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Cozzi A, Di Leo G, Houssami N, Gilbert FJ, Helbich TH, Álvarez Benito M, Balleyguier C, Bazzocchi M, Bult P, Calabrese M, Camps Herrero J, Cartia F, Cassano E, Clauser P, de Lima Docema MF, Depretto C, Dominelli V, Forrai G, Girometti R, Harms SE, Hilborne S, Ienzi R, Lobbes MBI, Losio C, Mann RM, Montemezzi S, Obdeijn IM, Aksoy Ozcan U, Pediconi F, Pinker K, Preibsch H, Raya Povedano JL, Rossi Saccarelli C, Sacchetto D, Scaperrotta GP, Schlooz M, Szabó BK, Taylor DB, Ulus SÖ, Van Goethem M, Veltman J, Weigel S, Wenkel E, Zuiani C, Sardanelli F. Preoperative breast MRI positively impacts surgical outcomes of needle biopsy-diagnosed pure DCIS: a patient-matched analysis from the MIPA study. Eur Radiol 2024; 34:3970-3980. [PMID: 37999727 PMCID: PMC11166778 DOI: 10.1007/s00330-023-10409-5] [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: 08/06/2023] [Revised: 09/16/2023] [Accepted: 10/11/2023] [Indexed: 11/25/2023]
Abstract
OBJECTIVES To investigate the influence of preoperative breast MRI on mastectomy and reoperation rates in patients with pure ductal carcinoma in situ (DCIS). METHODS The MIPA observational study database (7245 patients) was searched for patients aged 18-80 years with pure unilateral DCIS diagnosed at core needle or vacuum-assisted biopsy (CNB/VAB) and planned for primary surgery. Patients who underwent preoperative MRI (MRI group) were matched (1:1) to those who did not receive MRI (noMRI group) according to 8 confounding covariates that drive referral to MRI (age; hormonal status; familial risk; posterior-to-nipple diameter; BI-RADS category; lesion diameter; lesion presentation; surgical planning at conventional imaging). Surgical outcomes were compared between the matched groups with nonparametric statistics after calculating odds ratios (ORs). RESULTS Of 1005 women with pure unilateral DCIS at CNB/VAB (507 MRI group, 498 noMRI group), 309 remained in each group after matching. First-line mastectomy rate in the MRI group was 20.1% (62/309 patients, OR 2.03) compared to 11.0% in the noMRI group (34/309 patients, p = 0.003). The reoperation rate was 10.0% in the MRI group (31/309, OR for reoperation 0.40) and 22.0% in the noMRI group (68/309, p < 0.001), with a 2.53 OR of avoiding reoperation in the MRI group. The overall mastectomy rate was 23.3% in the MRI group (72/309, OR 1.40) and 17.8% in the noMRI group (55/309, p = 0.111). CONCLUSIONS Compared to those going directly to surgery, patients with pure DCIS at CNB/VAB who underwent preoperative MRI had a higher OR for first-line mastectomy but a substantially lower OR for reoperation. CLINICAL RELEVANCE STATEMENT When confounding factors behind MRI referral are accounted for in the comparison of patients with CNB/VAB-diagnosed pure unilateral DCIS, preoperative MRI yields a reduction of reoperations that is more than twice as high as the increase in overall mastectomies. KEY POINTS • Confounding factors cause imbalance when investigating the influence of preoperative MRI on surgical outcomes of pure DCIS. • When patient matching is applied to women with pure unilateral DCIS, reoperation rates are significantly reduced in women who underwent preoperative MRI. • The reduction of reoperations brought about by preoperative MRI is more than double the increase in overall mastectomies.
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Affiliation(s)
- Andrea Cozzi
- Unit of Radiology, IRCCS Policlinico San Donato, Via Rodolfo Morandi 30, 20097, San Donato Milanese, Italy
- Imaging Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Giovanni Di Leo
- Unit of Radiology, IRCCS Policlinico San Donato, Via Rodolfo Morandi 30, 20097, San Donato Milanese, Italy
| | - Nehmat Houssami
- The Daffodil Centre, Faculty of Medicine and Health, The University of Sydney (Joint Venture with Cancer Council NSW), Sydney, Australia
| | - Fiona J Gilbert
- Department of Radiology, School of Clinical Medicine, Cambridge Biomedical Campus, University of Cambridge, Cambridge, UK
| | - Thomas H Helbich
- Division of General and Paediatric Radiology, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
- Division of Molecular and Structural Preclinical Imaging, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | | | - Corinne Balleyguier
- Department of Radiology, Institut Gustave Roussy, Villejuif, France
- Biomaps, UMR1281 INSERM, CEA, CNRS, Université Paris-Saclay, Villejuif, France
| | - Massimo Bazzocchi
- Institute of Radiology, Department of Medicine, Ospedale Universitario S. Maria della Misericordia, Università degli Studi di Udine, Udine, Italy
| | - Peter Bult
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Massimo Calabrese
- Unit of Oncological and Breast Radiology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Julia Camps Herrero
- Department of Radiology, Hospital Universitario de La Ribera, Alzira, Spain
- Ribera Salud Hospitals, Valencia, Spain
| | - Francesco Cartia
- Unit of Breast Imaging, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Enrico Cassano
- Breast Imaging Division, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Paola Clauser
- Division of General and Paediatric Radiology, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | | | - Catherine Depretto
- Unit of Breast Imaging, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Valeria Dominelli
- Breast Imaging Division, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Gábor Forrai
- Department of Radiology, MHEK Teaching Hospital, Semmelweis University, Budapest, Hungary
- Department of Radiology, Duna Medical Center, GE-RAD Kft, Budapest, Hungary
| | - Rossano Girometti
- Institute of Radiology, Department of Medicine, Ospedale Universitario S. Maria della Misericordia, Università degli Studi di Udine, Udine, Italy
| | - Steven E Harms
- Breast Center of Northwest Arkansas, Fayetteville, AR, USA
| | - Sarah Hilborne
- Department of Radiology, School of Clinical Medicine, Cambridge Biomedical Campus, University of Cambridge, Cambridge, UK
| | - Raffaele Ienzi
- Department of Radiology, Di.Bi.MED, Policlinico Universitario Paolo Giaccone Università degli Studi di Palermo, Palermo, Italy
| | - Marc B I Lobbes
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Medical Imaging, Zuyderland Medical Center, Sittard-Geleen, The Netherlands
| | - Claudio Losio
- Department of Breast Radiology, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Ritse M Mann
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Radiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Stefania Montemezzi
- Department of Radiology, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Inge-Marie Obdeijn
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Umit Aksoy Ozcan
- Department of Radiology, Acıbadem Atasehir Hospital, Istanbul, Turkey
| | - Federica Pediconi
- Department of Radiological, Oncological and Pathological Sciences, Università degli Studi di Roma "La Sapienza", Rome, Italy
| | - Katja Pinker
- Division of General and Paediatric Radiology, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
- Department of Radiology, Breast Imaging Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Heike Preibsch
- Department of Diagnostic and Interventional Radiology, University Hospital of Tübingen, Tübingen, Germany
| | | | | | - Daniela Sacchetto
- Kiwifarm S.R.L., La Morra, Italy
- Disaster Medicine Service 118, ASL CN1, Levaldigi, Italy
| | | | - Margrethe Schlooz
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Botond K Szabó
- Department of Radiology, Barking Havering and Redbridge University Hospitals NHS Trust, London, UK
| | - Donna B Taylor
- Medical School, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Australia
- Department of Radiology, Royal Perth Hospital, Perth, Australia
| | - Sila Ö Ulus
- Department of Radiology, Acıbadem Atasehir Hospital, Istanbul, Turkey
| | - Mireille Van Goethem
- Gynecological Oncology Unit, Department of Obstetrics and Gynecology, Department of Radiology, Multidisciplinary Breast Clinic, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Jeroen Veltman
- Maatschap Radiologie Oost-Nederland, Oldenzaal, The Netherlands
| | - Stefanie Weigel
- Clinic for Radiology and Reference Center for Mammography, University of Münster, Münster, Germany
| | - Evelyn Wenkel
- Department of Radiology, University Hospital of Erlangen, Erlangen, Germany
| | - Chiara Zuiani
- Institute of Radiology, Department of Medicine, Ospedale Universitario S. Maria della Misericordia, Università degli Studi di Udine, Udine, Italy
| | - Francesco Sardanelli
- Unit of Radiology, IRCCS Policlinico San Donato, Via Rodolfo Morandi 30, 20097, San Donato Milanese, Italy.
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy.
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Miller K, Gannon MR, Medina J, Clements K, Dodwell D, Horgan K, Park MH, Cromwell DA. Mastectomy patterns among older women with early invasive breast cancer in England and Wales: A population-based cohort study. J Geriatr Oncol 2023; 14:101653. [PMID: 37918190 DOI: 10.1016/j.jgo.2023.101653] [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: 06/16/2023] [Revised: 07/29/2023] [Accepted: 10/19/2023] [Indexed: 11/04/2023]
Abstract
INTRODUCTION Older women with early invasive breast cancer (EIBC) are more likely to receive a mastectomy compared with younger women. This study assessed factors associated with receiving a mastectomy among older women with EIBC, with a particular focus on comorbidity and frailty. MATERIALS AND METHODS Women diagnosed with EIBC (stages I-IIIa) aged ≥50 years from 2014 to 2019 in English and Welsh NHS organisations who received breast surgery were identified from cancer registration datasets linked to routine hospital data. Separate multivariable logistic regression models explored factors associated with mastectomy use, within each tumour stage (T1-T3). For each tumour stage, risk-adjusted rates of mastectomy were calculated for each NHS organisation and displayed using funnel plots. RESULTS We included 106,952 women with EIBC: 23.4% received a mastectomy as their first breast cancer surgery. Receipt of mastectomy was more common among patients with a higher tumour stage (T1: 12.3%; T2: 37.6%; T3: 77.5%), and mastectomy use increased with age within each tumour stage category (50-59 vs 80 + years: 11.8% vs 26.3% for T1; 31.5% vs 56.9% for T2; 73.4% vs 90.3% for T3). Results from a multivariable regression model showed that more severe frailty was associated with mastectomy use for women with T1 (p = 0.002) or T2 (p = 0.003) tumours, but may not be for women with T3 tumours (p = 0.041). There was no association between comorbidity and mastectomy use after accounting for frailty (all p > 0.1). Adjusting for clinical and patient factors only slightly reduced the association between age and mastectomy use. Variation in mastectomy use between NHS organisations was greatest for women with T2 EIBC (unadjusted range: 17.7% to 68.4%). DISCUSSION Older women with EIBC are more commonly treated with mastectomy. This could not be explained by tumour characteristics or physical fitness, raising questions about whether surgical decision-making inconsistently incorporates information on patient fitness and functional age.
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Affiliation(s)
- Katie Miller
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK; Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK.
| | - Melissa Ruth Gannon
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK; Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Jibby Medina
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK; Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Karen Clements
- National Cancer Registration and Analysis Service, NHS England, 1st Floor, 5 St Philip's Place, Birmingham, UK
| | - David Dodwell
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Kieran Horgan
- Department of Breast Surgery, St James's University Hospital, Leeds, UK
| | - Min Hae Park
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK; Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - David Alan Cromwell
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK; Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
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Joshi S, Ramarajan L, Ramarajan N, Lee SS, Deshpande O, Fernandes E, Engineer M, Srivastava G, Vanmali V, Kannan S, Hawaldar R, Nair N, Parmar V, Thakkar P, Chitkara G, Gupta S, Badwe R. Effectiveness of a Decision Aid Plus Standard Care in Surgical Management Among Patients With Early Breast Cancer: A Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2335941. [PMID: 37782500 PMCID: PMC10546236 DOI: 10.1001/jamanetworkopen.2023.35941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 08/09/2023] [Indexed: 10/03/2023] Open
Abstract
Importance Patients with early breast cancer must choose between undergoing breast conservation surgery or mastectomy. This decision is often difficult as there are trade-offs between breast conservation and adverse effects, and women with higher decisional conflict have a harder time choosing the therapy that suits their preferences. Objective To study the impact of a decision aid with a patient preference assessment tool for surgical decision-making on patients' decisional conflict scale (DCS) score. Design, Setting, and Participants This 3-group randomized clinical trial was conducted between June 2017 and December 2019 at a single high-volume tertiary care cancer center in Mumbai, India. A research questionnaire comprising 16 questions answered on a Likert scale (from 1, strongly agree, to 5, strongly disagree) was used to measure DCS scores and other secondary psychological variables, with higher scores indicating more decisional conflict. The Navya Patient Preference Tool (Navya-PPT) was developed as a survey-based presentation of evidence in an adaptive, conjoint analysis-based module for and trade-offs between cosmesis, adverse effects of radiotherapy, and cost of mandatory radiation following breast-conserving surgery. Adult patients with histologically proven early breast cancer (cT1-2, N0-1) who were eligible for breast-conserving surgery as per clinicoradiological assessment were included. Those who were pregnant or unable to read the research questionnaire or who had bilateral breast cancer were excluded. Data were analyzed from January to June 2020. Interventions Patients were randomized 1:1:1 to study groups: standard care including clinical explanation about surgery (control), standard care plus the Navya-PPT provided to the patient alone (solo group), and standard care plus the Navya-PPT provided to the patient and a caregiver (joint group). Main Outcomes and Measures The primary end point of the study was DCS score. The study was 80% powered with 2-sided α = .01 to detect an effect size of 0.25 measured by Cohen d, F test analysis of variance, and fixed effects. Results A total of 245 female patients (median [range] age, 48 [23-76] years) were randomized (82 to control, 83 to the solo group, and 80 to the joint group). The median (range) pathological tumor size was 2.5 (0-6) cm. A total of 153 participants (62.4%) had pN0 disease, 185 (75.5%) were hormone receptor positive, 197 (80.4%) were human epidermal growth factor receptor 2 negative, 144 (58.6%) were of middle or lower socioeconomic status, and 114 (46.5%) had an education level lower than a college degree. DCS score was significantly reduced in the solo group compared with control (1.34 vs 1.66, respectively; Cohen d, 0.50; SD, 0.31; P < .001) and the joint group compared with control (1.31 vs 1.66, respectively; Cohen d, 0.54; SD, 0.31; P < .001). Conclusions and Relevance The results of this study demonstrated lower decisional conflict as measured by DCS score following use of the online, self-administered Navya-PPT among patients with early breast cancer choosing between breast-conserving surgery vs mastectomy. Trial Registration Clinical Trials Registry of India Identifier: CTRI/2017/11/010480.
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Affiliation(s)
- Shalaka Joshi
- Department of Surgical Oncology, Tata Memorial Centre, and Homi Bhabha National Institute, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | | | | | - Serenity S. Lee
- The Wharton School, University of Pennsylvania, Philadelphia
| | - Ojas Deshpande
- Clinical Research Secretariat, Tata Memorial Centre and Homi Bhabha National Institute, Mumbai, India
| | - Elizabeth Fernandes
- Clinical Research Secretariat, Tata Memorial Centre and Homi Bhabha National Institute, Mumbai, India
| | - Mitchelle Engineer
- Department of Surgical Oncology, Tata Memorial Centre, and Homi Bhabha National Institute, Mumbai, India
| | | | - Vaibhav Vanmali
- Clinical Research Secretariat, Tata Memorial Centre and Homi Bhabha National Institute, Mumbai, India
| | - Sadhana Kannan
- Clinical Research Secretariat, Tata Memorial Centre and Homi Bhabha National Institute, Mumbai, India
| | - Rohini Hawaldar
- Clinical Research Secretariat, Tata Memorial Centre and Homi Bhabha National Institute, Mumbai, India
| | - Nita Nair
- Department of Surgical Oncology, Tata Memorial Centre, and Homi Bhabha National Institute, Mumbai, India
| | - Vani Parmar
- Department of Surgical Oncology, Tata Memorial Centre, and Homi Bhabha National Institute, Mumbai, India
| | - Purvi Thakkar
- Department of Surgical Oncology, Tata Memorial Centre, and Homi Bhabha National Institute, Mumbai, India
| | - Garvit Chitkara
- Department of Surgical Oncology, Tata Memorial Centre, and Homi Bhabha National Institute, Mumbai, India
| | - Sudeep Gupta
- Department of Medical Oncology, Tata Memorial Centre, and Homi Bhabha National Institute, Mumbai, India
| | - Rajendra Badwe
- Department of Surgical Oncology, Tata Memorial Centre, and Homi Bhabha National Institute, Mumbai, India
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4
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Ryan JF, Lesniak DM, Cordeiro E, Campbell SM, Rajaee AN. Surgeon Factors Influencing Breast Surgery Outcomes: A Scoping Review to Define the Modern Breast Surgical Oncologist. Ann Surg Oncol 2023; 30:4695-4713. [PMID: 37036590 DOI: 10.1245/s10434-023-13472-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 03/26/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND Modern breast surgical oncology incorporates many aspects of care including preoperative workup, surgical management, and multidisciplinary collaboration to achieve favorable oncologic outcomes and high patient satisfaction. However, there is variability in surgical practice and outcomes. This review aims to identify modifiable surgeon factors influencing breast surgery outcomes and provide a definition of the modern breast surgical oncologist. METHODS A systematic literature search with additional backward citation searching was conducted. Studies describing modifiable surgeon factors with associated breast surgery outcomes such as rates of breast conservation, sentinel node biopsy, re-excision, complications, acceptable esthetic outcome, and disease-free and overall survival were included. Surgeon factors were categorized for qualitative analysis. RESULTS A total of 91 studies met inclusion criteria describing both modifiable surgeon factor and outcome data. Four key surgeon factors associated with improved breast surgery outcomes were identified: surgical volume (45 studies), use of oncoplastic techniques (41 studies), sub-specialization in breast surgery or surgical oncology (9 studies), and participation in professional development activities (5 studies). CONCLUSIONS On the basis of the literature review, the modern breast surgical oncologist has a moderate- to high-volume breast surgery practice, understands the use and application of oncoplastic breast surgery, engages in additional training opportunities, maintains memberships in relevant societies, and remains up to date on key literature. Surgeons practicing in breast surgical oncology can target these modifiable factors for professional development and quality improvement.
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Affiliation(s)
- Joanna F Ryan
- Department of Surgery, University of Alberta, Edmonton, Canada
| | - David M Lesniak
- Department of Surgery, University of Alberta, Edmonton, Canada
| | - Erin Cordeiro
- Department of Surgery, University of Ottawa, Ottawa, Canada
| | - Sandra M Campbell
- John W. Scott Health Sciences Library, University of Alberta, Edmonton, Canada
| | - A Nikoo Rajaee
- Department of Surgery, University of Alberta, Edmonton, Canada.
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Chen YW, Orlas C, Kim T, Chang DC, Kelleher CM. Workforce Attrition Among Male and Female Physicians Working in US Academic Hospitals, 2014-2019. JAMA Netw Open 2023; 6:e2323872. [PMID: 37459094 PMCID: PMC10352856 DOI: 10.1001/jamanetworkopen.2023.23872] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 05/28/2023] [Indexed: 07/20/2023] Open
Abstract
Importance Retaining female physicians in the academic health care workforce is necessary to serve the needs of sociodemographically diverse patient populations. Objective To investigate differences in rates of leaving academia between male and female physicians. Design, Setting, and Participants This cohort study used Care Compare data from the Centers for Medicare & Medicaid Services for all physicians who billed Medicare from teaching hospitals from March 2014 to December 2019, excluding physicians who retired during the study period. Data were analyzed from November 11, 2021, to May 24, 2022. Exposure Physician gender. Main Outcome and Measures The primary outcome was leaving academia, which was defined as not billing Medicare from a teaching hospital for more than 1 year. Multivariable logistic regression was conducted adjusting for physician characteristics and region of the country. Results There were 294 963 physicians analyzed (69.5% male). The overall attrition rate from academia was 34.2% after 5 years (38.3% for female physicians and 32.4% for male physicians). Female physicians had higher attrition rates than their male counterparts across every career stage (time since medical school graduation: <15 years, 40.5% vs 34.8%; 15-29 years, 36.4% vs 30.3%; ≥30 years, 38.5% vs 33.3%). On adjusted analysis, female physicians were more likely to leave academia than were their male counterparts (odds ratio, 1.25; 95% CI, 1.23-1.28). Conclusions and Relevance In this cohort study, female physicians were more likely to leave academia than were male physicians at all career stages. The findings suggest that diversity, equity, and inclusion efforts should address attrition issues in addition to recruiting more female physicians into academic medicine.
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Affiliation(s)
- Ya-Wen Chen
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
- Codman Center for Clinical Effectiveness in Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
| | - Claudia Orlas
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
- Pediatric Surgery Trials and Outcomes Research Center, MassGeneral Hospital for Children, Boston, Massachusetts
| | - Tommy Kim
- Codman Center for Clinical Effectiveness in Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
- UMass Chan Medical School, Worcester, Massachusetts
| | - David C. Chang
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
- Codman Center for Clinical Effectiveness in Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
| | - Cassandra M. Kelleher
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
- Pediatric Surgery Trials and Outcomes Research Center, MassGeneral Hospital for Children, Boston, Massachusetts
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6
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Dutta R, Mahajan A, Patil P, Bhandoria G, Sarang B, Virk S, Khajanchi M, Jain S, Bains L, Bhandarkar P, Chatterjee S, Roy N, Gadgil A. Breast Conservative Surgery for Breast Cancer: Indian Surgeon's Preferences and Factors Influencing Them. Indian J Surg Oncol 2023; 14:11-17. [PMID: 36891421 PMCID: PMC9986359 DOI: 10.1007/s13193-022-01601-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 07/19/2022] [Indexed: 11/29/2022] Open
Abstract
Background It is well established that disease-free survival and overall survival after breast conservation surgery (BCS) followed by radiotherapy are equivalent to that after mastectomy. However, in Asian countries, the rate of BCS continues to remain low. The cause may be multifactorial including the patient's choice, availability and accessibility of infrastructure, and surgeon's choice. We aimed to elucidate the Indian surgeons' perspective while choosing between BCS and mastectomy, in women oncologically eligible for BCS. Methods We conducted a survey-based cross-sectional study in January-February 2021. Indian surgeons with general surgical or specialised oncosurgical training, who consented to participate were included in the study. Multinomial logistic regression was performed to assess the effect of study variables on offering mastectomy or BCS. Results A total of 347 responses were included. The mean age of the participants was 43 ± 11 years. Sixty-three of the surgeons were in the 25-44 years age group with the majority (80%) being males. 66.4% of surgeons 'almost always' offered BCS to oncologically eligible patients. Surgeons who had undergone specialised training in oncosurgery or breast conservation surgery were 35 times more likely to offer BCS (p < 0.01). Surgeons working in hospitals with in-house radiation oncology facilities were 9 times more likely to offer BCS (p < 0.05). Surgeons' years of practice, age, sex and hospital setting did not influence the surgery offered. Conclusion Two-thirds of Indian surgeons preferred BCS over mastectomy. Lack of radiotherapy facilities and specialised surgical training were deterrents to offering BCS to eligible women. Supplementary Information The online version contains supplementary material available at 10.1007/s13193-022-01601-y.
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Affiliation(s)
- Rohini Dutta
- World Health Organisation Collaborating Centre for Research in Surgical Care Delivery in Low-Middle-Income Countries, Mumbai, India.,Christian Medical College and Hospital, Ludhiana, Punjab India
| | - Anshul Mahajan
- World Health Organisation Collaborating Centre for Research in Surgical Care Delivery in Low-Middle-Income Countries, Mumbai, India.,Government Medical College Amritsar, Punjab, India
| | - Priti Patil
- World Health Organisation Collaborating Centre for Research in Surgical Care Delivery in Low-Middle-Income Countries, Mumbai, India
| | - Geetu Bhandoria
- World Health Organisation Collaborating Centre for Research in Surgical Care Delivery in Low-Middle-Income Countries, Mumbai, India
| | - Bhakti Sarang
- World Health Organisation Collaborating Centre for Research in Surgical Care Delivery in Low-Middle-Income Countries, Mumbai, India
| | - Sargun Virk
- Sri Guru Ram Das Institute of Health and Science, Amritsar, Punjab India
| | - Monty Khajanchi
- World Health Organisation Collaborating Centre for Research in Surgical Care Delivery in Low-Middle-Income Countries, Mumbai, India
| | - Samarvir Jain
- World Health Organisation Collaborating Centre for Research in Surgical Care Delivery in Low-Middle-Income Countries, Mumbai, India.,Dayanand Medical College and Hospital, Ludhiana, Punjab India
| | - Lovenish Bains
- World Health Organisation Collaborating Centre for Research in Surgical Care Delivery in Low-Middle-Income Countries, Mumbai, India.,Maulana Azad Medical College, New Delhi, India
| | - Prashant Bhandarkar
- World Health Organisation Collaborating Centre for Research in Surgical Care Delivery in Low-Middle-Income Countries, Mumbai, India
| | - Shamita Chatterjee
- Institute of Post-Graduate Medical Education & Research, Seth Sukhlal Karnani Memorial Hospital, Kolkata, India
| | - Nobhojit Roy
- World Health Organisation Collaborating Centre for Research in Surgical Care Delivery in Low-Middle-Income Countries, Mumbai, India.,Department of Public Health Systems, Karolinska Institute, 171 77 Stockholm, Sweden.,The George Institute for Global Health, New Delhi, India
| | - Anita Gadgil
- World Health Organisation Collaborating Centre for Research in Surgical Care Delivery in Low-Middle-Income Countries, Mumbai, India.,The George Institute for Global Health, New Delhi, India
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7
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Li Z, Liu Y, Zhang J, Li Y, Du K, Zhang S, Han H, Zhang J. A large single-center prospective study to investigate the factors influencing the choice of breast-conserving surgery versus mastectomy in Chinese women with early breast cancer. World J Surg Oncol 2023; 21:43. [PMID: 36765355 PMCID: PMC9921411 DOI: 10.1186/s12957-023-02924-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 01/30/2023] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND Compared to mastectomy, breast-conserving surgery (BCS) provides the same survival rate and a higher quality of life for patients with early breast cancer (EBC). However, Chinese women with EBC are known to have a low BCS rate. A large prospective cohort study was conducted to investigate the factors influencing the choice of BCS in this population. METHODS In 2017, all women with unilateral EBC and eligible for BCS at our institution were enrolled. Before surgery, the patient's trust in the surgeon and her perceived strength of the surgeon's recommendation of BCS were measured through an in-person interview and validated ad hoc questionnaire. Multivariate logistic regressions on BCS procedure vs. mastectomy were used to estimate the odds ratio (OR). RESULTS One thousand one hundred thirty-six patients enrolled at analysis had an average age of 51.8 and tumor size of 2.4 cm. 19.9% of patients had BCS. The "strong" level of trust in the surgeon was significantly associated with BCS with an OR of 2.944 (p<0.001) when compared to the "average or under" trust. The "strong" and "moderate" strengths in surgeon recommendation for BCS were also found to be significantly associated with the BCS procedure with ORs of 12.376 (p <0.001) and 1.757 (p =0.040), respectively, compared to the "neutral or dissuaded" strength. CONCLUSIONS Stronger trust in surgeons and BCS recommendation by surgeons are associated with a higher rate of BCS in Chinese women with EBC. Interventional trials are needed to confirm this finding.
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Affiliation(s)
- Zhensheng Li
- Department of Radiation Oncology, the Fourth Hospital of Hebei Medical University, Shijiazhuang, 050035, China.
| | - Yunjiang Liu
- Department of Breast Surgery, the Fourth Hospital of Hebei Medical University, Shijiazhuang, 050035, China.
| | - Jing Zhang
- grid.452582.cDepartment of Breast Surgery, the Fourth Hospital of Hebei Medical University, Shijiazhuang, 050035 China
| | - Yue Li
- grid.452582.cDepartment of Radiation Oncology, the Fourth Hospital of Hebei Medical University, Shijiazhuang, 050035 China
| | - Kaiye Du
- grid.452582.cDepartment of Radiation Oncology, the Fourth Hospital of Hebei Medical University, Shijiazhuang, 050035 China
| | - Shuo Zhang
- grid.452582.cDepartment of Breast Surgery, the Fourth Hospital of Hebei Medical University, Shijiazhuang, 050035 China
| | - Huina Han
- grid.452582.cDepartment of Radiation Oncology, the Fourth Hospital of Hebei Medical University, Shijiazhuang, 050035 China
| | - Jun Zhang
- grid.452582.cDepartment of Radiation Oncology, the Fourth Hospital of Hebei Medical University, Shijiazhuang, 050035 China
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8
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Lee ACH, Madariaga MLL, Liao C, Ferguson MK. Gender Bias in Judging Frailty and Fitness for Lung Surgery. Ann Thorac Surg 2023; 115:356-361. [PMID: 34902299 DOI: 10.1016/j.athoracsur.2021.11.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 10/20/2021] [Accepted: 11/16/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Disparities in surgical care for lung cancer have been well documented, and unconscious bias may be a source of inequity. We assessed whether gender biases exist when nonclinical decision makers render decisions about major lung surgery. METHODS Amazon Mechanical Turk workers, remotely located "crowdworkers" readily available for hire to perform discrete on-demand tasks on the Amazon Mechanical Turk platform, were each shown 4 videos of different standardized patients (SPs) in a clinic setting, 1 video in each energy level (vigorous or frail) and race category (White or Black), randomized to male or female. Workers scored video characteristics and whether they would support the SP's decision to undergo a major lung operation. RESULTS A total of 855 workers were recruited. The frail White male SP was more likely to have support to undergo lung surgery than the frail White female SP, while the frail Black male SP was much less likely to have support to undergo lung surgery than the frail Black female SP. There were no significant differences in support for surgery between the vigorous male and female SPs and ratings by male and female workers in their recommendations. CONCLUSIONS Biases related to patient gender exist in the general population and affect views on surgery, particularly in the setting of frailty. Understanding such differences may aid in educational efforts directed at reducing gender-based biases in treatment recommendations.
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Affiliation(s)
- Andy Chao Hsuan Lee
- Section of Thoracic Surgery, Department of Surgery, University of Chicago, Chicago, Illinois
| | - Maria Lucia L Madariaga
- Section of Thoracic Surgery, Department of Surgery, University of Chicago, Chicago, Illinois
| | - Chuanhong Liao
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois
| | - Mark K Ferguson
- Section of Thoracic Surgery, Department of Surgery, University of Chicago, Chicago, Illinois.
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9
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Kelleher CM, Chang DC. Equal Work for Equal Pay. Ann Surg 2023; 277:e247-e248. [PMID: 36538636 DOI: 10.1097/sla.0000000000005734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Cassandra M Kelleher
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
- Pediatric Surgery Trials and Outcomes Research Center (PSTORC), MassGeneral for Children Boston, MA, USA
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
- Codman Center for Clinical Effectiveness in Surgery Boston, MA, USA
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10
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Rooney MM, Thomas SM, Taskindoust M, Greenup RA, Rosenberger LH, Hwang ES, Plichta JK. The role of tumor phenotype in the surgical treatment of early-stage breast cancer. Am J Surg 2023; 225:84-92. [PMID: 36180300 PMCID: PMC9912362 DOI: 10.1016/j.amjsurg.2022.09.029] [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: 04/18/2022] [Revised: 07/10/2022] [Accepted: 09/18/2022] [Indexed: 01/29/2023]
Abstract
BACKGROUND We investigated whether tumor phenotype influences surgical decision-making, and how that may impact overall survival (OS) for early-stage breast cancer. METHODS Women aged 18-69 with cT0-2/cN0/cM0 breast cancer in the National Cancer Database (2010-2017) were included. A generalized logistic model was used to identify factors associated with surgery type. A Kaplan-Meier curve was used to visualize unadjusted OS, and the log-rank test was used to test for differences in OS between surgery types. RESULTS Of 597,149 patients, 58% underwent lumpectomy with radiation (BCT), 25% unilateral mastectomy (UM), and 17% bilateral mastectomy (BM). After adjustment, HER2+ and triple-negative (TN) tumors were less likely to undergo UM than BCT, versus hormone receptor-positive tumors (OR = 0.881, 95% CI = 0.860-0.903; OR = 0.485, 95% CI = 0.470-0.501). UM and BM had worse 5-year OS versus BCT (UM: 0.926, vs BM: 0.952, vs BCT: 0.960). CONCLUSIONS BCT is increasingly used to treat HER2+ and TN tumors. More extensive surgery is not associated with better survival outcomes, regardless of tumor phenotype.
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Affiliation(s)
| | - Samantha M Thomas
- Duke Cancer Institute, Durham, NC, USA; Duke University, Department of Biostatistics & Bioinformatics, Durham, NC, USA
| | | | | | - Laura H Rosenberger
- Duke Cancer Institute, Durham, NC, USA; Duke University Medical Center, Department of Surgery, Durham, NC, USA
| | - E Shelley Hwang
- Duke Cancer Institute, Durham, NC, USA; Duke University Medical Center, Department of Surgery, Durham, NC, USA
| | - Jennifer K Plichta
- Duke Cancer Institute, Durham, NC, USA; Duke University Medical Center, Department of Surgery, Durham, NC, USA; Duke University Medical Center, Department of Population Health Sciences, New Haven, NC, USA.
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11
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Gong P, Chin SL, Allen WM, Ballal H, Anstie JD, Chin L, Ismail HM, Zilkens R, Lakhiani DD, McCarthy M, Fang Q, Firth D, Newman K, Thomas C, Li J, Sanderson RW, Foo KY, Yeomans C, Dessauvagie BF, Latham B, Saunders CM, Kennedy BF. Quantitative Micro-Elastography Enables In Vivo Detection of Residual Cancer in the Surgical Cavity during Breast-Conserving Surgery. Cancer Res 2022; 82:4093-4104. [PMID: 36098983 PMCID: PMC9627129 DOI: 10.1158/0008-5472.can-22-0578] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 05/29/2022] [Accepted: 09/08/2022] [Indexed: 01/07/2023]
Abstract
Breast-conserving surgery (BCS) is commonly used for the treatment of early-stage breast cancer. Following BCS, approximately 20% to 30% of patients require reexcision because postoperative histopathology identifies cancer in the surgical margins of the excised specimen. Quantitative micro-elastography (QME) is an imaging technique that maps microscale tissue stiffness and has demonstrated a high diagnostic accuracy (96%) in detecting cancer in specimens excised during surgery. However, current QME methods, in common with most proposed intraoperative solutions, cannot image cancer directly in the patient, making their translation to clinical use challenging. In this proof-of-concept study, we aimed to determine whether a handheld QME probe, designed to interrogate the surgical cavity, can detect residual cancer directly in the breast cavity in vivo during BCS. In a first-in-human study, 21 BCS patients were scanned in vivo with the QME probe by five surgeons. For validation, protocols were developed to coregister in vivo QME with postoperative histopathology of the resected tissue to assess the capability of QME to identify residual cancer. In four cavity aspects presenting cancer and 21 cavity aspects presenting benign tissue, QME detected elevated stiffness in all four cancer cases, in contrast to low stiffness observed in 19 of the 21 benign cases. The results indicate that in vivo QME can identify residual cancer by directly imaging the surgical cavity, potentially providing a reliable intraoperative solution that can enable more complete cancer excision during BCS. SIGNIFICANCE Optical imaging of microscale tissue stiffness enables the detection of residual breast cancer directly in the surgical cavity during breast-conserving surgery, which could potentially contribute to more complete cancer excision.
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Affiliation(s)
- Peijun Gong
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia.,Corresponding Author: Peijun Gong, BRITElab, Harry Perkins Institute of Medical Research, Perth 6009, Australia. Phone: 61-8-6488-6774; E-mail:
| | - Synn Lynn Chin
- Breast Centre, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Wes M. Allen
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia
| | - Helen Ballal
- Breast Centre, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - James D. Anstie
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia
| | - Lixin Chin
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia
| | - Hina M. Ismail
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia
| | - Renate Zilkens
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Division of Surgery, Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Devina D. Lakhiani
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia
| | | | - Qi Fang
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia
| | - Daniel Firth
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia
| | - Kyle Newman
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia
| | - Caleb Thomas
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia
| | - Jiayue Li
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia.,Australian Research Council Centre for Personalised Therapeutics Technologies, Melbourne, Victoria, Australia
| | - Rowan W. Sanderson
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia
| | - Ken Y. Foo
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia
| | - Chris Yeomans
- PathWest, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Benjamin F. Dessauvagie
- PathWest, Fiona Stanley Hospital, Murdoch, Western Australia, Australia.,Division of Pathology and Laboratory Medicine, Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Bruce Latham
- PathWest, Fiona Stanley Hospital, Murdoch, Western Australia, Australia.,The University of Notre Dame, Fremantle, Western Australia, Australia
| | - Christobel M. Saunders
- Breast Centre, Fiona Stanley Hospital, Murdoch, Western Australia, Australia.,Division of Surgery, Medical School, The University of Western Australia, Perth, Western Australia, Australia.,Breast Clinic, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Brendan F. Kennedy
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia.,Australian Research Council Centre for Personalised Therapeutics Technologies, Melbourne, Victoria, Australia
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12
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Zaveri S, Nevid D, Ru M, Moshier E, Pisapati K, Reyes SA, Port E, Romanoff A. Racial Disparities in Time to Treatment Persist in the Setting of a Comprehensive Breast Center. Ann Surg Oncol 2022; 29:6692-6703. [PMID: 35697955 DOI: 10.1245/s10434-022-11971-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 05/16/2022] [Indexed: 01/02/2023]
Abstract
BACKGROUND Racial disparities in breast cancer care have been linked to treatment delays. We explored whether receiving care at a comprehensive breast center could mitigate disparities in time to treatment. METHODS Retrospective chart review identified breast cancer patients who underwent surgery from 2012 to 2018 at a comprehensive breast center. Time-to-treatment intervals were compared among self-identified racial and ethnic groups by negative binomial regression models. RESULTS Overall, 2094 women met the inclusion criteria: 1242 (59%) White, 262 (13%) Black, 302 (14%) Hispanic, 105 (5%) Asian, and 183 (9%) other race or ethnicity. Black and Hispanic patients more often had Medicaid insurance, higher American Society of Anesthesiologists (ASA) scores, advanced-stage breast cancer, mastectomy, and additional imaging after breast center presentation (p < 0.05). After controlling for other variables, racial or ethnic minority groups had consistently longer intervals to treatment, with Black women experiencing the greatest disparity (incidence rate ratio 1.42). Time from initial comprehensive breast center visit to treatment was also significantly shorter in White patients versus non-White patients (p < 0.0001). Black race, Medicaid insurance/being uninsured, older age, earlier stage, higher ASA score, undergoing mastectomy, having reconstruction, and requiring additional pretreatment work-up were associated with a longer time from initial visit at the comprehensive breast center to treatment on multivariable analysis (p < 0.05). CONCLUSION Racial or ethnic minority groups have significant delays in treatment even when receiving care at a comprehensive breast center. Influential factors include insurance delays and necessity of additional pretreatment work-up. Specific policies are needed to address system barriers in treatment access.
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Affiliation(s)
- Shruti Zaveri
- Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Daniella Nevid
- Dubin Breast Center, Tisch Cancer Institute, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Meng Ru
- Department of Population Health Science and Policy, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Erin Moshier
- Department of Population Health Science and Policy, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kereeti Pisapati
- Dubin Breast Center, Tisch Cancer Institute, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sylvia A Reyes
- Dubin Breast Center, Tisch Cancer Institute, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Elisa Port
- Dubin Breast Center, Tisch Cancer Institute, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Anya Romanoff
- Department of Global Health and Health System Design, The Icahn School of Medicine at Mount Sinai, New York, NY, USA. .,The New York Academy of Medicine, 1216 Fifth Avenue, Room 556C, New York, NY, 10029, USA.
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13
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Faeni H, Yarso KY, Wasita B, Rahayu RF, Suyatmi S, Wiyono N, Persik RN, Wicaksana IH, Azmiardi A, Ramadhanty Z. Age as a Determinant in Selecting Type of Breast Cancer Surgery in Lovely Pink Solo Cancer Community. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.8683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Breast-Conserving Surgery as a treatment option for older patients with early breast cancerHanum Faeni, MD1., Kristanto Yuli Yarso, MD2., Brian Wasita, MD3., Rachmi Fauziah Rahayu, MD4., Suyatmi Suyatmi, MD5., Nanang Wiyono, MD6., Riza Novierta Persik, MD3., Iman Hakim Wicaksana, MD1., Akhmad Azmiardi, MD7., Zhafira Ramadhanty, MD8.1 Resident of Surgery, Department of Surgery, Universitas Sebelas Maret, Surakarta, Jawa Tengah, Indonesia2 Oncology Surgeon, Department of Surgery, Universitas Sebelas Maret, Surakarta, Jawa Tengah, Indonesia3 Department of Anatomical Pathology, Universitas Sebelas Maret, Surakarta, Jawa Tengah, Indonesia4 Department of Radiology, Universitas Sebelas Maret, Surakarta, Jawa Tengah, Indonesia5 Department of Histology, Universitas Sebelas Maret, Surakarta, Jawa Tengah, Indonesia6 Department of Anatomy, Universitas Sebelas Maret, Surakarta, Jawa Tengah, Indonesia7 Doctoral Program on Public Health, Universitas Sebelas Maret, Surakarta, Jawa Tengah, Indonesia8 Medical Student, Universitas Sebelas Maret, Surakarta, Jawa Tengah, Indonesia
Objective: Breast cancer is one of the most common malignancies in Indonesia. Breast cancer occurs due to rapid and abnormal cell growth due to infiltration of lymphatic tissue and blood vessels. For this reason, surgery is vital to use as a treatment for breast cancer at an early stage. There are two surgical methods: Breast-Conserving Surgery (BCS) and mastectomy. In this regard, several factors have been studied to influence patients in choosing BCS or mastectomy. Looking at the age factor, the results varied and differed significantly throughout the study.Method: This analytical study used a retrospective cross-sectional approach. The research subjects were patients with breast cancer who were the Lovely Pink community members in Surakarta City, Central Java. Subjects were selected by simple random sampling with inclusion criteria consisting of female patients aged 20 to 80 years, being diagnosed with stage 1 and 2 breast cancer, and having received surgery employing BCS or mastectomy techniques.Result: This study was conducted on 218 breast cancer patients who had undergone mastectomy or BCS in Surakarta City, Central Java. It was found that 104 patients were < 50 years old and 114 patients > 50 years old. 76 patients (34.9%) and 142 patients (65.1%) had a total income of more or less than Rp2.5 million/month. As many as 155 patients (71.1%) and 63 patients (28.9%) had no history of disease. Based on the type of surgery performed, 141 people (64.7%) underwent mastectomy, and 77 people (35.3%) underwent BCS.Conclusion: It can be concluded that patients prefer to undergo mastectomy with significant results at the age of under and above 50 years supported by income, medical history, and work history.Keywords: breast-conserving surgery, mastectomy, age
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14
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Modified Radical Mastectomy vs Breast-Conserving Surgery: Current Clinical Practice in Women with Early Stage Breast Cancer at a Corporate Tertiary Cancer Center in India. Indian J Surg Oncol 2021; 13:322-328. [DOI: 10.1007/s13193-021-01457-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 09/28/2021] [Indexed: 10/20/2022] Open
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15
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Philpot S, Youl PH, Harden H, Morris M, Furnival C, Dunn N, Moore J, Theile DE. Development and implementation of a population-based breast cancer quality index in Queensland, Australia. J Cancer Policy 2021; 29:100291. [DOI: 10.1016/j.jcpo.2021.100291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 05/16/2021] [Accepted: 05/26/2021] [Indexed: 11/28/2022]
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16
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Response to: Comment on "Underemployment of Female Surgeons" The Global Challenge of Unequal Work Opportunities for Women in Surgery. Ann Surg 2021; 274:e919-e920. [PMID: 34016815 DOI: 10.1097/sla.0000000000004943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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17
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Atallah D, Arab W, El Kassis N, Nasser Ayoub E, Chahine G, Salem C, Moubarak M. Breast and tumor volumes on 3D-MRI and their impact on the performance of a breast conservative surgery (BCS). Breast J 2020; 27:252-255. [PMID: 33336469 DOI: 10.1111/tbj.14137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 12/07/2020] [Accepted: 12/08/2020] [Indexed: 01/11/2023]
Abstract
Breast conservation rate is being increasingly used nowadays as a marker of breast cancer care among hospitals. Searching for the ideal technique to predict the feasibility of BCS is ongoing. For this matter, the preoperative MRIs of 169 patients operated with radical or conservative surgery were reviewed. We estimated the tumor volume (TV) and breast volume (BV) on enhanced 3D-MRI and compared the tumor-to-breast volume ratio (TV/BV) in both groups. The mean ratio was 9.5% in the mastectomy group and 1.7% in the BCS group. A tumor-to-breast volume ratio less than 4% seemed to favor the adoption of a conservative option. Our data suggest that preoperative 3D-MRI can orient the surgical approach by assessing the TV/BV ratio, increasing lumpectomy rates with clear margins and good cosmetic outcome.
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Affiliation(s)
- David Atallah
- Faculty of Medicine, Saint Joseph University, Beirut, Lebanon.,Department of Gynecology and Obstetrics, Hôtel-Dieu de France University Hospital, Beirut, Lebanon
| | - Wissam Arab
- Faculty of Medicine, Saint Joseph University, Beirut, Lebanon.,Department of Gynecology and Obstetrics, Hôtel-Dieu de France University Hospital, Beirut, Lebanon
| | - Nadine El Kassis
- Faculty of Medicine, Saint Joseph University, Beirut, Lebanon.,Department of Gynecology and Obstetrics, Hôtel-Dieu de France University Hospital, Beirut, Lebanon
| | - Eliane Nasser Ayoub
- Faculty of Medicine, Saint Joseph University, Beirut, Lebanon.,Department of Anesthesiology, Hôtel-Dieu de France University Hospital, Beirut, Lebanon
| | - Georges Chahine
- Faculty of Medicine, Saint Joseph University, Beirut, Lebanon.,Department of Oncology, Hôtel-Dieu de France University Hospital, Beirut, Lebanon
| | - Christine Salem
- Faculty of Medicine, Saint Joseph University, Beirut, Lebanon.,Department of Radiology, Hôtel-Dieu de France University Hospital, Beirut, Lebanon
| | - Malak Moubarak
- Faculty of Medicine, Saint Joseph University, Beirut, Lebanon.,Department of Gynecology and Obstetrics, Hôtel-Dieu de France University Hospital, Beirut, Lebanon
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18
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Savelberg W, Boersma LJ, Smidt M, van der Weijden T. Implementing a breast cancer patient decision aid: Process evaluation using medical files and the patients' perspective. Eur J Cancer Care (Engl) 2020; 30:e13387. [PMID: 33314448 PMCID: PMC8365645 DOI: 10.1111/ecc.13387] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 10/29/2020] [Accepted: 11/18/2020] [Indexed: 11/30/2022]
Abstract
Objective Although patient decision aids (PtDAs) have been shown to improve shared decision‐making, integration into clinical care pathways remains limited. This study investigated, among other outcomes, the uptake of the PtDA by professionals and the uptake as perceived by patients. Methods We performed a process evaluation among four breast cancer care teams that had been exposed to a multifaceted implementation strategy. Data were gathered by auditing patient files using a standardised data extraction sheet and conducting telephone interviews with patients using a structured interview guide. We analysed the data by using descriptive statistics. Results We found that the implementation strategies, including advice on how and when to present the PtDA to the patient, were followed for 14% of the included patients (N = 84); 92% of the patients reported to have received a login code for the web‐based PtDA, while 67% logged in and used the PtDA at home. An important factor influencing the use was the clinician promoting it when delivering the PtDA (OR 9.95 95% CI 3.03–37.72). Discussion The implementation strategies were followed in 14% of the patients, and a high delivery of the PtDA was achieved. Redesigning the care pathway and providing personal instruction on using PtDAs seem crucial.
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Affiliation(s)
- Wilma Savelberg
- Department of Quality and Safety, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Liesbeth J Boersma
- Department of Radiotherapy (MAASTRO Clinic), Maastricht University Medical Centre, Maastricht, The Netherlands.,GROW School for Oncology and Developmental Biology, Maastricht, The Netherlands
| | - Marjolein Smidt
- GROW School for Oncology and Developmental Biology, Maastricht, The Netherlands.,Department of surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Trudy van der Weijden
- School CAPHRI, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands.,Department of Family Medicine, Maastricht University, Maastricht, The Netherlands
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Arabandi P, Slade AN, Sutton AL, McGuire KP, Sheppard V. Racial differences in the relationship between surgical choice and subsequent patient-reported satisfaction outcomes among women with early-stage hormone-positive breast cancer. Breast Cancer Res Treat 2020; 183:459-466. [PMID: 32676991 DOI: 10.1007/s10549-020-05784-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 07/02/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE The last fifteen years has seen a rising proportion of women who are eligible for breast conserving therapy (BCT) choosing mastectomy despite equivalent survival in early-stage breast cancer. We aim to explore potential racial differences in the association of surgical choice with subsequent patient-reported satisfaction outcomes. METHODS Women who were within one year of diagnosis with hormone receptor (HR)-positive breast cancer were asked the Short Version of Patient Satisfaction Questionnaire (PSQ-18), which assesses their overall satisfaction with their medical care. We conducted bivariate analyses, including paired t-tests, to clarify differences in these patient-reported factors by surgical choice and race. Multivariable linear regression models were used to adjust for clinical and demographic control variables. RESULTS For the sample of 279 women who underwent definitive surgery, women who received a mastectomy had lower levels of overall satisfaction, 71 vs. 75 (out of 90) (p = .001). In stratifying this relationship by race, the difference in total satisfaction score was largest among Black women (69 among mastectomy patients vs. 75 among BCT patients; p = 0.016). On multivariable linear regression, Black race and mastectomy status (together) exhibited a significantly large negative association with total satisfaction score, with negative associations across all domains of the PSQ-18. CONCLUSION Despite the high prevalence of mastectomy among Black women with early-stage, HR-positive breast cancer, this population is more likely to report lower levels of patient satisfaction compared to patients receiving BCT. These findings suggest there may be potential racial differences in the psychosocial consequences of surgical choice.
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Affiliation(s)
- Prudvi Arabandi
- Massey Cancer Center, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Alexander N Slade
- Massey Cancer Center, Virginia Commonwealth University Health System, Richmond, VA, USA.
| | - Arnethea L Sutton
- Department of Health Behavior & Policy, Virginia Commonwealth University, Richmond, VA, USA
| | - Kandace P McGuire
- Massey Cancer Center, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Vanessa Sheppard
- Department of Health Behavior & Policy, Virginia Commonwealth University, Richmond, VA, USA
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Golla V, Shan Y, Mehta HB, Klaassen Z, Tyler DS, Baillargeon J, Kamat AM, Freedland SJ, Gore JL, Chamie K, Kuo YF, Williams SB. Impact of Diagnosing Urologists and Hospitals on the Use of Radical Cystectomy. EUR UROL SUPPL 2020; 19:27-36. [PMID: 34337452 PMCID: PMC8317809 DOI: 10.1016/j.euros.2020.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2020] [Indexed: 11/22/2022] Open
Abstract
Background One out of five patients with muscle-invasive bladder cancer undergo radical cystectomy—a guideline-recommended treatment. Previous studies have primarily evaluated patient characteristics associated with the use of radical cystectomy, ignoring potential nesting of data. Objective To determine the impact of patient, diagnosing urologist, and hospital characteristics on the variation in the use of radical cystectomy. Design, setting, and participants This is a retrospective cohort study using the Surveillance, Epidemiology, and End Results Registry (SEER)-Medicare linked database. Outcome measurements and statistical analysis A total of 7097 muscle-invasive bladder cancer patients and 4601 diagnosing urologists affiliated to 822 hospitals from January 1, 2002 to December 31, 2012 were analyzed. Multilevel logistic regression analyses were used to determine variation and factors associated with the use of radical cystectomy. Results and limitations Of the 7097 patients, only 27% underwent radical cystectomy. The intraclass correlation coefficient for variation in the use of radical cystectomy attributed to the hospital level was 4.3%. Higher radical cystectomy volume by diagnosing urologists (more than five vs zero to one surgery: odds ratio [OR], 1.27; 95% confidence interval [CI], 1.00–1.62) and hospitals (more than five vs zero to four surgeries: OR,1.48; 95% CI, 1.14–1.93) was associated with increased use of radical cystectomy. Patients diagnosed by female rather than male urologists were more likely to undergo radical cystectomy (OR, 1.32; 95% CI, 1.07–1.62). Conclusions We found that 4.3% variation in the use of radical cystectomy was attributed to the hospital level, leaving 95.7% variation in use unexplained. We identified significantly increased use among higher-volume and female diagnosing urologists. These findings support further investigation into measures beyond hospital volume, which largely impact the utilization of radical cystectomy. Patient summary In this large population-based study, we found that 4.3% of variation in the use of radical cystectomy was attributed to the hospital level, leaving 95.7% variation in use unexplained. Higher radical cystectomy volume of diagnosing urologists and female urologists were independently associated with increased use of radical cystectomy. These findings support further investigation into measures beyond hospital volume, which largely impact the utilization of radical cystectomy.
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Affiliation(s)
- Vishnukamal Golla
- Department of Urology, University of California, Los Angeles, CA, USA
| | - Yong Shan
- Department of Surgery, Division of Urology, The University of Texas Medical Branch, Galveston, TX, USA
| | - Hemalkumar B. Mehta
- Department of Surgery, Section of Urology, Medical College of Georgia, Georgia Regents University, Augusta, GA, USA
| | - Zachary Klaassen
- Department of Surgery, Section of Urology, Medical College of Georgia, Georgia Regents University, Augusta, GA, USA
| | - Douglas S. Tyler
- Department of Surgery, The University of Texas Medical Branch at Galveston, Galveston, TX, USA
| | - Jacques Baillargeon
- Department of Preventive Medicine and Community Health, Sealy Center of Aging, The University of Texas Medical Branch, Galveston, TX, USA
| | - Ashish M. Kamat
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - John L. Gore
- Department of Urology, The University of Washington, Seattle, WA, USA
| | - Karim Chamie
- Department of Urology, University of California, Los Angeles, CA, USA
| | - Yong-Fang Kuo
- Department of Preventive Medicine and Community Health, Sealy Center of Aging, The University of Texas Medical Branch, Galveston, TX, USA
| | - Stephen B. Williams
- Department of Surgery, Division of Urology, The University of Texas Medical Branch, Galveston, TX, USA
- Corresponding author. Division of Urology, The University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555, USA. Tel.: +1-409-747-7333; Fax: +1-409-772-0088.
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21
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Abstract
OBJECTIVE This study evaluates the impact of individual surgeons and institutions on the use of mastectomy or breast conserving surgery (BCS) among elderly women with breast cancer. SUMMARY OF BACKGROUND DATA Current literature characterizes patient clinical and demographic factors that increase likelihood of mastectomy use. However, the impact of the individual provider or institution is not well understood, and could provide key insights to biases in the decision-making process. METHODS A retrospective cohort study of 29,358 women 65 years or older derived from the SEER-Medicare linked database with localized breast cancer diagnosed from 2000 to 2009. Multilevel, multivariable logistic models were employed, with odds ratios (ORs) used to describe the impact of demographic or clinical covariates, and the median OR (MOR) used to describe the relative impact of the surgeon and institution. RESULTS Six thousand five hundred ninety-four women (22.4%) underwent mastectomy. Unadjusted rates of mastectomy ranged from 0% in the bottom quintile of surgeons to 58.0% in the top quintile. On multivariable analysis, the individual surgeon (MOR 1.97) had a greater impact on mastectomy than did the institution (MOR 1.71) or all other clinical and demographic variables except tumor size (OR 3.06) and nodal status (OR 2.95). Surgeons with more years in practice, or those with a lower case volume were more likely to perform mastectomy (P < 0.05). CONCLUSION The individual surgeon influences the likelihood of mastectomy for the treatment of localized breast cancer. Further research should focus on physician-related biases that influence this decision to ensure patient autonomy.
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22
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Vongsaisuwon M, Pongpirul K, Chatamara K. Clinical outcomes and surgical preferences for breast-conserving surgery and mastectomy: a propensity score-matched analysis. ASIAN BIOMED 2019. [DOI: 10.1515/abm-2019-0046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Abstract
Background
While numerous randomized controlled trials have demonstrated long-term survival rates for patients with early-stage breast cancer treated with breast-conserving surgery (BCS) comparable to mastectomy, the latter remains the most prevalent surgical option to treat early-stage breast cancer in Thailand.
Objectives
To investigate the potential determinants affecting the decision on selecting BCS or mastectomy for the treatment of early-stage breast cancer and to compare the disease-free survival and overall survival between the treatments using a propensity score-matched analysis.
Methods
Patients diagnosed nonmetastatic breast cancer at the Queen Sirikit Breast Cancer Center from January 2006 to December 2015, were retrospectively identified and grouped intro patients who received BCS or mastectomy. After propensity score matching, 356 BCS and 209 mastectomy patients were identified, and statistical analysis was conducted to determine treatment selection factors and compare disease-free and overall survival.
Results
Disease-free survival and overall survival in months comparing BCS and mastectomy were not statistically different with P values of 0.11 and 0.77, respectively. Determinants of treatment selection found that younger age, surgeon preference, smaller tumor size, and lower tumor grade were statistically significant factors in the selection of BCS over mastectomy. The majority of surgeons had a preference for one treatment over the other (P < 0.001).
Conclusion
The outcome of BCS is comparable to mastectomy in early-stage breast cancer patients. Key determinants affecting the selection of treatment were identified to be patient age, characteristics of the tumor, and surgeon’s preference.
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Affiliation(s)
- Mawin Vongsaisuwon
- Department of Surgery, Faculty of Medicine, Chulalongkorn University , Bangkok 10330 , Thailand
| | - Krit Pongpirul
- Department of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University , Bangkok 10330 , Thailand
- Department of International Health, Johns Hopkins Bloomberg School of Public Health , MD 21205 , Baltimore , USA
| | - Kris Chatamara
- Queen Sirikit Centre for Breast Cancer, King Chulalongkorn Memorial Hospital , Bangkok 10330 , Thailand
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23
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Chen R, You S, Yin Z, Zhu Q, Jiang C, Li S, Li Y, Zha X, Wang J. Non-doctoral factors influencing the surgical choice of Chinese patients with breast cancer who were eligible for breast-conserving surgery. World J Surg Oncol 2019; 17:189. [PMID: 31711515 PMCID: PMC6849271 DOI: 10.1186/s12957-019-1723-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 10/10/2019] [Indexed: 11/13/2022] Open
Abstract
Background The rate of breast-conserving surgery (BCS) is low in China. Many patients choose mastectomy even when informed that there is no difference in the overall survival rate compared with that of BCS plus radiotherapy. This study aimed to investigate the factors that influenced the surgical choice in patients eligible for BCS. Methods Female patients with breast carcinoma were enrolled in a single center from March 2016 to January 2017. They made their own decision regarding the surgical approach. Univariate analysis was employed to determine the factors associated with the different breast surgical approaches. Significant factors (defined as P < 0.05) were then incorporated into multivariate logistic regression models to determine the factors that independently influenced patients’ decision. Results Of the 271 patients included, 149 were eligible for BCS; 65 chose BCS and 84 chose mastectomy. On the basis of univariate analysis, patients with younger age, higher income and education, shorter admission to surgery interval, and shorter confirmed diagnosis to surgery interval were more likely to choose BCS than mastectomy (P < 0.05). Meanwhile, patients who resided in rural regions, did not have general medicare insurance, and were diagnosed with breast cancer preoperatively were more inclined to choose mastectomy than BCS (P < 0.05). The multivariate model revealed three independent influencing factors: age at diagnosis (P = 0.009), insurance status (P = 0.035), and confirmed diagnosis to surgery interval (P = 0.037). In addition, patients receiving neoadjuvant chemotherapy (NCT) were more inclined to choose mastectomy. Conclusion Surgical choice of patients eligible for BCS was affected by several factors, and age at diagnosis, confirmed diagnosis to surgery interval, and insurance status were independent factors.
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Affiliation(s)
- Rui Chen
- Breast Disease Department, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Sainan You
- Breast Disease Department, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zinan Yin
- Endocrine Department, Peking Union Medical College Hospital, Beijing, China
| | - Qiannan Zhu
- Breast Disease Department, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Chaojun Jiang
- Breast Disease Department, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shuo Li
- Breast Disease Department, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yan Li
- Breast Disease Department, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xiaoming Zha
- Breast Disease Department, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China.
| | - Jue Wang
- Breast Disease Department, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China.
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Abstract
OBJECTIVE To estimate whether there are differences in obstetric interventions or outcomes by the gender of the delivering physician. METHODS We conducted a retrospective cohort study of all nulliparous women delivering singleton, vertex, live births at 37 weeks of gestation or greater at a tertiary care institution (2014-2015). Patient clinical characteristics were analyzed by delivering physician gender. The primary outcomes were delivery mode and episiotomy. Secondary outcomes included major perineal laceration, postpartum hemorrhage, 5-minute Apgar score less than 7, cord umbilical artery pH less than 7.0, and neonatal intensive care unit admission. Univariable and hierarchical multivariable analyses including physician as a random effect were utilized for analyses. RESULTS Of the 7,027 women who met inclusion criteria, 81.3% (n=5,716) were delivered by a female physician. Women delivered by female physicians were slightly younger than those delivered by male physicians and were more likely to be publicly insured (11.7% vs 7.1%, P<.001). Mode of delivery did not differ by physician gender; the cesarean delivery rate was 20.6% for male physicians and 20.5% for female physicians (P=.61). Although the episiotomy rate did differ by physician gender, with 5.9% of patients delivered by male physicians undergoing episiotomy compared with 3.6% of patients delivered by female physicians (P=.001), this finding did not persist in the multivariable model after accounting for potential confounders (adjusted odds ratio 0.87, 95% CI 0.49-1.56). There were no differences by physician gender regarding any of the examined secondary outcomes in univariable or multivariable analyses. CONCLUSION Outcomes of nulliparous women undergoing a trial of labor did not differ by delivering physician gender.
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Ferdous M, Turin TC. Provider-level characteristics are significantly associated with the increased likelihood of mastectomy over conservative surgery among elderly women with breast cancer. Evid Based Nurs 2019; 23:79. [PMID: 31492739 DOI: 10.1136/ebnurs-2019-103153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2019] [Indexed: 11/03/2022]
Affiliation(s)
- Mahzabin Ferdous
- Department of Family Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Tanvir C Turin
- Department of Family Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada .,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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26
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Hooper RC, Hsu J, Duncan A, Bensenhaver JM, Newman LA, Kidwell KM, Chung KC, Momoh AO. Breast Cancer Knowledge and Decisions Made for Contralateral Prophylactic Mastectomy: A Survey of Surgeons and Women in the General Population. Plast Reconstr Surg 2019; 143:936e-945e. [PMID: 31033815 DOI: 10.1097/prs.0000000000005523] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Decisions made to undergo contralateral prophylactic mastectomy, in women at low risk for bilateral disease, are often attributed to a lack of knowledge. This study examines the role knowledge plays in determining surgical treatment for unilateral breast cancer made by laywomen and surgeons for themselves or loved ones. METHODS The study cohort had three groups: (1) laywomen in the general population, (2) breast surgeons, and (3) plastic surgeons. Laywomen were recruited using Amazon Mechanical Turk Crowd Sourcing. Breast and plastic surgeons from nine states were sent electronic surveys. Demographic and contralateral prophylactic mastectomy-specific data on decisions and knowledge were collected and analyzed. RESULTS Surveys from 1333 laywomen, 198 plastic surgeons, and 142 breast surgeons were analyzed. A significantly greater proportion of laywomen in the general population favored contralateral prophylactic mastectomy (67 percent) relative to plastic (50 percent) and breast surgeons (26 percent) (p < 0.0001). Breast surgeons who chose contralateral prophylactic mastectomy were younger (p = 0.044) and female (0.012). On assessment of knowledge, 78 percent of laywomen had a low level of breast cancer knowledge. Laywomen with higher levels of breast cancer knowledge had lower odds of choosing contralateral prophylactic mastectomy (OR, 0.37; 95 percent CI, 0.28 to 0.49). CONCLUSIONS Fewer women are likely to make decisions in favor of contralateral prophylactic mastectomy with better breast cancer-specific education. A knowledge gap likely explains the lower rates with which surgeons choose contralateral prophylactic mastectomy for themselves or loved ones; however, some surgeons who were predominantly young and female favor contralateral prophylactic mastectomy. Improving patient education on surgical options for breast cancer treatment is critical, with well-informed decisions as the goal.
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Affiliation(s)
- Rachel C Hooper
- From the Section of Plastic Surgery, Department of Surgery, University of Michigan Health System; the Department of Surgery, Henry Ford Health System; and the Department of Biostatistics, University of Michigan School of Public Health
| | - Jessica Hsu
- From the Section of Plastic Surgery, Department of Surgery, University of Michigan Health System; the Department of Surgery, Henry Ford Health System; and the Department of Biostatistics, University of Michigan School of Public Health
| | - Anthony Duncan
- From the Section of Plastic Surgery, Department of Surgery, University of Michigan Health System; the Department of Surgery, Henry Ford Health System; and the Department of Biostatistics, University of Michigan School of Public Health
| | - Jessica M Bensenhaver
- From the Section of Plastic Surgery, Department of Surgery, University of Michigan Health System; the Department of Surgery, Henry Ford Health System; and the Department of Biostatistics, University of Michigan School of Public Health
| | - Lisa A Newman
- From the Section of Plastic Surgery, Department of Surgery, University of Michigan Health System; the Department of Surgery, Henry Ford Health System; and the Department of Biostatistics, University of Michigan School of Public Health
| | - Kelly M Kidwell
- From the Section of Plastic Surgery, Department of Surgery, University of Michigan Health System; the Department of Surgery, Henry Ford Health System; and the Department of Biostatistics, University of Michigan School of Public Health
| | - Kevin C Chung
- From the Section of Plastic Surgery, Department of Surgery, University of Michigan Health System; the Department of Surgery, Henry Ford Health System; and the Department of Biostatistics, University of Michigan School of Public Health
| | - Adeyiza O Momoh
- From the Section of Plastic Surgery, Department of Surgery, University of Michigan Health System; the Department of Surgery, Henry Ford Health System; and the Department of Biostatistics, University of Michigan School of Public Health
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El Sharouni MA, Witkamp AJ, Sigurdsson V, van Diest PJ. Trends in Sentinel Lymph Node Biopsy Enactment for Cutaneous Melanoma. Ann Surg Oncol 2019; 26:1494-1502. [PMID: 30719636 PMCID: PMC6456485 DOI: 10.1245/s10434-019-07204-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Indexed: 01/23/2023]
Abstract
BACKGROUND Over recent years, sentinel lymph node biopsy (SLNB) recommendations in guidelines for cutaneous melanoma have changed considerably. We aimed to assess trends in enactment of SLNB to evaluate to what extent guidelines were adhered to, and to identify clinical and pathological determinants of (non-)adherence. METHODS Clinicopathological data from the Dutch nationwide network and registry of histopathology and cytopathology were retrieved from patients diagnosed with primary cutaneous melanoma in The Netherlands between 2003 and 2014. SLNB enactment was analyzed per year. Multivariable regression models were developed to assess the determinants of SLNB enactment. RESULTS A total of 51,510 primary cutaneous melanomas in 49,514 patients were diagnosed, of which 24,603 melanomas were eligible for SLNB as they were staged T1b or higher. In practice, only 9761 (39.7%) patients underwent SLNB, with an increasing trend from 39.1% in 2003 to 47.8% in 2014 (p < 0.001). A total of 759 (2.9%) of 26,426 patients without SLNB indication underwent SLNB anyway. Variables significantly associated with enactment of SLNB were male sex, younger age, and melanoma on sites other than the head and neck. CONCLUSIONS Although there was an increasing trend in time in SLNB enactment, enactment of SLNB did not comply well with recommendations in (inter)national guidelines. Female sex, higher age, and melanoma located on the head and neck were associated with non-enactment of SLNB.
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Affiliation(s)
- Mary-Ann El Sharouni
- Department of Dermatology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands.
| | - Arjen J Witkamp
- Department of Surgery, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Vigfús Sigurdsson
- Department of Dermatology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Paul J van Diest
- Department of Pathology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
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Savelberg W, Boersma LJ, Smidt M, Goossens MFJ, Hermanns R, van der Weijden T. Does lack of deeper understanding of shared decision making explains the suboptimal performance on crucial parts of it? An example from breast cancer care. Eur J Oncol Nurs 2019; 38:92-97. [PMID: 30717943 DOI: 10.1016/j.ejon.2018.12.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 12/06/2018] [Accepted: 12/13/2018] [Indexed: 11/18/2022]
Abstract
PURPOSE Although most of the clinicians in breast cancer care seem to approve of shared decision making (SDM), actual implementation is limited. The aim of this study was to explore the experiences, issues and concerns of early-adopter professionals with regards to shared decision making. METHODS This qualitative descriptive study was part of a pilot study aimed at implementing SDM in breast cancer teams. We interviewed 27 clinicians; 9 breast cancer surgeons, 11 nurse practitioners and 7 nurses. The teams were exposed to a multifaceted implementation programme, among others: a patient decision aid (PtDA), a procedure to disseminate the PtDA and advice on redesigning the clinical pathway. RESULTS Participants considered SDM, including the delivery of the PtDA, to be a team effort, in which every professional should take responsibility. Most clinicians primarily focused on the first steps of SDM ignoring preference and decision talk. The remaining steps, like the uptake of the PtDA in the clinical pathway, were regarded as challenging, with surgeons, intentionally or unconsciously, delegating this responsibility to nurses. One barrier to successfully implementing SDM seems to lie in the fact that clinicians were unaware of their lack of competency regarding SDM. CONCLUSIONS A deeper understanding is needed among clinicians of what SDM actually is and how a PtDA contributes to this process. Nurses play an important role in the delivery of the PtDA, but their role is not clearly defined. Teams should consider a clear realignment of tasks between surgeons and nurses, which implies redesign of the pathway.
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Affiliation(s)
- W Savelberg
- Department of Quality and Safety, Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX, Maastricht, the Netherlands.
| | - L J Boersma
- Oncology Centre, Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX, Maastricht, the Netherlands; Maastricht University Medical Centre, Department of Radiotherapy (MAASTRO Clinic), GROW School for Oncology and Developmental Biology, Dr. Tanslaan 12, 6229 ET, Maastricht, the Netherlands.
| | - M Smidt
- Oncology Centre, Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX, Maastricht, the Netherlands.
| | - M F J Goossens
- Faculty of Health, Medicine and Life Sciences, Maastricht University, Universiteitssingel 40, 6229 ER, Maastricht, the Netherlands.
| | - R Hermanns
- Faculty of Health, Medicine and Life Sciences, Maastricht University, Universiteitssingel 40, 6229 ER, Maastricht, the Netherlands.
| | - T van der Weijden
- School CAPHRI, Care and Public Health Research Institute, Maastricht University, Universiteitssingel 40, 6229 ER, Maastricht, the Netherlands; Department of Family Medicine, Maastricht University, Debeyeplein 1, 6229 ER, Maastricht, the Netherlands.
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Carlino G, Rinaldi P, Giuliani M, Rella R, Bufi E, Padovano F, Ciardi C, Romani M, Belli P, Manfredi R. Ultrasound-guided preoperative localization of breast lesions: a good choice. J Ultrasound 2018; 22:85-94. [PMID: 30367356 DOI: 10.1007/s40477-018-0335-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Accepted: 10/11/2018] [Indexed: 12/31/2022] Open
Abstract
PURPOSE The aim of the study was to verify whether ultrasound (US)-guided preoperative localization of breast lesions is an adequate technique for correct and safe surgical resection and to contribute positively and effectively to this topic in the literature with our results. METHODS From June 2016 to November 2016, 155 patients with both benign and malignant breast lesions were selected from our institute to undergo US localization before surgery. The lesions included were: sonographically visible and nonpalpable lesions; palpable lesions for which a surgeon had requested US localization to better evaluate the site and extension; sonographically visible, multifocal breast lesions, both palpable and nonpalpable. US localization was performed using standard linear transducers (Siemens 18 L6, 5.5-8 MHz, 5.6 cm, ACUSON S2000 System, Siemens Medical Solutions). The radiologist used a skin pen to mark the site of the lesion, and the reported lesion's depth and distance from the nipple and pectoral muscle were recorded. The lesions were completely excised by a team of breast surgeons, and the surgical specimens were sent to the Radiology Department for radiological evaluation and to the Pathology Department for histological assessment. RESULTS In 155 patients who underwent to preoperative US localization, 188 lesions were found, and the location of each lesion was marked with a skin pen. A total of 181 lesions were confirmed by the final histopathologic exam (96.28%); 132 of them (72.92%) were malignant, and 124 of these (93.93%) showed free margins. CONCLUSIONS US-guided preoperative localization of sonographically visible breast lesions is a simple and nontraumatic procedure with high specificity and is a useful tool for obtaining accurate surgical margins.
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Affiliation(s)
- Giorgio Carlino
- Department of Radiology, Fondazione Policlinico A. Gemelli IRCCS - Università Cattolica Sacro Cuore, Largo Agostino Gemelli 8, 00168, Rome, Italy.
| | - Pierluigi Rinaldi
- Department of Radiology, Fondazione Policlinico A. Gemelli IRCCS - Università Cattolica Sacro Cuore, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Michela Giuliani
- Department of Radiology, Fondazione Policlinico A. Gemelli IRCCS - Università Cattolica Sacro Cuore, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Rossella Rella
- Department of Radiology, Fondazione Policlinico A. Gemelli IRCCS - Università Cattolica Sacro Cuore, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Enida Bufi
- Department of Radiology, Fondazione Policlinico A. Gemelli IRCCS - Università Cattolica Sacro Cuore, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Federico Padovano
- Department of Radiology, Fondazione Policlinico A. Gemelli IRCCS - Università Cattolica Sacro Cuore, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Chiara Ciardi
- Department of Radiology, Fondazione Policlinico A. Gemelli IRCCS - Università Cattolica Sacro Cuore, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Maurizio Romani
- Department of Radiology, Fondazione Policlinico A. Gemelli IRCCS - Università Cattolica Sacro Cuore, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Paolo Belli
- Department of Radiology, Fondazione Policlinico A. Gemelli IRCCS - Università Cattolica Sacro Cuore, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Riccardo Manfredi
- Department of Radiology, Fondazione Policlinico A. Gemelli IRCCS - Università Cattolica Sacro Cuore, Largo Agostino Gemelli 8, 00168, Rome, Italy
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Campbell I, Lao C, Blackmore T, Edwards M, Hayes L, Ng A, Lawrenson R. Surgical treatment of early stage breast cancer in the Auckland and Waikato regions of New Zealand. ANZ J Surg 2018; 88:1263-1268. [DOI: 10.1111/ans.14840] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 08/01/2018] [Accepted: 08/04/2018] [Indexed: 02/03/2023]
Affiliation(s)
- Ian Campbell
- School of Medicine; The University of Auckland; Auckland New Zealand
- Waikato District Health Board; Hamilton New Zealand
| | - Chunhuan Lao
- Medical Research Centre, University of Waikato; Hamilton New Zealand
| | - Tania Blackmore
- Medical Research Centre, University of Waikato; Hamilton New Zealand
| | - Melissa Edwards
- School of Medicine; The University of Auckland; Auckland New Zealand
| | - Louise Hayes
- Waikato District Health Board; Hamilton New Zealand
| | - Alex Ng
- Department of General Surgery, Auckland City Hospital; Auckland New Zealand
| | - Ross Lawrenson
- Waikato District Health Board; Hamilton New Zealand
- Medical Research Centre, University of Waikato; Hamilton New Zealand
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Huntington SF, Hoag JR, Zhu W, Wang R, Zeidan AM, Giri S, Podoltsev NA, Gore SD, Ma X, Gross CP, Davidoff AJ. Oncologist volume and outcomes in older adults diagnosed with diffuse large B cell lymphoma. Cancer 2018; 124:4211-4220. [PMID: 30216436 DOI: 10.1002/cncr.31688] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 05/21/2018] [Accepted: 06/26/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND Although provider-level volume is frequently associated with outcomes in cancers requiring complex surgeries, whether similar relations exist for cancers treated primarily with systemic therapy is unknown. METHODS Using a population-based cohort analysis of older adults diagnosed with diffuse large B cell lymphoma (DLBCL) during the years 2004-2011, we evaluated the association between oncologist volume and 4 clinical outcomes (receipt of any chemotherapy, receipt of an anthracycline-containing or equivalent regimen, early hospitalization, and overall survival). Our primary explanatory variable was lymphoma treatment volume, defined as the number of patients with newly diagnosed lymphoma for which an oncologist initiated therapy during a 12-month look-back period from each incident DLBCL case. RESULTS We identified 8247 Medicare beneficiaries who were newly diagnosed with DLBCL. Chemotherapy was administered to 6202 (75.2%) beneficiaries, and 71.4% of cytotoxic regimens contained an anthracycline. Beneficiaries who were treated by higher-volume oncologists had increased odds of receiving chemotherapy (adjusted odds ratio [aOR], 1.45; 95% confidence interval [CI], 1.24-1.70; P <.001) and of receiving an anthracycline-containing regimen (aOR, 1.26; 95% CI, 1.06-1.50; P = .009). Receiving care from a higher-volume provider was also associated with decreased hospitalization (aOR, 0.80; 95% CI, 0.69-0.95; P = .007) and improved survival (adjusted hazard ratio, 0.85; 95% CI, 0.79-0.92; P < .001). CONCLUSION In older adults diagnosed with DLBCL, receiving care from a provider with more experience treating lymphoma patients was associated with receipt of guideline-adherent therapy, reduced hospitalizations, and improved survival. Clinical volume may be an important factor in providing high-quality cancer care in the modern era.
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Affiliation(s)
- Scott F Huntington
- Department of Internal Medicine, Section of Hematology, Yale University, New Haven, Connecticut.,Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut
| | - Jessica R Hoag
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut
| | - Weiwei Zhu
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut
| | - Rong Wang
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut.,Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
| | - Amer M Zeidan
- Department of Internal Medicine, Section of Hematology, Yale University, New Haven, Connecticut.,Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut
| | - Smith Giri
- Department of Internal Medicine, Section of Hematology, Yale University, New Haven, Connecticut.,Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut
| | - Nikolai A Podoltsev
- Department of Internal Medicine, Section of Hematology, Yale University, New Haven, Connecticut
| | - Steven D Gore
- Department of Internal Medicine, Section of Hematology, Yale University, New Haven, Connecticut
| | - Xiaomei Ma
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut.,Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
| | - Cary P Gross
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut
| | - Amy J Davidoff
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut.,Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
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Do Estimates of Treatment Risk Based on Clinical Vignettes Differ by Physician Gender? Ann Thorac Surg 2018; 106:1868-1872. [PMID: 30205117 DOI: 10.1016/j.athoracsur.2018.07.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 06/07/2018] [Accepted: 07/09/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Clinical vignettes are frequently used as instructional and evaluative instruments for physicians. Physicians' gender is a source of unconscious bias in treatment recommendations. This study assessed whether interpretation of information in clinical vignettes differed by physicians' gender as a possible source of unconscious bias. METHODS Thoracic surgeons and physicians in cardiothoracic surgical training were asked to provide estimates of major complication rates for lung resection on the basis of anonymized clinical vignettes of patients undergoing lung resection. Vignettes were categorized as low, average, and high risk by using a sum of Charlson Comorbidity Index (possible range, 0 to 37) and a combined physiologic score, EVAD (forced expiratory volume in 1 second, diffusing capacity of lung for carbon monoxide, age; possible range, 0 to 12); participants were not aware of the risk scores or vignette categories. Generalized estimating equation linear regression models were fit with risk scores treated as a continuous independent variable. RESULTS A total of 247 physicians (105 practicing surgeons, 142 trainees; 203 men, 44 women) participated in one or more of the studies. Nearly all (103; 98%) of the practicing surgeons rated themselves as competent or expert in lung resection compared with 77 (54%) of the trainees (p < 0.001). Participants' complication estimates mirrored both vignette risk category and combined risk score. There was no significant difference between men and women physicians in their estimates of complication rates. CONCLUSIONS Unconscious bias related to physicians' gender is not associated with differential use of information in clinical vignettes. Any possible bias may arise from face-to-face interactions with patients. Research into physicians' and patients' gender differences during such interactions is warranted.
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Gu J, Groot G, Boden C, Busch A, Holtslander L, Lim H. Review of Factors Influencing Women's Choice of Mastectomy Versus Breast Conserving Therapy in Early Stage Breast Cancer: A Systematic Review. Clin Breast Cancer 2018; 18:e539-e554. [DOI: 10.1016/j.clbc.2017.12.013] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 12/22/2017] [Indexed: 01/11/2023]
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Gu J, Groot G. Creation of a new clinical framework - why women choose mastectomy versus breast conserving therapy. BMC Med Res Methodol 2018; 18:77. [PMID: 29986654 PMCID: PMC6038174 DOI: 10.1186/s12874-018-0533-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 06/27/2018] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Clinical medicine has lagged behind other fields in understanding and utilizing frameworks to guide research. In this article, we introduce a new framework to examine why women choose mastectomy versus breast conserving therapy in early stage breast cancer, and highlight the importance of utilizing a conceptual framework to guide clinical research. METHODS The framework we present was developed through integrating previous literature, frameworks, theories, models, and the author's past research. RESULTS We present a conceptual framework that illustrates the central domains that influence women's choice between mastectomy versus breast conserving therapy. These have been organized into three broad constructs: clinicopathological factors, physician factors, and individual factors with subgroups of sociodemographic, geographic, and individual belief factors. The aim of this framework is to provide a comprehensive basis to describe, examine, and explain the factors that influence women's choice of mastectomy versus breast conserving therapy at the individual level. CONCLUSION We have developed a framework with the purpose of helping health care workers and policy makers better understand the multitude of factors that influence a patient's choice of therapy at an individual level. We hope this framework is useful for future scholars to utilize, challenge, and build upon in their own work on decision-making in the setting of breast cancer. For clinician-researchers who have limited experience with frameworks, this paper will highlight the importance of utilizing a conceptual framework to guide future research and provide an example.
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Affiliation(s)
- Jeffrey Gu
- Department of Community Health and Epidemiology, University of Saskatchewan, Box 7, Health Science Building, 107 Wiggins Rd, Saskatoon, SK, S7N 5E5, Canada.
| | - Gary Groot
- Community Health and Epidemiology, College of Medicine, University of Saskatchewan, Saskatoon, Canada
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Suggs PD, Holliday TL, Thompson SN, Richmond BK. Factors Affecting Choice of Treatment for Early-Stage Breast Cancer in West Virginia: A 10-Year Experience from a Rural Tertiary Care Center. Am Surg 2017. [DOI: 10.1177/000313481708300726] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Recent literature shows changing trends in use of breast conservation surgery (BCS), mastectomy, and contralateral prophylactic mastectomy (CPM) in women with early-stage breast cancer (ESBC). We analyzed factors associated with selection of these treatment modalities in a rural West Virginia tertiary care hospital. We conducted a 10-year analysis of women treated for ESBC at our institution from the institutional cancer registry. Variables were compared between patients choosing BCS versus mastectomy. In women who chose mastectomy, predictors for choice of CPM were also examined. Variables with P < 0.05 on univariate analysis were entered into a multivariate logistic regression model to define independent predictors of treatment choice. The mastectomy rate increased from 18.0 per cent in 2006 to 40.2 per cent in 2013. On multivariate analysis, insurance status (P < 0.001), comorbidities (P = 0.001), and surgeon graduation after 1987—a surrogate for surgeon age—(P = 0.010) predicted receipt of mastectomy. Of those receiving mastectomy, 106 (25.1%) elected CPM. CPM rates increased from 8.0 per cent in 2006 to 45.0 per cent in 2013. Younger age at diagnosis (P < 0.001) and use of preoperative MRI (P = 0.012) independently predicted use of CPM versus unilateral mastectomy. Rates of mastectomy and CPM in ESBC have increased in West Virginia over time. Independent predictors of selecting mastectomy over BCS included insurance status, surgeon age, and associated comorbidities. Younger patients and patients receiving preoperative MRI were more likely to choose CPM. Awareness of these factors will aid in counseling women with ESBC and allow clinicians to address potential biases or disparities that may affect treatment choices. Further prospective study of these findings is warranted.
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Affiliation(s)
- Patrick D. Suggs
- West Virginia University School of Medicine, Morgantown, West Virginia
| | - Tyler L. Holliday
- West Virginia University School of Medicine, Morgantown, West Virginia
| | - Stephanie N. Thompson
- Charleston Area Medical Center Health Education and Research Institute, Charleston, West Virginia
| | - Bryan K. Richmond
- Department of Surgery, West Virginia University–Charleston Division, Charleston, West Virginia
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Ferguson MK, Huisingh-Scheetz M, Thompson K, Wroblewski K, Farnan J, Acevedo J. The Influence of Physician and Patient Gender on Risk Assessment for Lung Cancer Resection. Ann Thorac Surg 2017; 104:284-289. [PMID: 28410637 DOI: 10.1016/j.athoracsur.2017.01.066] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Revised: 12/13/2016] [Accepted: 01/13/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Women do not receive appropriate surgical therapy for lung cancer as often as men. Patient gender may influence treatment recommendations; less is known about the effect of physician gender on recommendations. METHODS Gender-neutral vignettes representing low-risk, average-risk, and high-risk candidates for lung resection were paired with concordant videos of standardized patients (SPs). Cardiothoracic trainees and practicing thoracic surgeons read a vignette, provided an initial estimate of the percentage risk of major adverse events after lung resection, viewed a video (randomized to male or female SP), provided a final estimate of risk, and ranked the importance of the video in the final risk estimate. RESULTS Overall, 107 surgeons participated, of whom 90 were men. Initial estimated risks mirrored actual vignette risks: 10.4% ± 9.9 for low risk, 17.6% ± 13.2 for average risk, and 21.0% ± 14.7 for high risk (p < 0.001). After SP videos were viewed and final risk estimates were rendered, there was a significant difference between male and female physicians in the absolute change in estimated risk (p = 0.002), with male physicians having larger changes than female physicians. There was also an effect of SP gender that varied by vignette type (p < 0.001). Increasing video importance scores were directly associated with increasing change in risk scores for average-risk and high-risk vignette/video combinations (p < 0.001 for each). CONCLUSIONS Differences in estimating complication risk for lung resection candidates are related to physician and patient gender. This may influence recommendations for surgical treatment. Understanding such differences may help reduce inequities in treatment recommendations.
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Affiliation(s)
- Mark K Ferguson
- Department of Surgery, The University of Chicago, Chicago, Illinois; Comprehensive Cancer Center, The University of Chicago, Chicago, Illinois.
| | | | | | - Kristen Wroblewski
- Department of Public Health Sciences, The University of Chicago, Chicago, Illinois
| | - Jeanne Farnan
- Department of Medicine, The University of Chicago, Chicago, Illinois
| | - Julissa Acevedo
- Center for Research Informatics, The University of Chicago, Chicago, Illinois
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Variability in practice patterns in stress urinary incontinence and pelvic organ prolapse: results of an IUGA survey. Int Urogynecol J 2016; 28:735-744. [PMID: 27752749 DOI: 10.1007/s00192-016-3174-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 09/23/2016] [Indexed: 10/20/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Members of the International Urogynecological Association (IUGA) come from different geographic locations and practice settings. A member survey regarding practice patterns provides valuable information for practitioners and researchers alike, and allows the IUGA to discover areas to focus on education and information dissemination. METHODS A questionnaire was developed by the IUGA Research and Development committee and distributed electronically to IUGA surgeons. Answers were analyzed in reference to demographics, geographic distribution, and academic affiliation. RESULTS Five hundred sixty-four members answered the questionnaire, representing a 28 % response rate, and closely reflecting the geographic distribution of IUGA membership. Preferred surgical treatment for uncomplicated SUI was the mid-urethral trans-obturator sling (49.7 %). Vaginal mesh was mainly used for repair of recurrent POP (20.4 %). Pessary use was offered "always" or "frequently" by 61.5 %, with no difference in academic affiliation, but significant differences based on region of practice. Compared to practitioners in non-academic centers, those with academic affiliation utilized Urodynamic studies (UDS) and Magnetic Resonance Imaging (MRI) more frequently in the evaluation of POP. Regions of practice significantly influenced the majority of practice patterns, with the highest impact found in the use of robotic assistance. CONCLUSIONS Many practice patterns in the evaluation and treatment of POP and SUI depend on academic affiliation and geographic location. Practice patterns are not always based on most recent evidence-based data.
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Simpson JS, Scheer AS. A Review of the Effectiveness of Breast Surgical Oncology Fellowship Programs Utilizing Kirkpatrick's Evaluation Model. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2016; 31:466-471. [PMID: 26058681 DOI: 10.1007/s13187-015-0866-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
It has been 10 years since the first class of Society of Surgical Oncology (SSO) fellowship trained Breast Surgical Oncologist entered practice. To date, there has been no publications examining the effectiveness of these training programs that are today throughout North America and Europe. This evaluative review examines the effectiveness of these fellowship training programs through the lens of the Kirkpatrick Evaluation Model. An extensive review of the literature was performed, and articles were categorized to capture how fellows are reacting to the program, what they are learning, and how the program is effecting their career path and impacting their patients. We can conclude that there is both direct and indirect evidence to support the effectiveness of this training program, but there is a paucity of direct evidence as one progresses from a level 1 Kirkpatrick analysis to a level 4. This review sets the framework for program evaluation in surgical fellowships and should encourage stakeholders to constantly evaluate the impact their program is having on trainees and oncology patients.
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Affiliation(s)
- Jory S Simpson
- St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada.
| | - A S Scheer
- St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada
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Fisher S, Yasui Y, Dabbs K, Winget M. Using Multilevel Models to Explain Variation in Clinical Practice: Surgeon Volume and the Surgical Treatment of Breast Cancer. Ann Surg Oncol 2016; 23:1845-51. [PMID: 26842490 DOI: 10.1245/s10434-016-5118-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Indexed: 11/18/2022]
Abstract
PURPOSE To investigate the relationship between surgeon caseload and surgery type, and variation in the surgical treatment of early stage breast cancer patients in Alberta, Canada. METHODS All women diagnosed with stage I to III breast cancer in Alberta from 2002 to 2010 were identified from the Alberta Cancer Registry. Type of surgery, surgeon (anonymized), and hospital were obtained from provincial physician claims data. Multilevel logistic regression with surgeons and hospitals as crossed random effects was used to estimate adjusted odds ratios (OR) of receiving mastectomy by surgeon volume. Empirical Bayes estimation was used to estimate adjusted OR for individual surgeons and hospitals. RESULTS Mastectomy was found to be inversely related to surgeon volume among stage I and II patients. Patients whose surgery was conducted by a low-volume surgeon had twice the odds of receiving mastectomy as those that had surgery performed by a very high-volume surgeon (stage I OR 2.36, 95 % confidence interval 1.40, 3.97; stage II OR 1.96, 95 % confidence interval 1.13, 3.42). OR of mastectomy varied widely by individual surgeon beyond the variation explained by the factors investigated. CONCLUSIONS Surgeon characteristics, including surgeon volume, are associated with surgery type received by breast cancer patients in Alberta. Significant variation in the likelihood of breast-conserving surgery (BCS) by surgeon is concerning given the potential benefits of BCS for those who are eligible.
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Affiliation(s)
- Stacey Fisher
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Yutaka Yasui
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Kelly Dabbs
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Marcy Winget
- School of Public Health, University of Alberta, Edmonton, AB, Canada. .,Department of Medicine, Stanford University, Stanford, CA, USA.
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40
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Factors associated with surgical management in an underinsured, safety net population. Surgery 2016; 159:580-90. [DOI: 10.1016/j.surg.2015.08.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 08/11/2015] [Accepted: 08/15/2015] [Indexed: 01/11/2023]
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Fisher S, Gao H, Yasui Y, Dabbs K, Winget M. Survival in stage I-III breast cancer patients by surgical treatment in a publicly funded health care system. Ann Oncol 2015; 26:1161-1169. [PMID: 25712459 PMCID: PMC4516043 DOI: 10.1093/annonc/mdv107] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 02/02/2015] [Accepted: 02/16/2015] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Recent investigations of breast cancer survival in the United States suggest that patients who receive mastectomy have poorer survival than those who receive breast-conserving surgery (BCS) plus radiotherapy, despite clinically established equivalence. This study investigates breast cancer survival in the publicly funded health care system present in Alberta, Canada. PATIENTS AND METHODS Surgically treated stage I-III breast cancer cases diagnosed in Alberta from 2002 to 2010 were included. Demographic, treatment and mortality information were collected from the Alberta Cancer Registry. Unadjusted overall and breast cancer-specific mortality was assessed using Kaplan-Meier and cumulative incidence curves, respectively. Cox proportional hazards models were used to calculate stage-specific mortality hazard estimates associated with surgical treatment received. RESULTS A total of 14 939 cases of breast cancer (14 633 patients) were included in this study. The unadjusted 5-year all-cause survival probabilities for patients treated with BCS plus radiotherapy, mastectomy, and BCS alone were 94% (95% CI 93% to 95%), 83% (95% CI 82% to 84%) and 74% (95% CI 70% to 78%), respectively. Stage II and III patients who received mastectomy had a higher all-cause (stage II HR = 1.36, 95% CI 1.13-1.48; stage III HR = 1.74, 95% CI 1.24-2.45) and breast cancer-specific (stage II HR = 1.39, 95% CI 1.09-1.76; stage III HR = 1.79, 95% CI 1.21-2.65) mortality hazard compared with those who received BCS plus radiotherapy, adjusting for patient and clinical characteristics. BCS alone was consistently associated with poor survival. CONCLUSIONS Stage II and III breast cancer patients diagnosed in Alberta, Canada, who received mastectomy had a significantly higher all-cause and breast cancer-specific mortality hazard compared with those who received BCS plus radiotherapy. We suggest greater efforts toward educating and encouraging patients to receive BCS plus radiotherapy rather than mastectomy when it is medically feasible and appropriate.
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Affiliation(s)
| | | | | | - K Dabbs
- Department of Surgery, University of Alberta, Edmonton
| | - M Winget
- School of Public Health; Cancer Care, Alberta Health Services, Edmonton, Canada; Department of Medicine, Stanford University, Stanford, USA.
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Onitilo AA, Engel JM, Stankowski RV, Doi SAR. Survival Comparisons for Breast Conserving Surgery and Mastectomy Revisited: Community Experience and the Role of Radiation Therapy. Clin Med Res 2015; 13:65-73. [PMID: 25487237 PMCID: PMC4504664 DOI: 10.3121/cmr.2014.1245] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Accepted: 07/14/2014] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Evidence suggests superiority of breast conserving surgery (BCS) plus radiation over mastectomy alone for treatment of early stage breast cancer. Whether the superiority of BCS plus radiation is related to the surgical approach itself or to the addition of adjuvant radiation therapy following BCS remains unclear. MATERIALS AND METHODS We conducted a retrospective cohort study of women with breast cancer diagnosed from 1994-2012. Data regarding patient and tumor characteristics and treatment specifics were captured electronically. Kaplan-Meier survival analyses were performed with inverse probability of treatment weighting to reduce selection bias effects in surgical assignment. RESULTS Data from 5335 women were included, of which two-thirds had BCS and one-third had mastectomy. Surgical decision trends changed over time with more women undergoing mastectomy in recent years. Women who underwent BCS versus mastectomy differed significantly regarding age, cancer stage/grade, adjuvant radiation, chemotherapy, and endocrine treatment. Overall survival was similar for BCS and mastectomy. When BCS plus radiation was compared to mastectomy alone, 3-, 5-, and 10-year overall survival was 96.5% vs 93.4%, 92.9% vs 88.3% and 80.9% vs 67.2%, respectively. CONCLUSION These analyses suggest that survival benefit is not related only to the surgery itself, but that the prognostic advantage of BCS plus radiation over mastectomy may also be related to the addition of adjuvant radiation therapy. This conclusion requires prospective confirmation in randomized trials.
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Affiliation(s)
- Adedayo A Onitilo
- Department of Hematology/Oncology, Marshfield Clinic-Weston Center, Weston, Wisconsin, USA School of Population Health, University of Queensland, Brisbane, Australia
| | - Jessica M Engel
- Department of Hematology/Oncology, Marshfield Clinic Cancer Care, Stevens Point, Wisconsin, USA
| | | | - Suhail A R Doi
- School of Population Health, University of Queensland, Brisbane, Australia
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Unger JM, Hershman DL, Martin D, Etzioni RB, Barlow WE, LeBlanc M, Ramsey SR. The diffusion of docetaxel in patients with metastatic prostate cancer. J Natl Cancer Inst 2014; 107:dju412. [PMID: 25540245 DOI: 10.1093/jnci/dju412] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Diffusion of new cancer treatments can be both inefficient and incomplete. The uptake of new treatments over time (diffusion) has not been well studied. We analyzed the diffusion of docetaxel in metastatic prostate cancer. METHODS We identified metastatic prostate cancer patients diagnosed from 1995 to 2007 using the Surveillance, Epidemiology, and End Results Program (SEER)-Medicare database. Medicare claims through 2008 were analyzed. We assessed cumulative incidence of docetaxel by socioeconomic, demographic, and comorbidity variables, and compared diffusion patterns to landmark events including release of phase III results and FDA approval dates. We compared docetaxel diffusion patterns in prostate cancer to those in metastatic breast, lung, ovarian, and gastric cancers. To model docetaxel use over time, we used the classic "mixed influence" deterministic diffusion model. All statistical tests were two-sided. RESULTS We identified 6561 metastatic prostate cancer patients; 1350 subsequently received chemotherapy. Among patients who received chemotherapy, docetaxel use was 95% by 2008. Docetaxel uptake was statistically significantly slower (P < .01) for patients older than 65 years, blacks, patients in lower income areas, and those who experienced poverty. Eighty percent of docetaxel diffusion occurred prior to the May, 2004 release of phase III results showing superiority of docetaxel over standard-of-care. The maximum increase in the rate of use of docetaxel occurred nearly simultaneously for prostate cancer as for all other cancers combined (in 2000). CONCLUSION Efforts to increase the diffusion of treatments with proven survival benefits among disadvantaged populations could lead to cancer population survival gains. Docetaxel diffusion mostly preceded phase III evidence for its efficacy in castration-resistant prostate cancer, and appeared to be a cancer-wide-rather than a disease-specific-phenomenon. Diffusion prior to definitive evidence indicates the prevalence of off-label chemotherapy use.
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Affiliation(s)
- Joseph M Unger
- Affiliations of authors: SWOG Statistical Center, Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (JMU, WEB, ML); University of Washington, Department of Health Services Research, Seattle, WA (DM); Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (SRR, RBE); Division of Hematology/Oncology, Columbia University, New York, NY (DLH).
| | - Dawn L Hershman
- Affiliations of authors: SWOG Statistical Center, Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (JMU, WEB, ML); University of Washington, Department of Health Services Research, Seattle, WA (DM); Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (SRR, RBE); Division of Hematology/Oncology, Columbia University, New York, NY (DLH)
| | - Diane Martin
- Affiliations of authors: SWOG Statistical Center, Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (JMU, WEB, ML); University of Washington, Department of Health Services Research, Seattle, WA (DM); Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (SRR, RBE); Division of Hematology/Oncology, Columbia University, New York, NY (DLH)
| | - Ruth B Etzioni
- Affiliations of authors: SWOG Statistical Center, Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (JMU, WEB, ML); University of Washington, Department of Health Services Research, Seattle, WA (DM); Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (SRR, RBE); Division of Hematology/Oncology, Columbia University, New York, NY (DLH)
| | - William E Barlow
- Affiliations of authors: SWOG Statistical Center, Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (JMU, WEB, ML); University of Washington, Department of Health Services Research, Seattle, WA (DM); Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (SRR, RBE); Division of Hematology/Oncology, Columbia University, New York, NY (DLH)
| | - Michael LeBlanc
- Affiliations of authors: SWOG Statistical Center, Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (JMU, WEB, ML); University of Washington, Department of Health Services Research, Seattle, WA (DM); Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (SRR, RBE); Division of Hematology/Oncology, Columbia University, New York, NY (DLH)
| | - Scott R Ramsey
- Affiliations of authors: SWOG Statistical Center, Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (JMU, WEB, ML); University of Washington, Department of Health Services Research, Seattle, WA (DM); Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (SRR, RBE); Division of Hematology/Oncology, Columbia University, New York, NY (DLH)
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Factors which affect the use of lumpectomy and mastectomy in an underinsured, safety net hospital population. Am J Surg 2014; 209:985-91. [PMID: 25457245 DOI: 10.1016/j.amjsurg.2014.07.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Revised: 06/25/2014] [Accepted: 07/21/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND This study was performed to evaluate variables that affect the use of mastectomy and lumpectomy in an underinsured population. METHODS A retrospective review of all patients who underwent breast cancer operations from July 2001 to February 2011 at a safety net hospital was performed. Univariate and multivariate analyses were performed to identify variables, which were associated with the type of operation. RESULTS Of the 412 patients, 81% of the patients were underinsured or uninsured. Most patients (58%) presented with clinical stage 2A/B disease. Mastectomy was performed in 37% of patients and lumpectomy in 63%. In multivariate analysis, clinical tumor size (P = .035) and pathologic stage (P = .003) remained associated with mastectomy, while use of preoperative chemotherapy (P = .004) and type of surgeon (P = .001) was associated with lumpectomy. CONCLUSIONS Most patients underwent lumpectomy despite later stage at presentation. Preoperative chemotherapy was associated with increased likelihood of lumpectomy.
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Olsen-Deeter L, Hsu CH, Nodora JN, Bouton ME, Nalagan J, Martinez ME, Komenaka IK. Factors which affect use of breast conservation and mastectomy in an underinsured Hispanic population. Surg Oncol 2014; 23:186-91. [PMID: 25443563 DOI: 10.1016/j.suronc.2014.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 08/19/2014] [Accepted: 09/11/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND Despite no difference in overall survival between breast conservation and mastectomy, significant variation exists between institutions and within populations. Less data exists about racial and ethnic minority populations. The current study was performed to evaluate variables that affect use of breast conservation and mastectomy in an underinsured Hispanic population. METHODS A retrospective review was performed of all patients who self-identified as of Hispanic ethnicity and underwent breast cancer operations from July 2001 to February 2011 at a safety net hospital. Sociodemographic, clinical, and treatment variables were evaluated. All patients with documented contraindications to breast conservation were excluded. Univariate analysis and multivariate analysis were performed to identify variables which were associated with type of operation. RESULTS The average age of the 219 patients included was 50 years. Most of the patients (93%) were insured with Medicaid or uninsured and 59% presented with clinical stage 2A/B cancers. Mastectomy was performed in 33% of patients and 67% had breast conservation. In adjusted multivariate analysis higher pathologic stage (p=0.01) and English speakers (p=0.03) were associated with mastectomy. By contrast, higher BMI (p=0.03) and use of preoperative chemotherapy (p=0.01) were associated with breast conservation. CONCLUSIONS In this underinsured Hispanic population, patients with higher pathologic stage and English speaking patients were more likely to undergo mastectomy. Patients who underwent preoperative chemotherapy and who had higher BMI were more likely to undergo breast conservation.
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Affiliation(s)
| | - Chiu-Hsieh Hsu
- Arizona Cancer Center, University of Arizona, Tucson, AZ, USA; Mel and Enid Zuckerman Arizona College of Public Health, University of Arizona, Tucson, AZ, USA
| | - Jesse N Nodora
- Moores University of California San Diego Cancer Center, San Diego, CA, USA
| | | | | | | | - Ian K Komenaka
- Maricopa Medical Center, Phoenix, AZ, USA; Arizona Cancer Center, University of Arizona, Tucson, AZ, USA.
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Abstract
Recent studies have shown that the number of women undergoing risk-reducing mastectomy has increased rapidly in the USA in the past 15 years. Although a small rise in the number of bilateral risk-reducing procedures has been noted in high-risk gene mutation carriers who have never had breast cancer, this number does not account for the overall increase in procedures undertaken. In patients who have been treated for a primary cancer and are judged to be at high risk of a contralateral breast cancer, contralateral risk-reducing mastectomy is often, but not universally, indicated. However, many patients undergoing contralateral risk-reducing mastectomy might not be categorised as high risk and therefore any potential benefit from this procedure is unproven. At a time when breast-conserving surgery has become more widely used, this sharp increase in contralateral risk-reducing mastectomy is surprising. We have reviewed the literature in an attempt to establish what is driving the increase in this procedure in moderate-to-low-risk populations and to assess its justification in terms of risk-benefit analysis.
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Feigelson HS, James TA, Single RM, Onitilo AA, Aiello Bowles EJ, Barney T, Bakerman JE, McCahill LE. Factors associated with the frequency of initial total mastectomy: results of a multi-institutional study. J Am Coll Surg 2013; 216:966-75. [PMID: 23490543 DOI: 10.1016/j.jamcollsurg.2013.01.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Revised: 01/11/2013] [Accepted: 01/16/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND Several previous studies have reported conflicting data on recent trends in use of initial total mastectomy (TM); the factors that contribute to TM variation are not entirely clear. Using a multi-institution database, we analyzed how practice, patient, and tumor characteristics contributed to variation in TM for invasive breast cancer. STUDY DESIGN We collected detailed clinical and pathologic data about breast cancer diagnosis, initial, and subsequent breast cancer operations performed on all female patients from 4 participating institutions from 2003 to 2008. We limited this analysis to 2,384 incident cases of invasive breast cancer, stages I to III, and excluded patients with clinical indications for mastectomy. Predictors of initial TM were identified with univariate analyses and random effects multivariable logistic regression models. RESULTS Initial TM was performed on 397 (16.7%) eligible patients. Use of preoperative MRI more than doubled the rate of TM (odds ratio [OR] = 2.44; 95% CI, 1.58-3.77; p < 0.0001). Increasing tumor size, high nuclear grade, and age were also associated with increased rates of initial TM. Differences by age and ethnicity were observed, and significant variation in the frequency of TM was seen at the individual surgeon level (p < 0.001). Our results were similar when restricted to tumors <20 mm. CONCLUSIONS We identified factors associated with initial TM, including preoperative MRI and individual surgeon, that contribute to the current debate about variation in use of TM for the management of breast cancer. Additional evaluation of patient understanding of surgical options and outcomes in breast cancer and the impact of the surgeon provider is warranted.
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Hershman DL, Wright JD. Comparative effectiveness research in oncology methodology: observational data. J Clin Oncol 2012; 30:4215-22. [PMID: 23071228 DOI: 10.1200/jco.2012.41.6701] [Citation(s) in RCA: 114] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
The goal of comparative effectiveness research is to inform clinical decisions between alternate treatment strategies using data that reflect real patient populations and real-world clinical scenarios for the purpose of improving patient outcomes. Observational studies using population-based registry data are increasingly relied on to fill the information gaps created by lack of evidence from randomized controlled trials. Administrative data sets have many advantages, including large sample sizes, long-term follow-up, and inclusion of data on physician and systems characteristics as well as cost. In this review, we describe the characteristics of many of the commonly used population-based data sets and discuss the elements included within these data sets. An overview of common research themes that rely on population-based data and illustrative examples are presented. Finally, an overview of the analytic techniques commonly employed by health services researchers to limit the effects of selection bias and confounding is discussed. The analysis of well-designed studies of comparative effectiveness is complex. However, careful framing, appropriate study design, and application of sophisticated analytic techniques can improve the accuracy of nonrandomized studies. There are multiple areas where the unique characteristics of observational studies can inform medical decision making and health policy, and it is critical to appreciate the opportunities, strengths, and limitations of observational research.
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Affiliation(s)
- Dawn L Hershman
- Columbia University Medical Center and the Herbert Irving Comprehensive Cancer Center, New York, NY, USA.
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Hawley ST, Lillie SE, Morris A, Graff JJ, Hamilton A, Katz SJ. Surgeon-level variation in patients' appraisals of their breast cancer treatment experiences. Ann Surg Oncol 2012; 20:7-14. [PMID: 23054105 DOI: 10.1245/s10434-012-2582-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2012] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND PURPOSE While variation in breast cancer quality indicators has been studied, to date there have been no studies examining the degree of surgeon-level variation in patient-reported outcomes. The purpose of this study is to examine surgeon-level variation in patient appraisals of their breast cancer care experiences. METHODS Survey responses and clinical data from breast cancer patients reported to Detroit and Los Angeles Surveillance, Epidemiology and End Results registries from 6/2005 to 2/2007 were merged with attending surgeon surveys (1,780 patients, 291 surgeons). Primary outcomes were patient reports of access to care, care coordination, and decision satisfaction. Random-effects models examined variation due to individual surgeons for these three outcomes. RESULTS Mean values on each patient-reported outcome scale were high. The amount of variation attributable to individual surgeons in the unconditional models was low to modest: 5.4% for access to care, 3.3% for care coordination, and 7.5% for decision satisfaction. Few factors were independently associated with patient reports of better access to or coordination of care, but less-acculturated Latina patients had lower decision satisfaction. CONCLUSIONS Patients reported generally positive experiences with their breast cancer treatment, though we found disparities in decision satisfaction. Individual surgeons did not substantively explain the variation in any of the patient-reported outcomes.
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Affiliation(s)
- Sarah T Hawley
- Division of General Medicine, University of Michigan Health System, Center for Clinical Management Research, Ann Arbor VA Medical Center, Ann Arbor, MI, USA.
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