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Lindenblatt N, Leuenberger NJ, Harder Y, Kappos EA, Pusic AL, Shaw J, Giovanoli P, Fontein DBY. Measuring quality of care in autologous breast reconstruction: a Delphi consensus. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:107254. [PMID: 38056020 DOI: 10.1016/j.ejso.2023.107254] [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: 01/03/2023] [Revised: 10/15/2023] [Accepted: 10/29/2023] [Indexed: 12/08/2023]
Abstract
Measuring and benchmarking quality of care in surgical oncology has been gaining popularity. In autologous breast reconstruction (ABR), a standardized set of indicators to assess quality of care is lacking. In this study, we defined a set of evidence-based quality indicators for autologous breast reconstruction. First, we performed a systematic review to identify factors related to quality of care in ABR. Variables were categorized depending on their function: indicators related to outcome, indicators related to process and case-mix variables. The review was followed by a 3-round Delphi Consensus to determine which indicators and case-mix-variables were considered relevant and feasible for inclusion in an ABR standard set of indicators. 932 unique articles were identified, of which 110 papers were included in the study. Indicators were categorized by function: outcome, process and case-mix variables. In total, 8 process indicators and 41 outcome indicators were extracted. 30 case-mix-variables were included. Following 3 rounds of questioning in the Delphi Consensus, all respondents agreed on type of ABR, oncological outcomes and patient satisfaction for the standard set. Indicators related to complications were consistently ranked highly. Most process indicators were not chosen after 3 rounds of questioning. 11 case-mix-variables were included in the final set. Following the Delphi Consensus, it was possible to identify 33 process and outcome indicators and 11 case-mix-variables for inclusion for a standard set of quality indicators. With the inclusion of both objective and patient-reported outcome measures, this set of indicators provides a multidimensional measurement tool for quality assessment for ABR.
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Affiliation(s)
- N Lindenblatt
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - N J Leuenberger
- Department of Hand and Plastic Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Y Harder
- Department of Plastic, Reconstructive and Aesthetic Surgery, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale (EOC), Lugano, Switzerland; Faculty of Biomedical Sciences, Università Della Svizzera Italiana, Lugano, Switzerland
| | - E A Kappos
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Basel, Switzerland; Faculty of Medicine, University of Basel, Basel, Switzerland
| | - A L Pusic
- Division of Plastic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - J Shaw
- Patient Advocacy Group, Oncoplastic Breast Consortium, University Hospital Basel, Basel, Switzerland
| | - P Giovanoli
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - D B Y Fontein
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland.
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Peoples AE, Waler AR, Duet ML, Prabhu SS, Katz AJ. Comparing Outcomes in the Therapeutic and Prophylactic Breast for Bilateral Mastectomy With Implant-Based Breast Reconstruction. Ann Plast Surg 2023; 90:S375-S378. [PMID: 36811478 DOI: 10.1097/sap.0000000000003460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
BACKGROUND Increasingly patients with unilateral breast cancer elect to undergo bilateral mastectomy with subsequent reconstruction. Studies have aimed to better identify the risks associated with performing mastectomy on the noncancerous breast. Our study aims to identify differences in complications between therapeutic and prophylactic mastectomy in patients undergoing implant-based breast reconstruction. METHODS A retrospective analysis of implant-based breast reconstruction from 2015 to 2020 at our institution was completed. Patients with less than 6-month follow-up after final implant placement had reconstruction using autologous flaps, expander or implant rupture, metastatic disease requiring device removal, or death before completion of reconstruction were excluded. McNemar test identified differences in incidence of complications for therapeutic and prophylactic breasts. RESULTS After analysis of 215 patients, we observed no significant difference in incidence of infection, ischemia, or hematoma between the therapeutic and prophylactic sides. Therapeutic mastectomies had higher odds of seroma formation ( P = 0.03; odds ratio, 3.500; 95% confidence interval, 1.099-14.603). Radiation treatment status was analyzed for patients with seroma; 14% of patients unilateral seroma of the therapeutic side underwent radiation (2 of 14), compared with 25% patients with unilateral seroma of the prophylactic side (1 of 4). CONCLUSIONS For patients undergoing mastectomy with implant-based reconstruction, the therapeutic mastectomy side has an increased risk of seroma formation.
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A Comparison of Complications in Therapeutic versus Contralateral Prophylactic Mastectomy Reconstruction: A Paired Analysis. Plast Reconstr Surg 2022; 149:1037-1047. [PMID: 35245238 DOI: 10.1097/prs.0000000000008981] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Although breast reconstruction after bilateral mastectomies including a contralateral prophylactic mastectomy is known to have a higher overall complication profile, whether reconstructive complication rates differ between the therapeutic mastectomy and contralateral prophylactic mastectomy sides remains unclear. METHODS Women undergoing bilateral mastectomies with autologous or implant-based breast reconstruction for a unilateral breast cancer at a single institution were identified (2009 to 2019). Postoperative complications were stratified by laterality (therapeutic mastectomy versus contralateral prophylactic mastectomy). Paired data were analyzed to compare the risks of complications between prophylactic and therapeutic reconstruction sides in the same patient. RESULTS A total of 130 patients (260 reconstructions) underwent bilateral autologous or implant-based reconstruction. Although most women underwent a simple mastectomy, a higher proportion of therapeutic mastectomies were modified radical mastectomies including axillary lymph node dissections compared to contralateral prophylactic mastectomies (15.4 percent versus 0 percent). Forty-four percent of women completed postmastectomy radiation therapy of the therapeutic side before definitive reconstruction. Overall, both therapeutic and prophylactic reconstructions had a similar incidence of reconstructive failure (p = 0.57), return to the operating room (p = 0.44), mastectomy skin flap necrosis (p = 0.32), seroma (p = 0.82), fat necrosis (p = 0.16), wound infection (p = 0.56), and cellulitis (p = 0.56). Nearly one-fifth of patients experienced complications limited to the prophylactic side [contralateral prophylactic mastectomy reconstruction complications, n = 26 (20.0 percent); therapeutic mastectomy reconstruction complications, n = 15 (11.5 percent)]. CONCLUSION Despite a history of local radiation therapy and more extensive oncologic surgery on the therapeutic side, there are no significant differences in the incidence of postsurgical complications on the therapeutic mastectomy and contralateral prophylactic mastectomy sides after bilateral reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
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Hughes TM, Ellsworth B, Berlin NL, Sinco B, Bredbeck B, Baskin A, Wang T, Nathan H, Dossett LA. Statewide Episode Spending Variation of Mastectomy for Breast Cancer. J Am Coll Surg 2022; 234:14-23. [PMID: 35213456 DOI: 10.1097/xcs.0000000000000005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Centralizing complex cancer operations, such as pancreatectomy and esophagectomy, has been shown to increase value, largely due to reduction in complications. For high-volume operations with low complication rates, it is unknown to what degree value varies between facilities, or by what mechanism value may be improved. To identify possible opportunities for value enhancement for such operations, we sought to describe variations in episode spending for mastectomy with a secondary aim of identifying patient- and facility-level determinants of variation. STUDY DESIGN Using the Michigan Value Collaborative risk-adjusted, price-standardized claims data, we evaluated mean spending for patients undergoing mastectomy at 74 facilities (n = 7,342 patients) across the state of Michigan. Primary outcomes were 30- and 90-day episode spending. Using linear mixed models, facility- and patient-level factors were explored for association with spending variability. RESULTS Among 7,342 women treated across 74 facilities, mean 30-day spending by facility ranged from $11,129 to $20,830 (median $14,935). Ninety-day spending ranged from $17,303 to $31,060 (median $23,744). Patient-level factors associated with greater spending included simultaneous breast reconstruction, bilateral surgery, length of stay, and readmission. Among women not undergoing reconstruction, variation persisted, and length of stay, bilateral surgery, and readmission were all associated with increased spending. CONCLUSION Michigan hospitals have significant variation in spending for mastectomy. Reducing length of stay through wider adoption of same-day discharge for mastectomy and reducing the frequency of bilateral surgery may represent opportunities to increase value, without compromising patient safety or oncologic outcomes.
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Affiliation(s)
- Tasha M Hughes
- From the Department of Surgery (Hughes, Berlin, Bredbeck, Wang, Nathan, Dossett), Michigan Medicine, Ann Arbor, MI
- the Center for Healthcare Outcomes and Policy (Hughes, Berlin, Sinco, Bredbeck, Wang, Nathan, Dossett), Michigan Medicine, Ann Arbor, MI
| | - Brandon Ellsworth
- the University of Michigan School of Medicine, Ann Arbor, MI (Ellsworth, Baskin)
| | - Nicholas L Berlin
- From the Department of Surgery (Hughes, Berlin, Bredbeck, Wang, Nathan, Dossett), Michigan Medicine, Ann Arbor, MI
- the Center for Healthcare Outcomes and Policy (Hughes, Berlin, Sinco, Bredbeck, Wang, Nathan, Dossett), Michigan Medicine, Ann Arbor, MI
| | - Brandy Sinco
- the Center for Healthcare Outcomes and Policy (Hughes, Berlin, Sinco, Bredbeck, Wang, Nathan, Dossett), Michigan Medicine, Ann Arbor, MI
| | - Brooke Bredbeck
- From the Department of Surgery (Hughes, Berlin, Bredbeck, Wang, Nathan, Dossett), Michigan Medicine, Ann Arbor, MI
- the Center for Healthcare Outcomes and Policy (Hughes, Berlin, Sinco, Bredbeck, Wang, Nathan, Dossett), Michigan Medicine, Ann Arbor, MI
| | - Alison Baskin
- the University of Michigan School of Medicine, Ann Arbor, MI (Ellsworth, Baskin)
| | - Ton Wang
- From the Department of Surgery (Hughes, Berlin, Bredbeck, Wang, Nathan, Dossett), Michigan Medicine, Ann Arbor, MI
- the Center for Healthcare Outcomes and Policy (Hughes, Berlin, Sinco, Bredbeck, Wang, Nathan, Dossett), Michigan Medicine, Ann Arbor, MI
| | - Hari Nathan
- From the Department of Surgery (Hughes, Berlin, Bredbeck, Wang, Nathan, Dossett), Michigan Medicine, Ann Arbor, MI
- the Center for Healthcare Outcomes and Policy (Hughes, Berlin, Sinco, Bredbeck, Wang, Nathan, Dossett), Michigan Medicine, Ann Arbor, MI
| | - Lesly A Dossett
- From the Department of Surgery (Hughes, Berlin, Bredbeck, Wang, Nathan, Dossett), Michigan Medicine, Ann Arbor, MI
- the Center for Healthcare Outcomes and Policy (Hughes, Berlin, Sinco, Bredbeck, Wang, Nathan, Dossett), Michigan Medicine, Ann Arbor, MI
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Hughes TM, Dossett LA. Financial Toxicity: Exploring the Role of Treatment Choice. J Am Coll Surg 2021; 233:456-458. [PMID: 34446218 DOI: 10.1016/j.jamcollsurg.2021.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 06/07/2021] [Indexed: 10/20/2022]
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Char SN, Bloom JA, DeMarco D, Chatterjee A. Evaluating the Quality of Cost-Effectiveness Literature in Breast Surgery: What Do We Do Well and How Can We Do Better? A Systematic Review. Am Surg 2021; 88:2660-2669. [PMID: 33861654 DOI: 10.1177/00031348211011148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Surgical options for breast cancer are numerous and span multiple surgical disciplines. Decision analyses aid surgeons in making the most cost-effective choice, thus reducing health care expenditure while maximizing patient outcome. In this study, we aimed to evaluate existing breast surgery cost-effectiveness literature against the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) validated scoring system. METHODS A PRISMA search was performed for cost-effectiveness within breast surgery. Articles were scored with CHEERS criteria on a 0-24 scale and qualitative data were collected. Subgroup analysis was performed comparing pre-CHEERS (published in 2013 or earlier) and post-CHEERS (published in 2014 or later) cohorts. Chi-squared analysis was performed to compare where studies lost points between cohorts. RESULTS Of 2279 articles screened, 46 articles were included. The average CHEERS score was 18.18. Points were most often lost for characterizing heterogeneity, followed by discount rate, incremental costs and outcomes, and abstract. Quality-adjusted life year was the most commonly used health outcome, with visual model or analog scales as the most commonly used measure of effectiveness obtained primarily from surgeons or physicians. Most articles characterized uncertainty by deterministic sensitivity analysis, followed by both deterministic and probabilistic, then probabilistic. Average CHEERS scores were similar between pre- and post-CHEERS cohorts (17.67 vs. 18.40, P > .05) There were several significant differences in where articles lost points between pre- and post-CHEERS cohorts. DISCUSSION In order to standardize the reporting of results, cost-effectiveness studies in breast surgery should adhere to the current CHEERS criteria and aim to better characterize heterogeneity in their analyses.
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Affiliation(s)
- Sydney N Char
- 12261Tufts University School of Medicine, Boston, MA, USA
| | - Joshua A Bloom
- Department of Surgery, 1867Tufts Medical Center, Boston, MA, USA
| | - Danielle DeMarco
- Department of Surgery, 1867Tufts Medical Center, Boston, MA, USA
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Santosa KB, Oliver JD, Momoh AO. Contralateral prophylactic mastectomy and implications for breast reconstruction. Gland Surg 2021; 10:498-506. [PMID: 33634008 DOI: 10.21037/gs.2020.03.15] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Contralateral prophylactic mastectomy (CPM) rates have continued to rise in the United States, impacting all stakeholders including plastic and reconstructive surgeons. Multiple factors may be influencing this trend, including patient decision-making characteristics, knowledge about breast cancer disease and prognosis, advances in genetic testing and enhanced imaging capabilities, sociodemographic factors, and access to specialty surgical services such as breast reconstruction. In this review, the authors shed light on the current state of CPM and summarize the literature analyzing its increasing prevalence in the United States, as well as outline future directions for study and dissemination of knowledge from providers to patients surrounding this important and complex treatment decision.
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Affiliation(s)
- Katherine B Santosa
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Jeremie D Oliver
- Department of Biomedical Engineering, School of Dentistry, School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Adeyiza O Momoh
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
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The relationship between contralateral prophylactic mastectomy and breast reconstruction, complications, breast-related procedures, and costs: A population-based study of health insurance data. Surgery 2020; 168:859-867. [DOI: 10.1016/j.surg.2020.06.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 06/09/2020] [Accepted: 06/18/2020] [Indexed: 12/20/2022]
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Agarwal S, Pappas L, Matsen CB, Agarwal JP. Second primary breast cancer after unilateral mastectomy alone or with contralateral prophylactic mastectomy. Cancer Med 2020; 9:8043-8052. [PMID: 32918537 PMCID: PMC7643660 DOI: 10.1002/cam4.3394] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 07/05/2020] [Accepted: 07/12/2020] [Indexed: 12/12/2022] Open
Abstract
Background An increasing number of patients undergo contralateral prophylactic mastectomy (CPM) for unilateral breast cancer. However, the benefit of CPM has not been quantified in the setting of contemporary breast cancer therapy. Methods We performed an analysis of 180 068 patients in the Surveillance, Epidemiology, and End Results (SEER) database, diagnosed with unilateral ductal breast carcinoma between 1998 and 2013 and treated with unilateral mastectomy (UM) or CPM. UM was performed in 146 213 patients (81.2%); CPM was performed in 33 855 patients (19.8%). Primary outcome of interest was cumulative incidence of a second primary breast cancer in the ipsilateral or contralateral breast greater than 3 months after initial diagnosis. Cumulative incidence analysis was based on a Cox proportional model to generate curves of second primary breast cancer in any breast, ipsilateral breast only, or contralateral breast only. Results Patients who underwent CPM had a significantly reduced incidence of second primary breast cancer 10 and 15 years after surgery (CPM 0.93% [0.73%, 1.12%] vs UM 4.44% [4.28%, 4.60%]). Patients who underwent CPM had significantly lower adjusted hazard of second primary breast cancer when compared with UM (HR 0.38 vs 1.0, P < .0001). Conclusions CPM offers some protection from a second primary breast cancer, attributable to a reduced incidence in the contralateral breast. These findings provide additional information to providers and patients as they make decisions regarding surgical management. They should also be interpreted in the context of the absolute incidence of second primary breast cancer after UM and previous literature demonstrating no survival benefit.
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Affiliation(s)
- Shailesh Agarwal
- Department of Surgery, University of Chicago Medical Center, Chicago, IL, USA
| | - Lisa Pappas
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Cindy B Matsen
- Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Jayant P Agarwal
- Department of Surgery, University of Utah, Salt Lake City, UT, USA
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Woeste MR, Bhutiani N, Geller AE, Eldridge-Hindy H, McMasters KM, Ajkay N. Identifying Factors Predicting Prolonged Opioid Use After Mastectomy. Ann Surg Oncol 2020; 27:993-1001. [DOI: 10.1245/s10434-019-08171-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Indexed: 01/14/2023]
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Metcalfe KA, Retrouvey H, Kerrebijn I, Butler K, O'Neill AC, Cil T, Zhong T, Hofer SOP, McCready DR. Predictors of uptake of contralateral prophylactic mastectomy in women with nonhereditary breast cancer. Cancer 2019; 125:3966-3973. [PMID: 31435939 DOI: 10.1002/cncr.32405] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 06/21/2019] [Accepted: 06/27/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND The rates of contralateral prophylactic mastectomy (CPM) are increasing in women with breast cancer. Previous retrospective research has examined clinical and demographic predictors of the uptake of CPM. However, to the authors' knowledge, there has been very little prospective research to date that has examined psychosocial functioning prior to breast cancer surgery to determine whether psychosocial functioning predicts uptake of CPM. The current study was conducted to evaluate demographic, clinical, and psychosocial predictors of the uptake of CPM in women with unilateral breast cancer without a BRCA1 or BRCA2 mutation. METHODS Women with unilateral non-BRCA-associated breast cancer completed questionnaires prior to undergoing breast cancer surgery. Participants completed demographic and psychosocial questionnaires assessing anxiety, depression, cancer-related distress, optimism/pessimism, breast satisfaction, and quality of life. Pathological and surgical data were collected from medical charts. RESULTS A total of 506 women consented to participate, 112 of whom (22.1%) elected to undergo CPM. Age was found to be a significant predictor of CPM, with younger women found to be significantly more likely to undergo CPM compared with older women (P < .0001). The rate of CPM was significantly higher in women with noninvasive breast cancer compared with those with invasive breast cancer (P < .0001). Women who elected to undergo CPM had lower levels of presurgical breast satisfaction (P = .01) and optimism (P = .05) compared with women who did not undergo CPM. CONCLUSIONS Psychosocial functioning at the time of breast cancer surgery decision making impacts decisions related to CPM. Women who have lower levels of breast satisfaction (body image) and optimism are more likely to elect to undergo CPM. It is important for health care providers to take psychosocial functioning into consideration when discussing surgical options.
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Affiliation(s)
- Kelly A Metcalfe
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada.,Women's College Research Institute, Toronto, Ontario, Canada
| | - Helene Retrouvey
- Division of Plastic Surgery, University Health Network and Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Isabel Kerrebijn
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
| | - Kate Butler
- Division of Plastic Surgery, University Health Network and Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Anne C O'Neill
- Division of Plastic Surgery, University Health Network and Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Tulin Cil
- Division of General Surgery, Princess Margaret Hospital, Toronto, Ontario, Canada
| | - Toni Zhong
- Division of Plastic Surgery, University Health Network and Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Stefan O P Hofer
- Division of Plastic Surgery, University Health Network and Mount Sinai Hospital, Toronto, Ontario, Canada
| | - David R McCready
- Division of General Surgery, Princess Margaret Hospital, Toronto, Ontario, Canada
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Impact of anticipated financial burden on patient decision to undergo contralateral prophylactic mastectomy. Surgery 2018; 164:856-865. [DOI: 10.1016/j.surg.2018.05.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 04/06/2018] [Accepted: 05/01/2018] [Indexed: 01/05/2023]
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