Technical factors, surgeon case volume and positive margin rates after breast conservation surgery for early-stage breast cancer

BACKGROUND

For patients with breast cancer, a negative surgical margin at first breast-conserving surgery (BCS) minimizes the need for reoperation and likely reduces postoperative anxiety. We assessed technical factors, surgeon and hospital case volume and margin status after BCS in early-stage breast cancer.

METHODS

We performed a retrospective cohort study using a regional cancer centre database of patients who underwent BCS for breast cancer from 2000 to 2002. We considered the influence of patient, tumour and technical factors (e.g., size of specimen and preoperative diagnosis of cancer available) and surgeon and hospital case volume on margin status at first and final operation. We performed univariate and multivariate regression analyses.

RESULTS

We reviewed 489 cases. There were no differences in patient or tumour characteristics among the low-, medium- and high-volume surgeon groups. High-volume surgeons were significantly more likely than other surgeons to operate with a confirmed preoperative diagnosis and to resect a larger volume of tissue. In our univariate analysis and at first operation, the rates of positive margins were 16.4%, 32.9% and 29.1% for high-, medium- and low-volume surgeons, respectively (p = 0.002). In the multivariate analysis, tumour factors (palpability, size, histology), presence of a confirmed preoperative diagnosis and size of resection specimen significantly predicted negative margins. However, when we controlled for these and other factors, high surgeon volume was not a predictor of negative margins at first surgery (odds ratio 1.8, 95% confidence interval 0.9-3.8, p = 0.09). Increased hospital volume was not associated with a lower rate of positive margins at first surgery.

CONCLUSION

Various tumour and technical factors were associated with negative margins at first BCS, whereas surgeon and hospital volume status were not. Technical steps that are under the control of the operating surgeon are likely effective targets for quality initiatives in breast cancer surgery.

Is there an increased risk of GERD after Helicobacter pylori eradication?: a meta-analysis

OBJECTIVES

Some studies suggest that eradication of Helicobacter pylori (Hp) might increase the risk of gastroesophageal reflux disease (GERD) in a portion of patients. We aimed to conduct a meta-analysis to investigate this.

METHODS

A comprehensive, English, multiple-source literature search was performed from 1983 to February 2007. Only randomized controlled trial (RCT) and cohort studies comparing the prevalence of GERD in patients free from GERD at baseline with Hp eradication vs. those with persistent Hp were included. Quality of RCTs and cohorts was assessed by Jadad and New Castle-Ottawa scores, respectively. Meta-analysis of pooled odds ratios (ORs) was performed using Review Manager 4.2.10.

RESULTS

Twelve (7 RCTs and 5 cohorts) of 271 articles were included. In six RCTs using erosive GERD as outcome, the OR for the frequency of GERD in Hp eradicated group vs. persistent Hp group was 1.11 (0.81-1.53, P=0.52). In five RCTs using symptomatic outcome, the OR for the frequency of GERD in Hp eradicated group vs. persistent Hp was 1.22 (0.89-1.69, P=0.22). In cohort studies, the OR for the frequency of GERD in Hp eradicated group vs. persistent Hp was 1.37 (0.89-2.12; P=0.15). Test of heterogeneity was not significant for any analyses. The results were consistent in subgroup and sensitivity analyses, including cohort studies vs. RCTs, high-quality studies vs. low-quality studies, and use of endoscopic vs. symptomatic outcomes except for the subgroup of patients with peptic ulcer disease (PUD) in cohort studies (OR: 2.04 (1.08-3.85); P=0.03).

CONCLUSIONS

There is no association between Hp eradication and development of new cases of GERD in the population of dyspeptic patients. However, in cohort studies, there seems to be a twofold higher risk of development of erosive GERD in patients with PUD. The effect in RCTs of patients with PUD did not show a significant difference.

A systematic review and meta-analysis of oncologic outcomes of pre- versus postoperative radiation in localized resectable soft-tissue sarcoma

BACKGROUND

The goal of this study was to determine the oncologic outcomes in localized resectable soft-tissue sarcoma after pre- versus postoperative radiation.

METHODS

Literature searches through MEDLINE, EMBASE, CancerLit, and the Cochrane Database were performed with the following search terms: sarcoma, radiation, preoperative, and postoperative. Two reviewers independently assessed all eligible publications with the Detsky Quality Scale for Randomized Trials and the Newcastle-Ottawa Quality Assessment Scale for case-control studies. The primary outcome measure was the pooled odds ratio and 95% confidence intervals (95% CI) for the risk of local recurrence calculated through the fixed- and random-effects methods. Time-dependent survival data were calculated as an average across all studies.

RESULTS

Five eligible studies were identified including a total of 1,098 patients. The P value for heterogeneity was 0.259, and the variability (I (2)) in results across studies due to true differences in treatment effect was 25%. The risk for local recurrence was lower in the preoperative group with an odds ratio of 0.61 (95% CI 0.42-0.89) by means of the fixed-effects method, and an odds ratio of 0.67 (95% CI 0.39-1.15) by means of the random-effects method. Average survival was 76% (range 62-88%) in the preoperative group and 67% (range 41-83%) in the post-operative group.

CONCLUSIONS

The delay in surgical resection necessary to complete preoperative radiation does not seem to increase the risk of lethal metastatic spread. The risk of local recurrence may be lower after preoperative radiation. These findings must be interpreted with caution because of the heterogeneity and bias in the available studies.

Primary tumor and patient characteristics in breast cancer as predictors of adjuvant chemotherapy regimen: A regression model

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Background: Adjuvant chemotherapy is used to reduce the risk of recurrence of breast cancer. This study was undertaken to determine which patient and tumor characteristics are important in guiding the choice of adjuvant chemotherapy. Methods: A retrospective review was undertaken of patients diagnosed with breast cancer (stages I-III) at a regional cancer center from 2004–7. Patient and tumor characteristics were identified and chemotherapy regimens compared. Binary logistic regression analysis was performed to the choice of FEC/D, CEF, AC/T, or ddAC/T against AC or CMF, or the choice of chemotherapy to hormonal therapy only. Univariate analysis was used to select factors (p<0.1) for entry into a multivariate stepwise logistic regression model using the forward method. Odds ratios with 95% CI were calculated. A p-value of < 0.05 was significant and comparisons were two tailed. Results: Model 1 (n=871) included regimen (AC or CMF vs. aggressive regimen) as the dependant variable. Indicators of choice of aggressive regimen were higher stage [OR 4.7 (CI 3.3, 6.8)], positive nodes [2.5 (1.6, 3.8)], negative PR [2.1 (1.4, 3.1)], higher grade [1.4 (1.0, 1.8)], and age [0.91 (0.88, 0.92)]. Model 2 (n=640) involved choice of any regimen (chemotherapy vs. hormonal therapy only) as the dependant variable. Indicators of choice of chemotherapy were higher stage [7.19 (2.8, 18.4)], higher grade [7.02 (3.3, 14.8)], positive nodes [3.25 (0.98, 10.77)], age [0.85 (0.81, 0.90)], and ER negativity [0.04 (0.004, 0.37)]. Factors not significant in both models were: family history, comorbidities (renal/hepatic dysfunction, diabetes, cardiac history, or neuropathy), treating medical oncologist, histology, Her2/neu, > 3 positive nodes, ratio of positive to total nodes, multicentricity, multifocality, and positive margin status. Conclusions: This study verifies known important factors for choice of chemotherapy regimen as found in current guidelines, quantifies their effects at our center, and excludes others thought to be important. Further studies are required to confirm these results both nationally and internationally, where risk stratification may be different, and if variables predicting adjuvant radiation therapy are similar.

No significant financial relationships to disclose.

Two-years biochemical failure-free survival following high intensity focused ultrasound (HIFU) for localized prostate cancer: Prospective single center study of 196 patients

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Background: HIFU is an emerging ablative modality for the treatment of localized prostate cancer with limited reports on oncological outcome. We prospectively analyzed our 2-year results. Methods: 253 consecutive patients (age: 64+8) were treated with a planed single session of HIFU using the Ablatherm integrated imaging model system between January 2006 and June 2008. Patients were followed (median: 12; range 3–24 months) with PSA measurement every 3 months. Patients who received prior radiation or hormonal therapy (n=25) and patient for whom at least 2 consecutive PSA measurements were not available (n = 32) were excluded, leaving a total of 196 patients for analysis. Mean pre-treatment PSA was 6.9+3.3. Biopsy Gleason scores at diagnosis (median 9 cores) were 5, 6, 3+4, 4+3 in 1, 91, 66 and 38 patients, respectively. Biochemical failure (BCF) is reported using the Stephenson (PSA >0.4ng/ml and rising), Horwitz (2 consecutive increases of at least 0.5ng/ml) and Phoenix (nadir+2ng/ml) definitions. Results: 196 patients (age: 64+8) met the inclusion criteria for analysis. 75 had low and 121 had intermediate D'Amico's risk stratification disease. Mean and median absolute PSA nadir levels were 0.28+0.53 and 0.06 ng/ml respectively. It was achieved in median time of 3 months and remained unchanged in 70% of the patients throughout the follow-up. Overall 2 years BCF free rates were 70 % (62–78%), 86 % (81–91%) and 96% (91–99%) according to the Stephenson, Horwitz and Phoenix definitions, respectively; with no significant differences between risk groups. Predictors of BCF were absolute nadir [HR: 3.0 (2.3–3.8)] and pre-treatment PSA [HR: 1.1 (1.0–1.2)]. Conclusions: This is the only study to date that analyzed post HIFU BCF free rates according to post radical prostatectomy definition of BCF. BCF usually occur in the first year and plateau thereafter. Short term results by all BCF definitions are promising with similar results for patients with low and intermediate risk. Pre-HIFU PSA and post-HIFU PSA nadir levels are predictors for BCF.

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Classification and appraisal of the level of clinical evidence of publications from the Canadian Association of Pediatric Surgeons for the past 10 years

INTRODUCTION

Increasing evidence is placed on the evidence-based quality of publications. We classified the publication type and assessed the reporting quality of the highest evidence level publications from the Canadian Association of Pediatric Surgeons between 1998 and 2007.

METHODS

All publications from Canadian Association of Pediatric Surgeons issues in the Journal of Pediatric Surgery from 1998 to 2007 were classified by study type and level of evidence (Oxford Center for Evidence-based Medicine Levels of Evidence). Cohort studies (level 2) were evaluated by 2 independent assessors using the Newcastle-Ottawa Quality Assessment Scale (NOQAS). Reliability and chi(2) analyses were performed.

RESULTS

Three hundred two publications were classified by level of evidence as follows: level 2, 46; level 3, 13; level 4, 109; and level 5, 134. The median NOQAS score of the 46 level-2 cohort studies was 8 (range, 5-9), and the interrater reliability was 0.94 (95% confidence interval, 0.89-0.96). There was a significant increase in the number of level-2 evidence publications (P = .001) over the study period.

CONCLUSIONS

Level-2 evidence cohort studies met a high scientific standard as assessed by the NOQAS and significantly increased in number over the study period. However, there were no level-1 evidence (randomized controlled trial) publications, and most were in the lower evidence classification levels (3-5).

Long-term outcomes for laparoscopic versus open resection of nonmetastatic colorectal cancer

BACKGROUND

Skepticism prevails over the role of minimally invasive surgery in the treatment of colorectal cancer. Long-term data on the safety and efficacy of this technique remain scarce. A nonrandomized, prospective comparison of laparoscopic colorectal cancer surgery (LS) with open surgery (OS) was undertaken to evaluate long-term survival.

METHODS

A total of 233 patients with nonmetastatic colorectal cancer underwent either a laparoscopic (n = 116) or an open (n = 117) potentially curative resection. Almost all patients between July 1996 and December 2002 were randomized within two consecutive trials; however, prior to this, a significant proportion of patients received open surgery. The primary endpoints were overall survival, disease-free survival, and cumulative disease recurrence. Analysis was by intention to treat.

RESULTS

Median follow-up was 40 months for the LS group and 58 months for the OS group. No statistically significant difference was found between the LS and OS groups regarding overall survival (P = 0.603 for colon cancer and P = 0.841 for rectal cancer), disease-free survival (P = 0.684 for colon cancer and P = 0.625 for rectal cancer), and overall recurrence (P = 0.383 for colon cancer and P = 0.166 for rectal cancer). Cumulative recurrence rate in colon cancer favors OS (P = 0.018). In rectal cancer, this did not differ between the two treatment modalities (P = 0.965). Tumor resection margins and lymph node harvest were similar in the two surgery groups. Perioperative mortality in the LS group was also no different from the OS group (P = 0.644 for 30-day mortality and P = 0.692 for in-hospital mortality).

CONCLUSION

Long-term survival data support LS as a safe, effective alternative to conventional surgery for treating potentially curative colorectal cancer. However, the higher cumulative recurrence associated with LS in the colonic cancer group needs further research into its underlying cause.

Retrospective comparison of an endoscopic assisted versus a purely endoscopic approach to sellar tumour resection

INTRODUCTION

The purely endoscopic approach to sellar tumors is thought to offer improved visualization and decreased complications compared to the endoscopic assisted approach.

METHODS

This retrospective study was approved by the Research Ethics Board (REB) of McMaster University. Seventy-one consecutive patients who underwent sellar surgery at our institution from January 2003 to October 2005 were reviewed. 40 patients underwent an endoscopic assisted (microscope) approach, while 31 underwent a purely endoscopic approach. Populations were compared for differences in demographics, OR times, outcome measures, and complication rates.

RESULTS

The groups were demographically equivalent. The pathology was similar across both groups. Both groups had a reduction of volume and invasion post operatively. There was a trend toward greater reduction in tumour volume and a significant decrease in tumour invasion in the purely endoscopic group. Both groups demonstrated similar improvements in visual fields. The purely endoscopic group had an improvement of 0.33 axes (p<0.05) in pituitary function. Overall, complications were reduced in the purely endoscopic group. A trend toward shorter operative times (128 minutes vs 135 minutes) and length of hospital stay (3.6 days (p<0.05) vs 5.4 days) in the purely endoscopic group.

CONCLUSION

Our purely endoscopic group demonstrated a trend, as skill and confidence increased so did the size and invasiveness of the tumours being resected. Overall, the purely endoscopic technique showed improved total tumour resection, improved pituitary function, similar visual field outcomes, less post operative complications, decreased operative times and reduced hospital stay when compared to the endoscopic assisted technique.

A systematic meta-analysis of randomized controlled trials of adjuvant chemotherapy for localized resectable soft-tissue sarcoma

BACKGROUND

The use of adjuvant chemotherapy to treat adults with localized resectable soft-tissue sarcoma remains controversial. The objective of this systematic review was to update the 1997 meta-analysis of randomized controlled trials (RCTs) to reassess the efficacy of doxorubicin-based chemotherapy with respect to recurrence and survival.

METHODS

A comprehensive literature search was performed to identify RCTs of adjuvant chemotherapy for adult patients diagnosed with localized resectable soft-tissue sarcoma. Two reviewers independently assessed eligibility and quality of the studies using a modified version of the Detsky Quality Scale. The outcome measures were local, distant, and overall recurrence and survival calculated through the fixed effect or random effect model.

RESULTS

Four new eligible trials were identified allowing for a total of 18 trials representing 1953 patients to be included in the analysis. The odds ratios (OR) for local recurrence was 0.73 (95% confidence interval [CI] 0.56-0.94; P = .02) in favor of chemotherapy. For distant and overall recurrence the OR was 0.67 (95% CI 0.56-0.82; P = .0001) in favor of chemotherapy. In terms of survival, doxorubicin alone had an OR of 0.84 (95% CI, 0.68-1.03; P = .09), which as not statistically significant. However, the OR for doxorubicin combined with ifosfamide was 0.56 (95% CI, 0.36-0.85; P = .01) in favor of chemotherapy.

CONCLUSIONS

This updated meta-analysis confirms the marginal efficacy of chemotherapy in localized resectable soft-tissue sarcoma with respect to local recurrence, distant recurrence, overall recurrence, and overall survival. These benefits are further improved with the addition of ifosfamide to doxorubicin-based regimens, but must be weighed against associated toxicities.

Computer navigation in total hip replacement: a meta-analysis

Proponents of navigated hip arthroplasty have suggested that it may increase the precision of acetabular component placement. We conducted a systematic review and meta-analysis to evaluate the validity of this theory. We searched, in duplicate, MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials for randomised trials comparing the use of computer navigation with the freehand technique for acetabular cup placement within the desired alignment. We assessed the methodological quality of the studies and abstracted the relevant data. Tests of heterogeneity and publication bias were performed. From the three studies included, there was no evidence of heterogeneity between studies. A total of 250 patients were entered into the analysis. The beneficial odds ratio for the number of outliers was 0.285 (95% confidence interval [CI]: 0.143 to 0.569; p < 0.001). We conclude that navigation in hip arthroplasty improves the precision of acetabular cup placement by decreasing the number of outliers from the desired alignment.

Early mortality from off-pump and on-pump coronary bypass surgery in Canada: a comparison of the STS and the EuroSCORE risk prediction algorithms

OBJECTIVE

Early mortality from off-pump and on-pump coronary artery bypass graft (CABG) surgery was assessed and compared with two widely used risk algorithms for CABG: The Society of Thoracic Surgeons (STS) and the European System for Cardiac Operative Risk Evaluation (EuroSCORE).

METHOD

From March 12, 2001, to December 31, 2002, 1657 consecutive patients were treated with off-pump CABG and 1693 consecutive patients were treated with on-pump CABG. The predicted risk of mortality scores for the STS and EuroSCORE models were calculated. The predictive accuracy for early mortality was assessed by comparing the observed and expected mortalities for equal-sized quantiles of risk using the Hosmer-Lemeshow goodness-of-fit test. The discriminatory power of the models was evaluated by calculating the area under the receiver operating characteristic (ROC) curves.

RESULTS

The observed postoperative mortality was 1.8% (95% CI 1.3% to 2.4%) for off-pump CABG and 1.5% (95% CI 1.1% to 2.1%) for on-pump CABG. For both on-pump and off-pump CABG surgery, the Hosmer-Lemeshow goodness-of-fit test indicated good accuracy. The area under the ROC curve was 0.81 (95% CI 0.73 to 0.90) for the STS and 0.79 (95% CI 0.71 to 0.88) for EuroSCORE in off-pump CABG (P=0.567). The area under the ROC curve was 0.82 (95% CI 0.73 to 0.91) for STS and 0.81 (95% CI 0.71 to 0.90) for EuroSCORE in on-pump CABG (P=0.616). The STS-predicted risk of stroke, prolonged ventilation and renal failure were similar to the observed data, with relatively good discriminatory powers for both off-pump and on-pump CABG.

CONCLUSION

Both the STS and EuroSCORE risk algorithms are good predictors of early mortality from off-pump or on-pump CABG surgery. However, the generalizability of these results in the Canadian context would require a broader sampling of Canadian centres, including ones that provide both on-pump and off-pump CABG.

Complementary and alternative medicine use in patients with fractures

Complementary and alternative medicine (CAM) encompasses dietary supplements, herbs, homeopathic medicines, and other modalities. In light of prevalent CAM use, patient interest, increasing CAM expenditures, and possible interactions with traditional treatments or healing we identified the following in patients with fractures: prevalence of CAM use, the amount of money patients are spending on CAMs, and the number of patients who disclose CAM use to their orthopaedic surgeon and the reasons for withholding disclosure. Factors associated with CAM use were evaluated. Of the 322 patients with fractures surveyed, 35% were using CAMs. Of the patients using CAMs, 50% spent more than $25 per month. Fifty-five percent of the patients using CAMs had not discussed their CAM use with their orthopaedic surgeon citing "it was not an important issue to discuss." Factors associated with CAM use included level of education (odds ratio, 2.5; 95% confidence interval, 1.4-4.7) and psychiatric disorders (odds ratio, 2.5; 95% confidence interval, 1.3-5.0). To avoid possible interactions with traditional treatments and to identify side effects, surgeons should ask patients with fractures about CAM use in an unbiased fashion, as most patients will not voluntarily disclose their use.