Abstract P1-10-08: Breast Reconstruction Surgery Following Mastectomy: Love or Money?

Introduction

All women should be considered for breast reconstruction following mastectomy, providing they are medically fit. The proportion of women having a reconstruction varies significantly from centre to centre; a key reason for this is the availability of reconstruction in that centre. In countries with an insurance funded health care system, breast reconstruction may also be influenced by the ability to pay. In the UK, breast reconstruction is available for free on the National Health Service (NHS). The aim of our study was to identify any other factors that may influence a woman's decision to have a reconstruction. Methods

All women having a mastectomy under the care of one breast surgeon between 2000 and 2010 were included. Data were collected retrospectively and included: age at surgery, marital status, dependents under 18, employment status, home circumstances and Zip code. The Index of Multiple deprivation (IMD2007) was derived for each patient from their zip code using the UK National Statistics data. The patients were divided into two main groups: those who underwent reconstruction and those who opted for mastectomy only. The Mann-Whitney U test was used to determine whether there was a statistical difference between the two patient groups using the statistical package R.

Results

A total of 272 patients underwent mastectomy during the study period, of these patients 148 had mastectomy only (median age 67, range 34 — 95) and 124 had a reconstruction (median age 51, range 28-73). When the two groups were compared statistical analysis revealed that the reconstruction group were younger (P<0.002), more likely to be married or have a partner (p=0.00065), have dependents (P<0.0005) and work (P<0.0005). There was no significant difference between the two groups socioeconomic status.

Conclusion

These data suggest that social and economical inequalities do not affect the decision making process for breast cancer patients in a society where health care is free at the point of delivery. However young age and a stable family/partner do.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-10-08.

Breast Specialist Nurses – Expensive Hand Holding or Cost-Effective Counselling?

IntroductionCounselling breast cancer patients for reconstruction is complex and time consuming. Post-reconstruction satisfaction has been shown to be related to the quality of information provided to patients. Decisions regarding the type of breast reconstruction suitable for each patient is multi-factorial, including the autologous tissue available, general health, patient lifestyle and suitability, as well as patient preference. In our institution we offer a full range of reconstruction techniques. Initial pre-operative counselling is performed by a breast reconstruction specialist nurse at a consultation lasting at least 1 hour. During this time, all reconstructive options are discussed.Implications of surgery, photographs of post-operative results and the details of the procedures are explained and written information is provided. The option to meet a patient advocate at a later date is offered. An indication of the suitable reconstructive options available to the individual is given, however the surgeon, at a separate consultation lasting 10 minutes, performs the formal assessment of reconstructive type.MethodA comparison was made of patient satisfaction with pre-operative counselling and information giving, between those patients who were counselled by the operative surgeon alone and those counselled by the Breast Reconstruction Specialist nurse. A questionnaire to assess patient satisfaction with the reconstruction counselling was designed in conjunction with the Clinical Psychology team. This questionnaire was posted retrospectively to all patients who had undergone reconstruction counselling irrespective of whether they had subsequently undergone breast reconstruction. Patients were asked to respond to questions on a 5 point Likert scale. Patients were divided into 2 groups dependent on the person performing the counselling, ie. surgeon or nurse. All questionnaires were anonymous.ResultsQuestionnaires were allocated a random number and the data were analyzed independently by 2 separate clinical psychologists, blinded to which group the patients belonged to. Group 1 was counselled by the operative surgeon alone and Group 2 by the Breast Reconstruction Nurse. There was a very high response rate in both groups (70% in Group 1 and 71% in Group 2). Qualitative and quantitative data were analyzed separately. There was a high satisfaction rating in both groups with responses to all questions having a mean rating of above 4 out of 5. Patient satisfaction between the 2 groups was compared using the Mann-Whitney U test. There was no significant reported difference between how useful each of the groups found the contact.ConclusionEmploying a Specialist Nurse to perform the time-consuming pre-operative counselling for breast reconstruction is a cost effective measure, allowing Surgeons time to assess more patients or perform more appropriate skilled tasks instead. Patient satisfaction with the counselling service and information-giving was equal in both groups suggesting that nurse-led counselling, even for complex surgical procedures, is acceptable to patients. Having someone, other than the operative surgeon, give an independent and unbiased perspective on reconstructive options may be important in patient decision making.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1075.

Idefix insulator activity can be modulated by nearby regulatory elements

Insulators play important roles in controlling gene activity and maintaining regulatory independence between neighbouring genes. In this article, we show that the enhancer-blocking activity of the insulator present within the LTR retrotransposon Idefix can be abolished if two copies of the region containing the insulator—specifically, the long terminal repeat (LTR)—are fused to the retrotransposon's 5′ untranslated region (5′ UTR). The presence of this combination of two [LTR-5′ UTR] modules is a prerequisite for the loss of enhancer-blocking activity. We further show that the 5′ UTR causes flanking genomic sequences to be displaced to the nuclear periphery, which is not observed when two insulators are present by themselves. This study thus provides a functional link between insulators and independent genomic modules, which may cooperate to allow the specific regulation of defined genomic loci via nuclear repositioning. It further illustrates the complexity of genomic regulation within a chromatic environment with multiple functional elements.

Wallerian degeneration of injured axons and synapses is delayed by a Ube4b/Nmnat chimeric gene

Axons and their synapses distal to an injury undergo rapid Wallerian degeneration, but axons in the C57BL/WldS mouse are protected. The degenerative and protective mechanisms are unknown. We identified the protective gene, which encodes an N-terminal fragment of ubiquitination factor E4B (Ube4b) fused to nicotinamide mononucleotide adenylyltransferase (Nmnat), and showed that it confers a dose-dependent block of Wallerian degeneration. Transected distal axons survived for two weeks, and neuromuscular junctions were also protected. Surprisingly, the Wld protein was located predominantly in the nucleus, indicating an indirect protective mechanism. Nmnat enzyme activity, but not NAD+ content, was increased fourfold in WldS tissues. Thus, axon protection is likely to be mediated by altered ubiquitination or pyridine nucleotide metabolism.

Nerve regeneration in Wld(s) mice is normalized by actinomycin D

Injured nerves of Wld(s) mice neither degenerate nor regenerate for several weeks. We have conjectured that Wld(s) axons have the ability to regenerate but its expression is impaired by the Schwann cells of the undegenerated distal stump. To test this conjecture, transcription was locally arrested with actinomycin D (ActD), nerves were crushed, and regrowth was evaluated. In normal CD1 nerves injected with ActD 3 days before the crush, the rate of elongation was not affected but the delay of regrowth was shortened. In sharp contrast, ActD normalized the elongation of Wld(s) axons. When Wld(s) nerves were crushed past the treated segment, axons did not regenerate. After 7, but not 4, days of treatment, intact CD1 and Wld(s) axons presented a local sprouting response. We conclude that Wld(s) axons can regenerate in a normal way but do not do so because the undegenerated Schwann cells of the distal stump repress the regrowth program. We present a model axon that includes a destruction program and a post-transcriptional trophic regulation of its phenotype.

Drug accumulation and elimination in Calliphora vicina larvae

Calliphora vicina larvae were fed on drug-laden muscle from three suicides involving amitriptyline, temazepam and a combination of trazodone and trimipramine; triplicate daily harvestings were analysed. The limit of detection for all four drugs was 0.01 micrograms drug/g larvae. Mean drug concentrations (microgram/g) in the initial muscle were:amitriptyline, 2.68; temazepam, 4.04; trazodone, 21.56; and trimipramine, 19.58. Larval rearings for days 4-8 (15 larval samples per drug) had mean and ranges of drug concentrations (microgram/g) of 0.10 (r, 0.02-0.24) for amitriptyline; 0.52 (r, 0.26-0.78) for temazepam; 0.13 (r, 0.05-0.32) for trazodone; and 0.28 (r, 0.10-0.59) for trimipramine. After day 8 there was a precipitous fall in larval drug concentrations associated with pupariation. At day 11 ranges of drug concentrations (microgram/g) were: amitriptyline, < 0.01-0.01; temazepam, 0.01-0.08; trazodone, < 0.01-0.01; and trimipramine, 0.04-0.04. Day 16 pupae had corresponding ranges (microgram/g) of < 0.01, 0.01-0.01, < 0.01 and < 0.01-0.02. Transfer to drug-free food at day 5 led to similar falls in drug concentrations (microgram/g) from day 5 to day 6: 0.08-0.03 for amitriptyline, 0.61-0.09 for temazepam, 0.13-0.01 for trazodone, and 0.30-0.02 for trimipramine. The results show considerable variation in larval drug concentrations, both at the same developmental stage and at different stages of the life cycle, under conditions which closely reflect case situations. In practice, the precipitous decrease in drug concentrations in non-feeding larvae and at pupariation make it desirable to sample only larvae actively feeding on a corpse.