Should surgeons as well as radiologists report mammograms in symptomatic patients?

This study compared the accuracy of interpretation by surgeons and radiologists of 1053 women who had two view mammography and a histological or cytological diagnosis of benign or malignant breast disease. Patients with large or locally advanced breast cancers who had definite clinical findings where radiology was not required to make a diagnosis were excluded. The sensitivity for radiologists was non-significantly greater (81%) than surgeons (78%), but specificity and positive predictive value was identical in the two groups of readers. Combining the reports of the radiologists and surgeons increased sensitivity to 85.4% which is a significant increase in the sensitivity of the radiologist alone, P =0.02. This study indicates that symptomatic mammograms should be read by surgeons as well as radiologists.     

Can an educational application increase risk perception accuracy amongst patients attending a high-risk breast cancer clinic?

ObjectivesTo design, develop and test the effect of an educational initiative to improve risk perception amongst patients attending a high-risk breast cancer clinic. This was achieved through three objectives – 1. identifying an optimal method of presenting risk data, 2. designing and building a risk application, and 3. testing the ability of the application to successfully modify patients perceived risk of cancer.Materials and methodsA mobile application was developed for this project using best practice methods for displaying risk information. Patients (n = 84) were randomly allocated into two groups – ‘Control’ or ‘Treatment’. Both groups underwent standard risk counseling while the application was employed in the ‘Treatment’ group. The patients were surveyed before their session, immediately after and six weeks later.ResultsIncreases in accuracy were seen in both groups with larger increases demonstrated in the ‘Treatment’ group with ‘Personal 10 Year Risk’ statistically significant (‘Control’ group increase from 21% to 48% vs the ‘Treatment’ group increase from 33% to 71% - p = 0.003).ConclusionThis project demonstrated trends towards improved risk perception, however mixed logistic regression was unable to show a 30% difference between groups. Numerical literacy and understanding of risk were identified as issues amongst the general population. Overestimating risk remains high amongst attendees.Using mobile applications to convey risk information to patients is a new and evolving area with a corresponding paucity of data. We have demonstrated its potential and emphasised the importance of designing how this information is communicated to patients in order to make it understandable and meaningful.     

What do breast surgeons do?

Background

There are an increasing number of fellowship-trained breast surgeons and surgical oncologists who dedicate their clinical practice exclusively to breast disease. However, there are little published data regarding characteristics of a breast surgical practice.

Methods

All patient visits at a university-based breast surgery practice were reviewed for calendar years 2006 and 2007.

Results

There were 10,381 patient visits, of which 2,334 (22%) represented new patients. Of these, 11% were referred with a diagnosis of cancer. Out of the remainder, 29% had a needle biopsy (8% by the surgeon and 21% by radiology), 29% underwent surgery, and 13% were ultimately diagnosed with cancer. After completion of initial therapy, 6 months or 1 year follow-up was recommended for 59% of the patients.

Conclusions

The specialty of breast surgery is unique in its nonoperative volume and extensive duration of follow-up. Strategies need to be designed to make this process more time-efficient for the surgeon.     

Objective analyses of mastalgia in breast clinics: Is breast pain questionaire a useful tool in a busy breast clinic?

The aim of this study was to investigate the feasibility of use of breast pain questionnaire (BPQ), a short, focussed and robustly designed tool to assess severity of mastalgia and its impact on quality of life, in a busy breast clinic. Seventy-four consecutive women completed BPQ prior to their consultation with a Breast Surgeon. Based on the BPQ score, mastalgia was graded as mild (score 0-100) in 26%, moderate (score 101-200) in 59% and severe (score >200) in 15% of patients. In 93% of patients breast pain lasted for more than 5 days and visual analogue score (VAS) was more than 3.5 in 82% of patients. The breast pain was described as mild (12%) discomforting (55%), distressing (22%) excruciating (3%) or horrible (8%). All results are presented as median (interquartile ranges). Out of maximum possible 100, overall pain rating was 17(9-31), percent sensory component was 21(12-33) and percent affective component was 0(0-17). The percent VAS was 60(40-80), percent pain index was 40(40-60) and quality of life score (maximum possible 60) was 20(0-40). Of maximum possible score of 360, total breast pain was 137(99-180). In conclusion BPQ can be used routinely in a busy breast clinic as a quick, user-friendly and reliable tool to assess the degree and severity of breast pain in order to provide an organised approach to the management of mastalgia.     

Can we rely on PET in the follow-up of advanced seminoma patients?

The management of residuals after completion of chemotherapy in advanced seminoma is controversial. It has been proposed that fluorodeoxyglucose-positron emission tomography (FDG-PET) can be used as a follow-up. In this study we investigated FDG-PET as a follow-up tool in advanced seminoma patients treated previously with chemotherapy or radiotherapy. Thirty-seven patients assigned to an advanced seminoma group based on CT and/or FDG-PET/CT and then treated with chemotherapy were included in the study. All these patients underwent FDG-PET/CT examination as a part of the follow-up scheme. Patients underwent retroperitoneal lymph node dissection (RPLND), radiotherapy, or were followed clinically by CT and/or PET/CT every 6 months. In 8 cases FDG-PET was positive: 5 of them underwent RPLND and 3 radiotherapy. Two patients with negative FDG-PET but positive CT also underwent RPLND. The remaining patients with negative FDG-PET results were followed up. FDG-PET/CT was false positive in one case >3 cm and one <3 cm, in 6 cases >3 cm it was true negative. While FDG-PET can find a viable tumor, there also is an important question of false positive results. It was clinically proven that a negative FDG-PET was correlated with stable disease, but we were unable to examine specimens in these cases.     

How can we build mentorship in surgeons of the future?

Background: In the past, surgical training has been based on traditional apprenticeship model of mentoring. To cope with the rapidly changing environment of modern surgery, the mentoring process may require significant modernization. Methods: Literature for this review was identified by searching for the MeSH heading ‘mentors’ in Ovid MEDLINE, EMBASE, PsycINFO and Cochrane Library databases (1950 to September 2010). The literature was reviewed to specifically identify challenges of mentoring future surgeons and to delineate a framework to establish a mentor–mentee relationship by means of a formal mentoring scheme. Results: Multidimensional approaches, models and methods of delivering mentoring are essential to meet the challenges of modern surgery. We advocate a 10‐stage approach to implement a formal mentoring scheme at local, national and international levels. Conclusion: Formalizing the mentoring process, with local, national and international schemes, will initiate mentoring relationships and cultivate a mentoring culture. Ultimately, this will maintain and improve patient care.     

Is sarcopenia a missed factor in the management of patients with metastatic breast cancer?

BackgroundSarcopenia has emerged as an important parameter to predict outcomes and treatment toxicity. However, limited data are available to assess sarcopenia prevalence in metastatic breast cancer and to evaluate its management.MethodsThe SCAN study was a cross-sectional multicenter French study that aimed to estimate sarcopenia prevalence in a real-life sample of metastatic cancer patients. Sarcopenia was identified by low muscle mass (estimated from the skeletal muscle index at the third lumbar, via computed tomography) and low muscle strength (defined by handgrip strength). Three populations were distinguished based on EWGSOP criteria: a sarcopenic group with low muscle mass AND strength, a pre-sarcopenic group with low muscle mass OR strength and a normal group with high muscle mass AND strength.ResultsAmong 766 included patients, 139 patients with breast cancer and median age of 61.2 years (29.9–97.8 years) were evaluable; 29.5% were sarcopenic and 41.0% were pre-sarcopenic. Sarcopenic patients were older (P < 0.01), had a worse PS-score (P < 0.05), and a higher number of metastatic sites (P < 0.01), the majority being hepatic and bone. A moderate agreement between the oncologist's diagnosis and sarcopenia evaluation by muscle mass and strength was recognized (Cohen's kappa = 0.45). No associations were found between sarcopenia and adverse event occurrence in the 12 patients for whom these were reported. Sarcopenic patients were underdiagnosed and nutritional care and physical activity were less proposed.ConclusionIt is necessary to evaluate sarcopenia due to its impact on patient prognosis, and its utility in guiding patient management in metastatic breast cancer.