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Eden CM, Kim L, Jao L, Syrnioti G, Johnson J, Liu A, Zhou XK, Siegel B, Newman LA, Malik M, Ju T. Disaggregating the Asian-American Breast Cancer Population: Disparities in Reconstruction Rates. J Surg Res 2024; 298:214-221. [PMID: 38626719 DOI: 10.1016/j.jss.2024.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 02/15/2024] [Accepted: 03/21/2024] [Indexed: 04/18/2024]
Abstract
INTRODUCTION Breast cancer (BC) incidence has been increasing among Asian-Americans (AsAms); recent data suggest these patients are less likely to undergo postmastectomy breast reconstruction (PMBR) compared to non-Asian women. Historically, AsAm BC patients are reported in aggregate, masking heterogeneity within this population. We aim to identify patterns of postmastectomy reconstruction among disaggregated AsAm BC patients at our institution. METHODS A retrospective chart review was performed for BC patients who underwent mastectomy between 2017 and 2021. Patient demographic and clinical information was collected including self-reported race/ethnicity and reconstruction at time of mastectomy. Self-identified Asian patients were disaggregated into East Asian, Southeast Asian, South Asian, and 'Asian Other.' We examined rates of reconstruction between the different races and the disaggregated Asian subgroups. Univariable and multivariable analysis was performed to examine patient factors associated with PMBR. RESULTS Six hundred and five patients met inclusion criteria. Forty seven percent of patients identified as Asian, 36% of which as East Asian. Forty four percent of all patients underwent PMBR. Southeast Asian and South Asian women were least likely to undergo reconstruction, while Hispanic and non-Hispanic Black women were most likely to pursue PMBR (P = 0.020). On multivariable analysis, Hispanic, non-Hispanic White, and non-Hispanic Black women were more likely to undergo reconstruction compared to Asian women. Other factors associated with reconstruction were coverage with private insurance and diagnosis of noninvasive disease. CONCLUSIONS Rates of PMBR are lower among AsAms than non-Asian patients and vary between Asian ethnic subgroups. Further investigation is needed to identify patterns of reconstruction among the disaggregated AsAm population to address disparities.
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Affiliation(s)
- Claire M Eden
- Department of Surgery, New York Presbyterian Queens, Weill Cornell Medicine, Flushing, New York.
| | - Leslie Kim
- Department of Surgery, New York Presbyterian Queens, Weill Cornell Medicine, Flushing, New York
| | - Laura Jao
- Department of Surgery, New York Presbyterian Queens, Weill Cornell Medicine, Flushing, New York
| | - Georgia Syrnioti
- Department of Surgery, New York Presbyterian, Weill Cornell Medicine, New York, New York
| | - Josh Johnson
- Department of Surgery, New York Presbyterian, Weill Cornell Medicine, New York, New York
| | - Anni Liu
- Department of Surgery, New York Presbyterian, Weill Cornell Medicine, New York, New York
| | - Xi Kathy Zhou
- Department of Surgery, New York Presbyterian, Weill Cornell Medicine, New York, New York
| | - Beth Siegel
- Department of Surgery, New York Presbyterian Queens, Weill Cornell Medicine, Flushing, New York
| | - Lisa A Newman
- Department of Surgery, New York Presbyterian, Weill Cornell Medicine, New York, New York
| | - Manmeet Malik
- Department of Surgery, New York Presbyterian Queens, Weill Cornell Medicine, Flushing, New York
| | - Tammy Ju
- Department of Surgery, New York Presbyterian Queens, Weill Cornell Medicine, Flushing, New York
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Lattimore CM, Meneveau MO, Desai R, Camacho TF, Squeo GC, Showalter SL. Are There Disparities in Breast Reconstruction After Contralateral Prophylactic Mastectomy? J Surg Res 2024; 298:277-290. [PMID: 38636184 PMCID: PMC11144118 DOI: 10.1016/j.jss.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 10/26/2023] [Accepted: 03/18/2024] [Indexed: 04/20/2024]
Abstract
INTRODUCTION Despite national guidelines against contralateral prophylactic mastectomy (CPM) in low- to moderate-risk breast cancer, CPM use continues to rise. Breast reconstruction improves health-related quality of life and satisfaction among women undergoing mastectomy. Given the lack of data regarding factors associated with reconstruction after CPM and the known benefits of reconstruction, we sought to investigate whether disparities exist in receipt of reconstruction after CPM. METHODS The 2004-2017 National Cancer Database was queried to identify women diagnosed with breast cancer who underwent unilateral mastectomy with CPM. Patients were divided into two groups: those who underwent planned reconstruction at any timepoint and those who did not. A secondary analysis comparing types of reconstruction (tissue, implant, combined) was conducted. Patient, tumor, and demographic characteristics were analyzed using chi-square test and odds ratios were calculated using generalized estimating equations. RESULTS The cohort included 1,73,249 women: 95,818 (55.3%) underwent reconstruction and 77,431 (45.7%) did not. Both the rate CPM and the proportion of women undergoing reconstruction after CPM increased between 2004 and 2017. Of the women who had reconstruction, 40,840 (51.7%) received implants, 29,807 (37.7%) had tissue, and 8352 (10.6%) had combined reconstruction. After adjusted analysis, factors associated with reconstruction were young age, Hispanic ethnicity, private insurance, and living in an area with the highest education and median income (P < 0.01). Patients who underwent reconstruction were less likely to have radiation (P < 0.01) and chemotherapy (P < 0.01), more likely to have stage I disease (P < 0.01), and to be treated at an integrated cancer center (P < 0.01). CONCLUSIONS Reconstruction after CPM is disproportionately received by younger women, Hispanics, those with private insurance, and higher socioeconomic status and education. While the rate of reconstruction after CPM is increasing, there remain significant disparities. Conscious efforts must be made to eliminate these disparities, especially given the known benefits of reconstruction after mastectomy.
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Affiliation(s)
- Courtney M Lattimore
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Max O Meneveau
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Raj Desai
- Division of Translational Research & Applied Statistics, Department of Public Health Sciences, University of Virginia Health System, Charlottesville, Virginia
| | - T Fabian Camacho
- Division of Translational Research & Applied Statistics, Department of Public Health Sciences, University of Virginia Health System, Charlottesville, Virginia
| | - Gabriella C Squeo
- Department of Plastic and Maxillofacial Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Shayna L Showalter
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia.
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Ray HR, Doren EL, Adamson K, Kong AL, Cortina CS. Risk Factors for Skin Flap and Nipple-Areolar Necrosis in Patients Undergoing Nipple-Sparing Mastectomy With Deep Inferior Epigastric Perforator Flap Reconstruction. Am Surg 2024:31348241250039. [PMID: 38671547 DOI: 10.1177/00031348241250039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024]
Abstract
INTRODUCTION Nipple-sparing mastectomy (NSM) with deep inferior epigastric perforator (DIEP) flap reconstruction is a surgical option for select patients with or at risk of breast cancer. However, post-operative skin flap and nipple-areolar complex (NAC) necrosis remain common complications. This study aimed to identify factors associated with necrosis in patients undergoing NSM with DIEP reconstruction. METHODS A retrospective cohort study was performed from 2015 to 2023. 74 variables were analyzed in patients undergoing NSM with DIEP. Patients were stratified into 3 groups based on post-operative skin/NAC necrosis: none, partial thickness, and full thickness. Comparative and descriptive statistics were performed via t-tests, ANOVA, and chi-squared tests. RESULTS 34 women with 31 breast cancers met inclusion. 44% experienced necrosis: 15% partial thickness and 29% full thickness. The majority were white (85.3%) with mean age of 50 years (SD = 9.11). In patients with immediate DIEP reconstruction, hypoperfused areas identified by SPY angiography increased risk of necrosis (P = .012). Approximately 50% of both partial thickness and full thickness necrosis patients had concerns on SPY angiography. Former smokers in the full thickness necrosis group had more pack years than those without necrosis (9 vs .65 pack years, P = .035). CONCLUSION In patients receiving NSM with DIEP flap reconstruction, those with hypoperfusion on SPY angiography and longer smoking history had higher necrosis rates. This supports the continued used of SPY angiography and the role of pre-operative counseling in former smokers with increased pack years on their risk of necrosis and the role of preventative measures in the perioperative setting.
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Affiliation(s)
- Hannah R Ray
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Erin L Doren
- Department of Plastic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Karri Adamson
- Department of Plastic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Amanda L Kong
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
- Medical College of Wisconsin Cancer Center, Milwaukee, WI, USA
| | - Chandler S Cortina
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
- Medical College of Wisconsin Cancer Center, Milwaukee, WI, USA
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Rogers C, Cobb AN, Lloren JIC, Chaudhary LN, Johnson MK, Huang CC, Teshome M, Kong AL, Singh P, Cortina CS. National trends in neoadjuvant chemotherapy utilization in patients with early-stage node-negative triple-negative breast cancer: the impact of the CREATE-X trial. Breast Cancer Res Treat 2024; 203:317-328. [PMID: 37864105 PMCID: PMC10872271 DOI: 10.1007/s10549-023-07114-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 08/24/2023] [Indexed: 10/22/2023]
Abstract
PURPOSE Neoadjuvant chemotherapy (NAC) for triple-negative breast cancer (TNBC) allows for assessment of tumor pathological response and has survival implications. In 2017, the CREATE-X trial demonstrated survival benefit with adjuvant capecitabine in patients TNBC and residual disease after NAC. We aimed to assess national rates of NAC for cT1-2N0M0 TNBC before and after CREATE-X and examine factors associated with receiving NAC vs adjuvant chemotherapy (AC). METHODS A retrospective cohort study of women with cT1-2N0M0 TNBC diagnosed from 2014 to 2019 in the National Cancer Database (NCDB) was performed. Variables were analyzed via ANOVA, Chi-squared, Fisher Exact tests, and a multivariate linear regression model was created. RESULTS 55,633 women were included: 26.9% received NAC, 52.4% AC, and 20.7% received no chemotherapy (median ages 53, 59, and 71 years, p < 0.01). NAC utilization significantly increased over time: 19.5% in 2014-15 (n = 3,465 of 17,777), 27.1% in 2016-17 (n = 5,140 of 18,985), and 33.6% in 2018-19 (n = 6,337 of 18,871, p < 0.001). On multivariate analysis, increased NAC was associated with younger age (< 50), non-Hispanic white race/ethnicity, lack of comorbidities, cT2 tumors, care at an academic or integrated-network cancer program, and diagnosis post-2017 (p < 0.05 for all). Patients with government-provided insurance were less likely to receive NAC (p < 0.01). Women who traveled > 60 miles for treatment were more likely to receive NAC (p < 0.01). CONCLUSION From 2014 to 2019, NAC utilization increased for patients with cT1-2N0M0 TNBC. Racial, socioeconomic, and access disparities were observed in who received NAC vs AC and warrants interventions to ensure equitable care.
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Affiliation(s)
- Christine Rogers
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI, 53226, USA
| | - Adrienne N Cobb
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI, 53226, USA
| | - Jan I C Lloren
- Zibler School of Public Health, University of Wisconsin at Milwaukee, Milwaukee, WI, USA
| | - Lubna N Chaudhary
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
- Medical College of Wisconsin Cancer Center, Milwaukee, WI, USA
| | - Morgan K Johnson
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI, 53226, USA
| | - Chiang-Ching Huang
- Zibler School of Public Health, University of Wisconsin at Milwaukee, Milwaukee, WI, USA
| | - Mediget Teshome
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amanda L Kong
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI, 53226, USA
- Medical College of Wisconsin Cancer Center, Milwaukee, WI, USA
| | - Puneet Singh
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Chandler S Cortina
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI, 53226, USA.
- Medical College of Wisconsin Cancer Center, Milwaukee, WI, USA.
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Johnson MK, Cortina CS, Hsu TL, Huang S, Frebault J, Huang CC, Kong AL. National Trends in "Going Flat" After Mastectomy. Ann Surg Oncol 2023; 30:6374-6382. [PMID: 37458947 DOI: 10.1245/s10434-023-13845-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 05/28/2023] [Indexed: 09/20/2023]
Abstract
INTRODUCTION The "Going Flat" movement became widely publicized in 2016 and provides information and support to women who choose to forego post-mastectomy breast reconstruction (PMBR). The objectives of this study were to evaluate temporal trends in PMBR to ascertain the potential impact of this movement and assess which factors are associated with going flat. METHODS A retrospective cohort analysis was performed using the NCDB of women with non-metastatic breast cancer who underwent mastectomy between 2004 and 2019. Trends in going flat after mastectomy were examined and stratified by age (< 50, 50-69, ≥ 70). A multivariate logistic regression model was used to identify factors associated with going flat. RESULTS 650,983 patients met the inclusion criteria: 244,201 (37.5%) underwent PMBR and 406,782 (62.5%) went flat. Among women < 70, rates of going flat steadily decreased from 2004 to 2015 and then stabilized after 2015, coinciding with the rise of the "Going Flat" movement. In multivariate analysis, non-White race, older age, increasing comorbidities, government provided insurance, treatment at a community program, radiotherapy, and adjuvant chemotherapy were associated with a higher likelihood of going flat (p < 0.001). CONCLUSION In the first 2 years after the "Going Flat" movement, the number of women going flat after mastectomy has stabilized in women < 70 for the first time in over a decade. These trends suggest that the social and cultural impact of this movement may have contributed to the stabilization of PMBR rates.
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Affiliation(s)
- Morgan K Johnson
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI, 53226, USA
| | - Chandler S Cortina
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI, 53226, USA
- MCW Cancer Center, Milwaukee, WI, USA
| | - Tzu-Lun Hsu
- Zilber School of Public Health, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - Shane Huang
- Department of Statistics, University of Wisconsin-Madison, Madison, WI, USA
| | - Julia Frebault
- Department of Surgery, Hennepin Healthcare, Minneapolis, MN, USA
| | - Chiang-Ching Huang
- Zilber School of Public Health, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - Amanda L Kong
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI, 53226, USA.
- MCW Cancer Center, Milwaukee, WI, USA.
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Johnson MK, Cortina CS, Kong AL. ASO Author Reflections: The Potential Impact of the "Going Flat" Movement on National Rates of Post-Mastectomy Breast Reconstruction. Ann Surg Oncol 2023; 30:6383-6384. [PMID: 37442912 DOI: 10.1245/s10434-023-13869-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 06/19/2023] [Indexed: 07/15/2023]
Affiliation(s)
- Morgan K Johnson
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Chandler S Cortina
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
- MCW Cancer Center, Milwaukee, WI, USA
| | - Amanda L Kong
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.
- MCW Cancer Center, Milwaukee, WI, USA.
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Cortina CS, Cobb AN, Kong AL. Invited Commentary: Current and Future Opportunities in Mitigating Breast Cancer Disparity. J Am Coll Surg 2023; 236:1239-1241. [PMID: 37058342 DOI: 10.1097/xcs.0000000000000664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
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Fasano G, Bayard S, Tamimi R, An A, Zenilman ME, Davis M, Newman L, Bea VJ. Postmastectomy Breast Reconstruction Patterns at an Urban Academic Hospital and the Impact of Surgeon Gender. Ann Surg Oncol 2022; 29:5437-5444. [PMID: 35583690 PMCID: PMC9116063 DOI: 10.1245/s10434-022-11807-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 04/08/2022] [Indexed: 11/18/2022]
Abstract
Background Postmastectomy breast reconstruction is an essential element of multidisciplinary breast cancer care but may be underutilized. Methods This retrospective study analyzed mastectomy patients (2018–2021) at an urban hospital. Multivariable logistic regression was performed, and a mixed-effects logistic regression model was constructed to determine patient-level factors (age, race, body mass index, comorbidities, smoking status, insurance, type of surgery) and provider-level factors (breast surgeon gender, participation in multidisciplinary breast clinic) that influence reconstruction. Results Overall, 167 patients underwent mastectomy. The reconstruction rate was 35%. In multivariable analysis, increasing age (odds ratio [OR] 0.95; 95% confidence interval [CI] 0.91–0.99) and Medicaid insurance (OR 0.18; 95% CI 0.06–0.53) relative to private insurance were negative predictors, whereas bilateral mastectomy was a positive predictor (OR 7.07; 95% CI 2.95–17.9) of reconstruction. After adjustment for patent age, race, insurance, and type of surgery, female breast surgeons had 3.7 times greater odds of operating on patients who had reconstruction than males (95% CI 1.20–11.42). Conclusion Both patient- and provider-level factors have an impact on postmastectomy reconstruction. Female breast surgeons had nearly four times the odds of caring for patients who underwent reconstruction, suggesting that a more standardized process for plastic surgery referral is needed.
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Affiliation(s)
- Genevieve Fasano
- Department of Surgery, New York-Presbyterian, Weill Cornell Medicine, New York, NY, USA
| | - Solange Bayard
- Department of Surgery, New York-Presbyterian, Weill Cornell Medicine, New York, NY, USA
| | - Rulla Tamimi
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Anjile An
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Michael E Zenilman
- Department of Surgery, New York-Presbyterian, Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Melissa Davis
- Department of Surgery, New York-Presbyterian, Weill Cornell Medicine, New York, NY, USA
| | - Lisa Newman
- Department of Surgery, New York-Presbyterian, Weill Cornell Medicine, New York, NY, USA
| | - Vivian J Bea
- Department of Surgery, New York-Presbyterian, Brooklyn Methodist Hospital, Brooklyn, NY, USA.
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Taqi K, Pao JS, Chen L, Ma C, Zhang M, McKevitt E, Bazzarelli A, Dingee C, Warburton R. Immediate breast reconstruction in locally advanced breast cancer: is it safe? Breast Cancer Res Treat 2021; 190:175-182. [PMID: 34467443 DOI: 10.1007/s10549-021-06366-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 08/09/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Immediate breast reconstruction (IBR) following mastectomy remains controversial for locally advanced breast cancer over concerns regarding recurrence and complications which may delay adjuvant therapies. This study aimed to compare the oncologic outcomes and surgical safety of IBR following mastectomy with mastectomy alone (MA) for locally advanced breast cancer. METHODS All patients treated at the Providence Breast Center between 2012 and 2017 for biopsy-proven locally advanced breast cancer, AJCC (8th edition) clinical stages (IIB-IIIC), were included. Primary outcomes were overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS). Secondary outcomes included recurrence rate, adjuvant therapy use, and reoperation. RESULTS 267 patients (112 IBR, 155 MA) were included. On average, IBR patients were younger (48.82 years vs 61.42 years, P < 0.001). Median study follow-up was 50.7 months. OS was higher among IBR patients (86.6% vs 73.5%, P < 0.05). However, no significant differences were found in DSS (87.5% vs 84.5%, P = 0.34), DFS (79.5% vs 78.7%, P = 0.55), local recurrence (0% vs 1.9%, P = 0.194), adjuvant therapy use (95.5% vs 91.6%, P = 0.155), or reoperation (1.8% vs 1.3%, P = 0.559). CONCLUSION IBR is a safe option for patients with locally advanced breast cancer and does not negatively impact survival, cancer recurrence rates, and use of adjuvant therapy.
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Affiliation(s)
- Kadhim Taqi
- Department of Surgery, Division of General Surgery, University of British Columbia Faculty of Medicine, Vancouver, BC, Canada
| | - Jin-Si Pao
- Division of General Surgery, Department of Surgery, Providence Health Care Breast Centre, Providence Breast Centre & University of British Columbia, Mount Saint Joseph Hospital, 3rd Floor, 3080 Prince Edward Street, Vancouver, BC, V5T 3N4, Canada
- Department of Surgery, Division of General Surgery, University of British Columbia Faculty of Medicine, Vancouver, BC, Canada
| | - Leo Chen
- Department of Surgery, Division of General Surgery, University of British Columbia Faculty of Medicine, Vancouver, BC, Canada
| | - Crystal Ma
- Division of General Surgery, Department of Surgery, Providence Health Care Breast Centre, Providence Breast Centre & University of British Columbia, Mount Saint Joseph Hospital, 3rd Floor, 3080 Prince Edward Street, Vancouver, BC, V5T 3N4, Canada
| | - Mabel Zhang
- Division of General Surgery, Department of Surgery, Providence Health Care Breast Centre, Providence Breast Centre & University of British Columbia, Mount Saint Joseph Hospital, 3rd Floor, 3080 Prince Edward Street, Vancouver, BC, V5T 3N4, Canada
| | - Elaine McKevitt
- Division of General Surgery, Department of Surgery, Providence Health Care Breast Centre, Providence Breast Centre & University of British Columbia, Mount Saint Joseph Hospital, 3rd Floor, 3080 Prince Edward Street, Vancouver, BC, V5T 3N4, Canada
- Department of Surgery, Division of General Surgery, University of British Columbia Faculty of Medicine, Vancouver, BC, Canada
| | - Amy Bazzarelli
- Division of General Surgery, Department of Surgery, Providence Health Care Breast Centre, Providence Breast Centre & University of British Columbia, Mount Saint Joseph Hospital, 3rd Floor, 3080 Prince Edward Street, Vancouver, BC, V5T 3N4, Canada
- Department of Surgery, Division of General Surgery, University of British Columbia Faculty of Medicine, Vancouver, BC, Canada
| | - Carol Dingee
- Division of General Surgery, Department of Surgery, Providence Health Care Breast Centre, Providence Breast Centre & University of British Columbia, Mount Saint Joseph Hospital, 3rd Floor, 3080 Prince Edward Street, Vancouver, BC, V5T 3N4, Canada
- Department of Surgery, Division of General Surgery, University of British Columbia Faculty of Medicine, Vancouver, BC, Canada
| | - Rebecca Warburton
- Division of General Surgery, Department of Surgery, Providence Health Care Breast Centre, Providence Breast Centre & University of British Columbia, Mount Saint Joseph Hospital, 3rd Floor, 3080 Prince Edward Street, Vancouver, BC, V5T 3N4, Canada.
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