Universal genetic counseling in breast cancer patients significantly improves overall testing rates and improves completion rates in subpopulations.

PURPOSE: The NCCN guidelines recommend genetic testing in those patients at increased risk of breast cancer in order to identify candidates for increased frequency of screening or prophylactic mastectomy. However, genetic testing may now identify patients who may benefit from recently developed targeted breast cancer therapy. In order to more widely identify these patients, we implemented genetic counseling for all patients diagnosed with breast cancer. METHODS: In 2021, all patients evaluated within a Midwestern community hospital system diagnosed with breast cancer were offered genetic counseling. This group of patients was compared to a cohort of patients in 2021 who were offered genetic counseling based on NCCN guidelines. With Pearson's chi square, Fisher's Exact test, Mann-Whitney U, and multivariate regression as appropriate, individual demographic data and genetic testing completion between 2019 and 2021 were evaluated. RESULTS: A total of 973 patients were reviewed. 439 were diagnosed with breast cancer in 2019 and 534 in 2021. Demographics and stage at diagnosis (p = 0.194) were similar between years. Completion of genetic testing increased from 204 (46.5%) in 2019 to 338 (63.3%) in 2021 (p < 0.01) with the universal counseling protocol. Specifically, genetic testing completion increased significantly in older patients (p = 0.041) and patients receiving Medicare benefits (p = 0.005). The overall pathogenic variants found increased from 32 to 39 with the most common including BRCA2 (n = 11), CFTR (n = 9), CHEK2 (n = 8), BRCA1 (n = 6). CONCLUSION: Universal genetic counseling was related to a significant increase in genetic testing completion and an increase in pathogenic variants found among breast cancer patients, specifically in subpopulations which may have been previously excluded by traditional NCCN genetic testing screening guidelines.

Mathilde Schott, A Woman's Influence in the Revolution of the Scalpel in the 1890s.

Surgery relies on the scalpel; the surgeon's first instrument in every case. From early knives crafted in the pre-historic era to today, the scalpel has evolved along with medical and surgical fields but maintained its critical role and symbolism of operative intervention. A significant catalyst for change in surgical instrument development in the late 1800s was the evolution of anesthesia and antisepsis. Surgical instruments were affected by harsh sterilization techniques, creating need for a method to maintain surgical scalpel sharpness. Mathilde Schott, an early female biomedical engineering innovator, filed a patent (US431153) in 1890 for a detachable scalpel blade. Schott identified and responded to the needs of surgeons at the turn of the 20th century and created a detachable blade and stabilizing lever. Schott persevered in a society unaccustomed to women leaders, subsequently improving medicine, surgery, and engineering.

Racial disparities in breast cancer persist despite early detection: analysis of treatment of stage 1 breast cancer and effect of insurance status on disparities.

PURPOSE: Prior research demonstrates racial disparities in breast cancer treatment. Disparities are commonly attributed to more advanced stage at presentation or aggressive tumor biology. We seek to evaluate if racial disparities persist in the treatment of stage 1 breast cancer patients who by definition are not delayed in presentation. METHODS: We selected stage 1 breast cases in the National Cancer Data Base. Patients were divided into two cohorts based on race and included White and Black patients. We also performed a subgroup analysis of patients with private insurance for comparison to determine if private insurance diminished the racial disparities noted. We analyzed differences in time to treatments by race. RESULTS: Our analysis included 546,351 patients of which 494,784 (90.6%) were White non-Hispanic and 51,567 (9.4%) were Black non-Hispanic. Black women had significantly longer times to first treatment (35.5 days vs 28.1 days), surgery (36.6 days vs 28.8 days), chemotherapy (88.1 days vs 75.4 days), radiation (131.3 days vs 99.1 days), and endocrine therapy (152.1 days vs 126.5 days) than White women. When patients with private insurance were analyzed the difference in time to surgery decreased by 1.2 days but racial differences remained statistically significant. CONCLUSIONS: Despite selecting for early-stage breast cancer, racial disparities between White and Black women in time to all forms of breast cancer treatment persist. These disparities while likely not oncologically significant do suggest institutional barriers for obtaining care faced by women of color which may not be addressed with improving access to mammography alone.

Preoperative Panel Testing for Hereditary Cancer Syndromes Does Not Significantly Impact Time to Surgery for Newly Diagnosed Breast Cancer Patients Compared with BRCA1/2 Testing.

BACKGROUND: This study seeks to determine whether there is a delay in time to surgery in breast cancer patients with panel tests compared with traditional BRCA testing. METHODS: This study was a retrospective review of women diagnosed with breast cancer who underwent genetic evaluation from our institution's Genetic Counselor Database from January 2013 to August 2015. Patients were excluded if they were male, clinical information was unavailable, the patient underwent neoadjuvant chemotherapy, had a diagnosis of recurrent breast cancer during time of study, or had postoperative genetics evaluation. RESULTS: Included in the study were 138 patients. The time from diagnosis to surgery for BRCA1/2 tested patients was 43.5 days compared with 51.0 days in the panel group (p = 0.186). Turnaround time for genetic testing decreased during the period studied and was approximately 6 days longer for panel testing than BRCA testing. It took 12.2 days for BRCA results and 18.9 days for the panel results (p < 0.01). Turnaround time for BRCA1/2 testing in 2014 and 2015 was 12.4 and 10.5 days respectively, whereas panel testing was 20.5 and 18.2 days (p ≤ 0.001). Of the variables included in multivariable linear regression, only mastectomy significantly contributed to time to surgery (p < 0.001). DISCUSSION: Panel genetic testing did not delay time to surgery compared with BRCA testing alone. The use of panel testing has increased over time, and lab turnaround time has decreased. Mastectomy was the only clinical variable contributing to longer time to surgery.

The consequence of undertreatment of patients treated with breast conserving therapy for ductal carcinoma in-situ.

BACKGROUND: The use of clinical features to allocate adjuvant therapy in the treatment of ductal carcinoma in situ with breast-conserving therapy remains controversial. METHODS: A review of patients with ductal carcinoma in situ treated with breast-conserving therapy was performed. The recurrence rate was examined in relation to patient age, tumor characteristics, Van Nuys Prognostic Index, and the receipt of prescribed adjuvant therapies. RESULTS: Six percent of patients (17 of 294) had developed local recurrences after a median follow-up period of 63 months. Fifty-nine percent of patients (91 of 154) with estrogen receptor-positive tumors did not receive prescribed tamoxifen. Thirty-one percent of patients (45 of 147) with Van Nuys Prognostic Index scores ≥7 did not receive recommended radiation therapy. Receipt of prescribed adjuvant therapy did not result in a decrease in the rate of local recurrence. Patient age was the only factor associated with local recurrence on univariate but not on multivariate analysis (P = .374). CONCLUSIONS: A low rate of local recurrence was achieved despite a large number of patients' not receiving prescribed adjuvant therapies.

Survey of New York City resident physicians on cause-of-death reporting, 2010.

INTRODUCTION: Death certificates contain critical information for epidemiology, public health research, disease surveillance, and community health programs. In most teaching hospitals, resident physicians complete death certificates. The objective of this study was to examine the experiences and opinions of physician residents in New York City on the accuracy of the cause-of-death reporting system. METHODS: In May and June 2010, we conducted an anonymous, Internet-based, 32-question survey of all internal medicine, emergency medicine, and general surgery residency programs (n = 70) in New York City. We analyzed data by type of residency and by resident experience in reporting deaths. We defined high-volume respondents as those who completed 11 or more death certificates in the last 3 years. RESULTS: A total of 521 residents from 38 residency programs participated (program response rate, 54%). We identified 178 (34%) high-volume respondents. Only 33.3% of all respondents and 22.7% of high-volume residents believed that cause-of-death reporting is accurate. Of all respondents, 48.6% had knowingly reported an inaccurate cause of death; 58.4% of high-volume residents had done so. Of respondents who indicated they reported an inaccurate cause, 76.8% said the system would not accept the correct cause, 40.5% said admitting office personnel instructed them to "put something else," and 30.7% said the medical examiner instructed them to do so; 64.6% cited cardiovascular disease as the most frequent diagnosis inaccurately reported. CONCLUSION: Most resident physicians believed the current cause-of-death reporting system is inaccurate, often knowingly documenting incorrect causes. The system should be improved to allow reporting of more causes, and residents should receive better training on completing death certificates.

Surgical residents' perception of the 16-hour work day restriction: concern for negative impact on resident education and patient care.

BACKGROUND: Effective July 1, 2011, the Accreditation Council for Graduate Medical Education (ACGME) instituted a 16-hour duty period limitation for postgraduate year I (PGY I) residents. Our aim was to assess the attitudes and perception of general surgery residents regarding the new duty hour limitation as well as the transfer of care process under the new guidelines. STUDY DESIGN: An anonymous, web-based survey was conducted nationally 7 months after the institution of the 16-hour duty limitation. RESULTS: A total of 464 completed surveys were analyzed. Overall, 75% of residents expressed dissatisfaction with the new duty hour limitation. PGY II to V residents reported a higher level of dissatisfaction compared with PGY I residents (87% vs 54%, p < 0.01). Eighty-nine percent of PGY II to V residents responded that there has been a shift of responsibilities from the PGY I class to PGY II to V residents, with 73% reporting increased fatigue as a result. Seventy-five percent of PGY I and 94% of PGY II to V residents expressed concerns about the adverse impact of the restrictions on the education of PGY I residents (p < 0.01). Residents at all PGY training levels reported encountering problems due to inadequate sign-outs (PGY I, 59%; PGY II to V, 85%; p < 0.01). Sixty-two percent of PGY I residents and 54% of PGY II to V residents believed that the new 16-hour duty restriction contributes to inadequate sign-outs (p = NS). Most PGY II to V residents (86%) believe there is a decreased level of patient ownership due to the work hour restrictions. CONCLUSIONS: The results of the survey suggest that the majority of general surgery residents are concerned over the potential negative impact of the duty limitation on resident education and patient care. Further research is needed to address these concerns.