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...     

Determinants of Patients’ Choice of Reconstruction with Mastectomy for Primary Breast Cancer

Background: The aim of the study was to measure womens decisions about breast reconstruction (BR) after mastectomy and to assess the factors contributing to their decisions, in a context involving shared decision-making and maximum patient autonomy.Methods: Women who were about to undergo mastectomy for primary breast cancer were systematically offered choices concerning BR and time of reconstruction (intervention always covered by the French National Insurance System). Self-administered questionnaires were used prior to the operation.Results: Among the 181 respondents, 81% opted for BR and 19% for mastectomy alone. In comparison with those who chose mastectomy alone, those opting for BR more frequently recognized the importance of discussing these matters with the surgeon and their partner (adjusted odds ratio [OR^adj] = 13.45 and 3.59, respectively; P < .05) and realized that their body image was important (OR^adj = 10.55, P < .01); fears about surgery prevented some of the women from opting for BR (OR^adj = 0.688, P < .05). Among the women opting for BR, 83% chose immediate breast reconstruction (IBR) and 17% chose delayed breast reconstruction (DBR). The preference for IBR was mainly attributable to the fact that these women had benefited more frequently from doctor–patient discussions (OR^adj = 3.49, P < .05) but was also attributable to the patients physical and functional characteristics: they were in a poorer state of health (P < .05). The surgeons predicted their patients preferences fairly accurately.Conclusions: In a context of maximum autonomy, the great majority of the women chose IBR. The patients choices were explained mainly by their psychosocial characteristics. The indication for BR should be properly discussed between patients and surgeons before mastectomy.     

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.     

Striving to Do No Harm and Yet Respect Patient Autonomy: Plastic Surgeons’ Perspectives of the Consultation for Breast Reconstruction with Women Who Have Early-Stage Breast Cancer

Annals of Surgical Oncology - Rates of contralateral prophylactic mastectomy (CPM) have doubled over the last decade among women considered low risk for developing contralateral breast cancer....     

‘At All Costs’: Breast Cancer Patient Responses to Cost Transparency and Communication

Annals of Surgical Oncology -     

Surgeon-Level Variation in Patients’ Appraisals of Their Breast Cancer Treatment Experiences

Background and Purpose

While variation in breast cancer quality indicators has been studied, to date there have been no studies examining the degree of surgeon-level variation in patient-reported outcomes. The purpose of this study is to examine surgeon-level variation in patient appraisals of their breast cancer care experiences.

Methods

Survey responses and clinical data from breast cancer patients reported to Detroit and Los Angeles Surveillance, Epidemiology and End Results registries from 6/2005 to 2/2007 were merged with attending surgeon surveys (1,780 patients, 291 surgeons). Primary outcomes were patient reports of access to care, care coordination, and decision satisfaction. Random-effects models examined variation due to individual surgeons for these three outcomes.

Results

Mean values on each patient-reported outcome scale were high. The amount of variation attributable to individual surgeons in the unconditional models was low to modest: 5.4 % for access to care, 3.3 % for care coordination, and 7.5 % for decision satisfaction. Few factors were independently associated with patient reports of better access to or coordination of care, but less-acculturated Latina patients had lower decision satisfaction.

Conclusions

Patients reported generally positive experiences with their breast cancer treatment, though we found disparities in decision satisfaction. Individual surgeons did not substantively explain the variation in any of the patient-reported outcomes.     

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.

     

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.

     

Surgeons Underestimate Their Patients’ Desire for Preoperative Information

Background  Provision of adequate patient information may contribute to a “satisfying” surgical treatment. The patient’s views on successful transfer of information concerning operative characteristics may not be in concert with the surgeon’s. The aim of the present study was to determine opinions of both surgeons and patients about issues of surgical information. Methods  A group of surgeons (n = 24) and surgical patients (n = 125) responded to a questionnaire that included 80 topics involving domains of information on disease, physical examination, preoperative period, anesthesia, operation, postoperative period, self care, and general hospital issues. Both groups were asked for their opinion on what they considered important and useful preoperative information for patients. Questions were scored with a visual analog scale. The reliability of the questionnaire was calculated with Cronbach’s alpha. Differences in opinions between surgeons and patients were analyzed with Student’s t-test. Results  The Cronbach’s alpha of the questionnaire was high (0.91), indicating its high reliability. Patients scored significantly higher (p < 0.001) in most domains, including preoperative period, anaesthesia, operation, postoperative period, self care, and general hospital information. Women demonstrated a significantly higher need for information than men did. These findings were independent of patient age or complexity of operation. In contrast, surgeons thought that their patients desired more extensive information on cause, effect, and prognosis of the disease itself (p < 0.001). Conclusion  Surgeons generally underestimate their patients’ desire for receiving extensive information prior to a surgical procedure of any complexity. Surgeons should develop strategies to bridge this informational mismatch. Research institution: Department of Surgery. Máxima Medical Centre (MMC) Veldhoven, The Netherlands.     

Preoperative Predictors of Nipple–Areola Complex Involvement for Patients Undergoing Mastectomy for Breast Cancer

Background  

Proper patient selection is important for nipple-sparing mastectomy, and we aimed to identify preoperative factors predictive of pathologic nipple-areola complex (NAC) involvement to assist with surgical planning.