Clinical trial priorities among surgeons caring for breast cancer patients

BACKGROUND: Designing and prioritizing successful clinical trials benefits from increased community physician input. We surveyed practicing surgeons about current controversies in breast cancer surgery, reported practices of discussing trial participation, and perceived obstacles to trial participation. METHODS: A 44-question survey was mailed in 2005-2006 to 2,187 randomly selected American College of Surgeons members actively seeing breast cancer patients. Responses were analyzed by surgeon sex, practice type, oncology training, professional society membership, and breast cancer patient volume. RESULTS: A total of 923 responses were received, with 460 eligible responses remaining for analysis. Most surgeons infrequently or never discuss trial participation with breast cancer patients. Inadequate infrastructure presents the greatest physician obstacle to trial participation. Identifying proven indications for completion axillary dissection after positive sentinel node biopsy marks the highest-ranked research priority for surgeons providing breast care. CONCLUSIONS: Understanding topics of interest among practicing surgeons and addressing common obstacles to trial participation may result in improved breast cancer patient accrual through surgeons.     

Integration of electronic pathology reporting with clinical trial matching for advanced prostate cancer

IntroductionRacial/ethnic diversity in prostate cancer (CaP) clinical trials (CTs) is essential to address CaP disparities. California Cancer Registry mandated electronic reporting (e-path) of structured data elements from pathologists diagnosing cancer thereby creating an opportunity to identify and approach patients rapidly. This study tested the utility of an online CT matching tool (called Trial Library) used in combination with e-path to improve matching of underrepresented CaP patients into CTs at time of diagnosis.MethodsThis was a nonrandomized, single-arm feasibility study among patients with a new pathologic diagnosis of high-risk CaP (Gleason Score ≥8). Eligible patients were sent recruitment materials and enrolled patients were introduced to Trial Library.ResultsA total of 419 case listings were assessed. Patients were excluded due to physician contraindication, not meeting baseline eligibility, or unable to be reached. Final participants (N = 52) completed a baseline survey. Among study participants, 77% were White, 10% were Black/Hispanic/Missing, and 14% were Asian. The majority of the study participants were over 65 years of age (81%) and Medicare insured (62%). Additionally, 81% of participants reported using the Internet to learn about CaP. The majority (62%) of participants reported that Trial Library increased their interest in CT participation.ConclusionsThe current study demonstrated that leveraging structured e-path data reporting to a population-based cancer registry to recruit men with high risk CaP to clinical research is feasible and acceptable. We observed that e-path may be linked with an online CT matching tool, Trial Library. Future studies will prioritize recruitment from reporting facilities that serve more racially/ethnically diverse patient populations.     

Access to surgery following centralization of breast cancer surgical consultations

IntroductionTimely access to breast cancer surgery is imperative for patient outcome. Building upon our previous model, 5 breast surgeons centralized all breast surgical referrals using principles of centralized intake and nurse navigator triage. The goal of this study was to investigate whether centralization can further improve access to surgery.MethodsThis study was designed as a before-after series, comparing wait times for breast cancer surgery prior to centralization and after. Primary outcome was wait time from diagnosis to surgery, and secondary outcomes included median wait time, days required for 90% case completion, number of available operating days, and number of patients who underwent breast reconstruction and neoadjuvant therapy.ResultsOverall, centralization of breast cancer surgical referrals reduced wait time from 47 to 41 days. The median wait time and time required for 90% of case completion was reduced, despite a 7% reduction in operating room availability. Fewer patients underwent neoadjuvant therapy and more patients underwent breast reconstruction following centralization.ConclusionCentralization of surgical referrals for breast cancer patients improved access to surgery.     

Age-related differences in breast cancer stage at diagnosis between black and white patients in an urban community hospital

Background: Breast cancer mortality is significantly higher among black patients compared to white patients. Black women are reportedly at increased risk for early-onset breast cancer. Our goal was to evaluate stage distribution relative to age among black and white breast cancer patients in an institution with a relatively high minority patient population. Methods: We evaluated 425 patients diagnosed with breast cancer between 1990 and 1994: 56% white, 34% black, the remainder were other ethnicities. Patients were stratified by age: under 50 years versus 50 and older. Socioeconomic status was estimated by utilization of medical care in the private-practice setting versus the public clinic. Results: Significantly more black patients were younger at diagnosis compared to white patients (32% vs. 20%; p=0.008). There was a significantly more advanced stage distribution among the younger black patients, but not among the older black patients. Most of the black and white patients received private-practice care. Conclusions: These age-related differences in breast cancer stage distribution between black and white patients (which appeared independent of socioeconomic status) indicate that more aggressive screening and public education progams directed toward younger black women is warranted, and they lend support to the possibility of ethnicity-related variation in primary tumor biology.     

Does a dedicated program for young breast cancer patients affect the likelihood of fertility preservation discussion and referral?

PurposeTo assess whether a dedicated program for young breast cancer patients, including a nurse navigator, improves the frequency of: a) fertility discussion documentation and b) fertility preservation (FP) referrals.MethodsA retrospective chart review and prospective survey were undertaken of breast cancer patients diagnosed at age 40 or younger between 2011 and 2013 who received adjuvant or neo-adjuvant chemotherapy at two academic cancer centers in Toronto, Canada. The Odette Cancer Centre (OCC) has a dedicated program for young breast cancer patients while Princess Margaret Cancer Centre (PM) does not. Patient demographics, tumor pathology, treatment and fertility discussion documentation prior to systemic chemotherapy administration were extracted from patient records. Prospective surveys were administered to the same cohort to corroborate data collected.ResultsEighty-one patient charts were reviewed at both OCC and PM. Forty-seven and 49 at OCC and PM returned surveys for a response rate of 58% and 60% respectively. Chart reviews demonstrated no difference in the frequency of fertility discussion documentation (78% versus 75% for OCC and PM, p = 0.71); however, surveys demonstrated higher rates of recall of fertility discussion at OCC (96% versus 80%, p = 0.02). A greater proportion of women were offered FP referrals at OCC, as observed in chart reviews (56% versus 41%, p = 0.09), and surveys (73% versus 51%, p = 0.04). Time to initiation of chemotherapy did not differ between women who underwent FP and those who did not.ConclusionA dedicated program for young breast cancer patients is associated with a higher frequency of FP referrals without delaying systemic therapy.     

Preoperative Education for Total Joint Arthroplasty: Does Reimbursement Reduction Threaten Improved Outcomes?

BackgroundNurse navigation programs have been previously shown to reduce cost and improve outcomes after total joint arthroplasty (TJA). Medicare has proposed a 13.7% reduction in professional fee reimbursement for TJA procedures that may adversely impact providers’ and health systems’ ability to fund ancillary support resources such as nurse navigators.MethodsA consecutive series of primary TJAs performed between April 2019 and February 2020 was retrospectively reviewed. Clinical and financial outcomes of patients attending a nurse navigator–led preoperative education class were compared with those who did not attend.ResultsThere were 2057 TJAs identified during the study period. Most patients attended the preoperative education class (82.7%) and were discharged home (92.8%). Controlling for significant differences between groups, class attendance was associated with reduced length of stay (LOS), increased chance of 0- or 1-day LOS, reduced chance of discharge to a skilled nursing facility, and reduced hospital charges. For this patient sample, a proposed 13.7% reduction in nurse navigator–led classes was modeled to increase overall cost to payers by >$400,000 annually. Complete elimination of this class was estimated to increase the total annual cost by >$5,700,000 and cost per TJA by >$2700.ConclusionThe use of a nurse navigator–led preoperative education class was associated with shorter LOS, more frequent 0- and 1-day LOS, reduced discharge to skilled nursing facilities, and lower total hospital charges for those patients who attended. Potential reductions proposed by Medicare may interfere with the ability to support such services and negatively impact both clinical and financial outcomes.     

Challenges and Opportunities for Real-World Evidence in Metastatic Luminal Breast Cancer

BackgroundThe therapeutic armamentarium for patients with metastatic breast cancer is becoming more and more specific. Recommendations from clinical trials are not available for all treatment situations and patient subgroups, and it is therefore important to collect real-world data.SummaryTo develop recommendations for up-to-date treatments and participation in clinical trials for patients with metastatic breast cancer, the Prospective Academic Translational Research PRAEGNANT Network was established to optimize the quality of oncological care in the advanced therapeutic setting. The main aim of PRAEGNANT is to systematically record medical care for patients with metastatic breast cancer in the real-life setting, including the outcome and side effects of different treatment strategies, to monitor quality-of-life changes during therapy, to identify patients eligible for participation in clinical studies, and to allow targeted therapies based on the molecular structures of breast carcinomas.Key MessagesThis article describes the PRAEGNANT network and sheds light on the question of whether the various end points from clinical trials can be transferred to the real-world treatment situation.     

Patient Navigation and the Quality of Breast Cancer Care: An Analysis of the Breast Cancer Care Quality Indicators

Purpose

Patient navigation programs are initiated to help guide patients through barriers in a complex cancer care system. We sought to analyze the impact of our patient navigator program on the adherence to specific Breast Cancer Care Quality Indicators (BCCQI).

Methods

A retrospective cohort of patients with stage I–III breast cancer seen the calendar year prior to the initiation of the patient navigation program were compared with patients treated in the ensuing two calendar years. Quality indicators deemed appropriate for analysis were those associated with overcoming barriers to treatment and those associated with providing health education and improving patient decision-making.

Results

A total of 134 consecutive patients between January 1, 2006 and December 31, 2006 and 234 consecutive patients between January 1, 2008 and December 31, 2009 were evaluated for compliance with the BCCQI. There was no significant difference in the mean age or race/ethnic distribution of the study population. In all ten BCCQI evaluated, there was improvement in the percentage of patients in compliance from pre and post implementation of a patient navigator program (range 2.5–27.0 %). Overall, compliance with BCCQI improved from 74.1 to 95.5 % (p < 0.0001). Indicators associated with informed decision-making and patient preference achieved statistical significance, while only completion axillary node dissection in sentinel node-positive biopsies in the process of treatment achieved statistical significance.

Conclusions

The implementation of a patient navigator program improved breast cancer care as measured by BCCQI. The impact on disease-free and overall survival remains to be determined.     

Improving breast cancer quality of care with the use of patient navigators

The continuum of breast cancer care requires multidisciplinary efforts. Patient navigators, who perform outreach, coordination, and education, have been shown to improve some areas of care. However, little research has assessed the impact of navigators on breast cancer treatment in uninsured populations. Our objective is to report on the impact of a patient navigator program on breast cancer quality of care at a public hospital. One hundred consecutive newly diagnosed patients with breast cancer (Stages I to III) were identified (2005 to 2007). Forty-nine patients were treated before the use of navigators and 51 after program implementation. Nine breast cancer quality indicators were used to evaluate quality of care. Overall adherence to the quality indicators improved from 69 to 86 per cent with the use of patient navigators (P < 0.01). Only one individual indicator, use of surveillance mammography, improved significantly (52 to 76%, P < 0.05). All nine indicators reached 75 per cent or greater adherence rates after implementation of the navigator program compared with only four before implementation. Patient navigators appear to improve breast cancer quality of care in a public hospital. In populations in which cultural, linguistic, and financial barriers are prevalent, navigator programs can be effective in narrowing the observed gaps in the quality of cancer care.     

Intermammary breast cancer; the first reported case

IntroductionCancer of the breast is the most common cancer among females. The current study aims to report and discuss a rare case of breast cancer in the intermammary region.Case reportA 61-year-old lady presented with intermammary swelling for three months. Ultrasound examination showed a hypoechoic micro lobulated mass with internal vascularity seated on the chest wall. There was pathological lymphnodes in the right axilla. Core needle biopsy suspected invasive ductal carcinoma of no specific type. The patient was referred to an oncology center receiving 21 cycles of radiotherapy and hormonal therapy.DiscussionThe most common site of the occurrence of breast cancer is the upper outer quadrant (found in one-third of patients), followed by the upper inner quadrant (9.4%)—both lower outer and inner quadrants (5.2%) and rarely in the central portion. Intermammary breast cancer is an infrequent finding.ConclusionAlthough it is extremely rare, breast cancer could occur in the intermammary region. It has the same management strategy as breast cancer.     

Computed tomography rates in pediatric trauma patients among emergency medicine and pediatric emergency medicine physicians

BackgroundPediatric trauma patients undergo fewer computed tomography (CT) scans when evaluated at pediatric trauma centers (PTC) versus adult trauma centers (ATC) with no change in clinical outcome. Factors contributing to this difference are unclear. We sought to identify whether the training background of physicians, specifically emergency medicine (EM) versus pediatric emergency medicine (PEM), affected the CT rate of pediatric trauma patients within one institution.MethodsA single-center retrospective study of CT utilization based on attending physicians’ training in trauma patients <18 years between November 2018 and November 2020. Attendings were categorized into two groups: EM residency with no PEM fellowship, or pediatrics/EM residency with PEM fellowship. Primary outcomes measured were the proportion of patients receiving a CT and CT positivity rate.ResultsOf 463 study patients, CTs were obtained in 145/228 (64%) patients by EM, and 130/235 (55%) by PEM (p=.07). CT positivity rate was 21% and 19% in EM and PEM, respectively (p=.46). The mean number of CTs per patient in EM was 2.8 compared to 2.1 in PEM (p<.01), and for patients with an injury severity score (ISS) >15, mean number of CTs per patient increased to 4.9 in EM versus 2.4 in PEM (p=.01).ConclusionsThe mean number of CTs ordered per patient was statistically higher for EM attendings. The differences between CT rates highlight future opportunities for ongoing development of pediatric trauma imaging guidelines and radiation exposure reduction.Levels of evidenceRetrospective Study, Level III     

Awareness and Availability of Routine Germline BRCA1/2 Mutation Testing in Patients with Advanced Breast Cancer in Germany

IntroductionDiagnostic testing of germline mutations in breast cancer susceptibility genes 1 or 2 (gBRCA1/2) in patients with human epidermal growth factor receptor 2 negative (HER2–) advanced breast cancer (ABC; locally advanced or metastatic breast cancer) is necessary to assess eligibility for poly(ADP-ribose) polymerase inhibitors (PARPi). We investigated awareness, clinical practice, and the availability of gBRCA1/2 mutation testing in the German outpatient oncology setting.MethodsOffice-based oncologists completed a 23-item online survey. Responses were evaluated collectively and by center type.ResultsOf 50 oncologists, 33 and 17 were medical and gynecological oncologists, respectively. Oncologists treated a median of 65 (range 14–350) patients with ABC per year. The strongest decision factors to initiate gBRCA1/2 mutation testing were: patient''s known family history of gBRCA1/2 mutation-related cancer(s), guideline recommendations, and triple-negative breast cancer (TNBC). In routine practice, 86% of oncologists tested for gBRCA1/2 mutations. Most oncologists (76–98%) reported testing patients with a known family history of gBRCA1/2 mutation-related cancer(s) irrespective of receptor status. For unknown family history, 92% of oncologists reported testing patients with advanced TNBC versus 30% for HR+/HER2− ABC. Oncologists (66%) rated the awareness of therapeutic relevance of gBRCA1/2 mutation testing for targeted treatment selection as good to satisfactory; 22% rated awareness as poor to in­sufficient.ConclusionDiagnostic gBRCA1/2 mutation testing in patients with HER2− ABC is available and routinely performed in Germany''s outpatient oncology setting. However, specific patient subgroups were not routinely tested despite therapeutic indications. Given PARPi availability, opportunities exist to improve testing rates especially for patients with HR+/HER2− ABC without a known family history of gBRCA1/2 mutation-related cancer(s).     

The Evolution of Breast Cancer Navigation and Survivorship Care

Over the last several decades, breast screening, diagnosis, and treatment have evolved. With that evolutionary process, so have the complexities of oncology care, especially from the perspective of more fragmented care occurring. The majority of breast care is outpatient based. The need for patient navigation has heightened as this fragmentation and financial issues set before the oncologist and the patient continue to occur and in many situations increase. Without effective navigation, breast patients can fall through the cracks and not get diagnosed as early as possible, or not receive all appropriate treatment they need. We are also seeing a steady increase in the actual number of breast cancer patients being diagnosed and surviving long term. Unfortunately simultaneous to this happen there is also a growing shortage of oncology specialists in the USA. This results in a need to transition survivors back to their community physicians after the completion of their acute treatment, and to do so in an organized, anticipated manner that prepares the survivor and her PCP and gynecologist, the tools they all need for effective cancer survivorship management.     

Omission of chemotherapy for low-grade,luminal A N1 breast cancer: Patterns of care and clinical outcomes

PurposeMultiple ongoing randomized studies are assessing the impact of omission of chemotherapy (CT) in low-risk node-positive Luminal A breast. The goal of this investigation was to evaluate trends and practice patterns of adjuvant CT use in Luminal A pT1-3N1 breast cancer, along with determining the clinical benefit from adjuvant CT in this patient population.MethodsThe National Cancer Data Base was queried (2004–2014) for women with pT1-3N1 luminal A invasive ductal carcinoma receiving adjuvant hormonal therapy (HT). Multivariable logistic regression ascertained factors associated with adjuvant CT administration. Kaplan-Meier analysis evaluated overall survival (OS) between patients treated with CT/HT vs. HT alone, while sub-stratifying patients by age.ResultsOf 8548 total patients, 5182 (61%) received CT/HT, while 3366 (39%) received HT alone. A steady rise in omission of adjuvant CT was observed, from 14% (2004–2005) to 41% (2012–2014). A decision not to use CT was more likely in more recent time periods, in older patients, at academic centers, following lumpectomy, and with lower T classification (p < 0.05 for all). CT was associated with higher OS in all patients (p < 0.001) and women ≤50 years old (p = 0.030), but not for ages 51–60 (p = 0.116), 61–70 (p = 0.222), or >70 (p = 0.239).ConclusionsUsing CT for Luminal A N1 breast cancer is decreasing over time, primarily in older patients and at academic centers. Although CT is still associated with an OS advantage in all patients, subgroup analysis demonstrated no OS benefit in women >50 years of age. These results have implications on the ongoing randomized trials.     

Societal cost of subcutaneous and intravenous trastuzumab for HER2-positive breast cancer – An observational study prospectively recording resource utilization in a Swedish healthcare setting

IntroductionTrastuzumab is part of the standard treatment for HER2-positive breast cancer. The aim of this study was to estimate the societal value of trastuzumab administered through subcutaneous (SC) injection compared to intravenous (IV) infusion.MethodsFemale patients with HER2-positive breast cancer receiving SC or IV trastuzumab were consecutively enrolled from five Swedish oncology clinics from 2013 to 2015. Data on time and resource utilization was collected prospectively using patient and nurse questionnaires. Societal costs were calculated by multiplying the resource use by its corresponding unit price, including direct medical costs (pharmaceuticals, materials, nurse time, etc.), direct non-medical costs (transportation) and indirect costs (production loss, lost leisure time). Costs were reported separately for patients receiving trastuzumab for the first time and non-first time (“subsequent treatment”).ResultsIn total, 101 IV and 94 SC patients were included in the study. The societal costs were lower with SC administration. For subsequent treatments the cost difference was €117 (IV €2099; SC €1983), partly explained by a higher time consumption both for nurses (14 min) and patients (23 min) with IV administration. Four IV and 16 SC patients received trastuzumab for the first time and were analysed separately, resulting in a difference in societal costs of €897 per treatment. A majority of patients preferred SC to IV administration.ConclusionSC administration resulted in both less direct medical costs and indirect costs, and was consequently less costly than IV administration from a societal perspective in a Swedish setting.     

Inclusion of premenopausal women in breast cancer clinical trials

BackgroundPatients with premenopausal breast cancer (PMBC) have been historically excluded from some clinical trials because of the limitations of using endocrine therapy (ET) in this population. We analyzed breast cancer randomized clinical trials (RCTs) to determine the rates of and factors associated with inclusion of PMBC patients to provide a benchmark for PMBC inclusion in RCTs moving forward.MethodsUsing ClinicalTrials.Gov, we identified breast cancer phase III RCTs and extracted inclusion criteria and patient enrollment information. Multiple binary logistic regression modeling was used to assess trial-related factors that were associated with PMBC patient inclusion.ResultsOf 170 breast cancer RCTs identified, 131 (77.1%) included PMBC patients. Sixty-five (38.2%) trials analyzed patients with hormone-receptor-positive (HR+) and HER2-negative (HER2-) breast cancer, of which 31 (47.7%) allowed for enrollment of PMBC patients. Lower rates of PMBC inclusion were seen in trials that studied HR+/HER2-patients (47.7% PMBC inclusion in HR+/HER2-trials vs. 94.3% in non-HR+/HER2-trials, aOR 0.07 [95% CI: 0.02–0.19], p < 0.001) and in trials that randomized or mandated ET (44.4% in ET trials vs. 83.2% in non-ET trials, aOR 0.21 [95% CI: 0.10–0.83], p = 0.02). Trials studying chemotherapy (CT) were associated with inclusion of PMBC patients (100% in CT trials vs. 70.5% in non-CT trials, a OR 14.02 [95% CI: 1.54–127.91], p = 0.01). All surgical and radiation therapy clinical trials allowed for the inclusion of PMBC patients in their eligibility criteria.ConclusionsBreast cancer clinical trials should carefully select their enrollment criteria and consider inclusion of premenopausal patients when appropriate.     

Factors related to incomplete treatment of breast cancer in Kumasi,Ghana

PurposeThe burden of cancer in Africa is an enlarging public health challenge. Breast cancer in Ghana is the second most common cancer among Ghanaian women and the proportion of diagnosed patients who complete prescribed treatment is estimated to be very limited, thereby potentially adding to lower survival and poor quality of life after diagnosis. The objective of this study was to identify the patient and system factors related to incomplete treatment of breast cancer among patients.MethodsThis study was conducted at the Komfo Anokye Teaching Hospital in Kumasi, Ghana. We interviewed 117 breast cancer patients and next of kin of breast cancer patients diagnosed from 2008 to 2010.ResultsIslamic religion, seeking treatment with traditional healers, and lack of awareness about national health insurance coverage of breast cancer treatment were predictors of incomplete treatment.ConclusionsThe results of this study support that Ghanaian women with diagnosed breast cancer have multiple addressable and modifiable patient factors that may deter them from completing the prescribed treatment. The results highlight the need for developing and testing specific interventions about the importance of completing treatment with a special focus on addressing religious, cultural, and system navigation barriers in developing countries.     

Genetic Counseling and the Advanced Practice Oncology Nursing Role in a Hereditary Cancer Prevention Clinic: Hereditary Breast Cancer Focus (Part I)

Abstract:  Interest in hereditary breast cancer has increased rapidly among all health care providers as well as the laity. A major problem for health care providers, however, is the time and skill required for gathering family history, interpreting the pedigree, and providing genetic counseling for the high-risk patient so that BRCA testing, when indicated, can be pursued and screening and prevention strategies employed by the patient. The fields of hereditary cancer and molecular biology have developed at a rate that makes it difficult for physicians to keep up with this explosive knowledge. Therefore, "Who is going to take care of all of these crucial matters for patient benefit?" is a germane question. Our experience has confirmed that the advanced practice oncology nurse who is interested in cancer genetics can become skilled at providing this service to the patient and his/her family. This study portrays the role of such an oncology nurse in meeting this important public health challenge, with special attention devoted to the logistics of this role in the rapidly emerging field of hereditary breast cancer.     

Patterns of seeking medical care among Egyptian breast cancer patients: relationship to late-stage presentation

Breast cancer is the most common cancer among Egyptian women, accounting for 37.6% of female tumors, and is often diagnosed at later stages. The objective of this study was to investigate breast cancer patient navigation through the health care system in the Nile Delta. Interviews were conducted with 163 newly diagnosed breast cancer patients at the Tanta Cancer Center (TCC), the major cancer center of the region. Patients described their medical care pathway from the initial symptom experienced until their arrival at TCC. Patients whose initial contact was with a general surgeon (OR: 7.6, 95% CI: 2.1, 27.6), primary care provider (OR: 12.2, 95% CI: 2.9, 51.0), or gynecologist (OR: 8.6, 95% CI: 1.4, 53.4) were significantly more likely to experience a delay in reaching the TCC as compared to those visiting a surgical oncologist. Overcoming health care system and patient navigation barriers in developing countries may reduce the time for breast cancer patients to reach a cancer center for early management.     

Developing a comprehensive breast center

In 1985 the University of Michigan Medical Center established a multidisciplinary breast care center (BCC) to provide comprehensive diagnosis and treatment for patients with benign and malignant breast disease. Ninety-eight per cent of the first 500 new patients were women and 2 per cent were men. One-hundred thirty-one women (26.7%) and no men had breast cancer. Of the remaining 359 women, 75.3 per cent had some element of fibrocystic disease. Patients who had breast cancer were evaluated during their initial visit to the BCC by a nurse, general surgeon, radiation therapist, and oncologist. Ninety-five per cent of all patients were given a definitive treatment plan or a second opinion at the conclusion of their one visit to the center. Patient and physician satisfaction with the center concept has been high. The center emphasizes patient education and choice between mastectomy and breast-sparing procedures and radiation therapy for the control of primary cancers. Adjuvant chemotherapy or hormonal therapy is given to all nodal-positive patients. Establishment of multidisciplinary centers, such as the BCC, requires the commitment of all physician specialty groups, nursing and hospital administration. High quality patient care can be provided in such centers in a more efficient and coordinated manner than in the non-center setting. The center can serve as a source of increased patient referrals and research opportunities.