Association between age and access to immediate breast reconstruction in women undergoing mastectomy for breast cancer

BACKGROUND

National guidelines state that patients with breast cancer undergoing mastectomy in England should be offered immediate breast reconstruction (IR), unless precluded by their fitness for surgery or the need for adjuvant therapies.

METHODS

A national study investigated factors that influenced clinicians' decision to offer IR, and collected data on case mix, operative procedures and reconstructive decision-making among women with breast cancer having a mastectomy with or without IR in the English National Health Service between 1 January 2008 and 31 March 2009. Multivariable logistic regression was used to examine the relationship between whether or not women were offered IR and their characteristics (tumour burden, functional status, planned radiotherapy, planned chemotherapy, perioperative fitness, obesity, smoking status and age).

RESULTS

Of 13 225 women, 6458 (48·8 per cent) were offered IR. Among factors the guidelines highlighted as relevant to decision-making, the three most strongly associated with the likelihood of an offer were tumour burden, planned radiotherapy and performance status. Depending on the combination of their values, the probability of an IR offer ranged from 7·4 to 85·1 per cent. A regression model that included all available factors discriminated well between whether or not women were offered IR (c-statistic 0·773), but revealed that increasing age was associated with a fall in the probability of an IR offer beyond that expected from older patients' tumour and co-morbidity characteristics.

CONCLUSION

Clinicians are broadly following guidance on the offer of IR, except with respect to patients' age.

Socioeconomic deprivation and inpatient complication rates following mastectomy and breast reconstruction surgery

BACKGROUND

Socioeconomic deprivation is known to influence the presentation of patients with breast cancer and their subsequent treatments, but its relationship with surgical outcomes has not been investigated. A national prospective cohort study was undertaken to examine the effect of deprivation on the outcomes of mastectomy with or without immediate breast reconstruction.

METHODS

Data were collected on patient case mix, operative procedures and inpatient complications following mastectomy with or without immediate breast reconstruction in the English National Health Service between 1 January 2008 and 31 March 2009. Multivariable logistic regression was used to examine the relationship between patients' level of (regional) deprivation and the likelihood of local (mastectomy site, flap, flap donor and implant) and distant or systemic complications, after adjusting for potential confounding factors.

RESULTS

Of 13,689 patients who had a mastectomy, 2849 (20.8 per cent) underwent immediate reconstruction. In total, 1819 women (13.3 per cent) experienced inpatient complications. The proportion with complications increased from 11.2 per cent among the least deprived quintile (Q1) to 16.1 per cent in the most deprived (Q5). Complication rates were higher among smokers, the obese and those with poorer performance status, but were not affected by age, tumour type or Nottingham Prognostic Index. Adjustment for patient-related factors only marginally reduced the association between deprivation and complication incidence, to 11.4 per cent in Q1 and 15.4 per cent in Q5. Further adjustment for length of hospital stay, hospital case volume and immediate reconstruction rate had minimal effect.

CONCLUSION

Rates of postoperative complications after mastectomy and breast reconstruction surgery were higher among women from more deprived backgrounds.

Reoperation rates after breast conserving surgery for breast cancer among women in England: retrospective study of hospital episode statistics

OBJECTIVES

To examine whether rate of reoperation after breast conserving surgery is associated with patients' characteristics and investigate whether reoperation rates vary among English NHS trusts.

DESIGN

Cohort study using patient level data from hospital episode statistics.

SETTING

English NHS trusts.

PARTICIPANTS

Adult women who had breast conserving surgery between 1 April 2005 and 31 March 2008.

MAIN OUTCOME MEASURE

Reoperation rates after primary breast conserving surgery within 3 months, adjusted using logistic regression for tumour type, age, comorbidity, and socioeconomic deprivation. Tumours were grouped by whether a carcinoma in situ component was coded at the time of the primary breast conserving surgery.

RESULTS

55,297 women had primary breast conserving surgery in 156 NHS trusts during the three year period. 11,032 (20.0%, 95% confidence interval 19.6% to 20.3%) women had at least one reoperation. 10,212 (18.5%, 18.2% to 18.8%) had one reoperation only; of these, 5943 (10.7%, 10.5% to 11.0%) had another breast conserving procedure and 4269 (7.7%, 7.5% to 7.9%) had a mastectomy. Of the 45,793 women with isolated invasive disease, 8229 (18.0%) had at least one reoperation. In comparison, 2803 (29.5%) of the 9504 women with carcinoma in situ had at least one reoperation (adjusted odds ratio 1.9, 95% confidence interval 1.8 to 2.0). Substantial differences were found in the adjusted reoperation rates among the NHS trusts (10th and 90th centiles 12.2% and 30.2%).

CONCLUSION

One in five women who had breast conserving surgery in England had a reoperation. Reoperation was nearly twice as likely when the tumour had a carcinoma in situ component coded. Women should be informed of this reoperation risk when deciding on the type of surgical treatment of their breast cancer.

Regional variation in use of immediate breast reconstruction after mastectomy for breast cancer in England

AIMS

English national guidelines recommend that breast reconstruction is made available to women with breast cancer undergoing mastectomy. We examined the use of immediate reconstruction (IR) across English Cancer Networks, who are responsible for the regional organisation of cancer services and ensuring equitable access to treatment.

METHODS

We analysed Hospital Episodes Statistics data for all women with breast cancer who underwent mastectomy in the English NHS between April 2006 and February 2009. IR rates were calculated for the 30 Networks. Multivariable logistic regression was used to adjust the rates for patient age, comorbidity, ethnicity and socioeconomic deprivation.

RESULTS

Of 44 837 mastectomy patients, 7375 (16.5%) underwent IR. The IR rate was highest in women under 50 years (32.7%) and lowest in women aged 70 years or over (1.5%), and was lower in women with more comorbidities. Unadjusted IR rates varied from 8.4% to 31.9% among the 30 Networks (p<0.001). Adjusting for their patient characteristics did not appreciably reduce Network-level variation, with adjusted IR rates still ranging from 8.0% to 29.4% (p<0.001). The risk-model also suggested that non-white women and those from more deprived areas were less likely to undergo immediate reconstruction.

CONCLUSIONS

There is substantial regional variation in immediate reconstruction use in England that is not explained by the characteristics of the local patient population. English Cancer Networks should act to reduce this variation. They should also examine why rates of reconstruction differ between particular patient groups.

Survival after liver transplantation in the United Kingdom and Ireland compared with the United States

BACKGROUND AND OBJECTIVE

Surgical mortality in the US is widely perceived to be superior to that in the UK. However, previous comparisons of surgical outcome in the two countries have often failed to take sufficient account of case-mix or examine long-term outcome. The standardised nature of liver transplantation practice makes it uniquely placed for undertaking reliable international comparisons of surgical outcome. The objective of this study is to undertake a risk-adjusted disease-specific comparison of both short- and long-term survival of liver transplant recipients in the UK and Ireland with that in the US.

METHODS

A multicentre cohort study using two high quality national databases including all adults who underwent a first single organ liver transplant in the UK and Ireland (n = 5925) and the US (n = 41,866) between March 1994 and March 2005. The main outcome measures were post-transplant mortality during the first 90 days, 90 days to 1 year and beyond the first year, adjusted for recipient and donor characteristics.

RESULTS

Risk-adjusted mortality in the UK and Ireland was generally higher than in the US during the first 90 days (HR 1.17; 95% CI 1.07 to 1.29), both for patients transplanted for acute liver failure (HR 1.27; 95% CI 1.01 to 1.60) and those transplanted for chronic liver disease (HR 1.18; 95% CI 1.07 to 1.31). Between 90 days and 1 year post-transplantation, no statistically significant differences in overall risk-adjusted mortality were noted between the two cohorts. Survivors of the first post-transplant year in the UK and Ireland had lower overall risk-adjusted mortality than those transplanted in the US (HR 0.88; 95% CI 0.81 to 0.96). This difference was observed among patients transplanted for chronic liver disease (HR 0.88; 95% CI 0.81 to 0.96), but not those transplanted for acute liver failure (HR 1.02; 95% CI 0.70 to 1.50).

CONCLUSIONS

Whilst risk-adjusted mortality is higher in the UK and Ireland during the first 90 days following liver transplantation, it is higher in the US among those liver transplant recipients who survived the first post-transplant year. Our results are consistent with the notion that the US has superior acute perioperative care whereas the UK appears to provide better quality chronic care following liver transplantation surgery.

Epithelializing Stent for Benign Prostatic Hyperplasia: A Systematic Review of the Literature

PURPOSE

We systematically reviewed the literature on the effectiveness, durability and safety of the UroLume stent for men with benign prostatic hyperplasia.

MATERIALS AND METHODS

We searched the MEDLINE and EMBASE databases for 1989 to 2005. Reference lists of included studies and review articles were also searched. We contacted the UroLume manufacturer and key authors for additional information. Primary outcomes were treatment failure and urological symptom scores. Secondary outcomes were uroflow parameters and minor complications. Two reviewers independently assessed the methodological quality of the studies and extracted data.

RESULTS

A total of 20 case series evaluated the UroLume stent in a total of 990 patients with benign prostatic hyperplasia. Of the patients 84% who were catheter dependent voided spontaneously after stent insertion. Ten studies assessed symptoms before stent insertion and at some point within 1 year after stent insertion. All reported decreases in symptom scores, including Madsen-Iversen by 7.9 to 14.3 points and International Prostate Symptom Score by 10 to 12.4 points. Peak urine flow rates increased by 4.2 to 13.1 ml per second. A total of 104 stents (16%) failed in 606 patients who were evaluable at 1 year and migration was the commonest cause of failure (38 stents or 37%). Most patients initially experienced perineal pain or irritative voiding symptoms following stent placement.

CONCLUSIONS

Of men who were catheter dependent 84% voided spontaneously after insertion of a UroLume stent and the improvement in symptoms was similar to that seen after transurethral prostate resection. However, 1 of 6 men needed the UroLume removed within a year because of complications. Inadequate followup prevented conclusions on stent durability beyond 1 year. This review supports the recommendation that stents should be considered only in patients at high risk.

Continuous monitoring of the performance of hip prostheses

New brands of joint prosthesis are released for general implantation with limited evidence of their long-term performance in patients. The CUSUM continuous monitoring method is a statistical testing procedure which could be used to provide prospective evaluation of brands as soon as implantation in patients begins and give early warning of poor performance. We describe the CUSUM and illustrate the potential value of this monitoring tool by applying it retrospectively to the 3M Capital Hip experience. The results show that if the clinical data and methodology had been available, the CUSUM would have given an alert to the underperformance of this prosthesis almost four years before the issue of a Hazard Notice by the Medical Devices Agency. This indicates that the CUSUM can be a valuable tool in monitoring joint prostheses, subject to timely and complete collection of data. Regional or national joint registries provide an opportunity for future centralised, continuous monitoring of all hip and knee prostheses using these techniques.

Validity of conjoint analysis to study clinical decision making in elderly patients with aortic stenosis

OBJECTIVE

Written case simulations are increasingly being used to investigate clinical decision making. Our study was designed to determine the validity of written case simulations within a conjoint analysis approach.

STUDY DESIGN AND SETTING

We developed a series of 32 written case simulations that differed with respect to nine clinical characteristics. These case simulations represented elderly patients with aortic stenosis. The clinical characteristics varied according to a fractional factorial design. We analyzed retrospectively all consecutive patients of 70 years of age or older with an aortic stenosis in three university hospitals.

RESULTS

34 cardiologists from three Dutch hospitals gave their treatment advice to each of these case simulations on a six-point scale (ranging from 'certainly no' to 'certainly yes' to surgical treatment). We compared the influence that the clinical characteristics had on the responses to these case simulations with their influence on the actual treatment decision for 147 actual patients in the same three hospitals. We found a strong agreement. This agreement was only slightly affected by the cut-off value used to dichotomize the treatment advice into a recommendation in favor of or against surgical treatment.

CONCLUSION

Written case simulations reflect well how clinicians are influenced by specific clinical characteristics of their patients.

Relationship between outcome and annual surgical experience for the charnley total hip replacement. Results from a regional hip register

Using a regional arthroplasty register, we assessed the outcome, at five years, of 1198 primary Charnley total hip replacements (THRs) undertaken across a single health region in England in 1990. An independent clinical and radiological assessment was completed for 497 operations, carried out in 18 different hospitals, under the care of 56 consultants and by differing grades of surgeon. The overall number of failures in this group was 44 (8.9%). We found that the risk of failure in patients operated on by a consultant whose firm carried out 60 or more THRs in 1990 was 25% of that of patients under the care of a consultant whose firm undertook less than 30, adjusting for a number of patient, surgeon and hospital characteristics (16% v 4%; p < 0.001 for linear trend). Our study shows that the early outcome of hip replacement surgery varies with the number of replacements undertaken by the consultant firm. A national arthroplasty register would be a convenient source for such data.