Effect of standardised surgical assessment and shared decision-making on morbidity and patient satisfaction after breast conserving therapy: A cross-sectional study

BackgroundThe role of oncoplastic breast conserving therapy (OPBCT) on physical function, morbidity and patient satisfaction has yet to be defined. Additionally, technique selection should be individualised and incorporate patient preference. The study aim was to investigate differences between “standard” (sBCT) and oncoplastic breast conservation (OPBCT) in patient-reported outcomes (PROs) when patients have been assessed in a standardised manner and technique selection has been reached through shared decision-making (SDM).MethodsThis is a cross-sectional study of 215 women treated at a tertiary referral centre. Standardised surgical assessment included breast and lesion volumetry, definition of resection ratio, patient-related risk factors and patient preference. Postoperative morbidity and patient satisfaction were assessed by validated PROs tools (Diseases of the Arm, Shoulder and Hand-DASH and Breast-Q). Patient experience was assessed by semi-structured interviews.ResultsThere was no difference of the median values between OPBCT and sBCT in postoperative morbidity of the upper extremity (DASH 3.3 vs 5, p = 0.656) or the function of the chest wall (Breast-Q 82 vs 82, p = 0.758). Postoperative satisfaction with breasts did not differ either (Breast-Q 65 vs 61, p = 0.702). On the individual level, women that opted for OPBCT after SDM had improved satisfaction when compared to baseline (+3 vs ?1, p = 0.001). Shared decision-making changed patient attitude in 69.8% of patients, leading most often to de-escalation from mastectomy.ConclusionsThese findings support that a combination of standardised surgical assessment and SDM allows for tailored treatment and de-escalation of oncoplastic surgery without negatively affecting patient satisfaction and morbidity.     

Patient-reported outcomes in randomised controlled trials of gynaecological cancers: Investigating methodological quality and impact on clinical decision-making

AimThe aim for this study is to investigate the methodological quality and potential impact on clinical decision making of patient reported outcome (PRO) assessment in randomised controlled trials (RCTs) in the gynaecological cancer sites.MethodsA systematic review identified RCTs published between January 2004 and June 2012. Relevant studies were evaluated using a pre-determined extraction form which included: (1) Trial demographics and clinical and PRO characteristics; (2) level of PRO reporting and (3) bias, assessed using the Cochrane Risk of Bias tool. All studies were additionally analysed in relation to their relevance in supporting clinical decision making.ResultsFifty RCTs enrolling 24,991 patients were identified. In eight RCTs (16%) a PRO was the primary end-point. Twenty-one studies (42%) were carried out in a multi-national context. Where statistically significant PRO differences between treatments were found, it related in most cases to both symptoms and domains other than symptoms (n = 17, 57%). The majority of studies (n = 42, 84%) did not mention the mode of administration nor the methods of collecting PRO data. Statistical approaches for dealing with missing data were only explicitly mentioned in nine RCTs (18%). Sixteen RCTs (32%) were considered to be of high-quality and thus able to inform clinical decision making. Higher-quality PRO studies were generally associated with RCTs that were at a low risk of bias.ConclusionThis study showed that RCTs with PROs were generally well designed and conducted. In a third the information was very informative to fully understand the pros and cons of PROs treatment decision-making.     

Objectively measured breast symmetry has no influence on quality of life in breast cancer patients

Aims

This study investigates how quality of life (QoL) of breast cancer patients is related to breast symmetry.

Methods

We objectively measured breast symmetry using the breast analyzing tool (BAT) in 101 patients after breast conserving surgery for breast cancer at different time points during follow up. We correlated the results with the quality of life measured at the same time using the breast image scale (BIS), the EORTC QLQ-BR23 scale and a not validated sexual score scale. Age, tumour size, tumour/breast relation and the use of oncoplastic surgery were also correlated with symmetry and quality of life scales. Using multivariate analyses, independent parameters for an improved quality of life were identified.

Results

Mean age was 56 (±11.6), and 75.2% of patients had T1 or T2 tumours. Patient age (p = 0.03) and tumour size (p = 0.01) significantly influenced objectively measured breast symmetry. The cosmetic result was important for 53% of patients while 48% found it not important. Independent from this, neither overall quality of life nor breast self esteem was influenced by breast symmetry in our patients.

Conclusions

After breast cancer surgery, breast symmetry is not a major factor for patients’ quality of life and breast self esteem. Cosmetic result seems to be less important than oncologic outcome in patients with breast cancer.     

A prospective study comparing digital breast tomosynthesis with digital mammography in surveillance after breast cancer treatment

BackgroundAlthough the benefit of adjunct digital breast tomosynthesis (DBT) is established in population screening, its benefit in surveillance after breast cancer treatment is not well defined. We prospectively evaluated whether the addition of DBT to digital mammography (DM) reduced the rate of indeterminate findings compared to DM alone in patients after breast cancer treatment.MethodsPatients had both DM and DBT for routine surveillance. Two-dimensional synthesised mammogram (SM) was generated for each patient from DBT data. DM, SM, and DBT images were read for each patient by one of four radiologists credentialed for DBT. We compared the rates of indeterminate findings between DM + DBT with DM alone in patients with a range of breast densities and between DM and SM.ResultsA total of 618 patients and 1069 breasts were analysed. The rates of indeterminate findings for DM + DBT versus DM alone were 10.5% and 13.1%, respectively (p = 0.018). In breasts treated with surgery and radiotherapy (n = 558), the corresponding rates of indeterminate findings were 4.9% and 6.9%, respectively (p = 0.039). The rate of indeterminate findings for DM + DBT increased with increasing breast density (p = 0.019). There was no significant difference in the rates of indeterminate findings between DM and SM (13.1% versus 11.5%, p = 0.1).ConclusionThe addition of DBT to DM reduced the rate of indeterminate findings in surveillance of patients after breast cancer treatment. Further research is required to confirm whether DBT and SM could replace DM for patients undergoing surveillance.     

乳腺癌患者化疗后的心理痛苦与其生活质量之间的关系分析

目的 探讨乳腺癌患者化疗后不同程度的心理痛苦与其生活质量之间的关系。方法以本院2015年3月至2016年3月62例完成6个周期标准化疗的乳腺癌术后患者为研究对象,在化疗后分别完成心理痛苦温度计（DT）及乳腺癌生活质量量表（FACT-B）的测查,根据DT是否≥4分分为高分组和低分组,比较两组间生活质量的差异,同时分析心理痛苦与生活质量的相关性。结果 62例患者中有2例未完成问卷调查剔除。60例低分组和高分组患者生活质量的评分分别为（124.3±11.2）分和（89.5±15.6）分,组间的差异有统计学意义（t=10.06,P＜0.05）。60例患者的心理痛苦评分与生活质量评分呈显著负相关（r=-0.949,P＜0.05）。结论 乳腺癌患者化疗后存在不同程度心理痛苦,且心理痛苦的评分与其生活质量密切相关。     

Sexual Health as a Survivorship Issue for Female Cancer Survivors

As more and more people are successfully treated for and live longer with cancer, greater attention is being directed toward the survivorship needs of this population. Women treated for cancer often experience issues related to sexual health and intimacy, which are frequently cited as areas of concern, even among long‐term survivors. Unfortunately, data suggest that providers infrequently discuss these issues. We reviewed a contemporary understanding of sexual health of women and the impact of treatment on both sexual function and intimacy. We also provide a review of the diagnosis using the newest classification put forth by the American Psychiatric Association in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, and potential treatments, including both endocrine and nonendocrine treatments that the general oncologist may be asked about when discussing sexual health with his or her patients.     

乳腺癌患者术后生活质量评估的现状及进展

乳腺癌是严重影响以女性为主患者身心健康的常见恶性肿瘤,目前发病率仍呈逐年上升的趋势。手术及术后进一步治疗在乳腺癌患者的生理、心理及社会功能等方面引起的巨大变化逐渐引起了人们的关注,对其生活质量的相关研究也就越发显得迫切。作为评价乳腺癌患者术后生活质量必不可少的测量工具——量表的研制与应用方面的研究也显得尤为重要。本文对乳腺癌患者术后生活质量评测工具的现状及面临的问题加以综述,并分析影响乳腺癌患者生活质量的相关因素,有助于提高乳腺癌患者的生活质量。     

Biobanking in the digital pathology era

Digital Pathology is becoming more and more important to achieve the goal of precision medicine. Advances in whole-slide imaging, software integration, and the accessibility of storage solutions have changed the pathologists’ clinical practice, not only in terms of laboratory workflow but also for diagnosis and biomarkers analysis. In parallel with the pathology setting advancement, translational medicine is approaching the unprecedented opportunities unrevealed by artificial intelligence (AI). Indeed, the increased usage of biobanks’ datasets in research provided new challenges for AI applications, such as advanced algorithms, and computer-aided techniques. In this scenario, machine learning-based approaches are being propose in order to improve biobanks from biospecimens collection repositories to computational datasets. To date, evidence on how to implement digital biobanks in translational medicine is still lacking. This viewpoint article summarizes the currently available literature that supports the biobanks’ role in the digital pathology era, and to provide possible practical applications of digital biobanks.     

Symptoms after breast cancer treatment: are they influenced by patient characteristics?

PURPOSE: This study examines the burden of symptoms by treatment type and patient characteristics in a population-based sample of newly diagnosed breast cancer patients. METHODS: Using the Los Angeles County SEER Registry Rapid Case Ascertainment, we identified a cohort of breast cancer patients in 2000 and conducted telephone surveys in English and Spanish among participants. RESULTS: We completed interviews of 1,219 breast cancer patients and found almost half (46%) had at least one severe symptom (any of the following: nausea/vomiting, arm problems, hot flashes, vaginal dryness, difficulty sleeping) that interfered with her daily functioning or mood. Multi-variate analysis controlling for patient characteristics and treatment showed that older (OR=0.90; P<0.000), black (OR=0.50; P<0.000), Hispanic Spanish-speaking (OR=0.37; P<0.000), widowed or never married (OR=0.68; P=0.049), and working (OR=0.72; P=0.024) women were less likely to report severe symptoms than other women. Number of comorbid conditions (OR=1.21; P<0.000) and receipt of chemotherapy (OR=1.48; P=0.040) were positively associated with reporting symptoms. CONCLUSION: These findings estimate the prevalence of several mutable symptoms in breast cancer patients that can be addressed by appropriate treatments. Comorbidity is a significant predictor of symptoms, especially amongst those receiving chemotherapy. Variation in symptom reporting occurred by race/ethnicity and other sociodemographic characteristics, raising questions of different thresholds for reporting symptoms or truly fewer symptoms for some sociodemographic groups. Population-based estimates of the probability of symptoms in women with incident breast cancer can be used to provide patient education about potential outcomes following the treatment of breast cancer.     

Concise review on the safety of exercise on symptoms of lymphedema

Lymphedema is an atypical accumulation of high-protein fluid located just beneath the skin, which often occurs in the arm or leg. Exercising with lymphedema was traditionally considered to be unsafe. However, recent research indicates that exercise may be beneficial to individuals with lymphedema. Studies indicate that exercise can improve the range of motion and strength of the afflicted limb(s), as well as overall fitness and functional quality of life, and can be performed without exacerbating symptoms of lymphedema.     

Current state of digital mammography

Digital imaging is rapidly becoming modern radiology practice, resulting in the gradual replacement of conventional radiographs. At present high-quality digital mammography has been available for several years and is increasingly used for diagnostic and screening mammography. Some different digital mammography systems exist, which all have their advantages and disadvantages. Diagnostic accuracy of digital mammography has been shown to be at least equivalent to screen-film mammography (SFM). Digital mammography offers some potential advantages over SFM. This article describes the current state of digital mammography and presents data from clinical trials that support the use of digital mammography technology.     

Use of implicit persuasion in decision making about adjuvant cancer treatment: A potential barrier to shared decision making

BackgroundShared decision making (SDM) is widely advocated, especially for preference-sensitive decisions like those on adjuvant treatment for early-stage cancer. Here, decision making involves a subjective trade-off between benefits and side-effects, and therefore, patients' informed preferences should be taken into account. If clinicians consciously or unconsciously steer patients towards the option they think is in their patients' best interest (i.e. implicit persuasion), they may be unwittingly subverting their own efforts to implement SDM. We assessed the frequency of use of implicit persuasion during consultations and whether the use of implicit persuasion was associated with expected treatment benefit and/or decision making.MethodsObservational study design in which consecutive consultations about adjuvant systemic therapy with stage I–II breast cancer patients treated at oncology outpatient clinics of general teaching hospitals and university medical centres were audiotaped, transcribed and coded by two researchers independently.ResultsIn total, 105 patients (median age = 59; range: 35–87 years) were included. A median of five (range: 2–10) implicitly persuasive behaviours were employed per consultation. The number of behaviours used did not differ by disease stage (P = 0.07), but did differ by treatment option presented (P = 0.002) and nodal status (P = 0.01). About 50% of patients with stage I or node-negative disease were steered towards undergoing chemotherapy, whereas 96% of patients were steered towards undergoing endocrine therapy, irrespective of expected treatment benefit. Decisions were less often postponed if more implicit persuasion was used (P = 0.03).InterpretationOncologists frequently use implicit persuasion, steering patients towards the treatment option that they think is in their patients' best interest. Expected treatment benefit does not always seem to be the driving force behind implicit persuasion. Awareness of one's use of these steering behaviours during decision making is a first step to help overcome the performance gap between advocating and implementing SDM.     

Comparison of early quality of life in patients treated with radiotherapy following mastectomy or breast conservation therapy: A prospective study

Introduction

To compare quality of life (QOL) in breast cancer patients from a developing country after breast conservation surgery (BCS) or mastectomy and adjuvant radiotherapy (RT).

Materials and methods

In a 6-month period, all consecutive early and locally advanced breast cancer patients treated with either BCS or mastectomy and treated with RT were analyzed. All patients who underwent mastectomy were treated with 45 Gray/20#/4 weeks. Patients with BCS were treated with a dose of 45-50 Gray/25#/5 weeks to whole breast followed by tumor bed boost (15 Gray/6#/6 days with suitable energy electrons). Prospective evaluation of QOL using EORTC QLQ C30 and breast cancer specific QLQ BR23 was done before starting RT (baseline), at mid-RT and at RT conclusion for all patients.

Results

One hundred and thirteen patients had mastectomy and 142 patients underwent BCS. Reliability test (Cronbach alpha) for questionnaire filling was 0.669-0.886. At pre-RT assessment, global QOL scores in mastectomy and BCS groups were 71.1 and 71.3, respectively. There was no significant difference in pre-RT EORTC QLQ C30 functional and symptom domains between mastectomy and BCS patients. However, social function domain score was higher in patients who underwent mastectomy (83 versus 73.9; p = 0.018). In QLQ BR23 domains, body image and sexual functioning domains were similar between the two groups. However, sexual enjoyment (10.9 versus 47.6; p = 0.006) and future perspective (7.4 versus 37.1; p = 0.036) domains were significantly better in BCS arm. There was no difference between systemic side effect (BRSSE), breast symptom (BRBS) and arm symptom (BRAS) domain scores between the groups. There was no significant difference in change of QOL scores between mastectomy and BCS patients at RT completion as compared to baseline.

Conclusions

There was no significant difference in quality of life in patients with BCS versus those with mastectomy. However, patients who underwent BCS had better sexual enjoyment and future perspective scores compared with mastectomy patients. There was no significant change of QOL domain scores after RT in mastectomy and BCS patients.     

Time to deterioration in quality of life score as a modality of longitudinal analysis in patients with breast cancer

Purpose.

This prospective multicenter study explored different definitions of time to deterioration (TTD) in quality of life (QoL) scores, according to different cutoffs of the minimal clinically important difference (MCID) as a modality for longitudinal QoL assessment in breast cancer patients.

Methods.

QoL was assessed using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 and BR-23 before surgery, after surgery, and 6 and 12 months later. The global health score, arm symptoms score (BRAS), and breast symptoms score were analyzed. For a given baseline score, QoL was considered to have deteriorated if this score decreased by ≥5 points at any time point after baseline. Analyses were repeated using an MCID of 10 points and taking the score after surgery as the reference score (to explore the occurrence of response shift). TTD was calculated using the Kaplan–Meier method and Cox regression was used to identify independent factors associated with TTD.

Results.

Two hundred thirty-five patients underwent axillary lymph node dissection (ALND), 222 underwent sentinel lymph node biopsy (SLNB), and 61 underwent SLNB plus ALND. Patients who underwent SLNB had a significantly longer TTD for the BRAS dimension than those who underwent ALND. Cox multivariate analyses showed that treatment using SLNB and age >59 years were independently associated with longer TTD for the BRAS, whereas surgery elsewhere than at the Centre Georges François Leclerc was associated with a shorter TTD.

Conclusion.

Exploration of different definitions of TTD in QoL provides meaningful longitudinal QoL results for clinicians.