Surgeon characteristics and variations in treatment for early-stage breast cancer

HYPOTHESIS: Adherence to National Institutes of Health consensus statement recommendations for early-stage breast cancer will vary by surgeon characteristics. DESIGN: Secondary data analysis using the Surveillance, Epidemiology, and End Results national tumor registry linked with Medicare claims data. Logistic regression was used to analyze data on a cohort of 1045 surgeons who operated on 9449 Medicare patients with early-stage breast cancer. MAIN OUTCOME MEASURE: Care adherent to the 1990 National Institutes of Health consensus statement recommendations. RESULTS: Surgeon age and specialty were not associated with adherent care overall, nor among breast-conserving surgery or mastectomy subgroups. Patients of higher-volume surgeons were significantly more likely to undergo adherent care overall because of greater use of lymph node dissection among women who received either breast-conserving surgery or mastectomy. Patients of female surgeons and surgeons with a medical school affiliation were less likely to undergo adherent care overall, which was related to greater use of breast-conserving surgery and lesser use of lymph node dissection among patients who underwent breast-conserving surgery. CONCLUSIONS: Several surgeon characteristics are significantly associated with variations in breast cancer treatment received. These results warrant further investigation into the association between these surgeon characteristics and cancer care outcomes.     

Accumulation of persistent organochlorine contaminants in milk and serum of farmers from Ghana

In the present study, the concentrations of persistent organochlorine (OC) pesticides such as dichlorodiphenyltrichloroethane and its metabolites (DDTs), hexachlorocyclohexane isomers (HCHs), hexachlorobenzene (HCB) and dieldrin in pooled samples of human breast milk (n=109), and serum (n=115) from vegetable farmers in Ghana, during 2005, were determined. Gas chromatography with mass spectrometry was used to quantify residue levels on a lipid basis of the OCs. The pattern of OCs in human fluid showed that DDTs was consistently the prevalent OC in milk and blood. The levels of DDTs, HCHs, and dieldrin in the breast milk samples were found to correlate positively with age of the milk sample donors (r(s)=0.606, 0.770, and 0.540, respectively). When blood serum levels of the OCs were compared between male and female farmers, no pronounced relationship for HCHs and HCB (p>0.05) was observed. However, DDTs and dieldrin residues were significantly higher (p<0.05) in males than in females. There was association between breast milk and serum residues. When daily intakes of DDTs and HCHs to infants through human breast milk were estimated, some individual farmers (in the case of DDTs) and all farmers (in the case of HCHs) accumulated OCs in breast milk above the threshold (tolerable daily intake, TDI, guidelines proposed by Health Canada) for adverse effects, which may raise concern on children health.     

Hepatic amebic abscess: cholescintigraphic rim enhancement

Cholescintigrams of 17 amebic liver abscesses (ALAs) in 13 patients were studied retrospectively. Rim enhancement around a photopenic defect was seen in nine (53%) of 17 abscesses. Most of the ALAs were solitary, in the right lobe, and ovoid. All were contiguous with the liver capsule. Ultrasonograms, obtained in 11 of 13 patients, showed the ALAs to be predominantly hypoechoic, with low-level echoes on high-gain settings. No sonographic finding could be identified to correlate with rim enhancement. Cholescintigraphic rim enhancement may allow early diagnosis of ALA in patients with right-upper-quadrant pain, facilitating early institution of specific therapy while definitive serologic confirmation of ALA is awaited.     

Decentralization of breast cancer surgery in the United States

BACKGROUND: Physician volume of at least 15-30 annual breast cancer operations has been associated with higher 5-year survival rates. The authors sought to determine whether surgical volumes for breast cancer in the United States frequently reach this threshold. METHODS: The authors conducted a retrospective cohort study of 987 surgeons who operated on 8105 Medicare patients with breast cancer during 1994-1995 in 6 areas in the Surveillance, Epidemiology and End Results tumor registry. The 2-year physician volume of breast cancer operations was estimated among Medicare patients (approximating the on-average annual volumes for patients of all ages) and its association was examined with physician characteristics and with 3 measures of surgical care. RESULTS: The median 2-year Medicare volume for breast cancer surgeons was 6, and 79% of physicians performed < or = 12 operations. Approximately 50% of patients were cared for by physicians who performed < or = 12 operations over 2 years, and 10% of patients were cared for by physicians who performed > or = 30 operations. Surgeon characteristics of age, female gender, general surgery board certification, and academic affiliation were associated with modestly higher volumes of breast cancer surgery. Higher surgeon volumes were associated with higher patient receipt of breast-conserving surgery, testing for hormone receptors, and lymph node dissection during mastectomy. CONCLUSIONS: Most physicians who perform breast cancer surgery perform few annual operations in Medicare patients, and lower volumes are associated with differences in surgical processes of care. Because patients in the Medicare age group comprise almost 50% of all incident breast cancer cases, surgical volumes for patients of all ages also are likely to be low. It is likely that only approximately 10% of patients in the United States are treated by surgeons who performing at least 30 annual operations.     

Assessing proliferation, cell-cycle arrest and apoptotic end points in human buccal punch biopsies for use as pharmacodynamic biomarkers in drug development

Easily accessible normal tissues expressing the same molecular site(s) of drug action as malignant tissue offer an enhanced potential for early proof of anticancer drug mechanism and estimation of the biologically effective dose. Studies were undertaken in healthy male volunteers to assess the tolerability of single and multiple (four in 24 h) 3 mm punch biopsies of the buccal mucosa, and to determine the feasibility of detecting and quantifying a range of proliferation, cell-cycle arrest and apoptosis markers by immunohistochemistry (IHC) for use as potential pharmacodynamic (PD) end points. The biopsy procedure was well tolerated with 100% of volunteers stating that they would undergo single (n = 10) and multiple (n = 12) biopsies again. Total retinoblastoma protein (pRb), phosphorylated pRb (phospho-pRb), total p27, phosphorylated p27 (phospho-p27), phosphorylated-histone H3 (phospho-HH3), p21, p53, Cyclin A, Cyclin E, Ki67 all produced good signal detection, but M30, cleaved caspase 3 and terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labelling did not. Total pRb, phospho-pRb, total p27 and phospho-p27 were quantified further in a multiple biopsy study to allow components of variability to be addressed to inform future sizing decisions on intervention studies. Neither site of biopsy within the oral cavity, nor the nominal time of biopsy had any significant impact on any of the four markers expression levels. Inter- and intrasubject coefficients of variation (CVs) that could be used to size future intervention studies for pRb, phospho-pRb, total p27 and phospho-p27 were 14, 19, 18 and 16%; and 18, 29, 25 and 19%, respectively. In conclusion, quantitation of such markers in 3 mm buccal punch biopsies would be suitable to explore as PD end points within intervention studies of drugs acting on these pathways.     

The reliability of the Scale for the Evaluation and Identification of Seizures, Epilepsy, and Anticonvulsant Side Effects-B (SEIZES B)

The use of anti-epileptic medications (AEDs) is much higher in individuals with intellectual disabilities than in the general population. As many of these individuals rely on such medications, clinicians should consider psychometrically sound instruments for assessing adverse side effects of these medications as one aspect of routine clinical practice. The Scale for the Evaluation and Identification of Seizures, Epilepsy, and Anticonvulsant Side Effects-B (SEIZES B) was developed as a means to identify side effects specific to AEDs. The authors conducted a preliminary evaluation of the inter-rater and test-retest reliability of the SEIZES B on an adult population with developmental disabilities. The SEIZES B had moderately high stability across raters and adequate stability over time. Implications of these data for future research and practice are discussed.     

The Relationship Between Depression and Feeding Disorder Symptoms Among Persons with Severe and Profound Mental Retardation

Among the population at-large, the effect of depression on appetite and feeding behavior is well documented. Despite the prevalent nature of psychopathology among those with severe and profound mental retardation, little has been reported about the relationship between depression and problematic feeding behavior. Consequently, we assessed the relationship of depression and feeding problems across 54 participants diagnosed with either a mood disorder, pervasive developmental disorder, or no Axis I diagnosis. All participants were classified in the severe to profound range of mental retardation. Significant differences on the Screening Tool of Feeding Problems (STEP) were found across feeding problems, indicating that feeding problems may vary as a function of Axis I diagnostic classification.