Time trends (2006-2015) of quality indicators in EUSOMA-certified breast centres.

AIM OF THE STUDY: The European Society of Breast Cancer Specialists (EUSOMA) has fostered a voluntary certification process for breast centres to establish minimum standards and ensure specialist multidisciplinary care. Prospectively collected anonymous information on primary breast cancer cases diagnosed and treated in the units is transferred annually to a central EUSOMA data warehouse for continuous monitoring of quality indicators (QIs) to improve quality of care. Units have to comply with the EUSOMA Breast Centre guidelines and are audited by peers. The database was started in 2006 and includes over 110,000 cancers from breast centres located in Germany, Switzerland, Belgium, Austria, The Netherlands, Spain, Portugal and Italy. The aim of the present study is assessing time trends of QIs in EUSOMA-certified breast centres over the decade 2006-2015. MATERIALS AND METHODS: Previously defined QIs were calculated for 22 EUSOMA-certified breast centres (46122 patients) during 2006-2015. RESULTS: On the average of all units, the minimum standard of care was achieved in 8 of 13 main EUSOMA QIs in 2006 and in all in 2015. All QIs, except removal of at least 10 lymph nodes at axillary clearance and oestrogen receptor-negative tumours (T > 1 cm or N+) receiving adjuvant chemotherapy, improved significantly in this period. The desirable target was reached for two QIs in 2006 and for 7 of 13 QIs in 2015. CONCLUSION: The EUSOMA model of audit and monitoring QIs functions well in different European health systems and results in better performance of QIs over the last decade. QIs should be evaluated and adapted on a regular basis, as guidelines change over time.

The effect of EUSOMA certification on quality of breast cancer care.

AIM OF THE STUDY: The European Society of Breast Cancer Specialists (EUSOMA) has fostered a voluntary certification process for breast units to establish minimum standards and ensure specialist multidisciplinary care. In the present study we assess the impact of EUSOMA certification for all breast units for which sufficient information was available before and after certification. MATERIALS AND METHODS: For 22 EUSOMA certified breast units data of 30,444 patients could be extracted from the EUSOMA database on the evolution of QI's before and after certification. RESULTS: On the average of all units, the minimum standard of care was achieved for 12/13 QI's before and after EUSOMA certification (not met for DCIS receiving just one operation). There was a significant improvement of 5 QI's after certification. The proportion of patients with invasive cancer undergoing an axillary clearance containing >9 lymph nodes (91.5% vs 89.4%, p 0.003) and patients with invasive cancer having just 1 operation (83.1% vs 80.4%, p < 0.001) dropped, but remained above the minimum standard. The targeted standard of breast care was reached for the same 4/13 QI's before and after EUSOMA certification. CONCLUSION: Although the absolute effect of EUSOMA certification was modest it further increases standards of care and should be regarded as part of a process aiming for excellence. Dedicated units already provide a high level of care before certification, but continuous monitoring and audit remains of paramount importance as complete adherence to guidelines is difficult to achieve.

Treatment of breast cancer in the elderly: a prospective, population-based Swiss study.

OBJECTIVES: The primary objective of this population-based study is to describe the patterns of care of elderly patients with breast cancer (BC), and evaluate potential causative factors for the decrease in BC-specific survival (BCSS) in the elderly. PATIENTS AND METHODS: We included all or representative samples of patients with newly diagnosed BC from seven Swiss cancer registries between 2003 and 2005 (n=4820). Surgical and non-surgical BC treatment was analyzed over 5 age groups (<65, 65 to <70, 70 to <75, 75 to <80 and ≥80years), and the predictive impact of patient age on specific treatments was calculated using multivariate logistic regression analysis. RESULTS: The proportion of locally advanced, metastatic and incompletely staged BC increased with age. The odds ratio for performing breast-conserving surgery (BCS) in stages I-II BC (0.37), sentinel lymph node dissection (SLND) in patients with no palpable adenopathy (0.58), post-BCS radiotherapy (0.04) and adjuvant endocrine treatment (0.23) were all in disfavor of patients ≥80years of age compared to their younger peers. Only 36% of patients ≥80years of age with no palpable adenopathy underwent SLND. In the adjusted model, higher age was a significant risk factor for omitting post-BCS radiotherapy, SLND and adjuvant endocrine treatment. CONCLUSIONS: This study found an increase in incomplete diagnostic assessment, and a substantial underuse of BCS, post-BCS radiotherapy, SLND and adjuvant endocrine treatment in elderly patients with BC. There is a need for improved management of early BC in the elderly even in a system with universal access to health care services.

Can axillary reverse mapping avoid lymphedema in node positive breast cancer patients?

BACKGROUND: Tracing lymphatic drainage of the ipsilateral arm of node positive breast cancer patients, termed "axillary reverse mapping" (ARM), has recently been described in several reports. We analyzed our experience with this new technique in patients scheduled for axillary lymph node dissection (ALND) and evaluated its usefulness for reducing the incidence of lymphedema. METHODS: Blue dye was injected subcutaneously along the intermuscular groove of the upper inner arm; radioisotope was injected subcutaneously in the interdigital webspace of the hand. All blue and radioactive lymph vessels and lymph nodes were recorded. Only unsuspicious "ARM lymph nodes" located in the lateral part of the axillary basin were preserved. All other level I and II axillary lymph nodes were removed. Resected ARM nodes were immediately separated from all other lymph nodes. RESULTS: ARM was performed in 143 patients subsequently undergoing ALND. ARM lymph nodes were successfully identified in 112 cases (78%). In 55 patients at least one ARM lymph node had to be removed. In 14 of these, tumor involvement was confirmed. In 71 patients one or more ARM nodes were preserved. During a median follow-up time of 19 months no axillary recurrence was noted. 35 of 114 evaluated patients developed lymphedema. Preservation of ARM lymph nodes did not significantly decrease the incidence of lymphedema. CONCLUSION: ARM is feasible for patients with node positive breast cancer. However, we found no evidence that it reduces the incidence of lymphedema.

Predictors of state-of-the-art management of early breast cancer in Switzerland.

BACKGROUND: The aim of this study was to investigate predictors of state-of-the-art management of early breast cancer in Switzerland. PATIENTS AND METHODS: The study included 3499 women aged 25-79 years diagnosed with invasive breast cancer stages I-IIIA in 2003-2005. Patients were identified through population-based cancer registries and treated in all kinds of settings. Concordance with national and international recommendations was assessed for 10 items covering surgery, radiotherapy, systemic adjuvant therapy and histopathology reporting. We used multivariate logistic regression to identify independent predictors of high (10 points) and low (≤7 points) concordance. RESULTS: In one-third of the patients, management met guidelines in all items, whereas in about one-fifth, three or more items did not comply. Treatment by a surgeon with caseload in the upper tercile and team involved in clinical research were independent predictors of a high score, whereas treatment by a surgeon with a caseload in the lower tercile was associated with a low score. Socioeconomic characteristics such as income and education were not independent predictors, but patient's place of residence and age independently predicted management according to recommendations. CONCLUSION: Specialization and involvement in clinical research seem to be key elements for enhancing the quality of early breast cancer management at population level.

Use of intraoperative stereomicroscopy for preventing loss of metastases during frozen sectioning of sentinel lymph nodes in breast cancer.

AIMS: Optimal detection of metastases in sentinel lymph nodes (SLN) remains controversial. To determine the reliability of intraoperative frozen sections, SLN protocol with one frozen section was compared with macroscopic SLN evaluation with consecutive complete SLN embedding. METHODS AND RESULTS: SLN from 135 consecutive breast cancer patients were analysed under a sereomicroscope. Frozen sections were performed in suspicious or clearly involved SLN on cut surface. One control group (n = 143) underwent one intraoperative frozen section on each SLN. The second control group (n = 90) was subjected to stereomicroscopy and one intraoperative frozen section on each SLN. A conventional SLN protocol with cytokeratin immunohistochemistry was performed postoperatively in all cases. All groups were statistically comparable. In the study group metastases were suspected in 21 SLN (16%) under the stereomicroscope and all were confirmed histologically. The negative SLN rate was significantly lower in the study group than in the main control group (47% versus 64%, P = 0.008), suggesting loss of metastases during frozen sections. More macrometastases were detected in the study group (30% versus 15%, P = 0.006); there were no differences in isolated tumour cells or micrometastases. The false-negative rate was significantly lower in the control groups (29% versus 13% and 12%, P = 0.001). CONCLUSIONS: Frozen sections potentially lead to loss or reduced size of metastatic deposits in SLN. Avoiding intraoperative frozen sections on grossly inconspicuous SLN may therefore be justified.

[Loss of metastatic deposits in breast sentinel lymph nodes during intra-operative frozen section analysis]. / Potentieller Verlust von Metastasen in Sentinel Lymphknoten während der Schnellschnitt Untersuchung.

The intraoperative evaluation of sentinel lymph nodes is an ongoing debated issue. In this review we discuss different approaches to sentinel lymph node processing in an intra operative setting and in the consecutive embedding in paraffin. We propose a method, which uses routine intra operative examination of lymph nodes with stereo microscopy with selected frozen section analysis. We demonstrate preliminary data on a larger patient collective along with data on a control group. We could show in our study that a higher rate of metastates can be achieved avoiding intra operative frozen sections on grossly inconspicuous sentinel lymph nodes.

[Influence of prophylactic information on the frequency of baby blues]. / Einfluss eines prophylaktischen Aufklärungsgesprächs auf den Baby Blues.

BACKGROUND: Baby blues, a mood alteration, occurs in 30 to 80 % of the women during the first two weeks after childbirth. We evaluated if the frequency of baby blues can be influenced by oral and written information about these mood alterations. We wanted to find out whether information about postpartum depression could make these woman realize their own possible depression and therefore seek professional help more rapidly. PATIENTS AND METHODS: In a prospective randomized study German-speaking women were randomized on the second or third day after childbirth in our institution into an "information group" and a "control group". The first group was given oral and written information about baby blues and postpartum depression. Both groups were evaluated by Edinburgh Postpartum Depression Scale (EPDS) translated into German 3 days, 6 weeks and 3 months postpartum, by a visual-analogue questionnaire covering the first 6 weeks and by a self-report covering the whole period postpartum after 3 months. RESULTS: We obtained valuable information from 169 women. Only 12 (15 %) women of the "information group" experienced a baby blues vs. 25 (29 %) of the "control group" (RR 0.55, P = 0,027, CI 0.28 - 0.93). Concerning postpartum depression, no significant difference could be seen. The percentage of scores above 11 in the EPDS around birth was 8.5 % vs. 9.3 % in the information vs. control group. 6 weeks after birth the percentages were 7.5 vs. 7.1 % and 12 weeks after birth they were 7.3 % vs. 8.0 %. Of the women considering themselves as depressive by self evaluation 3 months postpartum, only a few sought help from a specialist: 7 of 13 in the Information vs. 4 of 14 in the control group. The difference is not statistically significant. CONCLUSION: We conclude that oral and written information about baby blues given postpartum can be an effective instrument to lower its frequency. No difference in postpartum depression could be registered - either in prevalence or in seeking professional help.

[Conservative treatment of puerperal breast abscesses with repeated sonographically guided aspirations and oral antibiotic administrations]. / Behandlung puerperaler Mammaabszesse durch wiederholte ultraschallgezielte Punktionen und perorale Antibiotikagabe.

BACKGROUND: Breast abscesses have usually been treated by incision and drainage. During the past 10 years conservative treatment with repeated ultrasound-guided drainage to evacuate the abscess combined with antibiotic treatment has become a valuable alternative. PATIENTS AND METHODS: From 1991 to 2003 the authors treated 17 patients with puerperal abscess with this method. Under local anesthesia with ultrasound guidance a thick needle (preferably a Venflon) is introduced into the cavity. The procedure is repeated every two or three days until the ultrasound image demonstrates a diameter of the cavity of 1.5 cm or less. The oral antibiotic treatment lasts for 6 to 10 days. RESULTS: In 7 cases only one puncture was needed, 5 cases needed 2 punctures while 4 women needed 3 or more punctures (up to 5). In 16 cases an open drainage could be avoided. One patient wanted to discontinue the conservative treatment after the first puncture and requested the surgical drainage. CONCLUSIONS: Conservative therapy with ultrasound-guided drainage of puerperal breast abscesses can therefore be recommended as a standard treatment.

[Perinatal mortality after previous cesarean section]. / Perinatale kindliche Todesfälle bei Kaiserschnitt in der mütterlichen Anamnese.

BACKGROUND: Perinatal neonatal mortality is increased where there is a maternal history of cesarean section (0.45 vs. 0.31 % in deliveries after previous vaginal delivery). In this study we have analyzed the causes of the perinatal deaths. PATIENTS AND METHODS: The increased risk was found by analyzing the database of the Swiss Working Group of Obstetric and Gynecological Institutions with its 29 046 deliveries with a history of previous cesarean section between 1983 and 1996. In this time period 130 perinatal neonatal deaths in deliveries after previous cesarean were recorded. RESULTS: The cause of death could be established in 124 cases. In the 42 term deliveries the causes of death were the following: malformations 20, uterine rupture 5, placental abruption 5, respiratory distress syndrome 5, and other causes 7. In the 82 preterm deliveries: prematurity caused by premature contractions/rupture of membranes 38, malformations 12, chorioamnionitis 12, placental abruption 9, severe growth retardation 4, complications of placenta praevia 2, uterine rupture 1, other causes 4. DISCUSSION: Preterm deliveries are more frequent (in births) after a previous c/s (7.75 vs. 5.55 % in multiparous mothers without previous cesarean) - not because of a higher frequency of preterm labor or premature rupture of membranes, but because of placental abruption, chorioamnionitis, placental insufficiency and severe growth retardation. Although some of the neonatal deaths are linked to the previous cesarean delivery, perinatal death after previous cesarean is a very rare event. A recommendation to routinely perform a repeat cesarean instead of a trial of labor seems not appropriate.

Premenopausal node-negative breast cancer: may adjuvant chemotherapy be indicated by the analysis of nuclear DNA dynamics?

The management of premenopausal node-negative breast cancer patients is discussed controversially. Accurate cellular as well as biochemical markers are essential for this cancer group to identify high risk patients needing adjuvant chemotherapy. In the present study, flow cytometric DNA analysis (DNA-ploidy status, DNA-index, S-phase fraction, S+(G2+M)-phase fraction) and clinico-pathological variables (clinical stage, tumor size, receptor status, age, histological type and grade) as prognostic factors were determined on paraffin-embedded tumors to predict overall survival (OS) and disease-free survival (DFS). Median observation time was 6.1 years (n = 57). S+(G2+M)-phase fraction was the only flow cytometric DNA predictor of overall survival in the univariate analysis (log-rank test): As compared to the patients with lower S+(G2+M)-phase fraction (< or = 9.3%), patients with S+(G2+M)-phase fraction greater than 9.3% had shorter survival (P = 0.039). Of all the clinico-pathological parameters analyzed (univariate analysis), the survival time was found to be longer when estrogen- and/or progesterone-receptor status was positive (overall survival: P = 0.039; disease-free survival: P = 0.017) and the histological grade was low (overall survival: I + II vs III: P = 0.024; I vs II vs III: P = 0.046). In the multivariate analysis, receptor status was the strongest predictor for overall and disease-free survival. These results suggest that S+(G2+M)-phase fraction in premenopausal node-negative breast cancer could be an additional valuable prognostic factor to classify high risk breast cancer patients needing adjuvant chemotherapy.

[Prognostic factors in endometrial cancer. A retrospective study based on 564 patients]. / Prognosefaktoren beim Endometriumkarzinom. Eine retrospektive Untersuchung anhand von 564 Patientinnen.

564 patients with cancer of the endometrium were treated at the Department of Obstetrics and Gynaecology of the University Hospital in Zurich during the years 1970-1989. The most important clinical and pathologic-anatomic prognostic factors were evaluated and compared with the literature in a retrospective study. Myometrial depth of infiltration and histological tumour grading could be confirmed as reliable prognostic factors. Their influence on survival curves was highly significant (log rank test: p = 0.0001). In agreement with other authors the prognostic influence of the uterine length is minimal and not significant. Therefore the replacement of the criterion uterine-sond length by depth of myometrial infiltration in the new FIGO classification of 1989 is justified also in view of our data.

[The value of obstetrical continuous-wave Doppler sonography: effect of various study modifications on the diagnosis of fetal growth retardation]. / Zur Validität der geburtshilflichen CW-Dopplersonographie: Einfluss verschiedener Untersuchungsmodifikationen auf die Diagnostik der fetalen Retardierung.

In a comparative study on 484 pregnant women the influence of different modifications of the examination by continuous wave (cw)--Doppler was tested. The aim was to improve the detection rate of foetal growth retardation (IUGR): 1. Among different definitions of normal ranges the mathematical "smoothing" of normal values by regression analysis improves the results. 2. Of the most commonly used flow indices the A/B ratio is more reliable than the resistance and the pulsatility index. 3. Comparing the results of one to three examinations of the same patient in the course of pregnancy the relation of sensitivity to specificity is best after two examinations. 4. On evaluating the examinations of the umbilical arteries and the arcuate arteries, an intolerably false positive rate was found in the evaluation of arcuate arteries by cw Doppler.

[Effectiveness of gynecologic preventive examinations--perspectives]. / Zur Effizienz gynäkologischer Vorsorgeuntersuchungen--Perspektiven.

Genital cancer and breast cancer cases were compiled from the data base of the Swiss working group of the Departments of Gynecology and Obstetrics. The total number of 390,000 cases was divided in two three-year periods (1983-1985 and 1986-1988) and then compared. With the exception of cervical cancer cases, which showed a significant increase of Stage 0/CIN III and a significant decrease of the more advanced stages, we noted a more or less unchanged distribution of the other cancer stages in respect of the manifestations. Screening methods allowing early diagnosis are still not used with appropriate technique and frequency, especially in the postmenopausal age.

Pregnancy and autonomic hyperreflexia in patients with spinal cord lesions.

Symptoms of autonomic hyperreflexia in patients with complete and incomplete paraplegia above D 7 can be caused by almost any stimulus in the abdominal area or in the lower extremities, specifically during parturition by the uterine contractions. The symptoms vary from pilo-erection and outbreaks of sweating to serious blood pressure crises and cerebrovascular accidents. Epidural anaesthesia and general anaesthesia are effective as therapy and also as prophylaxis. Frequent complications are anemia and urinary tract infections. Changes in bladder function as a result of pregnancy and childbirth were observed. Paraplegic expectant mothers experience premature labour pains more frequently than do others, and this implies the necessity for earlier clinical surveillance up to the time of delivery. The secondary uterine inertia frequently requires an operative termination of the birth. The perception of labour pains is clearly possible also with lesions above D 10.

[Thrombosis of the internal carotid artery and damage to the intima of a renal artery after blunt trauma]. / Thrombose der Arteria carotis interna und Intimaläsion einer Nierenarterie nach stumpfem Trauma: Eine FAllbeschreibung.

A 47 year-old man acquired intimal tears of the right internal carotid artery and the right renal artery by blunt injuries of the neck and the lumbar region in a horse riding accident. After a 10 days free period an occlusive thrombosis of the neck artery with fatal issue appeared. The clinical symptoms and diagnostic procedure are presented. Based on macroscopic, magnifying optical and histological necropsy findings these important artery injuries are discussed.