Changes of breast and axillary surgery patterns in patients with primary breast cancer during the past decade

PURPOSE

Breast-conserving therapy (BCT) is the standard procedure for most patients with primary breast cancer (BC). By contrast, axillary management is still under transition to find the right balance between avoiding of morbidity, maintaining oncological safety, and performing a staging procedure. The rising rate of primary systemic therapy creates further challenges for surgical management.

METHODS

Patients with primary, non-metastatic BC treated between 01.01.2003 and 31.12.2016 under guideline-adherent conditions were included in this study. For this prospectively followed cohort, breast and axillary surgery patterns are presented in a time-trend analysis as annual rate data (%) for several subgroups.

RESULTS

Overall, 6700 patients were included in the analysis. While BCT rates remained high (mean 2003-2016: 70.4%), the proportion of axillary lymph node dissection has declined considerably from 80.1% in 2003 to 16.0% in 2016, while the proportion for sentinel lymph node biopsy (SLND) has increased correspondingly from 10.3 to 76.4%. Among patients with cT1-2, cN0 breast cancer receiving BCT with positive SLND, the rate of axillary completion has decreased from 100% in 2008 to 24.4% in 2016.

CONCLUSIONS

In the past decade, SLNB has been established as the standard procedure for axillary staging of clinically node-negative patients. Surgical morbidity has been further reduced by the rapid implementation of new evidence from the ACOSOG Z0011 trial into clinical routine. The results reflect the transition towards more individually tailored, less invasive treatment for selected patient subgroups, especially in regards to axillary lymph node management.

Severe Fournier's gangrene-a conjoint challenge of gynaecology and plastic surgery

Necrotizing fasciitis (NF) is a rare soft tissue infection characterized by rapidly progressing necroses and a high mortality. Prompt diagnosis and immediate medical treatment including radical debridement and broad spectrum antibiotics are the key to successful management. We report on a 46-year-old diabetic female who developed extensive, deep necroses in the perineal area and proximal thighs within a few days. After initial gynaecological consultation, she was transferred directly to our department. Due to the suspicion of NF, an immediate radical debridement was performed. Two more debridements were necessary to control the infection. After stabilization, the extensive soft tissue defect was reconstructed using a combination of plastic reconstructive procedures. Due to early diagnosis, direct referral and immediate surgical treatment, the patient survived.

Expectations for Endoscopic Training During Gynaecological Specialty Training - Results of a Germany-wide Survey

Question: Endoscopy is an integral part of surgical gynaecology and is playing an increasingly important role in ensuring adequate gynaecological training in the context of specialty training in general. At present, little is known about the expectations and notions of young junior doctors with respect to endoscopic training. For this reason, junior doctors throughout Germany were surveyed on this topic and asked to share their opinions. Methods: Using an anonymized standardized survey, the following information was elicited: importance of endoscopic training, willingness to take courses, expectations for instructors and the hospital, ideas about the number of required operations, both as a surgical assistant and as a surgeon, as well as satisfaction with the current status of training. The questionnaires were sent via the Young Forum (Junges Forum) of the German Society of Gynaecology and Obstetrics (DGGG) and the newsletter of the Working Group for Gynaecological Endoscopy (AGE). Results: The evaluation of the study was based on 109 completed questionnaires. The resident junior doctors were 31 years old on average and were in their third to fourth year of their specialty training on average. The majority of the participants (87 %) considered the learning of endoscopic techniques to be very important and advocated regular participation in endoscopy training courses. Among the participants, 48 % were prepared to invest up to €1500 of their own funds to attend courses up to twice a year during the entire specialty training period. The expectations of the instructors and institutions focused on technical expertise, the willingness and time for teaching and on the number and range of surgical procedures, followed by being granted leave for the courses and having costs covered for the courses. Thirty-eight per cent stated that their expectations had been completely or mostly met and 62 % said they had been met in part or inadequately. Eighty-three per cent of the respondents reported that they would change specialty training institutions in order to achieve their own goals in the context of specialty training. Conclusions: This study presents data for the first time on the satisfaction of young junior doctors and their expectations for endoscopic specialty training. The residents exhibited a high level of interest in endoscopy and a high level of willingness to actively shape the specialty training, including course participation. However, there appears to be a great deal of room for improvement for endoscopic specialty training, independent of the current training institution, training year or sex of the junior doctors.

Senology in Gynaecology Specialist Training: a Baseline Survey from 2014

Introduction: Qualified training in senology is essential for maintaining adequate, high quality patient care. In order to meet the needs of doctors in training and those of the medical infrastructure it is necessary to assess the quality of training regularly, to enable its adaption and optimisation. Methods: We developed a comprehensive, 10 item online questionnaire to assess the quality of specialised training in senology. This questionnaire was sent to 4000 speciality trainees and young specialists countrywide via the DGGG newsletter and was accessible for over four weeks. Results: 111 obstetrics and gynaecology speciality trainees participated in this national survey, 79 % of whom were female. 33 % of participants were working at university hospitals, 29 % at hospitals offering maximal level care without an associated medical faculty, 37 % at hospitals offering primary and secondary level care and 2 % at gynaecology practices. 25 % of participants could imagine working in the field of senology in future. On average the current perception of general specialist training was satisfactory. Specialist trainees at university hospitals rated training in senology highest (score: 2.95) compared to those at other hospitals. A fixed rotation through a breast centre offering comprehensive advanced training was seen as a potential improvement to senology training. Conclusions: This is the first survey of specialised training in senology to be conducted in Germany. Results showed that there is significant potential for young doctors to enter the speciality in future. There are also significant differences in the perceived quality of senology training between training facilities. This survey aimed to determine the quality of specialised training at senology centres and hopes to contribute to a sustainable improvement in training. The intention is to continue to make senology attractive to gynaecologists and to ensure well-grounded training.

Psychosomatic Primary Care in Gynecology-Assessment and Acceptance by Residents for Obstetrics and Gynecology in Germany

Background: The course "Psychosomatic Primary Care" has been part of the training curriculum of obstetrics and gynecology in Germany since 2003. The aim of the course is to train up physicians, whose prior training primarily focussed on somatic care, to enable them to offer care also taking into account biopsychosocial aspects. Taking the guidelines for psychotherapy as a template, the aim of psychosomatic primary care is to recognize the etiological links between psychological and somatic factors which contribute to diseases. The necessity for a compulsory course as part of training in gynecology was recently critically discussed. Major points discussed included the question whether the current forms of teaching, consisting of courses, are outdated and whether the required skills should be part of regular daily training. Method: A 3-part online questionnaire consisting of 30 items was developed and sent to 2431 residents in the period from September to December 2012 through the online mailing list of the DGGG. Results: The 540 residents who responded to the questionnaire were predominantly female (83.3 %) with an average age of 30 years; 50.3 % were in their 1st to their 4th year of training. Over the longer term, the majority of respondents (56.1 %) hoped to continue working in a hospital and regularly (84.6 %) attended teaching courses voluntarily. 70.9 % of them had already attended the course "Psychosomatic Primary Care". Of the group who had completed the course, 29.4 % were satisfied with the offer. The main criticism directed against the course was its scope which 24.1 % considered completely inadequate. 24.5 % considered the course to be an important part of training, while 16.5 % would have preferred that the course be abolished. 18 % of respondents reported that psychosomatic medicine did not feature regularly in their daily clinical routine. Perspective: Because of the huge gap between what is currently offered and the experiences reported by the respondents, the Young Forum of the DGGG and the DGPFG have expanded the program of courses offered by the DGPFG, which will offer practice-oriented courses to future gynecologists across Germany in cooperation with the DAGG. The first courses are held in Heidelberg and Erlangen in 2014.