American Society of Breast Surgeons Presidential Address: Could Quality Measures Impede Quality Care?

Transparency and accountability are becoming more important, and publically reported quality measures will be used increasingly to determine how surgeons are viewed and reimbursed. That is a good thing if it is done correctly, but poorly designed quality measures might actually interfere with patient care. It will be necessary for ASBrS to remain involved in the development of relevant, true data-based measures of quality that have appropriate benchmarks and no unintended consequences. Importantly, the quality measures need to include all reasonable treatment options so that quality care is enhanced and not impeded.     

Can Breast Surgeons Provide Breast Cancer Genetic Testing? An American Society of Breast Surgeons Survey

Background

Whether breast cancer surgeons are adequately trained, skilled, and experienced to provide breast cancer genetic assessment, testing, and counseling came under debate in September 2013 when a major third-party payer excluded nongenetics specialists from ordering such testing. A literature search having failed to uncover any study on breast surgeons’ skill and practice in this area, the American Society of Breast Surgeons (ASBrS) surveyed its members on their experience with the recognized crucial components of such testing.

Methods

In late 2013, ASBrS e-mailed a link to an online questionnaire to its U.S. members (n = 2,603) requesting a self-assessment of skills and experience in genetic assessment, testing, interpretation, and counseling. After approximately 6 weeks, the results were collated and evaluated.

Results

By January 2, 2014, 907 responses (34.84 %) had arrived from breast surgeons nationwide working in academic settings (20 %), solo or small group private practice (39 %), large multispecialty groups (18 %), and other settings. More than half said they performed 3-generation pedigrees, ordered genetic testing, and provided pre- and posttest counseling. Most noted that they would welcome continuing educational support in genetics.

Conclusions

Currently the majority of breast surgeons provide genetic counseling and testing services to their patients. They report practices that meet or exceed recognized guidelines, including the necessary elements and processes for best practices in breast cancer genetics test counseling. Because breast cancer genetic testing is grossly underutilized relative to the size of the U.S. BRCA mutation carrier population, these appropriate services should not be restricted but rather supported and expanded.     

Early Results from a Novel Quality Outcomes Program: The American Society of Breast Surgeons’ Mastery of Breast Surgery

Background

In 2008, the American Society for Breast Surgeons launched its Mastery in Breast Surgery Pilot Program to demonstrate feasibility of a Web-based tool for breast surgeons to document and monitor quality outcomes.

Methods

Participating surgeons report performance of three quality measures for breast procedures: Was a needle biopsy performed to evaluate the breast lesion before the procedure? Was the surgical specimen oriented? For nonpalpable lesions localized with image guidance, was there intraoperative confirmation of removal? Data are collected through the American Society for Breast Surgeons’ Web-based software using a secure server and encrypted identification numbers. Surgeon demographic/practice characteristic data were collected, and logistic regression models were used to identify factors that affected quality measures.

Results

From October 2008 to December 2009, a total of 696 surgeons entered data for 28,798 breast procedures. Participants were diverse in years in practice, geographic location, practice setting and type, and proportion of practice made up of breast procedures. Delivery of “optimal care” (defined as delivery of all quality measures for which there was no valid clinical reason for nonperformance) was high for all surgeon demographic/practice characteristics, ranging from 81% to 94%. Statistically significant differences in delivery of quality measures were observed within all physician demographic/practice characteristic variables, but many absolute differences were small.

Conclusions

The high level of participation and volume of breast procedures for which quality measure data was entered demonstrate this is a feasible means of collecting quality performance data. Future development will include identifying/developing additional quality measures and establishing evidence-based benchmarks for care on the basis of data collected.

     

Locally Advanced Breast Cancer: Is Surgery Necessary?

Abstract: A retrospective analysis of the treatment of locally advanced breast cancer (LABC) was undertaken at Stanford Medical Center to assess the outcome of patients who did not undergo surgical removal of their tumors. Between 1981 and 1998, 64 patients with locally advanced breast cancer were treated with induction chemotherapy, radiation with or without breast surgery, and additional chemotherapy. Sixty-two (97%) patients received cyclophosphamide, doxorubicin, and 5-fluorouracil (CAF) induction chemotherapy. Induction chemotherapy was followed by local radiotherapy in 59 (92%) patients. Based on the clinical response to chemotherapy and patient preference, 44 (69%) patients received no local breast surgery. Radiotherapy was followed by an additional, non-doxorubicin-containing chemotherapy in all patients. The mean age of patients was 49 years. Of the 65 locally advanced breast cancers in 64 patients, 26 (41%) were stage IIIA, 35 (55%) were stage IIIB, and 4 (6%) were stage IV (supraclavicular lymph nodes only). Response to induction chemotherapy was seen in 59 patients (92%), with 29 (45%) achieving a complete clinical response and 30 (47%) a partial clinical response. With a mean follow-up of 51 months (range 7–187 months), 43 patients (67.2%) have no evidence of recurrent disease. Eight (12.5%) have recurred locally, and 21 (32.8%) have recurred with distant metastasis. Actuarial 5-year survival is 75%, disease-free survival is 58%, and local control rate is 87.5%. These data indicate that the routine inclusion of breast surgery in a combined modality treatment program for LABC does not appear necessary for the majority of patients who experience a response to induction chemotherapy.     

Inflammatory Breast Cancer: Is There a Role for Deescalation of Surgery?

Inflammatory breast cancer (IBC) is a rare and aggressive presentation of breast cancer, characterized by higher propensity for locoregional recurrence and distant metastasis compared with non-IBC. Because of extensive parenchymal and overlying dermal lymphatic involvement by carcinoma, IBC is unresectable at diagnosis. Trimodality therapy (neoadjuvant chemotherapy followed by modified radical mastectomy and adjuvant comprehensive chest wall and regional nodal radiotherapy) has been a well-accepted treatment algorithm for IBC. Over the last few decades, several innovations in systemic therapy have resulted in rising rates of pathologic complete response (pCR) in both the affected breast and the axilla. The latter may present an opportunity for deescalation of lymph node surgery in patients with IBC, as those with an axillary pCR may be able to avoid an axillary dissection. To this end, feasibility data are necessary to address this question. There are very limited data on the safety of breast conservation of IBC; therefore, mastectomy remains the standard of care for this disease. There are also no data addressing the safety of immediate reconstruction in patients with IBC. Considering that some degree of deliberate skin-sparing to facilitate immediate breast reconstruction would be expected, given the extensive skin involvement by disease at diagnosis, the safest oncologic strategy to breast reconstruction in IBC would be the delayed approach.

     

Axillary Node Staging for Microinvasive Breast Cancer: Is It Justified?

Background

The natural history and role of axillary staging in microinvasive breast cancer (DCISM) remains controversial. We report clinical characteristics and outcome in patients with DCISM, focusing on the role of sentinel lymph node (SLN) biopsy.

Methods

From our prospective database we retrospectively identified 112 patients with DCISM who underwent SLN biopsy between 1996 and 2004 at our institution. Median follow-up was 6?years.

Results

We found positive SLN in 12?% of patients (14 of 112): macrometastasis in 2.7?% (3 of 112) and micrometastases or isolated tumor cells (ITC) in 10?% (11 of 112). We performed axillary dissection (ALND) in all patients with macrometastasis (3 of 3), finding additional positive nodes in 66?% (2 of 3), and in 27?% of those with micrometastases/ITCs (3 of 11), finding no additional positive nodes. Among 98 patients with negative SLN (38?% of whom received systemic therapy), there were 5 locoregional recurrences (1 in the ipsilateral axilla, 4 in the ipsilateral breast, all DCIS) and 4 contralateral second primary cancers. Among 14 patients with positive SLN (82?% of whom received systemic adjuvant therapy), there were no locoregional or distant recurrences.

Conclusions

Our results suggest that SLN biopsy may be justified for DCISM, but is clearly most beneficial to identify a very small subset of DCISM patients (2.7?%, with SLN macrometastasis) who could benefit from systemic adjuvant therapy. The benefit of SLN biopsy for patients with SLN micrometastases/ITCs (pN0mi or pN0(i+)) is uncertain, and in these cases ALND does not appear to be warranted. We suggest a wider reappraisal of routine SLN biopsy for DCISM.     

Structured Ultrasonography Workshop for Breast Surgeons: Is It An Effective Training Tool?

Background  

Effective training is essential to ensure satisfactory performance in surgeon-performed ultrasonography (US) and guided breast needle biopsies (USGBB). This study aimed to determine the efficacy of conducting a structured workshop in the teaching of breast US application and in guided biopsy techniques.     

Intensity of Follow-Up After Breast Cancer Surgery: Low Versus High?

The incidence of breast cancer has been on the rise in the United States over the past several decades. The advanced longevity of the population during this same time period, specifically of elderly women, translates to increases in the absolute number of women diagnosed with breast cancer yearly. This, in combination with decreasing mortality rates, has now led to an increase in the number of breast cancer survivors who need long-term follow-up. There has been significant debate over what tests should be obtained, how often they should be obtained, how long surveillance should be continued, and by whom this should be performed. We review the published guidelines for surveillance, available data regarding low- versus high-intensity surveillance plans, current practice patterns, and recommendations for future strategies.     

American Society of Breast Surgeons’ Practice Patterns for Patients at Risk and Affected by Breast Cancer-Related Lymphedema

Annals of Surgical Oncology - In 2017, the American Society of Breast Surgeons (ASBrS) published expert panel recommendations for patients at risk for breast cancer-related lymphedema (BCRL) and...