Axillary Response in Patients Undergoing Neoadjuvant Endocrine Treatment for Node-Positive Breast Cancer: Systematic Literature Review and NCDB Analysis.

BACKGROUND: Several studies have proven that neoadjuvant endocrine therapy (NET) has a similar beneficial therapeutic effect in estrogen-positive (ER+) breast cancer (BC) with improved breast conservation rate in patients undergoing NET versus neoadjuvant chemotherapy (NAC). The impact of axillary complete pathologic response (pCR) is less clear. We evaluate the impact of NET on axillary downstaging and surgical management. METHODS: Using the National Cancer Database (NCDB), we identified all patients with node positive (N+), ER+, HER2- BC undergoing NET and performed a systemic review of literature using PRISMA guidelines. RESULTS: The literature review identified 1479 clinically N+ patients in four studies, 148 of whom had axillary pCR (10.0%). In the two studies of patients with invasive lobular carcinoma (ILC), 7.8% (69/883) of clinically N+ patients had axillary pCR. The NCDB query identified 4580 female patients with clinically N+ ER+ HER2- BC who underwent NET from 2010 to 2016 with mean age of 61.4 years. Patients who achieved a pCR were more likely to have N1 disease (p 0.008), moderately differentiated tumors (p 0.003), and ductal histology (p 0.04). There was no statistically significant difference in race, comorbidity score, education, income, hospital setting, or clinical tumor stage. Of the 4580 total patients, 663 (14.48%) had an axillary pCR (pN0) after NET, and 3917 (85.52%) remained pN+. CONCLUSIONS: We found that patients who underwent NET for N+ disease had a higher axillary pCR than previously reported (10%) in smaller studies. Although NET is not a common treatment option for women with N+ ER+ HER2- BC, it may be a suitable option for axillary downstaging, which is currently underutilized.

Quality of life and sexual well-being after nipple sparing mastectomy: A matched comparison of patients using the breast Q.

BACKGROUND: Nipple sparing mastectomy (NSM) is considered safe for select patients. Our objective was to examine quality of life (QOL) and satisfaction for NSM compared with skin sparing mastectomy (SSM). We aimed to evaluate these using the BREAST-Q. METHODS: After IRB approval, we analyzed patients who underwent NSM and reconstruction between July 2010-June 2015. NSM patients were matched with those after SSM based on age, race, and body mass index. Telephone interviews were prospectively conducted using the BREAST-Q Mastectomy Postoperative Module. Bivariate analysis and a paired samples t-test were performed. RESULTS: We identified 43 patients meeting our inclusion criteria with a response rate 60% (N = 26). NSM and SSM patients were matched well in age (P = 1.00), race (P = 1.00), and Body Mass Index (P = 0.99). There were no significant differences in stage, estrogen and progesterone status, HER2 expression, reconstruction type and radiation. Mean BREAST-Q scores did not vary between NSM and SSM in regards to satisfaction with breasts (P = 0.604), psychosocial well-being (P = 0.146), physical well-being (P = 0.121), and satisfaction with surgeon (P = 0.170). Sexual well-being was significantly higher in NSM patients (P = 0.011). CONCLUSION: NSM provides patients with favorable results in psychosocial, sexual, and physical well-being and overall satisfaction. Sexual well-being showed significant improvement for NSM.

Evaluating the Risk of Upstaging HER2-Positive DCIS to Invasive Breast Cancer.

BACKGROUND: Overexpression of human epidermal growth factor 2 (HER2) in invasive breast cancer (IBC) is an independent poor prognostic factor. However, the significance of HER2 overexpression in ductal carcinoma in situ (DCIS) is not well defined. The current study assessed the correlation of HER2+ DCIS with the rate of upstaging to IBC on the final pathology. METHODS: The study retrospectively analyzed patients with the diagnosis of DCIS on core needle biopsy (CNB) at the authors' institution from 2009 to 2016. Data were analyzed using two-sample t tests. Multivariate analysis was performed using logistic regression. RESULTS: The study found that HER2+ DCIS had significantly higher rates of upstaging to IBC than HER2- DCIS (odds ratio [OR] 1.89; p = 0.012). In addition, triple-positive disease was more than two times more likely to be upstaged (OR 2.5; p = 0.01), whereas patients with estrogen (ER)-positive, progesterone (PR)-positive, and HER2- diseases were half as likely to be upstaged (OR 0.5; p = 0.04). Upstaging did not differ for patients with triple-negative disease (OR 0.89; p = 0.8). Additionally, patients with HER2+ DCIS were significantly younger regardless of ER/PR status (p = 0.03). The overexpression of HER2 in patients with an initial diagnosis of DCIS on CNB were twice as likely to have IBC on the final pathology as those who did not. CONCLUSION: The results suggest that overexpression of HER2 may serve as a biomarker for risk stratification of patients with DCIS and may help to guide treatment strategies in the future. For institutions in which HER2 testing may be performed on DCIS, patients should be counseled appropriately about the risk of upgrade to IBC.

The Early Impact of the COVID-19 Pandemic on Lung, Colorectal, and Breast Cancer Screening and Treatment at a Tertiary Cancer Center.

OBJECTIVES: During the coronavirus-19 pandemic, experts recommended delaying routine cancer screening and modifying treatment strategies. We sought to understand the sequalae of these recommendations. MATERIALS AND METHODS: We performed a retrospective single-center analysis of screening, diagnosis, and treatment of lung, colorectal, and breast cancer. Data was collected from our institutional cancer registry. Prepandemic (2016-2019) was compared with pandemic (2020) data. RESULTS: Three thousand three sixty one screening chest computed tomography scans (CTs), 35,917 colonoscopies, and 48,093 screening mammograms were performed. There was no difference in CTs [81.0 (SEM10.0) vs. 65.6 (SEM3.29), P =0.067] or mammograms [1017.0 (SEM171.8) vs. 809.4 (SEM56.41), P =0.177] in 2020 versus prepandemic. There were fewer colonoscopies in 2020 [651.4 (SEM103.5) vs. 758.91 (SEM11.79), P =0.043]. There was a decrease in cancer diagnoses per month in 2020 of lung [22.70 (SEM1.469) vs. 28.75 (SEM0.8216), P =0.003] and breast [38.56 (SEM6.133) vs. 51.82 (SEM1.257), P =0.001], but not colorectal [13.11 (SEM1.467) vs. 15.88 (SEM0.585), P =0.074] cancer. There was no change in stage at presentation for lung ( P =0.717), breast ( P =0.115), or colorectal cancer ( P =0.180). Lung had a shorter time-to-treatment in 2020 [38.92 days (SEM 2.48) vs. 66 (SEM1.46), P =0.002]. CONCLUSIONS: In 2020, there was no difference in screening studies for lung and breast cancer but there was a decrease in new diagnoses. Although there were fewer colonoscopies performed in 2020, there was no change in new colorectal cancer diagnoses. Despite changes in guidelines during the pandemic, the time-to-treatment for lung cancer was shorter and was unchanged for colorectal and breast cancer. These findings highlight the importance of continuing care for a vulnerable patient population despite a pandemic.

Challenges to EHR implementation in electronic- versus paper-based office practices.

BACKGROUND: Challenges in implementing electronic health records (EHRs) have received some attention, but less is known about the process of transitioning from legacy EHRs to newer systems. OBJECTIVE: To determine how ambulatory leaders differentiate implementation approaches between practices that are currently paper-based and those with a legacy EHR system (EHR-based). DESIGN: Qualitative study. PARTICIPANTS: Eleven practice managers and 12 medical directors all part of an academic ambulatory care network of a large teaching hospital in New York City in January to May of 2006. APPROACH: Qualitative approach comparing and contrasting perceived benefits and challenges in implementing an ambulatory EHR between practice leaders from paper- and EHR-based practices. Content analysis was performed using grounded theory and ATLAS.ti 5.0. RESULTS: We found that paper-based leaders prioritized the following: sufficient workstations and printers, a physician information technology (IT) champion at the practice, workflow education to ensure a successful transition to a paperless medical practice, and a high existing comfort level of practitioners and support staff with IT. In contrast, EHR-based leaders prioritized: improved technical training and ongoing technical support, sufficient protection of patient privacy, and open recognition of physician resistance, especially for those who were loyal to a legacy EHR. Unlike paper-based practices, EHR-based leadership believed that comfort level with IT and adjustments to workflow changes would not be difficult challenges to overcome. CONCLUSIONS: Leadership at paper- and EHR-based practices in 1 academic network has different priorities for implementing a new EHR. Ambulatory practices upgrading their legacy EHR have unique challenges.

A qualitative analysis of an electronic health record (EHR) implementation in an academic ambulatory setting.

OBJECTIVES: To determine pre-implementation perspectives of institutional, practice and vendor leadership regarding best practice for implementation of two ambulatory electronic health records (EHRs) at an academic institution. DESIGN: Semi-structured interviews with ambulatory care network and information systems leadership, medical directors, practice managers and vendors before EHR implementation. Results were analysed using grounded theory with ATLAS.ti version 5.0. MEASUREMENTS: Qualitative data on perceived benefits of EHRs as well as facilitators and barriers to successful implementation. RESULTS: Interviewees perceived data accessibility, quality and safety measurement, improvement and reporting as benefits of EHR use. Six themes emerged for EHR implementation best practice: effective communication; successful system migration; sufficient hardware, technical equipment, support and training; safeguards for patient privacy; improved efficiency; and a sustainable business plan. CONCLUSIONS: Achieving the benefits of EHRs identified by our interviewees depends on successful implementation and use. Further identification of best implementation practices for EHRs is required, given the financial and clinical consequences of poor implementation.

Community-based health information technology alliances: potential predictors of early sustainability.

OBJECTIVE: To determine potential predictors of sustainability among community-based organizations that are implementing health information technology (HIT) with health information exchange, in a state with significant funding of such organizations. STUDY DESIGN: A longitudinal cohort study of community-based organizations funded through the first phase of the $440 million Healthcare Efficiency and Affordability Law for New Yorkers program. METHODS: We administered a baseline telephone survey in January and February 2007, using a novel instrument with open-ended questions, and collected follow-up data from the New York State Department of Health regarding subsequent funding awarded in March 2008. We used logistic regression to determine associations between 18 organizational characteristics and subsequent funding. RESULTS: All 26 organizations (100%) responded. Having the alliance led by a health information organization (odds ratio [OR] 11.4, P = .01) and having performed a community-based needs assessment (OR 5.1, P = .08) increased the unadjusted odds of subsequent funding. Having the intervention target the long-term care setting (OR 0.14, P = .03) decreased the unadjusted odds of subsequent funding. In the multivariate model, having the alliance led by a health information organization, rather than a healthcare organization, increased the odds of subsequent funding (adjusted OR 6.4; 95% confidence interval 0.8, 52.6; P = .08). CONCLUSION: Results from this longitudinal study suggest that both health information organizations and healthcare organizations are needed for sustainable HIT transformation.

Economic impact of hyponatremia in hospitalized patients: a retrospective cohort study.

BACKGROUND: Hyponatremia is the most common electrolyte abnormality seen in general hospital patients, with an incidence of 1% to 6% in the United States. OBJECTIVE: We aimed to evaluate the impact of varying levels of hyponatremia at admission on length of stay (LOS) and cost of care in adult hospitalized patients. METHODS: A retrospective cohort study was conducted using an existing clinical database from a large academic-setting hospital. All adult admissions from January 2004 through May 2005 with serum sodium level at admission of < or = 134 mEq/L were separated into 2 cohorts: patients with moderate-to-severe hyponatremia (serum sodium level at admission of < or = 129 mEq/L, n = 547) and patients with mild-to-moderate hyponatremia (serum sodium level of 130-134 mEq/L, n = 1500). ICD-9 diagnosis codes for these 2047 admissions with hyponatremia were used to identify a cohort of 7573 admissions with the same principal admitting diagnoses and a serum sodium level of 135 to 145 mEq/L. Differences in hospital LOS, intensive care unit (ICU) admission rate, and median total costs per admission between cohorts were examined using multiple linear regression, logistic, and quantile regression models. RESULTS: Admissions with hyponatremia had significantly longer hospital LOS than those admitted without hyponatremia (median LOS: moderate-to-severe hyponatremia, 8 days; mild-to-moderate hyponatremia, 8 days; normal, 6 days; P < 0.001). Patients with more severe hyponatremia were also more likely to be admitted to the ICU during the hospital stay (moderate-to-severe hyponatremia, 32%; mild-to-moderate hyponatremia, 26%; normal, 22%; P < 0.001). These trends were also reflected in the total costs per admission, with median costs of $16,606 for moderate-to-severe hyponatremia cases, $14,266 for mild-to-moderate hyponatremia cases, and $13,066 for normal admissions (P < 0.001). CONCLUSIONS: Hyponatremia at admission was associated with increased LOS and cost of care for hospitalized patients. Interventions or pharmacotherapies for the prompt treatment of hyponatremia could potentially reduce morbidity and LOS, thereby reducing the utilization of health care resources.

Correlates of expected satisfaction with electronic health records in office practices by practitioners.

Practitioners' resistance towards electronic health records (EHRs) is a known barrier to implementation and use. This is a cross-sectional study 467 practitioners working at 12 ambulatory care outpatient practices. We analyzed how mean expected satisfaction for future use of EHRs differed at both the level of the provider and the practice. We found that practitioners generally have positive expectations of EHR systems. However, these expectations depend on comfort with IT and typing skills.

Providers' expectations of ambulatory electronic health records (EHRs).

Little is known about how providers expect the implementation of a new electronic health record (EHR) will affect their clinical workflow. We found that providers currently completing clinical tasks electronically are more satisfied with task completion than those completing similar tasks on paper. Yet, these already electronic providers expect less future satisfaction with the new EHR compared with paper-based providers. Further understanding of provider expectations can assist in optimally tailoring implementation plans.