Breast Cancer Surgery: A Qualitative Exploration of Concerns Over Time.

INTRODUCTION: As outcomes for breast cancer patients improve, addressing the side effects and distress of treatment can optimize survivorship. Although distress in breast cancer is well known in literature, there is a lack of information on how these concerns change through the phases of the cancer care continuum. Therefore, this study investigates the longitudinal trajectory of worry in patients with nonmetastatic breast cancer. METHODS: Female patients with newly diagnosed stage I-III breast cancer comprised a mixed-methods, longitudinal study at a cancer center from June 2019 to June 2023. Patients completed an open-ended survey regarding their top three concerns. Responses were obtained before surgery and two weeks, three, six, nine months, and one year postoperatively. Responses were qualitatively coded and analyzed to determine themes of cancer-related distress. RESULTS: Participants (n = 262) were aged an average 57.53 y (±12.54), 65.8% had stage I disease at diagnosis, and 91.1% were White. Responses revealed that patients' top three sources of concerns varied by treatment phase. Overall, patients were worried about their cancer diagnosis and the risk of recurrence. Preoperatively, patients were worried about treatment timeline, while postoperative concerns transitioned to physical appearance and surgical side effects. CONCLUSIONS: Breast cancer patients consistently reported worries about cancer diagnosis, recurrence, and metastasis as well as the side effects and fear of treatments. However, patient worry appeared to be intrinsically linked with their treatment phase. Therefore, support and interventions should be catered to reflect the changing patterns of patients' sources of distress to optimize breast cancer patients' quality of life.

Postoperative Outcomes After Staged Versus Coordinated Breast Surgery and Bilateral Salpingo-Oophorectomy.

BACKGROUND: The objective of this study was to compare postoperative complication rates and healthcare charges between patients who underwent coordinated versus staged breast surgery and bilateral salpingo-oophorectomy (BSO). PATIENTS AND METHODS: The MarketScan administrative database was used to identify adult female patients with invasive breast cancer or BRCA1/BRCA2 mutations who underwent BSO and breast surgery (lumpectomy or mastectomy with or without reconstruction) between 2010 and 2015. Patients were assigned to the coordinated group if a breast operation and BSO were performed simultaneously or assigned to the staged group if BSO was performed separately. Primary outcomes were (1) incidence of 90-day postoperative complications and (2) 2-year aggregate perioperative healthcare charges. Fisher's exact tests, Wilcoxon rank-sum tests, and multivariable regression analyses were performed. RESULTS: Of the 4228 patients who underwent breast surgery and BSO, 412 (9.7%) were in the coordinated group and 3816 (90.3%) were in the staged group. The coordinated group had a higher incidence of postoperative complications (24.0% vs. 17.7%, p < 0.01), higher risk-adjusted odds of postoperative complications [odds ratio (OR) 1.37, 95% confidence interval (CI) 1.06-1.76, p = 0.02], and similar aggregate healthcare charges before (median charges: $106,500 vs. $101,555, p = 0.96) and after risk-adjustment [incidence rate ratio (IRR) 1.00, 95% CI 0.93-1.07; p = 0.95]. In a subgroup analysis, incidence of postoperative complications (12.9% for coordinated operations vs. 11.7% for staged operation, p = 0.73) was similar in patients whose breast operation was a lumpectomy. CONCLUSIONS: While costs were similar, coordinating breast surgery with BSO was associated with more complications in patients who underwent mastectomy, but not in patients who underwent lumpectomy. These data should inform shared decision-making in high-risk patients.

An Unintended Consequence of a New Opioid Legislation.

BACKGROUND: The Controlled Substance Act was enacted in efforts to reduce the abuse and misuse of opioid pain relievers. However, the effects of this regulation on the prescribing patterns of providers has yet to be realized. OBJECTIVE: We sought to identify the changes in opioid-prescribing patterns of an elective colorectal surgical practice as a result of this legislative change. DESIGN: This is a retrospective study of patients undergoing elective colorectal surgery. Patients were intentionally grouped into group A (January 1, 2012 to October 5, 2014) and group B (October 6, 2014 to December 31, 2016) to capture the period surrounding the new legislation. SETTINGS: We evaluated patients undergoing elective colorectal surgery at a single academic center over a 5-year period. PATIENTS: There were 443 patients undergoing elective colorectal surgery between 2012 and 2016. MAIN OUTCOME MEASURES: The primary outcome was total milligram morphine equivalent of pain medication prescribed at discharge. Secondary outcomes included total number of pills prescribed, total milligram morphine equivalent of pain medication at subsequent prescriptions, and numeric postoperative pain scores. RESULTS: Patients in group B were found to have a greater mean total milligram morphine equivalent prescribed at discharge (719 (SD 593) vs 660 (SD 548), p = 0.03), mean total quantity of pills prescribed at discharge (98 (SD 106) vs 87 (SD 63), p = 0.05), and mean total quantity of pills prescribed as subsequent prescriptions (77 (SD 117) vs 68 (SD 83), p = 0.05) compared with group A. On multivariable analysis, group B was a significant predictor of greater total milligram morphine equivalents prescribed at discharge compared with group A (p = 0.01). LIMITATIONS: This study is limited by analysis from a single institution. CONCLUSIONS: Efforts to minimize opioid prescriptions after surgery through legislation could result in unintended consequences. Recognition of this result is important to effectively reduce opioid prescriptions after surgery. See Video Abstract at http://links.lww.com/DCR/B96. UNA CONSECUENCIA NO DESEADA DE UNA NUEVA LEGISLACIÓN DE OPIOIDES: La Ley de Sustancias Controladas se promulgó con el fin de reducir el abuso y el uso indebido de analgésicos opioides. Sin embargo, los efectos de esta regulación en los patrones de prescripción de los proveedores aún no se han realizado.Se intento identificar los cambios en los patrones de prescripción de opioides de una práctica quirúrgica colorrectal electiva como resultado de este cambio legislativo.Este es un estudio retrospectivo de pacientes sometidos a cirugía colorrectal electiva. Los pacientes fueron agrupados intencionalmente en el Grupo A (1 de enero de 2012 al 5 de octubre de 2014) y el Grupo B (6 de octubre de 2014 al 31 de diciembre de 2016) para capturar el período que rodea la nueva legislación.Se evaluaron a los pacientes sometidos a cirugía colorrectal electiva en un solo centro académico durante un período de 5 años.Hubo 443 pacientes que se sometieron a cirugía colorrectal electiva entre 2012-2016.La medida de resultado primaria fue el equivalente de miligramos de morfina total de los analgésicos prescritos al momento del alta. Las medidas de resultado secundarias incluyeron el número total de píldoras prescritas, el equivalente total de miligramos de morfina de la medicación para el dolor en las prescripciones posteriores y las puntuaciones numéricas de dolor postoperatorio.Se encontró que los pacientes en el Grupo B tenían un equivalente de miligramos de morfina total total mayor prescrito al alta (719 [DE 593] v. 660 [DE 548], p = 0.03), cantidad total promedio de píldoras prescritas al alta (98 [SD 106] v. 87 [SD 63], p = 0.05), y la cantidad total promedio de píldoras recetadas como recetas posteriores (77 [SD 117] v. 68 [SD 83], p = 0.05) en comparación con el Grupo A. En análisis multivariable, el Grupo B fue un predictor significativo de mayores equivalentes de morfina en miligramos totales prescritos al alta en comparación con el grupo A (p = 0.01).Este estudio está limitado por el análisis de una sola instituciónLos esfuerzos para minimizar las recetas de opioides después de la cirugía a través de la legislación podrían tener consecuencias no deseadas. El reconocimiento de este resultado es importante para reducir eficazmente las recetas de opioides después de la cirugía. Consulte Video Resumen en http://links.lww.com/DCR/B96.

Ethanol Exposure History and Alcoholic Reward Differentially Alter Dopamine Release in the Nucleus Accumbens to a Reward-Predictive Cue.

BACKGROUND: Conditioned stimuli (CS) that predict reward delivery acquire the ability to induce phasic dopamine release in the nucleus accumbens (NAc). This dopamine release may facilitate conditioned approach behavior, which often manifests as approach to the site of reward delivery (called "goal-tracking") or to the CS itself (called "sign-tracking"). Previous research has linked sign-tracking in particular to impulsivity and drug self-administration, and addictive drugs may promote the expression of sign-tracking. Ethanol (EtOH) acutely promotes phasic release of dopamine in the accumbens, but it is unknown whether an alcoholic reward alters dopamine release to a CS. We hypothesized that Pavlovian conditioning with an alcoholic reward would increase dopamine release triggered by the CS and subsequent sign-tracking behavior. Moreover, we predicted that chronic intermittent EtOH (CIE) exposure would promote sign-tracking while acute administration of naltrexone (NTX) would reduce it. METHODS: Rats received 14 doses of EtOH (3 to 5 g/kg, intragastric) or water followed by 6 days of Pavlovian conditioning training. Rewards were a chocolate solution with or without 10% (w/v) alcohol. We used fast-scan cyclic voltammetry to measure phasic dopamine release in the NAc core in response to the CS and the rewards. We also determined the effect of NTX (1 mg/kg, subcutaneous) on conditioned approach. RESULTS: Both CIE and alcoholic reward, individually but not together, associated with greater dopamine to the CS than control conditions. However, this increase in dopamine release was not linked to greater sign-tracking, as both CIE and alcoholic reward shifted conditioned approach from sign-tracking behavior to goal-tracking behavior. However, they both also increased sensitivity to NTX, which reduced goal-tracking behavior. CONCLUSIONS: While a history of EtOH exposure or alcoholic reward enhanced dopamine release to a CS, they did not promote sign-tracking under the current conditions. These findings are consistent with the interpretation that EtOH can stimulate conditioned approach, but indicate that the conditioned response may manifest as goal-tracking.

Operative Management in Stage IV Breast Cancer.

Traditionally, surgical therapy for primary breast lesions in stage IV breast cancer has been reserved for palliation. Several retrospective studies have suggested a possible survival benefit with surgical resection of the primary tumor in patients with distant metastases. However, evidence from prospective, randomized controlled trials suggest that locoregional control provides no clear survival advantage for patients with stage IV breast cancer. Future areas of inquiry include identification of subsets of patients who may derive a survival benefit from locoregional control.