A Randomized Single-Blinded Study Comparing Preoperative with Post-Mastectomy PECS Block for Post-operative Pain Management in Bilateral Mastectomy with Immediate Reconstruction

BACKGROUND

Ultrasound-guided pectoralis muscle blocks (PECS I/II) are well established for postoperative pain control after mastectomy with reconstruction. However, optimal timing is unclear. We conducted a randomized controlled single-blinded single-institution trial comparing outcomes of block performed pre-incision versus post-mastectomy.

METHOD

Patients with breast cancer undergoing bilateral mastectomy with immediate expander/implant reconstruction were randomized to receive ultrasound-guided PECS I/II either pre-incision (PreM, n = 17) or post-mastectomy and before reconstruction (PostM, n = 17). The primary outcome was the average pain score using the Numerical Rating Score during post-anesthesia care unit (PACU) and inpatient stay, with the study powered to detect a difference in mean pain score of 2. Secondary outcomes included mean pain scores on postoperative day (POD) 2, 3, 7, 14, 90, and 180; pain catastrophizing scores; narcotic requirements; PACU/inpatient length of stay; block procedure time; and complications.

RESULT

No significant differences between the two groups were noted in average pain score during PACU (p = 0.57) and 24-h inpatient stay (p = 0.33), in the 2 weeks after surgery at rest (p = 0.90) or during movement (p = 0.30), or at POD 90 and 180 at rest (p = 0.42) or during movement (p = 0.31). Median duration of block procedure (PreM 7 min versus PostM 6 min, p = 0.21) did not differ. Median PACU and inpatient length of stay were the same in each group. Inpatient narcotic requirements were similar, as were length of stay and post-surgical complication rates.

CONCLUSION

Intraoperative ultrasound-guided PECS I/II block administered by surgeons following mastectomy had similar outcomes to preoperative blocks.

TRIAL REGISTRATION

This trial is registered with Clinical Research Information Service (NCT03653988).

Analysis of the Understanding and Worry about Lymphedema of Patients with Breast Cancer

BACKGROUND

Lymphedema is a potential lifelong sequela of breast cancer treatment. We sought to: (1) evaluate the worry and knowledge of patients about lymphedema, (2) quantify patients reporting lymphedema education and screening, and (3) determine willingness to participate in lymphedema screening and prevention programs.

PATIENTS AND METHODS

A survey evaluating lymphedema-related knowledge and worry was sent to patients treated for stage 0-III breast cancer. Exclusion criteria included > 10 years since diagnosis, missing clinical staging, and those without axillary surgery. Responses were linked with clinicopathologic information.

RESULTS

Of 141 patients meeting inclusion criteria, 89% of those without lymphedema were not at all or slightly worried about lymphedema. Higher levels of worry were associated with clinical stage II-III disease [odds ratio (OR) 2.63, p = 0.03], a history of axillary lymph node dissection (ALND) (OR 4.58, p < 0.01), and employment (OR 2.21, p = 0.05). A total of 102 (72%) patients recalled receiving lymphedema education. Lymphedema knowledge was limited, with < 25% of respondents answering > 50% of the risk factor questions correctly. Worry and knowledge were not significantly associated. Of patients without lymphedema, 36% were interested in learning more about lymphedema and 64% were willing to participate in or learn more about a screening program. Most (66%) felt that lymphedema information should be provided before and after cancer treatment.

DISCUSSION

A majority of our breast cancer survivors had limited knowledge about lymphedema risk factors. While most patients were not worried about developing lymphedema, higher worry was seen in patients with a higher clinical stage at diagnosis, ALND, and employment. Our findings suggest potential targets and timing for patient-centered educational interventions.

A Pilot Study of Preoperative Vandetanib on Markers of Proliferation and Apoptosis in Breast Cancer

INTRODUCTION

Preclinical data supports antitumor activity of tyrosine kinase inhibitor vandetanib with Ret as the therapeutic target in breast cancer. We investigated the effect of preoperative vandetanib on markers of proliferation and apoptosis in breast cancer.

METHODS

Patients with invasive breast cancer were randomly assigned vandetanib 300 mg or placebo PO daily for 2 weeks before operative resection from January 2014 to June 2017. Pretreatment and posttreatment specimens were analyzed by immunohistochemistry for Ki-67, TUNEL, and p-ERK with stratification by Ret expression by immunohistochemistry.

RESULTS

Ten patients were enrolled. There was no statistically significant difference in ERK activation compared with placebo (P=0.45); however, ERK activation was reduced 74% compared with pretreatment biopsy with vandetinib treatment (P=0.005) without a significant reduction in the placebo group (-29%, P=0.55). Mean change in Ki-67 after vandetanib treatment was +0.3% compared with +2.0% in placebo treated patients, P=0.72. Mean change in TUNEL was +0.48 apoptotic nuclei per HPF in the vandetanib arm compared with +1.02 in the placebo arm, P=0.32. In vandetanib treated patients, Ki-67 was reduced 0.3% in RET-positive tumors compared with increased 1.0% in RET-negative tumors, P=0.43 and TUNEL was increased 0.77 in RET-positive tumors and 0.2 in RET-negative tumors, P=0.21.

CONCLUSIONS

In this pilot study, no statistically significant differences on prespecified markers were seen with vandetanib compared with placebo. In accordance with the investigational hypothesis, there was a nonsignificant trend with vandetanib treatment of reduction in p-ERK and increased effects in Ret expressing tumors.

Teaching and Mentoring Early in Surgical Practice

BACKGROUND

Transitioning from trainee to independent surgeon is challenging, with teaching and mentoring learners adding complexity. This study aimed to identify benefits and challenges of teaching and mentoring residents early in surgical practice.

MATERIALS AND METHODS

A mixed-methods survey with multiple choice and open-ended questions was developed for early career (first 3 years) and experienced (more than 3 years) surgeons working with residents. The survey was initially piloted by 6 surgeons, revised according to feedback and distributed on Twitter. Quantitative and qualitative analyses were performed.

RESULTS

Seventy-three valid responses were analyzed, 21 (25%) from early career surgeons and 53 (75%) from experienced surgeons. The majority were women (62%), practiced in academics (78%) and lived in the United States (76%). Most of the early career and experienced surgeons selected the operating room as the most teaching challenging location (62% early career; and 60% experienced). Top teaching challenges of early career surgeons were the need to focus on own skills (24%) and concern for patient safety/outcomes (24%), while experienced surgeons reported need to focus on own skills (23%) and difficulty giving up control (23%). Open-ended responses identified themes related to teaching and mentoring. Comments highlighted benefits of organizational support to facilitate teaching and mentoring and negative experiences due to resident learners not respecting early career surgeons.

DISCUSSION

This pilot study explores an area not previously studied. Early career surgeons and experienced surgeons find many similar challenges and benefits of teaching and mentoring residents. Challenges and themes identified can guide early career surgeons and organizations with regard to teaching and mentoring.

Rate of BRCA mutation in patients tested under NCCN genetic testing criteria

BACKGROUND

BRCA genetic testing is recommended by the National Comprehensive Cancer Network (NCCN) in breast cancer patients who meet specific criteria. Limited data are available on the likelihood of detecting a mutation when these guidelines are followed.

METHODS

A retrospective chart review examined patients with breast cancer who underwent BRCA testing based on NCCN guidelines.

RESULTS

Twelve (6.0%) of the 199 patients had a deleterious BRCA mutation. Family history of BRCA mutations (50%, p = 0.019), age ≤45 at diagnosis (9.7%, p = 0.034) and meeting ≥3 NCCN criteria (13.3%, p = 0.03) yielded the highest rates of BRCA mutation. Having a family history of BRCA mutation and age ≤45 were associated with increased rate of BRCA mutation on multivariate analysis (OR 14.3, CI 1.2-166.3; OR 11.6, CI 1.2-108.6).

CONCLUSION

Select NCCN criteria are associated with higher rates of BRCA mutations. Waiting for genetic testing results to guide surgical management may be warranted in this subset of patients.

Use of a Coordinated Social Media Strategy to Improve Dissemination of Research and Collect Solutions Related to Workforce Gender Equity

Background: To increase awareness, search for solutions, and drive change, disparity-related research needs to be strategically disseminated. This study aimed to quantify whether a social media strategy could: (1) amplify dissemination of gender equity-related articles and (2) collect proposed solutions to gender equity issues. Methods: In April 2018, eight published journal articles covering separate gender equity issues were presented in a 1-hour Twitter chat hosted by Physician's Weekly. Metrics data were collected before, during, and after the chat. During the chat, one question related to each article was tweeted at a time. Qualitative data were extracted from responses and evaluated for thematic content. Results: In the 16-hour period during and following the chat, we tallied 1500 tweets from 294 participants and 8.6 million impressions (potential views). The Altmetric Attention Score of each article increased (average, 126.5 points; range, 91-208 points). Within the respective journal, the Altmetric Rank of seven articles improved (range, 3 to ≥19), while the eighth maintained its #1 rank. The one article for which share and download data were available experienced a 729% increase in shares following prechat posts and another 113% bump after the chat, a 1667% increase overall (n = 45-795). Similarly, downloads, and presumably reads, increased 712% following prechat posts and another 47% bump after the chat, a 1093% increase overall (n = 394-4700). We tallied 181 potential solutions to the eight gender equity-related questions. Conclusion: Our results demonstrate that social media can be used strategically to increase the dissemination of research articles and collect solution-focused feedback.

Intraoperative Radiotherapy for Breast Cancer Treatment in a Rural Community

BACKGROUND

Access to health care poses particular challenges for patients living in rural communities. Intraoperative radiotherapy (IORT) offers a treatment alternative to traditional whole-breast radiation therapy (WBRT) for select patients. This study aimed to analyze the use of IORT for patients undergoing breast-conserving surgery at an academic institution located in a rural state.

METHODS

A retrospective review analyzed all patients at a single institution with a diagnosis of ductal carcinoma in situ (DCIS) or invasive breast cancer from April 2012 to January 2017 who were undergoing breast-conserving surgery with either IORT or WBRT. Student's t test or Fisher's exact test was used to make statistical comparisons.

RESULTS

Patients undergoing IORT (n = 117) were significantly older than patients treated with WBRT (n = 191) (65.6 vs 58.6 years; p < 0.001) and had smaller tumors on both preoperative imaging (1.04 vs 1.66 cm; p < 0.05) and final pathology (0.99 vs 1.48 cm; p < 0.05). Patients receiving IORT lived farther from the treating facility than patients treated with WBRT (67.2 vs 30.8 miles; p < 0.05). To account for biases created in the IORT selection criteria, subgroup analysis was performed for women receiving WBRT who fulfilled IORT selection criteria, and distance traveled remained significant (67.2 vs 31.4 miles; p < 0.05). Neither recurrence nor survival differed between the IORT and WBRT groups. Medicare reimbursement for IORT was approximately 50% more than for WBRT.

CONCLUSIONS

For women from rural communities, IORT appears to be an attractive option because these women tend to be older and to live farther from the treatment facility.

Nipple-Sparing Mastectomy is Not Associated with a Delay of Adjuvant Treatment

BACKGROUND

High-volume single-institution studies support the oncologic safety of nipple sparing mastectomy (NSM). Concerns remain regarding the increased potential for complications, recurrence, and delays to subsequent adjuvant therapy. A national database was used to examine treatment and outcomes for NSM patients.

METHODS

Women undergoing unilateral NSM or skin sparing mastectomy (SSM) for stage 0-4 breast cancer from 2004 to 2013 were identified from the National Cancer Database. Demographic and oncologic characteristics, short-term outcomes and time to local and systemic treatment were compared.

RESULTS

NSM was performed on 8173 patients: 8.7% were node positive, and for stage 1-4 disease, 10.6% were triple negative (TN) and 15.3% were HER2-positive. NSM patients were less likely than SSM patients to receive chemotherapy [CT] (37.4 vs. 43.4%) or radiation [PMRT] (15.6 vs. 16.9%), and were also more likely to present with clinically early-stage disease. NSM patients with high-risk features were more likely to receive CT in the neoadjuvant [NCT] than adjuvant setting [AC] (OR 3.76, 1.81, and 1.99 for clinical N2/3, TN, and HER2-positive disease, all p < 0.001). On multivariate analysis, NSM patients had a higher rate of pathologic complete response [pCR] (OR 1.41, p < 0.001). Readmission rate, positive margin rate and time to CT, PMRT or hormonal therapy were not increased for NSM compared to SSM patients.

CONCLUSIONS

Over one third of NSM patients received chemotherapy and/or radiation. NSM patients with high-risk features were more likely to receive NAC and obtain a pCR. NSM patients did not experience worse outcomes or delayed adjuvant therapy compared to SSM.

Abstract P1-11-04: Long-term patient satisfaction with cosmetic outcome and psychosocial wellbeing after breast conserving therapy is affected only by lumpectomy volume

Introduction: Breast conserving therapy (BCT) is considered the treatment of choice for early stage breast cancer by National Cancer Institute guidelines. Little data exists on patient-reported satisfaction and quality of life outcomes after lumpectomy with radiation. This study aims to identify factors influencing satisfaction with cosmetic outcome and quality of life in patients receiving BCT using a validated instrument.

Methods: All patients treated with lumpectomy and radiation for breast cancer at our institution from 1997-2012 received a mailed questionnaire containing the BREAST-Q breast conservation module (graciously provided by Dr A. Pusic, Memorial Sloan Kettering Cancer Center), a validated quality of life survey instrument. A retrospective chart review was performed for survey responders for demographic, treatment, and staging information. Scores were calculated for satisfaction with appearance of the breast, adverse effects of radiation, sexual wellbeing, psychosocial wellbeing and physical wellbeing: upper body and arm. Pearson correlation coefficients were obtained. Wilcoxon rank-sum and one-way ANOVA were used to identify associations between patient variables and satisfaction scores. Multivariate regression was used to assess confounding variables.

Results: A total of 110 questionnaires (response rate of 29.5%) fit criteria for analysis. The mean age of respondents was 65.9±11.2 yrs, and mean time since diagnosis was 91.8±53.1 mos. We observed the strongest correlations between satisfaction with breast appearance and sexual wellbeing (r=0.66, p&lt;0.01), breast appearance and psychosocial wellbeing (r=0.62, p&lt;0.01), and fewer effects of radiation and physical wellbeing (r=0.65, p&lt;0.01). Lumpectomy volume was associated with decreased satisfaction with breast appearance (r=-0.32, p &lt;0.01) and psychosocial wellbeing (r=-0.19, p&lt;0.05). There was no correlation between satisfaction with breast appearance and patient age, time since surgery, history of re-excision, stage or localization technique. Patients with older age at diagnosis reported significantly fewer effects of radiation and better psychosocial, physical, and sexual wellbeing (all p&lt;0.05) (Table 1). The incidence of recurrence was 2.7% and did not impact satisfaction scores.

Distribution of Satisfaction/Quality of Life Outcomes by Age at Diagnosis  Satisfaction/Quality of Life*AgeNBreastAdverse Effects of RadiationPsychosocialSexualPhysical&lt;451458±2282±1973±1945±2074±1645-553264±2683±1980±2054±2579±1756-602667±1794±983±2370±1885±1361-651267±2989±2383±2053±2983±17&gt;652670±2391±1288±1663±2588±25All11065±2388±1682±2058±2482±19P 0.1590.0190.0140.0300.002*Rasch scores range from 0-100 where 100 indicates highest satisfaction

Conclusions: In women undergoing BCT, patient satisfaction with appearance of the breast and psychosocial wellbeing at 7.6 years of follow-up correlated with the volume of tissue removed but no other patient or tumor characteristics. Increasing age at diagnosis was associated with greater satisfaction in multiple domains. These results emphasize the importance of precise surgical technique and patient selection in order to achieve long-term patient satisfaction with BCT.

Citation Format: Welsh JL, Fu S, Liao J, Sugg SL, Scott-Conner CE, Weigel RJ, Erdahl LM, Lizarraga IM. Long-term patient satisfaction with cosmetic outcome and psychosocial wellbeing after breast conserving therapy is affected only by lumpectomy volume. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-11-04.

Contralateral Prophylactic Mastectomy: Factors Predictive of Occult Malignancy or High-Risk Lesion and the Impact of MRI and Genetic Testing

BACKGROUND

Despite decreasing rates of subsequent contralateral breast cancer after diagnosis of unilateral primary breast cancer, the proportion of patients electing contralateral prophylactic mastectomy (CPM) is increasing. Our aim was to identify risk factors associated with the identification of occult malignancy (OM) or high-risk lesion (HRL) in CPM to facilitate patient counseling and operative planning.

METHODS

We identified patients undergoing CPM in addition to mastectomy for index breast cancer between October 2008 and June 2013. Patient and tumor factors were analyzed to identify associations with OM or HRL in CPM.

RESULTS

Among 740 CPM patients, an OM was identified in 4.1 % and an HRL was identified in 10.5 %. On multivariable analysis, factors associated with either occult finding included older age [odds ratio (OR) 1.37, per 10-year increase], invasive lobular index tumor histology (OR 2.60), progesterone receptor (PR)-positive index tumor (OR 1.79), and neoadjuvant therapy (OR 0.55). Overall, 244 patients (33 %) underwent BRCA testing, and 38 (16 %) had a deleterious mutation; 494 patients (67 %) had a preoperative breast MRI. Neither absence of a deleterious BRCA mutation nor a negative preoperative MRI decreased the likelihood of an occult finding in CPM.

CONCLUSIONS

Although invasive cancer was identified infrequently in CPM specimens, the rate of HRL or OM in our study was 14.6 %. Older age and infiltrating lobular and PR-positive index breast cancers were associated with a higher risk of OM in CPM, while neoadjuvant therapy diminished the risk. BRCA testing and preoperative MRI were not associated with HRL or OM. This information is valuable for patient counseling and surgical planning.