Patient-reported observations on medical procedure timeliness (PROMPT) in breast cancer: a qualitative study.

PURPOSE: Timeliness of care is an important healthcare outcome measure. The objective of this study was to explore patient perspectives on the timeliness of breast cancer diagnosis and treatment at accredited breast cancer centers. METHODS: In this qualitative study, 1 hour virtual interviews were conducted with participants 18-75 years old who were diagnosed and treated for stage 0-III breast cancer at a National Accreditation Program for Breast Centers facility from 2018 to 2022. Thematic analysis was used to identify key themes of participant experiences. RESULTS: Twenty-eight participants were interviewed. Two thematic domains were identified: etiologies of expedited or delayed care and the impact of delayed or expedited care on patients. Within these domains, multiple themes emerged. For etiologies of expedited or delayed care, participants discussed (1) the effect of scheduling appointments, (2) the COVID-19 pandemic, (3) dissatisfaction with the timeline for various parts of the diagnostic workup, and (4) delays related to patient factors, including socioeconomic status. For the impact of expedited or delayed care, patients discussed (1) the emotional and mental impact of waiting, (2) the importance of communication and clear expectations, and (3) the impact of electronic health portals. Patients desired each care interval (e.g., the time from mammogram to breast biopsy) to be approximately 7 days, with longer intervals sometimes preferred prior to surgery. CONCLUSION: These patient interviews identify areas of delay and provide patient-centered, actionable items to improve the timeliness of breast cancer care.

Exploring Breast Surgeons' Attitudes on Universal Genetic Testing: A Qualitative Study.

BACKGROUND: The American Society of Breast Surgeons released a consensus statement that genetic testing should be made available to all patients with a personal history of breast cancer. However, it is not clear whether physicians feel comfortable with universal genetic testing (UGT) or if they have sufficient knowledge to interpret results and manage them appropriately. OBJECTIVE: The purpose of this study was to explore breast surgeons' attitudes toward UGT. METHODS: Breast surgeons were consented and scheduled for a semi-structured virtual interview. Transcripts were uploaded into qualitative analysis software where they were exhaustively and iteratively coded. Codes were then organized into higher-order categories and themes and data saturation were assessed. RESULTS: Thirty-one surgeons completed the qualitative interview. Most surgeons practiced in the academic or community setting and most practiced in the Midwest (71.0%). The majority (90.3%) reported having a structured genetics program. The majority (96.8%) referred their patients to genetics for counseling and most preferred ordering testing through a genetic services provider. Some surgeons had concerns about access to genetic services. A minority of surgeons order UGT for all newly diagnosed breast cancer patients. The majority of respondents thought that more training in genetics was needed for surgeons. Many surgeons expressed concern about the psychosocial effects of UGT on patients. CONCLUSIONS: Many surgeons expressed concerns about UGT, mainly related to discomfort with their training, access to genetic services, and the psychosocial impact on their patients. Future work is needed to determine how to improve surgeon's comfort level in implementing UGT.

A national quality improvement study identifying and addressing cancer screening deficits due to the COVID-19 pandemic.

BACKGROUND: Cancer-related deaths over the next decade are expected to increase due to cancer screening deficits associated with the coronavirus disease 2019 (COVID-19) pandemic. Although national deficits have been quantified, a structured response to identifying and addressing local deficits has not been widely available. The objectives of this report are to share preliminary data on monthly screening deficits in breast, colorectal, lung, and cervical cancers across diverse settings and to provide online materials from a national quality improvement (QI) study to help other institutions to address local screening deficits. METHODS: This prospective, national QI study on Return-to-Screening enrolled 748 accredited cancer programs in the United States from April through June 2021. Local prepandemic and pandemic monthly screening test volumes (MTVs) were used to calculate the relative percent change in MTV to describe the monthly screening gap. RESULTS: The majority of facilities reported monthly screening deficits (colorectal cancer, 80.6% [n = 104/129]; cervical cancer, 69.0% [n = 20/29]; breast cancer, 55.3% [n = 241/436]; lung cancer, 44.6% [n = 98/220]). Overall, the median relative percent change in MTV ranged from -17.7% for colorectal cancer (interquartile range [IQR], -33.6% to -2.8%), -6.8% for cervical cancer (IQR, -29.4% to 1.7%), -1.6% for breast cancer (IQR, -9.6% to 7.0%), and 1.2% for lung cancer (IQR, -16.9% to 19.0%). Geographic differences were not observed. There were statistically significant differences in the percent change in MTV between institution types for colorectal cancer screening (P = .02). CONCLUSION: Cancer screening is still in need of urgent attention, and the screening resources made available online may help facilities to close critical gaps and address screenings missed in 2020. LAY SUMMARY: Question: How can the effects of the coronavirus disease 2019 pandemic on cancer screening be mitigated? FINDINGS: When national resources were provided, including methods to calculate local screening deficits, 748 cancer programs promptly enrolled in a national Return-to-Screening study, and the majority identified local screening deficits, most notably in colorectal cancer. Using these results, 814 quality improvement projects were initiated with the potential to add 70,000 screening tests in 2021. Meaning: Cancer screening is still in need of urgent attention, and the online resources that we provide may help to close critical screening deficits.

Male Breast Cancer Patient and Surgeon Experience: The Male WhySurg Study.

BACKGROUND: Little is known about the experience of the male breast cancer patient. Mastectomy is often offered despite evidence that breast-conserving surgery (BCS) provides similar outcomes. METHODS: Two concurrent online surveys were distributed from August to October 2020 via social media to male breast cancer (MBC) patients and by email to American Society of Breast Surgeon members. The MBC patients were asked their opinions about their surgery, and the surgeons were asked to provide surgical recommendations for MBC patients. RESULTS: The survey involved 63 MBC patients with a mean age of 62 years (range, 31-79 years). Five MBC patients (7.9 %) stated that their surgeon recommended BCS, but 54 (85.7 %) of the patients underwent unilateral, and 8 (12.7 %) underwent bilateral mastectomy. Most of the patients (n = 60, 96.8 %) had no reconstruction. One third of the patients (n = 21, 33.3 %) felt somewhat or very uncomfortable with their appearance after surgery. The response rate was 16.5 % for the surgeons. Of the 438 surgeons who answered the survey, 298 (73.3 %) were female, 215 (51.7 %) were fellowship-trained, and 244 (58.9 %) had been practicing for 16 years or longer. More than half of surgeons (n = 259, 59.1 %) routinely offered BCS to eligible men, and 180 (41.3 %) stated they had performed BCS on a man with breast cancer. Whereas 89 (20.8 %) of the surgeons stated that they routinely offer reconstruction to MBC patients, 87 (20.3 %) said they do not offer reconstruction, 96 (22.4 %) said they offer it only if the patient requests it, and 157 (36.6 %) said they never consider it as an option. CONCLUSIONS: The study found discordance between MBC patients' satisfaction with their surgery and surgeon recommendations and experience. These data present an opportunity to optimize the MBC patient experience.

The Impact of Radiotherapy Delay in Breast Conservation Patients Not Receiving Chemotherapy and the Rationale for Dichotomizing the Radiation Oncology Time-Dependent Standard into Two Quality Measures.

INTRODUCTION: The Commission on Cancer/National Quality Forum breast radiotherapy quality measure establishes that for women < 70 years, adjuvant radiotherapy after breast conserving surgery (BCS) should be started < 1 year from diagnosis. This was intended to prevent accidental radiotherapy omission or delay due to a long interval between surgery and chemotherapy completion, when radiation is delivered. However, the impact on patients not receiving chemotherapy, who proceed from surgery directly to radiotherapy, remains unknown. PATIENTS AND METHODS: Patients aged 18-69, diagnosed with stage I-III breast cancer as their first and only cancer diagnosis (2004-2016), having BCS, for whom this measure would be applicable, were reviewed from the National Cancer Database. RESULTS: Among 308,521 patients, the median age was 57.0 years, and > 99% of all patients were compliant with the measure. The cohort of interest included 186,650 (60.5%) patients not receiving chemotherapy, with a mean age of 57.9 years. Of these, 90.5% received external beam radiotherapy (EBRT) and 9.5% brachytherapy. Among them, 24.9% started radiotherapy > 8 weeks after surgery. In a multivariable model, delay from surgery to radiotherapy increased the hazard ratios for overall survival to 9.0% (EBRT) per month and 3.0% (brachytherapy) per week. CONCLUSION: While 99.9% of patients undergoing BCS without chemotherapy remain compliant with the current quality measure, 25% have delays > 8 weeks to start radiation, which is associated with impaired survival. These data suggest that the current quality measure should be dichotomized into two, with or without chemotherapy, in order to impel prompt radiotherapy initiation and maximize outcomes in all patients.

Patient-reported outcomes among women with unilateral breast cancer undergoing breast conservation versus single or double mastectomy.

PURPOSE: More women with unilateral early stage breast cancer are electing bilateral mastectomy (BM). Many cite anxiety, fear of recurrence, and certain aesthetic desires in their decision-making. Yet conflicting data exist regarding how these factors both inform and are modulated by medical decision-making, especially among women eligible for breast conservation (BCT). This study sought to assess the trajectories of women undergoing various surgical procedures for breast cancer. METHODS: We performed a prospective longitudinal study of women with unilateral, non-hereditary breast cancer who underwent BCT, unilateral mastectomy (UM), or BM. Women completed surveys before surgery and at 1, 9, and 15 months postop. Surveys included questions about treatment preferences, decisional control, the HADS-A anxiety scale, the Fear of Relapse/Recurrence Scale (FRRS), and the BREAST-Q. The Kruskal-Wallis test was used to compare outcomes between BCT, UM, and BM groups at each time point. RESULTS: 203 women were recruited and 177 (87.2%) completed 15-month follow-up. Of these, 101 (57.0%) underwent BCT, 33 (18.6%) underwent UM, and 43 (24.2%) underwent BM. Generalized anxiety and FRRS scores were similar between BCT, UM, and BM groups and declined uniformly after surgery. Although baseline breast satisfaction was similar between groups, at 15 months, it was significantly lower in BM patients than in BCT patients. Women who felt "very" confident and "very" informed before surgery had lower anxiety, lower fear of recurrence, better psychosocial well-being (PSWB), and greater breast satisfaction at 15 months. CONCLUSION: While patients who undergo mastectomy have less long-term breast satisfaction, all patients can expect to experience similar improvements in anxiety and PSWB. Efforts should be made to ensure that patients are informed and confident regardless of which surgery is chosen, for this is the greatest predictor of better outcomes.

Covid-19 related oncologist's concerns about breast cancer treatment delays and physician well-being (the CROWN study).

PURPOSE: To examine how treatment delays brought on by the COVID-19 pandemic impacted the physical and emotional well-being of physicians treating these patients. METHODS: A cross-sectional survey of physician breast specialists was posted from April 23rd to June 11th, 2020 on membership list serves and social media platforms of the National Accreditation Program for Breast Centers and the American Society of Breast Surgeons. Physician well-being was measured using 6 COVID-19 burnout emotions and the 4-item PROMIS short form for anxiety and sleep disturbance. We examined associations between treatment delays and physician well-being, adjusting for demographic factors, COVID-19 testing and ten COVID-19 pandemic concerns. RESULTS: 870 physicians completed the survey, 61% were surgeons. The mean age of physicians was 52 and 548 (63.9%) were female. 669 (79.4%) reported some delay in patient care as a result of the COVID-19 pandemic. 384 (44.1%) and 529 (60.8%) of physicians scored outside normal limits for anxiety and sleep disturbance, respectively. After adjusting for demographic factors and COVID-19 testing, mean anxiety and COVID-19 burnout scores were significantly higher among physicians whose patients experienced either delays in surgery, adjuvant chemotherapy, radiation, breast imaging or specialty consultation. A multivariable model adjusting for ten physician COVID-19 concerns and delays showed that "delays will impact my emotional well-being" was the strongest concern associated with anxiety, sleep disturbance and COVID-19 burnout factors. CONCLUSIONS: Breast cancer treatment delays during the initial surge of the COVID-19 pandemic in the United States were associated with a negative impact on physician emotional wellness.

Improving the Breast Surgeon's Ergonomic Workload for Nipple-Sparing Mastectomies Using Exercise and Operating Room Positioning Protocol.

BACKGROUND: The objective of this study was to examine whether an exercise program and standardized operating room positioning protocol (EOPP) would improve surgeon muscle workload and/or surgeon perception of mental/physical workload for nipple-sparing mastectomy (NSM). METHODS: This prospective study analyzed muscle workload by EMG of four surgeons performing NSM before and after an EOPP. Surveys were administered assessing surgeon perception of mental/physical workload. EMG data were analyzed using repeated-measures ANOVA, controlling for surgeon, first assistant, duration and difficulty of procedure, left or right side, and sequence of the procedure. RESULTS: A total of 56 NSM cases performed by 3 surgeons were analyzed. One surgeon was excluded because of muscle injury and undergoing active physical therapy during the study period. After implementation of the EOPP, the left (P = 0.005) and right (P = 0.020) upper trapezii muscles had a significant decrease in overall ergonomic workload but there was no significant change in overall ergonomic workload for the bilateral cervical erector spinae, anterior deltoid, and lumbar erector spinae muscle groups. When analyzing muscle group exertion by surgeon, there was significant variability in all muscles except the left cervical erector spinae. Following the EOPP, surgeons reported that the procedures were more physically (P = 0.01) and mentally (P = 0.002) demanding and visualization (P = 0.04) was worse. The breast laterality and sequence did not affect muscle exertion. CONCLUSIONS: An EOPP decreased the overall ergonomic workload of one muscle group for surgeons performing NSM but did not impact surgeon perception of mental/physical workload. Further investigation is needed to improve surgeon ergonomics.

Patients Undergoing Bilateral Mastectomy and Breast-Conserving Surgery Have the Lowest Levels of Regret: The WhySurg Study.

BACKGROUND: The recent data on decision regret of patients undergoing breast cancer surgery are sparse. METHODS: An electronic cross-sectional survey was distributed to Love Research Army volunteers ages 18-70 years who underwent breast cancer surgery from 2009 to 2020. Decision regret scores were compared among patients who underwent bilateral mastectomy (BM), unilateral mastectomy (UM), breast-conserving surgery (BCS), and BCS first (BCS followed by re-excision or mastectomy) and between procedures during different time periods. Multivariable logistic regression, adjusted for patient and tumor factors, was used to determine whether surgery type was associated with a regret score in the highest quartile range. RESULTS: The survey was completed by 2148 women, 1525 (71.0%) of whom reported their surgery choice and answered all questions on the regret scale. The mean age of the participants was 50 years, and the median year of surgery was 2014. The median decision regret score for all the patients was 5 (interquartile range [IQR], 0-20) on a 100-point scale. The regret score of 342 participants (22.4%) was 25 or higher (BCS, 20.2%; BCS first, 31.9%; UM, 30.8%; BM, 15.4%; p < 0.001). In the multivariable analysis, BM was associated with less regret than UM (odds ratio [OR], 0.40 (range, 0.27-0.58); p < 0.001), BCS (OR, 0.56 (range, 0.38-0.83; p = 0.003), or BCS first (OR, 0.32; range, 0.21-0.49; p < 0.001). During the three periods analyzed (2009-2012, 2013-2016, and 2017-2020), the BM and BCS patients had the lowest regret scores of all the surgical types. CONCLUSIONS: Decision regret was low among the patients undergoing breast cancer surgery but lowest among the BM patients after adjustment for clinical and tumor factors including complications.

Uptake of Breast Cancer Clinical Trials at Minority Serving Cancer Centers.

BACKGROUND: Most minorities receive cancer care at minority-serving hospitals (MSHs) that have been associated with disparate treatment between Black and White patients. OBJECTIVE: Our aim was to examine the uptake of clinical trials that have changed axillary management in breast cancer patients at MSH and non-MSH cancer centers. METHODS: The National Cancer Database was used to identify patients eligible for the American College of Surgeons Oncology Group Z0011 and Z1071 trials, and mastectomy patients fulfilling the European AMAROS trial. Uptake of trial results (omission of axillary lymph node dissection) was analyzed between patients treated at MSHs and non-MSHs and adjusted for patient, tumor, and facility factors. MSHs were defined as the top decile of hospitals according to the proportion of Black and Hispanic patients treated. RESULTS: Of 7167 patients eligible for Z0011, 4546 for Z0171, and 9433 for AMAROS from 2015 to 2016, clinical trial uptake was seen in 1195 (74.6%) MSH and 4056 (72.9%) non-MSH patients (p = 0.173) for Z0011, 588 (41.9%) MSH and 1366 (43.5%) non-MSH patients for Z1071 (p = 0.302), and 272 (11.7%) MSH and 996 (14.0%) non-MSH patients (p = 0.005) for AMAROS. On adjusted analyses, MSH status was not significant for uptake of any of the three trials. Black race, socioeconomic status, and insurance were not associated with clinical trial uptake. CONCLUSION: The uptake of three landmark clinical trials of axillary management in breast cancer was not different at MSH and non-MSH centers despite adjustment for social determinants of health. At the Commission on Cancer-accredited centers in this analysis, MSH status did not affect the uptake of evidence-based care.

Recommendations for prioritization, treatment, and triage of breast cancer patients during the COVID-19 pandemic. the COVID-19 pandemic breast cancer consortium.

The COVID-19 pandemic presents clinicians a unique set of challenges in managing breast cancer (BC) patients. As hospital resources and staff become more limited during the COVID-19 pandemic, it becomes critically important to define which BC patients require more urgent care and which patients can wait for treatment until the pandemic is over. In this Special Communication, we use expert opinion of representatives from multiple cancer care organizations to categorize BC patients into priority levels (A, B, C) for urgency of care across all specialties. Additionally, we provide treatment recommendations for each of these patient scenarios. Priority A patients have conditions that are immediately life threatening or symptomatic requiring urgent treatment. Priority B patients have conditions that do not require immediate treatment but should start treatment before the pandemic is over. Priority C patients have conditions that can be safely deferred until the pandemic is over. The implementation of these recommendations for patient triage, which are based on the highest level available evidence, must be adapted to current availability of hospital resources and severity of the COVID-19 pandemic in each region of the country. Additionally, the risk of disease progression and worse outcomes for patients need to be weighed against the risk of patient and staff exposure to SARS CoV-2 (virus associated with the COVID-19 pandemic). Physicians should use these recommendations to prioritize care for their BC patients and adapt treatment recommendations to the local context at their hospital.

Virtual Surgical Fellowship Recruitment During COVID-19 and Its Implications for Resident/Fellow Recruitment in the Future.

BACKGROUND: The COVID-19 pandemic has overlapped with the scheduled interview periods of over 20 surgical subspecialty fellowships, including the Complex General Surgical Oncology (CGSO) fellowships in the National Resident Matching Program and the Society of Surgical Oncology's Breast Surgical Oncology fellowships. We outline the successful implementation of and processes behind a virtual interview day for CGSO fellowship recruitment after the start of the pandemic. METHODS: The virtual CGSO fellowship interview process at the University of Chicago Medicine and NorthShore University Health System was outlined and implemented. Separate voluntary, anonymous online secure feedback surveys were email distributed to interview applicants and faculty interviewers after the interview day concluded. RESULTS: Sixteen of 20 interview applicants (80.0%) and 12 of 13 faculty interviewers (92.3%) completed their respective feedback surveys. Seventy-five percent (12/16) of applicants and all faculty respondents (12/12) stated the interview process was 'very seamless' or 'seamless'. Applicants and faculty highlighted decreased cost, time savings, and increased efficiency as some of the benefits to virtual interviewing. CONCLUSIONS: Current circumstances related to the COVID-19 pandemic require fellowship programs to adapt and conduct virtual interviews. Our report describes the successful implementation of a virtual interview process. This report describes the technical steps and pitfalls of organizing such an interview and provides insights into the experience of the interviewer and interviewee.

Treatment delays from transfers of care and their impact on breast cancer quality measures.

PURPOSE: Despite delays between diagnosis and surgery adversely affecting survival, patients frequently transfer their breast cancer care between institutions. This study was performed to assess the prevalence and effect of such transfers of care (TsOC) on the time to surgery, and its impact on current time-dependent breast cancer quality metrics at Commission on Cancer (CoC) and National Accreditation Program for Breast Centers (NAPBC)-accredited institutions. METHODS: Patients having non-metastatic invasive breast cancer diagnosed between 2006 and 2015 at CoC and NAPBC centers ("reporting facilities") in the National Cancer Database were reviewed. TsOC refer to transferring into or out of a reporting facility between diagnosis and surgery. RESULTS: Among 622,793 patients, 36.6% of patients transferred care. TsOC add 7.3, 7.8, 8.7, and 9.8 days in time to surgery, chemotherapy, radiotherapy, and endocrine therapy, respectively (p's < 0.0001). On multivariable analysis, the odds of surgery occurring > 90 days from diagnosis were greatest for patients undergoing unilateral or bilateral mastectomy, Black or Hispanic patients, and those having TsOC (ORs > 1.73, p's < 0.0001). TsOC increase the odds of non-compliance, per patient, for chemotherapy, radiotherapy and endocrine therapy time-dependent measures by 65.4%, 25.6%, and 56.5%, respectively (p < 0.0001). CONCLUSIONS: TsOC for newly diagnosed breast cancers to or from an accredited facility result in delays in time to surgery which can affect compliance with time-dependent quality measures. Facilities frequently receiving transferred patients may be most adversely affected. Although non-compliance with these quality measures is low, institutions and accrediting bodies should be aware of these associations in order to comply with time-dependent standards.

Are we Overtreating Hormone Receptor Positive Breast Cancer with Neoadjuvant Chemotherapy? Role of OncotypeDx® for Hormone Receptor Positive Patients Undergoing Neoadjuvant Chemotherapy.

BACKGROUND: The utilization of OncotypeDx in the setting of neoadjuvant chemotherapy (NCT) is not well defined. The objective of this study was to determine what proportion of hormone receptor (HR)-positive patients undergoing NCT would not benefit from chemotherapy based on OncotypeDx recurrence scores (RS) and predictors of a high RS as defined by the TAILORx trial. METHODS: The National Cancer Data Base was used to identify patients with unilateral clinical stage I-III HR+/Her2- breast cancer who had an OncotypeDx score and who had undergone NCT. Patients undergoing adjuvant chemotherapy were used as a comparison group. RESULTS: Of 307,666 patients, 41.8% had testing with OncotypeDx. Of these, 76.6% had no chemotherapy, 22.3% adjuvant chemotherapy, and 1.1% NCT. OncotypeDx testing in NCT patients increased from 4.9% in 2010 to 8.2% in 2015. Of NCT patients with OncotypeDx testing, 11.6% had RS < 11, 44.4% RS 11-25, and 43.9% RS > 25. In patients age ≤ 50 years, 14.5% had RS < 11, 12.4% RS 11-15, 31.4% RS 16-25, and 41.7% RS > 25. Predictors of RS > 25 on multivariable analysis included grade 3 tumors (odds ratio [OR] 3.83) and PR-negative tumors (OR 5.26) but not clinical T or N stage (p > 0.05). CONCLUSIONS: More than half of patients with OncotypeDx testing are being overtreated with NCT, and a third of younger patients are being overtreated. Predictors of a high RS are reliably available at core biopsy, suggesting an application of OncotypeDx in determining the need for NCT for some HR-positive breast cancers.

An In-Visit Decision Aid for Surgeons to Address Decision Making for Bilateral Mastectomy for Newly Diagnosed Breast Cancer Patients.

BACKGROUND: Few decision aids for newly diagnosed breast cancer patients are used by surgeons during their consultations with patients. METHODS: From 2017 to 2019, an online interactive breast cancer in-visit decision aid (BIDA) was used on 63 patients and 57 patients underwent usual care (UC). We compared knowledge, decision involvement, anxiety and distress (HADS scale), quality of life (PROMIS), fear of recurrence, body image, and patient values between BIDA and UC before surgery. A knowledge score of ≥ 57% was considered "high knowledge." RESULTS: A total of 188 patients were enrolled of which 120 (63.8%) completed all study procedures. Patient demographic characteristics and anxiety and quality of life (QOL) at baseline were similar between patients in BIDA and UC cohorts. After seeing the surgeon, patients in the BIDA group had higher composite knowledge scores compared with UC patients [n = 55 (87.3%) vs. n = 39 (68.4%) respectively, p = 0.012]. Patients in the BIDA cohort reported being asked more often their surgical preference (p = 0.013) and discussing bilateral mastectomy (BM) as an option (p = 0.048). There was a trend of less patients in the BIDA cohort undergoing BM then in the UC cohort [10 (15.9%) vs. 14 (24.6%), p = 0.49]. Anxiety and distress, QOL, fear of recurrence, and body image were not significantly different between BIDA and UC cohorts. CONCLUSIONS: A decision aid used by surgeons during their consultation was associated with higher knowledge levels, patients reporting more discussion about BM, and a trend of lower BMs. A larger study with more patients is needed to confirm this finding.

Physician Knowledge of Breast Cancer Recurrence and Contralateral Breast Cancer Risk is Associated with Increased Recommendations for Contralateral Prophylactic Mastectomy: a Survey of Physicians at NAPBC-Accredited Centers.

BACKGROUND: Physician recommendation for contralateral prophylactic mastectomy (CPM) has been shown to influence whether a patient chooses CPM. Few studies have explored physician knowledge about contralateral breast cancer (CBC) and local recurrence (LR) risk and whether knowledge is associated with recommendation for CPM. METHODS: We conducted a cross-sectional survey of physicians at National Accreditation Program for Breast Centers-accredited breast centers across the USA. Physician knowledge levels of CBC and LR were assessed and correlated with recommendations for CPM. RESULTS: A total of 2412 physicians were surveyed with a 51% response rate (n = 1226). The results showed that 66% had correct knowledge about CBC risk and 57% had correct knowledge about LR. Moreover, 634 had high knowledge, viz. 176 (55.4%) breast surgeons, 171 (58.0%) medical oncologists, 196 (62.0%) radiation oncologists, and 72 (29.9%) plastic surgeons (p < 0.01). Compared with high knowledge, low knowledge was associated with favoring insurance coverage for patients at average CBC risk (53.8% vs. 39.8%, p < 0.01). Low knowledge was also associated with feeling that CPM was indicated in patients with high recurrence anxiety (39.2% vs. 28.9%), young patients with estrogen receptor (ER)-negative cancer (25.3% vs. 18.5%), and patients with two first-degree relatives with breast cancer (40.0% vs. 32.3%) (all p < 0.01). Multivariable analysis found physician type [odds ratio (OR) 3.76 for surgeons] and low knowledge (OR 1.46) to be significant independent predictors of favoring insurance coverage for CPM in patients at average risk. CONCLUSIONS: Physician knowledge about CBC and LR could be improved. Lower knowledge is associated with favorable physician recommendations for CPM. It is not clear whether improving physician knowledge will change recommendations for CPM.

The "Nipple Whipple"?! A Pilot Study to Assess the Ergonomic Effects of Nipple-Sparing Mastectomy.

BACKGROUND: Nipple-sparing mastectomies (NSMs) with reconstruction are believed to be more difficult to perform than skin-sparing mastectomies (SSMs), but there is little quantitative data to support this claim. METHODS: This prospective study analyzed four surgeons performing mastectomies. Electromyography (EMG) electrodes placed on selected muscle groups on each surgeon were used to capture muscle exertion intraoperatively and a percentage of maximum voluntary exertion was calculated (%MVE). Data regarding surgeon demographics, exercise habits, musculoskeletal problems, and surgery-specific workload was collected using a questionnaire. RESULTS: A total of 61 mastectomies were analyzed; 40 were NSM and 21 were SSM/total mastectomies. NSM were considered to be more mentally demanding and physically demanding than SSM (p < 0.001). When the surgeons' EMG data was analyzed as a group, there was a statistically significant difference in %MVE for NSM versus SSM at high muscle activity in bilateral anterior deltoid muscle groups and at average muscle activity for the left anterior deltoid muscle only. At low muscle activity, there was a statistically significant increase in activation for SSM versus NSM in bilateral cervical erector spinae. Repeated measures ANOVA was performed, which showed statistically significant differences at high muscle activity between NSM and SSM in the left cervical erector spinae and bilateral anterior deltoid muscles. CONCLUSIONS: Our pilot study shows that intraoperative EMGs can assess muscle activity for mastectomy operations and show a difference between NSM and SSM. This is the first study to provide quantitative data on muscle strain with NSM.

Impact of Breast Center Accreditation on Compliance with Breast Quality Performance Measures at Commission on Cancer-Accredited Centers.

PURPOSE: This study was designed to determine whether accreditation by the National Accreditation Program for Breast Centers (NAPBC) is associated with improved performance on six breast quality measures pertaining to adjuvant treatment, needle/core biopsy, and breast conservation therapy rates at Commission on Cancer (CoC) centers. METHODS: National Cancer Database 2015 data were retrospectively reviewed to compare patients treated at CoC centers with and without NAPBC accreditation for compliance on six breast cancer quality measures. Mixed effects modeling determined performance on the quality measures adjusting for patient, tumor, and facility factors. RESULTS: Of 1308 CoC facilities, 484 (37%) were NAPBC-accredited and 111,547 patients (48%) were treated at NAPBC centers. More than 80% of patients treated at both NAPBC and non-NAPBC centers received care in compliance with breast quality measures. NAPBC centers achieved significantly higher performance on four of the five quality measures than non-NAPBC centers at the patient level and on five of six measures at the facility level. For two measures, needle/core biopsy before surgical treatment of breast cancer and breast conservation therapy rate of 50%, NAPBC centers were twice as likely as non-NAPBC centers to perform at the level expected by the CoC (respectively odds ratio [OR] 1.96, 95% confidence interval [CI] 1.85-2.08, p < 0.0001; and OR 2.05, 95% CI 1.94-2.15, p < 0.0001). CONCLUSIONS: While NAPBC accreditation at CoC centers is associated with higher performance on breast quality measures, the majority of patients at all centers receive guideline-concordant care. Future studies will determine whether higher performance translates into improved oncologic and patient-reported outcomes.

Regional Variation in Performance for Commission on Cancer Breast Quality Measures and Impact on Overall Survival.

BACKGROUND: Adherence to quality measures has become an important indicator of cancer center performance for high-quality cancer care. We examined regional variation in performance for Commission on Cancer breast quality measures and its impact on overall survival (OS) for those measures that have been shown to impact OS. METHODS: Six breast quality measures were analyzed using the National Cancer Data Base from 2014 to 2015, and a multivariable model was used to assess performance for each measure by region. Kaplan-Meier and Cox proportional hazard models were used to examine OS between high- and low-performing centers from 2007 to 2012. RESULTS: Overall, 305,391 women had surgery at 1322 institutions in nine US regions; 90.8% underwent needle biopsy (range 86.0-92.6% between regions, p < 0.01), 69.8% had breast-conserving surgery (BCS) for stage 0-II cancer (60.9-79.3%, p < 0.01), 85.2% aged < 70 years had radiation therapy (RT) after BCS (79.6-90.8%, p < 0.01), 78.3% of women with four or more positive nodes had post-mastectomy RT (70.9-84.5%, p < 0.01), 90.9% with hormone receptor (HR)-positive stage IB-III cancer had hormone therapy (83.7-95.1%, p < 0.01), and 89.4% aged < 70 years with HR-negative stage IB-III cancer had chemotherapy (87.6-91.4%, p < 0.01). Multivariate analyses adjusted for patient and facility factors found that region was the only consistent predictor of non-compliance across measures. With median 65-month follow-up, there was no difference in OS between high- and low-performing centers for the three measures that have been shown to impact OS. CONCLUSIONS: There is significant regional variation in performance on the breast quality measures but this variation did not impact OS. Targeted efforts in certain areas of the country may help improve performance on these measures.

A Predictive Model for Axillary Node Pathologic Complete Response after Neoadjuvant Chemotherapy for Breast Cancer.

BACKGROUND: Recent trials have suggested the feasibility of performing a sentinel lymph node biopsy (SNB) following neoadjuvant chemotherapy (NAC). The selection of suitable patients for this approach remains controversial. We developed a predictive model to identify patients most likely to benefit from SNB following NAC. METHODS: The National Cancer Data Base was used to identify patients with clinically node positive (cN+) breast cancer undergoing NAC followed by breast surgery and axillary lymph node dissection (ALND). Patients were randomly assigned to a 70% testing or 30% validation cohort for model development. A predictive model was built based on significant factors associated with pathologic nodal response (pN0) and breast response. RESULTS: Using the testing cohort (n = 13,396), multivariate regression was used to identify predictors of pN0 based on preoperative factors. Younger age, hormone receptor (HR)-negative/Her2-negative, HR-positive/Her2-positive, HR-negative/Her2-positive, high-grade, ductal histology, cN1 versus cN2, and extent of breast response were all significant independent predictors of pN0 on adjusted analysis. The odds ratios translated into a 10-point scale correlating to a stepwise increase in pN0 response. The area under the curve for the ROC curves for the testing and validation cohorts was 0.781 and 0.788, respectively (p < 0.01). CONCLUSIONS: Our model incorporates known preoperative factors to predict the likelihood of pN0 response in patients with cN+ disease who undergo NAC. For patients with high scores, SNB should be considered over ALND, because these patients have a greater likelihood of having negative nodes at final pathology.