Abstract P3-14-02: Post mastectomy breast reconstruction in elderly women: Complications and the impact of individual surgeons

Purpose/Objective

In the United States over 40% of incident breast cancer diagnoses are in women over 65 years of age. Effective breast cancer treatments allow elderly patients to live long, healthy lives; questions regarding long-term quality of life are increasingly important. In women over 65, post-mastectomy breast reconstruction (PMBR) is uncommon with reported rates of 6-30%. The goal of this study is to report complication rates in elderly PMBR patients and to evaluate the impact of individual surgeons on PMBR in elderly patients.

Material/methods

We identified 19,417 Medicare beneficiaries diagnosed with localized breast cancer between 2005 and 2011 who underwent mastectomy. Medicare claims were used to identify PMBR, post-operative complications after PMBR (within 30 days of surgery), and long-term complications related to reconstruction (within three years following surgery). Mastectomy surgeon was identified from Medicare claims with surgeon characteristics identified through linkage to the American Medical Association (AMA) Masterfile.

Multi-level, multivariable logistic models clustered by surgeon and geographic area were used to determine the impact of surgeons on the likelihood of reconstruction. The intraclass correlation coefficient (ICC) and median odds ratio (MOR) were used to describe the relative impact of the individual surgeon. The ICC estimates the proportion of variability explained by the surgeon on PMBR rates. The MOR quantifies the likelihood of a patient having a different PMBR outcome if the patient were to change surgeons (or geographic area); it is directly comparable to odds ratios. Odds ratios (OR) were used to describe the impact of fixed demographic and clinical covariates.

Results

Among the entire cohort, 1,234 (6.4%) patients underwent PMBR. The post-operative complication rate was 8.4% and the long-term complication rate was 19.9%. Eighteen percent of the variability in PMBR use was attributed to the individual surgeon (ICC 0.181). The MOR for surgeon was found to be 1.85 (95% CI [1.70,1.99]), indicating that a patient had an 85% chance of having a different outcome (receiving or not receiving PMBR) if the patient saw a different mastectomy surgeon. The MOR for geographic area indicated that a patient had a 32% chance of having a different outcome if the patient saw a surgeon in a different geographic area (1.32, 95% CI [1.17, 1.47]). Patients who were Asian, single, older, of lower socioeconomic status, and underwent radiation therapy were less likely to undergo PMBR. Patients who had pre-operative MRI or received chemotherapy were more likely to undergo PMBR. Patients who were treated by female surgeons or plastic surgeons were significantly more likely to undergo PMBR. Overall, the individual surgeon was the most predictive of PMBR, except for the use of pre-operative MRI and mastectomy surgeon's specialty being plastic surgery.

Conclusion

A small minority of older women undergo PMBR despite having low post-operative and long-term complication rates. The individual surgeon and geographic area significantly influences whether older breast cancer patients will undergo PMBR. Future research should focus on surgeon characteristics that may influence a patient's decision to undergo PMBR.

Citation Format: Schoenbrunner AR, Fero KE, Boero IJ, Matsuno R, Kronstadt N, Lance S, Reid C, Wallace AM, Gosman AA, Murphy JD. Post mastectomy breast reconstruction in elderly women: Complications and the impact of individual surgeons [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-14-02.

Combining Multiple Types of Motor Rehabilitation Enhances Skilled Forelimb Use Following Experimental Traumatic Brain Injury in Rats

BACKGROUND

Neuroplasticity and neurorehabilitation have been extensively studied in animal models of stroke to guide clinical rehabilitation of stroke patients. Similar studies focused on traumatic brain injury (TBI) are lacking.

OBJECTIVE

The current study was designed to examine the effects of individual and combined rehabilitative approaches, previously shown to be beneficial following stroke, in an animal model of moderate/severe TBI, the controlled cortical impact (CCI).

METHODS

Rats received a unilateral CCI, followed by reach training, voluntary exercise, or unimpaired forelimb constraint, alone or in combination. Forelimb function was assessed at different time points post-CCI by tests of skilled reaching, motor coordination, and asymmetrical limb use.

RESULTS

Following CCI, skilled reaching and motor coordination were significantly enhanced by combinations of rehabilitation strategies, not by individual approaches. The return of symmetrical limb use benefited from forelimb constraint alone. None of the rehabilitation strategies affected the size of injury, suggesting that enhanced behavioral function was not a result of neuroprotection.

CONCLUSIONS

The current study has provided evidence that individual rehabilitation strategies shown to be beneficial in animal models of stroke are not similarly sufficient to enhance behavioral outcome in a model of TBI. Motor rehabilitation strategies for TBI patients may need to be more intense and varied. Future basic science studies exploring the underlying mechanisms of combined rehabilitation approaches in TBI as well as clinical studies comparing rehabilitation approaches for stroke versus TBI would prove fruitful.

Targeted gene inactivation of calpain-1 suppresses cortical degeneration due to traumatic brain injury and neuronal apoptosis induced by oxidative stress

Calpains are calcium-regulated cysteine proteases that have been implicated in the regulation of cell death pathways. Here, we used our calpain-1 null mouse model to evaluate the function of calpain-1 in neural degeneration following a rodent model of traumatic brain injury. In vivo, calpain-1 null mice show significantly less neural degeneration and apoptosis and a smaller contusion 3 days post-injury than wild type littermates. Protection from traumatic brain injury corroborated with the resistance of calpain-1 neurons to apoptosis induced by oxidative stress. Biochemical analysis revealed that caspase-3 activation, extracellular calcium entry, mitochondrial membrane permeability, and release of apoptosis-inducing factor from mitochondria are partially blocked in the calpain-1 null neurons. These findings suggest that the calpain-1 knock-out mice may serve as a useful model system for neuronal protection and apoptosis in traumatic brain injury and other neurodegenerative disorders in which oxidative stress plays a role.

Salmonella Thompson associated with improper handling of roast beef at a restaurant in Sioux Falls, South Dakota

In October 1996, we investigated an outbreak of Salmonella serotype Thompson infections associated with Restaurant A in Sioux Falls, South Dakota, and conducted two cohort studies among persons who ate at luncheons catered by Restaurant A. Fifty-two Salmonella Thompson infections were identified between 29 September and 14 October 1996. Infections occurred among employees and patrons at Restaurant A and among attendees at three luncheons catered by the restaurant on 7 October. Roast beef cooked at Restaurant A was the only food item significantly associated with illness. Cooking times and storage temperatures for roast beef were inadequate to prevent multiplication of Salmonella, and the chefs were unaware of proper cooking and storage temperatures. We conclude that improper handling of roast beef probably caused this outbreak of Salmonella Thompson infections. Better knowledge of food safety practices by the cooking staff at Restaurant A, through required food safety education, might have prevented the outbreak.

Guidelines for prevention and control of hepatitis A in American Indian and Alaska Native communities

The Aberdeen Area Indian Health Service, South Dakota Department of Health, and the Centers for Disease Control and Prevention have collaborated since 1985 to investigate hepatitis A in Indian communities in the Northern Plains and to implement clinical trials of hepatitis A vaccine. After licensure of the hepatitis A vaccine in February 1995, community wide immunization programs have been implemented effectively in several communities experiencing hepatitis A outbreaks. The state health department, tribal health departments, Indian Health Service facilities, Head Start programs and schools have provided hepatitis A immunizations to children aged 2-12 years in each of these communities after obtaining parental consent. Culturally-specific educational materials were developed and extensive health education efforts were provided by IHS and tribal programs. Hepatitis A contacts age 2-12 were offered the hepatitis A vaccine at the same time they were offered passive immunization with immune globulin. To date over 70% of parents contacted by letter or in person have returned consent forms to have their children immunized. Higher response rates were obtained in communities where home visits were made to explain this program in more detail. The outbreaks appear to have stopped after 70% or more of the children aged 2-12 years were immunized. Immunization programs are being implemented in all Northern Plains Indian communities utilizing hepatitis. A vaccine from the Vaccine For Children Program. These efforts will likely eliminate hepatitis A as a health problem for Indian communities.

HSV-1 thymidine kinase negative vaccine: pathogenicity, protection, and perils

Primary inoculation of mice and rabbits with an avirulent HSV-1 thymidine kinase negative (TK-) mutant reduced keratitis, mortality, and superinfection of the trigeminal ganglion (TG) as measured by cocultivation and iontophoresis-induced ocular shedding following ocular challenge with HSV-1 McKrae and W strains. However species differences were demonstrated; with complete protection in rabbits, and incomplete protection in mice. In mice, BUDR/autoradiography and restriction enzyme analysis identified both HSV-1 McKrae and W strains as having superinfected the TG, established latency and reactivated. Also, the avirulent TK negative inoculating strain was altered to a virulent TK positive strain through possible in vivo selection, mutation &/or host-modification, and possible in vivo recombination with the virulent challenge strains. We conclude that lower species differences require that potential HSV-1 vaccines be tested in non-human primates prior to clinical trials, and that a DNA-free subunit herpes vaccine represents a safer alternative to a live virus vaccine.