in adolescents was measured using the Japanese version of the revised PTG Inventory for Children (PTGI-C-R-J). Furthermore, hierarchical multiple regression analysis was implemented. To evaluate the impact of cancer-related communication on each subscale, the total score of cancer-related communication was switched with other subscales individually within the constructed model. RESULTS: A total of 97 breast cancer survivors and their adolescent children were included. The mean scores of the total PTGI-C-R-J and subscale scores for "personal strength," "new possibilities," "relating to others," "appreciation of life," and "spiritual change" were 9.0, 1.7, 1.8, 2.3, 2.4, and 0.9, respectively. The connection between PTG and cancer-related communication was partially clarified. The PTGI-C-R-J score was higher when adolescents shared more information regarding breast cancer with their mothers and lower when adolescents expressed more negative feelings toward their mothers. Communication regarding relationships with mothers was not correlated with PTG. CONCLUSIONS: Of all PTG domains, "relating to others" and "appreciation of life" were comparatively higher in adolescents. Health professionals should support breast cancer survivors to ensure that they convey appropriate information regarding their treatment plans and side effects to their adolescent children. Health professionals should help adolescent children express their negative feelings calmly and clearly.

Impact of the National Action Plan for Antimicrobial Resistance on Antibiotic Use for Mastitis Using a Japanese Nationwide Database.

Introduction: Mastitis is the inflammation of the mammary gland that mainly occurs during the lactation period and requires antibiotic treatment with little evidence for its efficacy. We investigated the effect of the National Action Plan for antimicrobial resistance aiming for appropriate antimicrobial stewardship on broad-spectrum antibiotics administration for mastitis despite the lack of a disease-specific antimicrobial agents manual. Methods: Using a large nationwide database, an interrupted time-series analysis was performed using data from 34,340 female patients who received antibiotics for mastitis between April 2012 and March 2020. This study compared the trend of outcomes before and after the publication date of the National Action Plan (April 2016). The outcomes were the proportion of broad-spectrum and first-choice narrow-spectrum antibiotic administration and surgical drainage within 30 days after the administration. Results: Broad-spectrum antibiotics were administered in 70% of the cases before and 67% of the cases after the National Action Plan publication date. The trend of broad-spectrum antibiotics administration significantly changed at the publication (-2.6% [95% confidence interval, -3.9% to -1.3%], p < 0.001) and the administration decreased after the publication (1.9% annual decrease, Ptrend < 0.001). The trend of first-choice antibiotics administration also changed at the publication (1.3% [0.1-2.4%], p = 0.028) and the administration increased after the publication (1.3% annual increase, Ptrend < 0.001). The occurrence of surgical drainage was stable during the study period. Conclusion: Despite the lack of a disease-specific antimicrobial manual, the publication of the National Action Plan improved antimicrobial stewardship for mastitis without any impact on a surgical treatment course.

Long-Term Risk of Being Bedridden in Elderly Patients Who Underwent Oncologic Surgery: A Retrospective Study Using a Japanese Claims Database.

BACKGROUND: Although functional outcomes are important in surgery for elderly patients, the long-term functional prognosis following oncologic surgery is unclear. We retrospectively investigated the long-term, functional and survival prognosis following major oncologic surgery according to age among elderly patients. METHODS: We used a Japanese administrative database to identify 11,896 patients aged ≥ 65 years who underwent major oncological surgery between June 2014 and February 2019. We investigated the association between age at surgery and the postoperative incidence of bedridden status and mortality. Using the Fine-Gray model and restricted cubic spline functions, we conducted a multivariable, survival analysis with adjustments for patient background characteristics and treatment courses to estimate hazard ratios for the outcomes. RESULTS: During a median follow-up of 588 (interquartile range, 267-997) days, 657 patients (5.5%) became bedridden and 1540 (13%) died. Patients aged ≥ 70 years had a significantly higher incidence of being bedridden than those aged 65-69 years; the subdistribution hazard ratios of the age groups of 70-74, 75-79, 80-84, and ≥ 85 years were 3.20 (95% confidence interval [CI], 1.53-6.71), 3.86 (95% CI 1.89-7.89), 6.26 (95% CI 3.06-12.8), and 8.60 (95% CI 4.19-17.7), respectively. Restricted cubic spline analysis demonstrated an increase in the incidence of bedridden status in patients aged ≥ 65 years, whereas mortality increased in patients aged ≥ 75 years. CONCLUSIONS: This large-scale, observational study revealed that older age at oncological surgery was associated with poorer functional outcomes and higher mortality among patients aged ≥ 65 years.

Human resources for administrative work to carry out a comprehensive genomic profiling test in Japan.

Comprehensive genomic profiling (CGP) tests have been nationally reimbursed in Japan since June 2019 under strict restrictions, and over 46,000 patients have taken the test. Core Hospitals and Designated Hospitals host molecular tumor boards, which is more time-consuming than simply participating in them. We sent a questionnaire to government-designated Cancer Genomic Medicine Hospitals, including all 12 Core Hospitals, all 33 Designated Hospitals, and 117 of 188 Cooperative Hospitals. The questionnaire asked how much time physicians and nonphysicians spent on administrative work for cancer genomic medicine. For every CGP test, 7.6 h of administrative work was needed. Physicians spent 2.7 h/patient, while nonphysicians spent 4.9 h/patient. Time spent preparing for molecular tumor boards, called Expert Panels, was the longest, followed by time spent participating in Expert Panels. Assuming an hourly wage of ¥24,000/h for physicians and ¥2800/h for nonphysicians, mean labor cost was ¥78,071/patient. On a monthly basis, more time was spent on administrative work at Core Hospitals compared with Designated Hospitals and Cooperative Hospitals (385 vs. 166 vs. 51 h/month, respectively, p < 0.001). Consequently, labor cost per month was higher at Core Hospitals than at Designated Hospitals and Cooperative Hospitals (¥3,951,854 vs. ¥1,687,167 vs. ¥487,279/month, respectively, p < 0.001). Completing a CGP test for a cancer patient in Japan is associated with significant labor at each hospital, especially at Core Hospitals. Streamlining the exchange of information and simplifying Expert Panels will likely alleviate this burden.

Erratum: Comparison of bleeding following gastrointestinal endoscopic biopsy in patients treated with and without direct oral anticoagulants.

[This corrects the article DOI: 10.1055/a-1981-2946.].

Postoperative Adjuvant Anastrozole for 10 or 5 Years in Patients With Hormone Receptor-Positive Breast Cancer: AERAS, a Randomized Multicenter Open-Label Phase III Trial.

PURPOSE: Treatment with an aromatase inhibitor for 5 years is the standard treatment for postmenopausal hormone receptor-positive breast cancer. We investigated the effects of extending this treatment to 10 years on disease-free survival (DFS). PATIENTS AND METHODS: This prospective, randomized, multicenter open-label phase III study assessed the effect of extending anastrozole treatment for an additional 5 years in postmenopausal patients who were disease-free after treatment with either 5 years of anastrozole alone or 2-3 years of tamoxifen followed by 2-3 years of anastrozole. Patients were allocated randomly (1:1) to continue anastrozole for an additional 5 years or stop anastrozole. The primary end point was DFS, including breast cancer recurrence, second primary cancers, and death from any cause. This study is registered with University Hospital Medical Information Network, Japan (UMIN) clinical trials registry (UMIN000000818). RESULTS: We enrolled 1,697 patients from 117 facilities between November 2007 and November 2012. Follow-up information was available for 1,593 patients (n = 787 in the continue group, n = 806 in the stop group), who were defined as the full analysis set, including 144 patients previously treated with tamoxifen and 259 patients who underwent breast-conserving surgery without irradiation. The 5-year DFS rates were 91% (95% CI, 89 to 93) in the continue group and 86% (95% CI, 83 to 88) in the stop group (hazard ratio, 0.61; 95% CI, 0.46 to 0.82; P < .0010). Notably, extended anastrozole treatment reduced the incidence of local recurrence (continue group, n = 10; stop group, n = 27) and second primary cancers (continue group, n = 27; stop group, n = 52). There was no significant difference in overall or distant DFS. Menopausal or bone-related all-grade adverse events were more frequent among patients in the continue group than those in the stop group, but the incidence of grade ≥3 adverse events was <1% in both groups. CONCLUSION: Continuing adjuvant anastrozole for an additional 5 years after 5 years of initial treatment with anastrozole or tamoxifen followed by anastrozole was well tolerated and improved DFS. Although no difference in overall survival was observed as in other trials, extended anastrozole therapy could be one treatment choice in postmenopausal patients with hormone receptor-positive breast cancer.

Exploring Predictive Risk Factors of Infusion Reactions with First Pertuzumab Administration in HER2-positive Breast Cancer Patients: A Single Institution Experience.

Introduction: Pertuzumab and trastuzumab are monoclonal antibodies used for treating HER2-positive breast cancer. These anti-HER2 antibodies may induce infusion reactions (IR), mainly upon first administration. We investigated factors predicting IR in the initial pertuzumab treatment for HER2-positive breast cancer. Methods: We retrospectively reviewed the medical records of 57 patients who first received pertuzumab-containing treatment in our hospital from January 2014 to February 2021. The frequency of IR during or immediately after pertuzumab administration was examined. We also analyzed patient characteristics that may represent possible risk factors for IR. Results: The incidence rate of IR was 44% (25/57). Red blood cell count (P < 0.001), hemoglobin (Hb) concentration (P = 0.0011), and hematocrit (P < 0.001) immediately before pertuzumab administration were significantly lower in patients with IR than in those without. In patients with IR, erythrocyte levels immediately before pertuzumab treatment were significantly lower than baseline when having received anthracycline-containing chemotherapy within three months. Logistic regression analysis showed that a decrease in Hb levels was a significant risk factor for IR (log odds ratio = -17). According to the receiver-operating characteristic analysis, a 10% decrease in Hb after anthracycline-containing treatment was the best cut-off value for predicting IR (sensitivity: 88%; specificity: 77%; area under the curve: 0.87). Conclusions: Our study showed a higher incidence of IR after pertuzumab treatment than in clinical trials. There was a strong association between IR occurrence and erythrocyte levels lower than baseline in the group that received anthracycline-containing chemotherapy immediately before.

Comparison of bleeding following gastrointestinal endoscopic biopsy in patients treated with and without direct oral anticoagulants.

Background and study aims Despite the widespread use of direct oral anticoagulants (DOACs), the association between DOAC use and complications (e. g., bleeding) following gastrointestinal endoscopic biopsy remains unclear. This study aimed to evaluate complications after biopsy in patients treated with DOACs in Japan, where biopsies would be generally performed without DOAC withdrawal based on guideline recommendations. Patients and methods Using a Japanese nationwide database, we identified patients taking DOACs who underwent gastrointestinal endoscopic biopsy (n  = 2,769, DOAC group) and those not taking DOACs (n = 129,357, control group) from April 2015 to November 2020. We conducted 1:4 propensity score (PS) matching and overlap PS-weighting analyses with adjustment for background characteristics to compare occurrence of post-procedure hemorrhage and stroke within 1 week after biopsy, and thrombin use on the day of biopsy without a diagnosis of hemorrhage. Results In total, 578 patients (0.44 %) developed post-procedure hemorrhage, and 13 patients (0.01 %) developed stroke. The DOAC group had more comorbidities than the control group. The PS matching analysis revealed no significant differences in post-procedure hemorrhage (odds ratio, 1.52 [95 % confidential interval, 0.96-2.41]) or stroke (1.00 [0.21-4.71]), whereas the DOAC group received thrombin more often than the control group (1.60 [1.30-1.95]). The results were equivalent in the overlap PS-weighting analysis. Conclusions The PS analyses showed no significant differences in complications following gastrointestinal endoscopic biopsy between DOAC users and non-users. These results suggest the safety of endoscopic biopsy without DOAC withdrawal although the need for careful hemostasis remains.

Clinical utility of Todai OncoPanel in the setting of approved comprehensive cancer genomic profiling tests in Japan.

Comprehensive cancer genome profiling (CGP) has been nationally reimbursed in Japan since June 2019. Less than 10% of the patients have been reported to undergo recommended treatment. Todai OncoPanel (TOP) is a dual DNA-RNA panel as well as a paired tumor-normal matched test. Two hundred patients underwent TOP as part of Advanced Medical Care B with approval from the Ministry of Health, Labour and Welfare between September 2018 and December 2019. Tests were carried out in patients with cancers without standard treatment or when patients had already undergone standard treatment. Data from DNA and RNA panels were analyzed in 198 and 191 patients, respectively. The percentage of patients who were given therapeutic or diagnostic recommendations was 61% (120/198). One hundred and four samples (53%) harbored gene alterations that were detected with the DNA panel and had potential treatment implications, and 14 samples (7%) had a high tumor mutational burden. Twenty-two samples (11.1%) harbored 30 fusion transcripts or MET exon 14 skipping that were detected by the RNA panel. Of those 30 transcripts, 6 had treatment implications and 4 had diagnostic implications. Thirteen patients (7%) were found to have pathogenic or likely pathogenic germline variants and genetic counseling was recommended. Overall, 12 patients (6%) received recommended treatment. In summary, patients benefited from both TOP DNA and RNA panels while following the same indication as the approved CGP tests. (UMIN000033647).

Treatments and outcomes of adult parapharyngeal and retropharyngeal abscess: 1882 cases from a Japanese nationwide database.

PURPOSE: Although parapharyngeal and retropharyngeal abscesses are potentially fatal deep neck abscesses, there is limited evidence for the treatment courses for adult patients with these abscesses. We aimed to describe the practice patterns and clinical outcomes of adult patients undergoing an emergency surgery for parapharyngeal or retropharyngeal abscesses using a nationwide database. MATERIALS AND METHODS: We identified patients aged ≥18 years who underwent emergency surgery for parapharyngeal (para group, n = 1148) or retropharyngeal (retro group, n = 734) abscesses from July 2010 to March 2020, using a nationwide inpatient database. We performed between-group comparisons of the baseline characteristics, treatment course, and outcomes. RESULTS: Compared with the retro group, the para group was more likely to be older (median, 66 vs. 60 years; P < 0.001) and have several comorbidities, such as diabetes (21 % vs 16 %; P = 0.010) and epiglottitis (33 % vs. 26 %; P = 0.002), except for peritonsillar abscess (14 % vs. 22 %; P < 0.001) and tonsillitis (2.1 % vs. 13 %; P < 0.001). Regarding intravenous drugs administered within 2 days of admission, approximately half of the patients received steroids, non-antipseudomonal penicillins, and lincomycins. The para group received more comprehensive treatments, such as tracheostomy, intensive care unit admissions, and swallowing rehabilitation, within total hospitalization than the retro group. Moreover, it demonstrated higher in-hospital mortality (2.7 % vs. 1.1 %; P = 0.017) and morbidity (16 % vs. 9.7 %; P < 0.001), and longer length of hospitalization than the retro group. CONCLUSION: The current nationwide study provided an overview of the characteristics, treatments, and outcomes for patients who underwent an emergency surgery for parapharyngeal or retropharyngeal abscess.

Risk factors for arm lymphedema following breast cancer surgery: a Japanese nationwide database study of 84,022 patients.

BACKGROUND: Although arm lymphedema is a well-known complication following breast cancer surgery, previous studies involving a small population showed inconsistent results regarding the risk. Therefore, we examined the risk factors using a Japanese nationwide database. METHODS: Female patients who underwent breast cancer surgery from April, 2016, to March, 2020, were identified from a Japanese nationwide database. Multivariable survival analyses for 19 baseline factors (12 patient characteristics, four tumor characteristics, and three surgical procedures) were conducted to investigate risk factors associated with treatments for postoperative lymphedema (such as lymphatic bypass, compositive drainage therapy, hospitalization, and Kampo use) with a multilevel model to adjust for within-hospital clustering. We also conducted multivariable analysis for five postoperative factors (two local complications and three postoperative therapies) with adjustment for 19 baseline factors. RESULTS: The study included 84,022 patients; 1547 (1.8%) received treatments for lymphedema during a median follow-up of 119 weeks (interquartile range, 59-187 weeks). Young age, obesity, smoking, collagen diseases, advanced cancer stage, total mastectomy, axillary dissection, postoperative bleeding, chemotherapy, and radiotherapy were identified as risk factors. Postoperative chemotherapy (hazard ratio, 3.78 [95% confidence interval, 3.35-4.26]) and axillary dissection (2.46 [1.95-3.11]) showed the highest odds ratio among the risk factors. The cumulative probabilities in high-risk patients reached approximately 3% at 1 year and 6% at 4 years after surgery. CONCLUSIONS: This study identified several risk factors for postoperative lymphedema in breast cancer surgery. The treatment initiation increased markedly within the first year and gradually after 1 year post-surgery.

Subcutaneous axillary primary epithelioid hemangioendothelioma: report of a rare case.

BACKGROUND: Epithelioid hemangioendothelioma (EHE) is a rare and slow-growing malignant vascular neoplasm composed of epithelioid endothelial cells within a distinctive myxohyaline stroma. It most commonly involves somatic soft tissue, lungs, liver and bone. Herein, we describe a case of EHE arising in the axillary region. CASE PRESENTATION: A 61-year-old man was under observation for multiple hepatic hemangiomas. Fluorodeoxyglucose-positron emission tomography/computed tomography showed specific uptake in a right axillary tumor. The patient was referred to our department for further investigation of the axillary tumor. An elastic-soft and poorly mobile tumor was palpable in the right axilla. Contrast-enhanced computed tomography showed a right axillary tumor and enlarged hepatic hemangiomas. In addition, multiple nodules in both lungs, a left renal angiomyolipoma, and left adrenal adenoma were revealed. Ultrasonography showed masses in both lobes of the thyroid gland, and a 30-mm lobulated hypoechoic mass in the axilla with well-defined and rough borders, showing internal heterogeneity. Fine-needle aspiration cytology was performed on the thyroid and axillary tumors: the thyroid tumor was class V, raising suspicion of papillary thyroid cancer (PTC); the left superior internal jugular node was class V, raising suspicion of metastasis of PTC; and the axillary tumor was class III, raising suspicion of a mesenchymal tumor with few epithelioid cells. The multiple lung nodules were diagnosed as metastatic tumors derived from thyroid cancer. We diagnosed these diseases as PTC of T1b(m)N1bM1(lung) Stage IVB and a right axillary tumor of unclear origin. However, it was assumed to be a primary mesenchymal tumor or a lymph node metastasis from lung cancer or occult breast cancer. We performed total thyroidectomy, left cervical lymph node dissection, and right axillary tumor excision. Histopathologic examination revealed the thyroid tumor as a PTC and the axillary tumor as an EHE. The EHE showed nuclear atypia, necrosis and high mitotic figures. Hence, it was considered to be a high-risk EHE. CONCLUSIONS: We experienced a rare primary subcutaneous axillary EHE with metastatic thyroid cancer in the lung. Since our case was classified as a high-risk EHE, a close follow-up would be appropriate.

Risk Factors for Postoperative Bleeding Following Breast Cancer Surgery: A Nationwide Database Study of 477,108 Cases in Japan.

BACKGROUND: Although postoperative bleeding is a common and serious complication in breast cancer surgery, the risk factors remain unclear. Therefore, we examined the risk factors using a Japanese nationwide database. METHODS: Patients who underwent breast cancer surgery between July 2010 and March 2020 were identified from a Japanese nationwide database. Multivariable analyses for 47 candidate risk factors (4 patient characteristics, 32 comorbidities, 5 tumor characteristics, 3 preoperative drug uses, and 3 surgical procedures) were conducted to investigate risk factors associated with postoperative bleeding requiring reoperation. Two sensitivity analyses were conducted: an analysis for postoperative bleeding with or without reoperation and an analysis for patients who underwent total mastectomy without breast reconstruction. RESULTS: Among the 477,108 patients included, 7048 (1.5%) developed postoperative bleeding and 2357 (0.5%) underwent reoperation for postoperative bleeding. Male sex, old age, body mass index ≥ 25.0 kg/m2, several comorbidities (deficiency anemia, cardiac arrhythmias, hypertension, liver disease, psychoses, and valvular disease), preoperative heparin use, and several procedures were identified as risk factors. Deficiency anemia showed the highest odds ratio among the risk factors (4.41 [95% confidence interval, 3.63-5.36]). High odds ratios were also observed in total mastectomy (2.32 [2.10-2.56]), flap reconstruction (1.93 [1.55-2.40]), and preoperative heparin use (1.64 [1.26-2.14]). The results corresponded with the sensitivity analyses. CONCLUSIONS: This study identified several risk factors for postoperative bleeding in breast cancer surgery, such as high body mass index, anemia, cardiovascular diseases, liver diseases, psychoses, preoperative heparin use, and surgical procedures.

Association of Operative Day of the Week with the Length of Stay and Total Hospitalization Costs in Patients with Partial Mastectomy: A Nationwide Database Study in Japan.

Introduction: Length of stay (LOS) is a major concern while optimizing medical resources and costs. Hence, factors influencing LOS should be investigated. In Japan, breast cancer surgery generally involves several days of hospitalization for observation, despite few complications. We hypothesized that the day of surgery (weekday; Monday-Friday) affects LOS. Methods: Using a Japanese nationwide database, we retrospectively identified 146,610 patients who underwent partial mastectomy for stage 0-III breast cancer from July 2010 to March 2017. We conducted multivariable linear and logistic regression analyses adjusting for background characteristics (such as comorbidities and hospital characteristics) with a generalized estimating equation for within-hospital clustering to compare postoperative and total LOS, total hospitalization costs, and postoperative complications between the groups for whom the surgery was performed on different days of the week. Results: In total, whereas the median postoperative LOS was 4 days (interquartile range, 3-6 days), the median total LOS was 6 days (5-8 days). The median total hospitalization cost was 6,189 US dollars (5,609-6,668 US dollars), and postoperative complications occurred in 3.3% of cases. Despite no significant difference in postoperative complications, Monday-Wednesday surgeries showed significantly shorter postoperative LOS than Friday surgeries (-0.11 days [95% confidence interval, -0.14 to -0.07] on Monday with reference to Friday). Nevertheless, Monday surgeries showed significantly increased total LOS (0.69 days [0.64-0.74]) and hospitalization costs (93 US dollars [71-116]) in comparison with Friday surgeries. Conclusions: The operative day of the week was associated with increased LOS and cost, with no difference in postoperative complications after partial mastectomy. Surgeries on Monday involved longer preoperative hospital stays and higher total hospitalization costs than those on other weekdays.