Squamous cell carcinoma of the breast.

PURPOSE: Squamous cell carcinoma (SCC) of the breast is rare and generally aggressive. In this study, we analyzed 33 patients treated at The University of Texas M.D. Anderson Cancer Center (Houston, TX) and a series of 137 patients identified through the Surveillance, Epidemiology, and End Results (SEER) database to make therapy recommendations. METHODS: Records of The University of Texas M.D. Anderson Cancer Center were searched for patients diagnosed with breast SCC from 1985 to 2001. All biopsy material was reviewed by a dedicated breast pathologist who performed immunohistochemistry for hormone receptors and the epidermal growth factor receptor (EGFR). We searched the SEER database for patients with breast SCC diagnosed between 1988 and 2001. RESULTS: We identified 33 patients with breast SCC, of whom two patients had metastatic disease at diagnosis. The median relapse-free survival (RFS) of 31 patients with localized disease was 20 months (range, 1 to 108 months), with a 26% RFS rate at 5 years. The median overall survival in these patients was 37 months (range, 12 to 108 months), with 40% surviving at 5 years. Median survival from the time recurrent disease was recognized was 14 months (range, 2 to 86 months). Tumors were usually hormone receptor-and HER2/neu-negative, though EGFR was frequently overexpressed. Information from the SEER database was consistent with most of our findings. CONCLUSION: SCC of the breast is aggressive and often treatment-refractory. The role of platinum salts, EGFR inhibitors, and other novel agents needs to be explored.     

Comparison of face‐to‐face and videoconferenced multidisciplinary clinical meetings

A trial of videoconferencing of multidisciplinary breast cancer clinical meetings between three public hospitals was conducted in an attempt to increase attendance by medical staff at the meetings, and thus facilitate multidisciplinary care for breast cancer patients. The videoconferences were compared with the previously existing face‐to‐face clinical meetings through questionnaires, attendance, number of cases discussed and anthropological analysis. Although more people attended the videoconferences than the face‐to‐face meetings, most of the participants in the trial preferred the face‐to‐face meetings to the videoconferences. The mean number of cases discussed at the videoconferences was significantly less than the mean number of cases presented at the face‐to‐face clinical meetings. The face‐to‐face meetings were informal, spontaneous and conducive to open discussion. In contrast, the videoconferences were formal and regimented. Multidisciplinary case discussion can be facilitated by videoconferencing. Some of the negative experiences we encountered could be overcome with changes in meeting format. Our experience may help others in setting up a successful multidisciplinary team via videoconference.     

The requirements of a specialist Breast Centre

IntroductionIn recognition of the advances and evidence based changes in clinical practice that have occurred in recent years and taking into account the knowledge and experience accumulated through the voluntary breast unit certification programme, Eusoma has produced this up-dated and revised guidelines on the requirements of a Specialist Breast Centre (BC).MethodsThe content of these guidelines is based on evidence from the recent relevant peer reviewed literature and the consensus of a multidisciplinary team of European experts. The guidelines define the requirements for each breast service and for the specialists who work in specialist Breast Centres.ResultsThe guidelines identify the minimum requirements needed to set up a BC, these being an integrated Breast Centre, dealing with a sufficient number of cases to allow effective working and continuing expertise, dedicated specialists working with a multidisciplinary approach, providing all services throughout the patients pathway and data collection and audit. It is essential that the BC also guarantees the continuity of care for patients with advanced (metastatic) disease offering treatments according to multidisciplinary competencies and a high quality palliative care service. The BC must ensure that comprehensive support and expertise may be needed, not only through the core BC team, but also ensure that all other medical and paramedical expertise that may be necessary depending on the individual case are freely available, referring the patient to the specific care provider depending on the problem.ConclusionsApplying minimum requirements and quality indicators is essential to improve organisation, performance and outcome in breast care. Efficacy and compliance have to be constantly monitored to evaluate the quality of patient care and to allow appropriate corrective actions leading to improvements in patient care.     

Improvement of best practice in early breast cancer: actionable surgeon and hospital factors

To identify actionable elements for improving best practice, this study examined the relative effects of patient, surgeon and hospital factors on surgical treatment variation of 2,929 early breast cancer patients, diagnosed from January 1998 to January 2002 in the region of the Comprehensive Cancer Centre North-Netherlands. Multilevel logistic regression was used to analyze the hierarchically structured data. Apart from the patient level, 43.3% of the treatment variation was due to the hospital and 56.7% to the surgeon, after adjustment for patient characteristics. Although hospital factors like volume, teaching status, and management and policy contributed to this variation, multidisciplinary care seemed the most important actionable hospital factor. Although the surgeon was shown to be an important starting point for quality improvement, actionable elements seemed difficult to identify as factors like surgeon experience and volume were not conclusive and significant variance on this level remained (σ² = 0.149, SE 0.053). We conclude that multidisciplinary care can improve best practice and that further research into actionable surgeon factors is needed.     

The design and implementation of a community breast cancer screening project.

A breast cancer screening program offers a community the opportunity to highlight and address an important health issue. This article has described the important elements of any such screening effort. To be successful, the program will require a multidisciplinary cadre of health care professionals working collaboratively throughout all phases of the planning, screening, and follow-up process. An agency should be identified to lead these professionals and monitor the progress of the screening effort. These screening programs can have direct and indirect benefits in the community. The direct benefits include improved access and delivery of health services, particularly those that meet state-of-the-art quality standards. The indirect benefits involve the promotion of breast cancer screening through education of women and providers about good breast health practices. As our experience in Michigan has shown, efforts featuring a broad coalition of forces can foster debate and discussion throughout the community and ultimately lead to improvements in the delivery of breast cancer screening services.     

An Educational Program to Transition Oncology Nurses at the Norwegian Radium Hospital to an Evidence-Based Practice Model: Development,Implementation, and Preliminary Outcomes

Increasingly, nurses are expected to systematically improve their practice according to principles of evidence-based practice (EBP). In 2009, the Norwegian Radium Hospital, inspired by the EBP nursing model at its sister institution, The University of Texas MD Anderson Cancer Center, began transitioning its oncology nurses to an EBP model. Norwegian Radium Hospital nursing leaders selected an EBP expert to design an EBP educational program. The program consisted of a 1-semester, 15-credit-hour postgraduate EBP course followed by a clinical practicum during which selected nurses worked in groups to apply principles of EBP to challenging clinical questions. As of this writing, 60 staff nurses have completed the program. Nurses participating in the EBP program have developed 13 evidence-based clinical guidelines, evidence-based clinical procedures, and patient information documents, 9 of which have been adopted as national standards. Participants have demonstrated increased confidence in providing the best available patient care, deeper reflection about their practice, and a sense of being valued by their nurse and physician colleagues. At the institutional level, the EBP project has resulted in higher confidence that patients are receiving patient-centered care based on the best scientific evidence. The project has also resulted in increased collaboration between nurses and other practitioners within multidisciplinary clinical problem-solving teams. This successful EBP program could serve as a model for other cancer hospitals desiring to move to an EBP patient-care model, not only for nursing practice but also, more broadly, for delivery of cancer care by diverse multidisciplinary teams.     

The role of the tumor board in a community hospital

A hospital tumor board is a multidisciplinary group of physicians that meets on a regular basis to review cancer cases. Through regular meetings, the tumor board will improve the quality of cancer care, provide educational opportunities for participants, and become an asset to the hospital and to the community. The use of multidisciplinary tumor-board consultations can ensure that the cancer patient has access to the best current thinking about cancer management. This structure provides the individual practitioner and his hospital with the educational, quality assurance, and legal mechanisms to deliver state-of-the-art care.     

Radical prostatectomy and collaborative care pathways

The purpose of this study was to describe the development, implementation, and evaluation of a collaborative care pathway for radical retropubic prostatectomy. The experience of Vanderbilt University Medical Center is described, and the literature was reviewed. In addition, an example of the radical prostatectomy care pathway is provided for an illustration of a care path. The experience of using collaborative care pathways at Vanderbilt Medical Center has resulted in decreased length of stays, decreased blood utilization, and decreased overall costs. Also, staff satisfaction has improved all without compromising patient care. Collaborative care pathways have been shown to be a cost effective way of standardizing patient care without sacrificing the quality of patient care. In addition, they allow for an easier way to critically evaluate outcomes, costs, and patient and staff satisfaction.     

A curriculum in palliative care for internal medicine housestaff: a pilot project

Despite dramatic growth in the number of hospice programs over the past 15 years, palliative care skills and principles receive minimal attention in medical schools and residency training programs. Northwestern University Medical School and Northwestern Memorial Hospital have developed a program in palliative care education for internal medicine housestaff. Residents, working with a multidisciplinary team of hospice staff, have primary responsibility for the care of terminally ill patients in the home. An inpatient unit is available for acute care when needed. A formal lecture series on symptom management, accompanied by a bibliography and defined learning objectives, provides a guide to the clinical experience. Participating residents also attend seminars focusing on physicians' coping skills and attitudes toward death and dying. Evaluation of the program in its first year shows a definite perception of educational benefit by residents, and enthusiasm for continued involvement in palliative care.     

多学科协作模式的延续性管理对乳腺癌患者术后恢复及不良情绪的影响

目的探讨多学科协作模式的延续性管理对乳腺癌患者术后恢复及不良情绪的影响。方法依据术后干预方式的不同将80例乳腺癌根治术后患者分为常规组(n=35)和多学科协作管理组(n=45),常规组实施常规术后干预,多学科协作管理组在此基础上实施多学科协作模式的延续性管理。比较两组患者的疼痛程度、不良情绪、营养指标、肢体功能恢复情况及自护能力。结果干预后,多学科协作管理组患者的视觉模拟评分量表(VAS)、焦虑自评量表(SAS)和抑郁自评量表(SDS)评分均明显低于常规组,血清白蛋白(ALB)、血清前白蛋白(PAB)水平均明显高于常规组(P﹤0.01)。干预后,多学科协作管理组患者肩关节内收、肩关节外展、肩关节伸屈和肩关节后伸的活动度均明显大于常规组(P﹤0.01)。干预后,多学科协作管理组患者的自护技能、自护责任感、自我概念和健康知识水平评分均明显高于常规组(P﹤0.01)。结论多学科协作模式的延续管理能够缓解乳腺癌术后患者的疼痛及焦虑、抑郁情绪,改善营养状态,促进肢体功能恢复,提高其自护能力。     

Planning for post-pandemic cancer care delivery: Recovery or opportunity for redesign?

The delivery of cancer care has never changed as rapidly and dramatically as we have seen with the coronavirus disease 2019 (COVID-19) pandemic. During the early phase of the pandemic, recommendations for the management of oncology patients issued by various professional societies and government agencies did not recognize the significant regional differences in the impact of the pandemic. California initially experienced lower than expected numbers of cases, and the health care system did not experience the same degree of the burden that had been the case in other parts of the country. In light of promising trends in COVID-19 infections and mortality in California, by late April 2020, discussions were initiated for a phased recovery of full-scale cancer services. However, by July 2020, a surge of cases was reported across the nation, including in California. In this review, the authors share the response and recovery planning experience of the University of California (UC) Cancer Consortium in an effort to provide guidance to oncology practices. The UC Cancer Consortium was established in 2017 to bring together 5 UC Comprehensive Cancer Centers: UC Davis Comprehensive Cancer Center, UC Los Angeles Jonsson Comprehensive Cancer Center, UC Irvine Chao Family Comprehensive Cancer Center, UC San Diego Moores Cancer Center, and the UC San Francisco Helen Diller Family Comprehensive Cancer Center. The interventions implemented in each of these cancer centers are highlighted, with a focus on opportunities for a redesign in care delivery models. The authors propose that their experiences gained during this pandemic will enhance pre-pandemic cancer care delivery.     

Elevating the art of medicine: A caregiver's reflection

The following narrative chronicles the unlikely events of the author, an editorial director of an oncology publication, whose experience with cancer was purely academic in nature until 2 family members were diagnosed simultaneously with breast cancer and melanoma, respectively. The perspective-altering encounters from inside the healthcare system revealed critical lessons regarding the importance of patient-centered care as key to empowering patients and creating a sense of peace for survivors.     

Multidisciplinary approach to cancer treatment: a model for breast cancer treatment at the M.D. Anderson Cancer Center

Despite that fact that a multidisciplinary approach is important for cancer treatment, this approach is not widely used in Japan. The M.D. Anderson Cancer Center (MDACC) is one of the most well-established cancer institutes in the world, and has implemented a unique multidisciplinary team management approach for the treatment of breast cancer. The efforts of MDACC to eliminate cancer have been ongoing for more than 60 years. Here, we describe the multidisciplinary approach used at MDACC for the treatment for breast cancer. We focus on the background of the institute, in terms of establishing its treatment model and educational system, and compare its multidisciplinary approach with the current approach used in Japan, in the hopes of influencing future directions in cancer therapy in Japan.     

The Van Nuys Breast Center: the first free-standing multidisciplinary breast center

This article describes the author's 30-year experience with the design and development of breast centers. It describes the author's initial attempt at developing a breast center at UCLA, the history of the Van Nuys Breast Center (its patient population, philosophy, problems, finances, and demise), and the development of the Harold E. and Henrietta C. Lee Breast Center. Breast centers are defined as focused multidisciplinary facilities of excellence, dealing with the complete range of breast problems. The main focus of this article is the Van Nuys Breast Center, which was the prototype model for most breast centers developed in the United States.     

Mentoring in the management of hematological malignancies

Aim: The Mentoring in Management of Haematological Malignancies (MMHM) project aimed to improve treatment outcomes, coordinate care and provide best practice for patients with hematological cancers, by developing a program of mentoring and multidisciplinary care between a regional and a metropolitan centre. Methods: A regular multidisciplinary meeting conducted by teleconference was established between a tertiary metropolitan site and a regional practice to discuss cases of patients with hematological malignancies. Information from multidisciplinary team meetings was recorded to capture adherence to process and clinician outcomes. An educational program was developed. A gap analysis was performed to identify differences in routine practice between the two centers. Clinician satisfaction with mentoring and educational interventions was assessed by structured survey. Results: The MMHM project developed a formal mentoring system to improve the management of patients by building on established links and developing an innovative model of web‐based multidisciplinary care. The project established a novel multidisciplinary meeting between a metropolitan and regional site. Common treatment policies were adopted between the two sites. Development of an educational framework and mentoring for health‐care professionals in regional areas was achieved by tutorials and workshops. Most participating clinicians indicated their high level of satisfaction with the mentoring project. Conclusion: The MMHM project was a successful pilot of a mentoring program in hematological cancers between metropolitan and regional centers that resulted in improved referral links, facilitated better care coordination, updated treatment policies and guidelines and increased clinician satisfaction and knowledge.     

Breast cancer: multidisciplinary care and clinical outcomes

A multidisciplinary approach to the management of breast cancer is the standard of care in developed health systems. We performed a systematic review to assess the extent and quality of evidence on whether multidisciplinary care (MDC), or related aspects of care contribute to clinical outcomes in breast cancer, and in particular whether these influence survival. Only two primary studies have looked at MDC and neither of these studies considered long-term outcomes. The studies of MDC (case series) provide weak evidence that MDC may alter treatment patterns. Several population-based cohort studies showed that related aspects of team work, specialist (surgeon) and hospital workload and specialisation, are associated with improved survival. This group of studies used better quality design with more clearly defined outcome measures, and most of the studies have allowed for possible confounding variables. Evidence of a survival benefit was most consistent for specialist (surgeon) effect. However, the reasons behind the improved survival reported in these studies are unclear, and it is unlikely that this is entirely attributable to treatment patterns. We conclude that although intrinsically multidisciplinary care should be associated with better survival, there remains a paucity of evidence to support this. Studies of the long-term clinical effects of MDC in breast cancer should be a priority for future evaluation.     

Survivorship care after breast cancer: Follow‐up practices of Australian health professionals and attitudes to a survivorship care plan

Objective: The increasing number of breast cancer survivors and the complexity of follow‐up care make the provision of high‐quality survivorship care a challenge. This study explored the follow‐up practices of health professionals and their attitudes to alternative models such as shared care and the use of a survivorship care plan. Methods: Specialist oncologists (surgeons, medical and radiation oncologists) breast physicians and breast‐care nurses completed an online survey. Results: A total of 217 practitioners completed the survey, which was estimated to include 42.8% of oncologists treating breast cancer in Australia. One‐third of responding specialists reported spending more than 25% of their clinical time providing follow‐up care. They reported many positive aspects to follow‐up consultations and viewed follow‐up care as an important part of their clinical role but expressed concern about the sustainability of follow‐up care in their practices. The follow‐up intervals and recommendations were in line with national guidelines. The specialists were supportive of sharing follow‐up care with primary‐care physicians, breast physicians and breast‐care nurses. Most professionals felt that a survivorship care plan would improve care and said they would use a proforma. Conclusion: The oncologists felt that follow‐up care was an important part of their role and they were supportive of the concepts of shared care programs and a survivorship care plan. Input from consumers is required to evaluate the acceptability of these alternative models and to assess ways of implementing these changes to work towards a more comprehensive and sustainable method of delivering survivorship care.     

Diagnostics in Patients Suspect for Breast Cancer in The Netherlands

The goal of this study was to describe the variation in hospital-based diagnostic care activities for patients with symptomatology suspect for breast cancer in The Netherlands. Two cohorts were included: the ‘benign’ cohort (30,334 women suspected of, but without breast cancer) and the ‘malignant’ cohort (2236 breast cancer patients). Hospital-based financial data was combined with tumor data (malignant cohort) from The Netherlands Cancer Registry. Patterns within diagnostic pathways were analyzed. Factors influencing the number of visits and number of diagnostic care activities until diagnosis were identified in the malignant cohort with multivariable Cox and Poisson regression models. Compared to patients with benign diagnosis, patients with malignant disease received their diagnosis less frequently in one day, after an equal average number of hospital visits and higher average number of diagnostic activities. Factors increasing the number of diagnostic care activities were the following: lower age and higher cM-and cN-stages. Factors increasing the number of days until (malignant) diagnosis were as follows: higher BIRADS-score, screen-detected and higher cN-and cT-stages. Hospital of diagnosis influenced both number of activities and days to diagnosis. The diagnostic care pathway of patients with malignant disease required more time and diagnostic activities than benign disease and depends on hospital, tumor and patient characteristics.     

Rural physicians' understanding of the state-of-the-art in breast, colon and rectum cancer treatment

Objectives: This study measured the impact of an educational intervention aimed at heightening rural physicians' awareness of state-of-the-art breast and colorectal cancer therapies.Methods: Pre- and post-intervention mailed surveys were administered to all primary-care physicians and referring physicians in the seven-county intervention region in North Carolina (NC) and a comparison region in South Carolina (SC).Results: The survey revealed few significant changes in physicians' perspectives that could be attributed to the intervention. Physicians erroneously stated that lumpectomy without follow-up radiation was acceptable for treating breast cancer (55%), failed to indicate that adjuvant therapy was an accepted practice for treating Stage I breast cancer (67%), failed to acknowledge chemotherapy as experimental for Dukes' B colon cancer patients (70%), and failed to recognize a combination of surgery, chemotherapy, and radiation as a standard treatment for rectal cancer (25%).Conclusions: The low levels of awareness of National Cancer Institute guidelines were reflected in low breast-sparing surgery rates for women living in the intervention region. Stronger consensus on appropriate cancer treatments is needed throughout the medical community in order to reduce undesired variation in rural, community-based cancer care.(S.E.T. is currently with the MD Anderson Comprehensive Cancer Center, University of Texas Medical College, USA)     

Urban-rural differences in the management of breast cancer

We conducted a population-based study with medical-record review of breast cancer patients as part of a larger study of an oncology outreach program to improve cancer management for rural patients within their community hospital. This analysis compares the breast cancer care received by the rural population before the oncology outreach program with that of the contiguous urban population. All 1986–87 cases in selected Illinois (United States) counties were identified using the Illinois State Cancer Registry. Data were obtained by hospital record audit and physician survey. Case follow-back was 98 percent complete. Rural cases were evaluated separately when they were diagnosed in an urban facility. State-of-the-art management was defined by the 1986–87 Physician Data Query and included diagnostic evaluation, prognostic evaluation, and stage-specific treatment. A summary variable incorporated whether or not the most appropriate management was offered. Compared with urban cases, rural cases diagnosed in rural hospitals were less likely to have staged tumors and more likely to have node dissections. Rural cases traveling to urban centers were less likely to have limited surgery, hormone therapy, and a biopsy as a first-step surgical procedure, and more likely to have node dissection.when this work was completed and now is with The Cancer Center, St Joseph Medical Center, Burbank, CA, USA.This study was conducted at the Illinois Department of Public Health in collaboration with the Regional Cancer Center, Memorial Cancer Center, Springfield, IL, USA.