Breast cancer surgery trends and outcomes: results from a national department of veterans affairs study

The Landscape of Care for Women Veterans with Cancer: An Evidence Map

BACKGROUND

Women are the fastest growing veteran group in the US and the number of women veterans (WVs) with cancer is rising; however, little is known about this population. Cancer care for WVs is complex and it is essential to understand their unique needs and care coordination challenges to provide evidence-based care. The purpose of this review is to map the quantity, distribution, and characteristics of literature describing cancer and its treatment among WVs.

METHODS

We searched MEDLINE (via PubMed), Embase (Elsevier), and Web of Science Core Collection (Clarivate) from inception through January, 2024. Publications were eligible that reported gender-specific data on any aspect of cancer care among WVs. Data was abstracted by a single investigator with over-reading.

RESULTS

Forty-six reports were included; 44 were observational and 19 had a women-only sample. There were no interventional reports and no qualitative reports had a patient sample. Breast cancer was the most commonly addressed (n = 19). There were six additional reports on sex-specific cancers. Many reports used large VA databases or previous trial data, creating the potential for patient overlap between reports. Among VA-specific areas of interest, only three reports evaluated the potential implications of racial differences and only two included a transgender population. No reports examined the effects of toxic exposures on cancer. Within the NCI Cancer Control Continuum, crosscutting areas were more commonly represented; over half (25) of the reports addressed epidemiology. There were few reports on focus areas and little overlap between focus and crosscutting areas.

DISCUSSION

Existing literature provides an inadequate understanding of the population of WVs with cancer. There is scant information regarding the population of WVs with cancer, their care preferences or experiences, or how to best identify and address unmet healthcare needs. It is imperative to expand research to provide evidence-based care for this population.

Clinical Complexity in Women Veterans: A Systematic Review of the Recent Evidence on Mental Health and Physical Health Comorbidities

A recent evidence map focused on women veterans underscored the limited number of articles published on mental health comorbid with physical health conditions in this population. The quality of this small body of research has yet to be evaluated. The aim of this systematic review was to evaluate and synthesize research published between 2008 and 2015 and identified in the Women Veterans' Health Research Evidence Map as related to mental and physical health comorbidities among women veterans. Following PRISMA guidelines, 23 published studies were identified and 21 were included in the review. In general, significant associations between several mental health conditions (e.g., depression, posttraumatic stress disorder, substance use disorders) and physical health disorders (e.g., cardiovascular disease, diabetes, gastrointestinal disorders, hypertension, obesity, pain, and urinary symptoms) and health behaviors (e.g., preventative care and treatment adherence) were noted. The majority of studies were rated as low risk of bias, with selection and detection bias most frequently observed across studies. Additionally, gaps in the recent literature were observed, including the need for further investigation of the role of medical conditions in complicating mental health symptoms and care provision. Results underscore the importance of healthcare providers attending to women veterans' mental and physical health simultaneously and irrespective of setting. Further, while the Department of Veterans Affairs continues to make sizable gains in its focus on women veterans' health, continued research on several health domains is needed to ensure adequate understanding of the health needs of women veterans.

Factors associated with readmissions in women participating in screening programs and treated for breast cancer: a retrospective cohort study

Background

We aimed to identify the risk factors associated with early, late and long-term readmissions in women diagnosed with breast cancer participating in screening programs.

Methods

We performed a multicenter cohort study of 1055 women aged 50–69 years participating in Spanish screening programs, diagnosed with breast cancer between 2000 and 2009, and followed up to 2014. Readmission was defined as a hospital admission related to the disease and/or treatment complications, and was classified as early (< 30 days), late (30 days-1 year), or long-term readmission (> 1 year). We used logistic regression to estimate the adjusted odds ratios (aOR), and 95% confidence intervals (95% CI) to explore the factors associated with early, late and long-term readmissions, adjusting by women’s and tumor characteristics, detection mode, treatments received, and surgical and medical complications.

Results

Among the women included, early readmission occurred in 76 (7.2%), late readmission in 87 (8.2%), long-term readmission in 71 (6.7%), and no readmission in 821 (77.8%). Surgical complications were associated with an increased risk of early readmissions (aOR = 3.62; 95%CI: 1.27–10.29), and medical complications with late readmissions (aOR = 8.72; 95%CI: 2.83–26.86) and long-term readmissions (aOR = 4.79; 95%CI: 1.41–16.31).

Conclusion

Our results suggest that the presence of surgical or medical complications increases readmission risk, taking into account the detection mode and treatments received. Identifying early complications related to an increased risk of readmission could be useful to adapt the management of patients and reduce further readmissions.

Trial Registration

ClinicalTrials.govIdentifier: NCT03165006. Registration date: May 22, 2017 (Retrospectively registered).

Unplanned readmissions following breast cancer surgery

BACKGROUND

Understanding the underlying factors associated with unplanned readmissions is an important first step toward interventions designed to improve quality of care. This study aimed to identify predictors of unplanned 30-day readmission using a national breast surgery cohort.

STUDY DESIGN

Using the National Cancer Database, we performed a review of patients undergoing surgery for breast cancer from 2006 to 2014. A multivariatble logistic regression model was generated to assess predictors of 30-day unplanned readmission.

RESULTS

Of 944,092 patients identified, 15,695 (1.7%) had an unplanned readmission within 30 days. Significant predictors of readmission included: increased procedure complexity, high co-morbidity score, Medicaid or lack of insurance, and low annual hospital volume; p < 0.0001.

CONCLUSION

Unplanned readmission following breast surgery is an uncommon event. However, our results demonstrate risk factors associated with higher rates of readmission following surgery. Understanding the underlying causes for readmission allows for identification of high-risk individuals and the design of targeted intervention programs.

Improving care of chronic conditions for women veterans: identifying opportunities for comparative effectiveness research

This article aims to critically analyze research focused on the findings for five chronic conditions: chronic pain, diabetes, cardiovascular disease, HIV and cancer among women veterans to identify opportunities for comparative effectiveness research. We provide a descriptive analysis from the relevant articles in prior systematic reviews. In order to identify potential gaps in research for these specific conditions, we also conducted a literature search to highlight studies focusing on women veterans published since the last systematic review. While the scientific knowledge base has grown for these chronic conditions among women veterans, the vast majority of the published literature remains descriptive and/or observational, with only a few studies examining gender differences and even fewer clinical trials. There is a need to conduct comparative effectiveness research on chronic conditions among women veterans to improve health and healthcare.

High body mass index and smoking predict morbidity in breast cancer surgery: a multivariate analysis of 26,988 patients from the national surgical quality improvement program database

OBJECTIVE

The purpose of this study was to examine the incidence of complications of breast cancer surgery in a multi-institutional, prospective, validated database and to identify preoperative risk factors that predispose to these complications.

BACKGROUND

There is an increased emphasis on clinical outcomes to improve the quality of surgical care. Although mastectomy and breast conserving surgery have low risk for complications, few US studies have examined the incidence of these complications in large, multicenter patient populations. The broad scale of the National Surgical Quality Improvement Program (NSQIP) data set facilitates multivariate analysis of patient characteristics that predispose to development of postoperative complications in breast cancer surgery.

METHODS

A prospective, multi-institutional study of patients undergoing mastectomy and breast conserving surgery was performed from the National Surgical Quality Improvement Program from 2005 to 2007. Study subjects were selected as a random sample of patients at more than 200 participating community and academic medical centers. Thirty-day morbidity was prospectively collected and the incidence of postoperative complications was determined, with particular emphasis on superficial and deep surgical site infections. Multivariate logistic regression was performed to identify independent risk factors for postoperative wound infections in each.

RESULTS

A total of 26,988 patients were identified who underwent mastectomy (N = 10,471) and breast conserving surgery (N = 16,517). As expected, the overall 30-day morbidity rate for all procedures was low (5.6%), with significantly higher morbidity for mastectomies (4.0%) than breast conserving surgery (1.6%, P < 0.001). The most common complications in all procedures were superficial surgical site infections and deep surgical site infections. Independent risk factors for development of any wound infection in patients undergoing mastectomy were a high body mass index, smoking, and diabetes (ORs = 1.8, 1.6, 1.8). In patients who had a lumpectomy, a high body mass index, smoking, and a history of surgery within 90 days prior to this procedure (ORs = 1.7, 1.9, 2.0) were independent risk factors.

CONCLUSIONS

Although complication rates in breast cancer surgery are low, wound infections remain the most common complication. A high body mass index and current tobacco use were the only independent risk factors for development of a postoperative wound infection across all procedures. This study highlights the benefit of a multi-institutional database in assessing risk factors for adverse outcomes in breast cancer surgery.

Initial experiences with a multidisciplinary approach to decreasing the length of hospital stay for patients undergoing unilateral mastectomy

BACKGROUND

We hypothesized that the introduction of a short-stay pathway would result in a significant reduction in length of stay for patients undergoing unilateral mastectomy, without a negative impact on patient safety.

MATERIALS AND METHODS

As part of a quality improvement project, a multidisciplinary committee designed a 1-day stay program for unilateral mastectomy patients. The study period was the first year after the 1-day pathway had routinely been implemented. We report on consecutive patients undergoing unilateral mastectomy ± tissue expander at Memorial Sloan-Kettering Cancer Center from July 1, 2009 to June 30, 2010. The primary endpoint was the percentage of patients discharged on postoperative day 1. Secondary endpoints included the incidence of postoperative complications within 30 days of surgery, reoperations, readmissions, and urgent-care visits within 7 days.

RESULTS

Over a 12-month period, 537 patients underwent unilateral mastectomy. Of those, 82.7% (444/537) were performed on a 1-day hospitalization basis, compared with 9.6% in 2008, before implementation of the 1-day plan. The 30-day complication rate was 6.1% (33/537). Overall, 2.6% of all patients had reoperation for hematoma (14/537), 0.9% had to be readmitted (5/537), and 1.5% (8/537) attended the urgent-care department. If all patients had stayed in the hospital for more than 1 day, none of the readmissions and only 2 urgent-care visits would have been prevented.

CONCLUSIONS

This study shows that a 1-day stay following mastectomy is easy to implement and safe for patients if a multidisciplinary team is involved in planning and implementation.

Screening for breast and prostate cancers: moving toward transparency

Despite mortality reductions found in early trials, recent population-based data suggest that breast and prostate cancer screening have not yielded expected benefits. Whereas evidence-based appraisals generally mistrust disease-specific mortality as a primary outcome measure, cancer screening trials have consistently used this endpoint, largely because of the impracticality of studies with enough statistical power to detect all-cause mortality reductions, which would require millions of subjects. The acceptance of disease-specific mortality as a practical surrogate for all-cause mortality may explain the discrepancy between expected and actual impact. Screening may reduce deaths from the target cancer but may increase deaths from other causes, most likely because of overdiagnosis, an increasingly recognized risk of cancer screening. Recognition of the discrepancy between the expected and the actual impact of screening and recognition of overdiagnosis as a source of harm may be critical for understanding and projecting the potential impact of cancer screening programs.

Effective breast reconstruction in female veterans

BACKGROUND

Despite increasing female veteran numbers, literature regarding reconstruction after breast cancer is lacking. The purpose of this study was to examine breast reconstruction referral rates and reconstruction outcomes at a tertiary Veterans Affairs hospital.

METHODS

Female breast cancer patients (1997-2008) were identified. Demographics, tumor stage, oncologic therapies, reconstructive timings and procedures, and complications were noted.

RESULTS

Eighty-two women underwent mastectomy (46%) or breast conservation (43%). The referral rates to plastic surgery were 61% (mastectomy) and 32% (overall). Reconstruction rates were 42% (mastectomy) and 22% (overall). Sixty-nine percent were suitable candidates and chose immediate (67%) or delayed (33%) reconstruction, with implant-based (44%), autologous (39%), or autologous plus implants (17%). There were complications (28%) but no mortalities. Comorbidities were not correlated with outcomes.

CONCLUSIONS

Breast reconstruction can be effectively delivered within the Veterans Affairs system. It is essential that sufficient Veterans Affairs resources be deployed to address the increasing reconstructive needs of female veterans.

Intraoperative myocardial acidosis as a risk for hospital readmission after cardiac surgery

BACKGROUND

This study elucidates the relationship between intraoperative myocardial acidosis/ischemia and the risk of unplanned hospital readmissions within 30 days and 6 months after cardiac surgery.

METHODS

Myocardial tissue pH (corrected to 37 degrees C: pH(37C)) was monitored in 221 patients during cardiac surgery. Regional myocardial acidosis was defined in terms of specific pH thresholds.

RESULTS

Fourteen percent and 27% of the patients were readmitted within 30 days and 6 months postoperatively, respectively. The mean number of readmissions was 1.67 +/- 1.24; pH(37C) <6.85 at the end of cardiopulmonary bypass (CPB) was identified as the threshold most significantly associated with readmission. This threshold was associated with a 6-fold increased risk of readmission within 30 days and a 5-fold increased risk within 6 months.

CONCLUSIONS

Persistent regional myocardial acidosis after weaning from CPB independently determines unplanned readmission rates up to 6 months postoperatively. This study underscores the importance of avoiding myocardial tissue acidosis during cardiac surgery.

Gender disparities in Veterans Health Administration care: importance of accounting for veteran status

BACKGROUND

In an effort to assess and reduce gender-related quality gaps, the Veterans Health Administration (VHA) has promoted gender-based research. Historically, such appraisals have often relied on secondary databases, with little attention to methodological implications of the fact that VHA provides care to some nonveteran patients.

OBJECTIVES

To determine whether conclusions about gender differences in utilization and cost of VHA care change after accounting for veteran status.

DESIGN

Cross-sectional.

SUBJECTS

All users of VHA in 2002 (N = 4,429,414).

MEASURES

Veteran status, outpatient/inpatient utilization and cost, from centralized 2002 administrative files.

RESULTS

Nonveterans accounted for 50.7% of women (the majority employees) but only 3.0% of men. Among all users, outpatient and inpatient utilization and cost were far lower in women than in men, but in the veteran subgroup these differences decreased substantially or, in the case of use and cost of outpatient care, reversed. Utilization and cost were very low among women employees; women spouses of fully disabled veterans had utilization and costs similar to those of women veterans.

CONCLUSIONS

By gender, nonveterans represent a higher proportion of women than of men in VHA, and some large nonveteran groups have low utilization and costs; therefore, conclusions about gender disparities change substantially when veteran status is taken into account. Researchers seeking to characterize gender disparities in VHA care should address this methodological issue, to minimize risk of underestimating health care needs of women veterans and other women eligible for primary care services.

Morbidity and mortality following breast cancer surgery in women: national benchmarks for standards of care

BACKGROUND

Most reports on postoperative (OP) morbidity and mortality following breast cancer surgery (BCS) are limited by relatively small sample size resulting in a lack of national benchmarks for quality of care. This paper reports the 30-day morbidity and mortality following BCS in women using a large prospective multi-institutional database.

METHODS

The National Surgical Quality Improvement Program Patient Safety in Surgery, prospectively collected inpatient and outpatient 30 day postoperative morbidity and mortality data on patients undergoing surgery at 14 university and 4 community centers. Using the procedure CPT code, the database was queried for all women undergoing mastectomy (MT) or lumpectomy with an axillary procedure (L-ANP). Morbidity and mortality were categorized as mortality, wound, cardiac, renal, pulmonary, and central nervous system. Logistic regression models for the prediction of wound complications were developed. Preoperative variables having bivariate relationships with postoperative wound complications with P < or = 0.20 were submitted for consideration.

RESULTS

We identified 1660 and 1447 women who underwent MT and l-ANP, respectively. The mean age was 55.9 years. The majority of procedures were under general anesthesia. The 30-day postoperative mortality for MT and l-ALNP were 0.24% and 0%, respectively. The most frequent morbid complication was wound infection, more commonly occurring in the mastectomy (4.34%) group versus the lumpectomy group (1.97%). Cardiac and pulmonary complications occurred infrequently in the mastectomy group (cardiac: MT, 0.12%; and pulmonary: MT, 0.66%). There were no cardiac or pulmonary complications in the lumpectomy group. CNS morbidities were rare in both surgical groups (MT, 0.12%; and l-ALNP, 0.07%). Development of a UTI was more common in women who underwent a mastectomy (0.66%) when compared with women that had a lumpectomy (0.14%). The only significant predictors of a wound complication were morbid obesity (BMI >30), having had a MT, low preoperative albumin and hematocrit greater than 45%.

CONCLUSION

Morbidity and mortality rates following BCS in women are low, limiting their value in assessing quality of care. Mastectomy carries higher complication rate than l-ANP with wound infection being the most common.

Relationship of Processes and Structures of Care in General Surgery to Postoperative Outcomes: A Hierarchical Analysis

BACKGROUND

The majority of studies relating processes and structures of surgical care to outcomes focus on mortality alone, even though morbidity outcomes are frequent, costly, and can have an adverse effect on a patient's short- and longterm survival and quality of life. The purpose of this study was to identify the important processes and structures of surgical care that relate to 30-day, risk-adjusted postoperative morbidity in general surgery.

STUDY DESIGN

Department of Veterans Affairs general surgery patients operated on in the period October 1, 2003 to September 30, 2004 at medical centers that participated in the Patient Safety in Surgery (PSS) Study and responded to a process and structure of care survey were included in this study. The patient's risk information was combined with key process and structure variables in a hierarchical maximum likelihood analysis to predict 30-day postoperative morbidity.

RESULTS

A number of hospital-level processes and structures of care were identified that predicted 30-day postoperative morbidity. The dominant factor was university affiliation. Affiliated hospitals showed an increase in risk of morbidity even after adjustment for patient risk.

CONCLUSIONS

Risk-adjusted morbidity is higher in Veterans Affairs hospitals that are affiliated with university medical centers. These findings mandate additional study to identify the exact factors responsible for this increased morbidity.

Factors associated with short-term hospital readmission rates for breast cancer patients in Western Australia: an observational study

BACKGROUND

Unplanned hospital readmissions after surgical treatment for breast cancer are an indicator of morbidity. We explore the relationship between the rate of unplanned hospital readmissions within 42 days of initial treatment and various factors, including tumor size and histology, lymph node involvement, type of surgical treatment, mastectomy, or breast-conserving surgery, and patient demographics.

METHODS

Linked Western Australian cancer mortality and hospital morbidity data were used in the assessment of readmissions within a period of 42 days after initial surgical treatment for breast cancer. Planned admissions for adjuvant treatment such as chemotherapy or radiotherapy were deleted. Survival models for multiple events per subject were applied to analyze the data.

RESULTS

The analysis reveals that patients more likely to experience lower recurrence of short-term unplanned hospital readmissions include those with smaller tumors, private insurance, and who reside in metropolitan areas. The model also includes important two-way interaction terms involving tumor histology, area of residence, and surgical treatment, and between lymph node involvement and patient age.

CONCLUSIONS

This study suggests that the choice of breast-conserving surgery as a treatment for breast cancer does not invariably result in better postoperative morbidity, but rather, that other factors, including tumor size and patient demographics, play a critical role in the short term. These results differ from a previous study of longterm hospital readmissions-country of birth and method of payment were found to be associated with short-term hospital admission but not with longterm readmissions.

Provider’s volume and quality of breast cancer detection and treatment

For many health conditions, the process or result of medical procedures improves with increasing caseload. The evidence about breast cancer has not been thoroughly assessed. This review synthesizes the literature about provider's volume and performance in either breast cancer screening with mammography or treatment. Articles published in English between 1990 and 2006 were identified by a computerized search and by review of reference lists. In screening with mammography, the reading volume of the radiologist and the screening volume of the facility influence different components of performance. The most conclusive evidence for breast cancer treatment concerns the association between the surgeon's caseload and the process or end-results of therapeutic interventions. Although the mechanisms of these associations still need to be clarified, large provider's volume in screening mammography or breast cancer treatment is often related to the quality of medical interventions.

Toward a VA Women's Health Research Agenda: setting evidence-based priorities to improve the health and health care of women veterans

The expansion of women in the military is reshaping the veteran population, with women now constituting the fastest growing segment of eligible VA health care users. In recognition of the changing demographics and special health care needs of women, the VA Office of Research & Development recently sponsored the first national VA Women's Health Research Agenda-setting conference to map research priorities to the needs of women veterans and position VA as a national leader in Women's Health Research. This paper summarizes the process and outcomes of this effort, outlining VA's research priorities for biomedical, clinical, rehabilitation, and health services research.

The state of women veterans' health research. Results of a systematic literature review

OBJECTIVE

Assess the state of women veterans' health research.

DESIGN

Systematic review of studies that pertained specifically to or included explicit information about women veterans. A narrative synthesis of studies in 4 domains/topics was conducted: Stress of military life; Health and performance of military/VA women; Health services research/quality of care; and Psychiatric conditions.

MEASUREMENTS AND MAIN RESULTS

We identified 182 studies. Of these, 2 were randomized-controlled trials (RCTs) and the remainder used observational designs. Forty-five percent of studies were VA funded. We identified 77 studies pertaining to the stress of military life, of which 21 reported on sexual harassment or assault. Rates of harassment ranged from 55% to 79% and rates of sexual assault from 4.2% to 7.3% in active duty military women and 11% to 48% among women veterans. Forty-two studies concerned the health and performance of military/VA women, with 21 studies evaluating sexual assault and posttraumatic stress disorder (PTSD) and their effect on health. Fifty-nine studies assessed various aspects of health services research. Eight studies assessed quality of care and 5, patient satisfaction. Twenty-five studies assessed utilization and health care organization, and findings include that women veterans use the VA less than men, that gender-specific reasons for seeking care were common among female military and veteran personnel, that provision of gender-specific care increased women veterans' use of VA, and that virtually all VAs have available on-site basic women's health services. Fifty studies were classified as psychiatric; 31 of these were about the risk, prevalence, and treatment of PTSD.

CONCLUSIONS

Most research on VA women's health is descriptive in nature and has concerned PTSD, sexual harassment and assault, the utilization and organization of care, and various psychiatric conditions. Experimental studies and studies of the quality of care are rare.