Patient Satisfaction With Treatment of Breast Cancer: Does Surgeon Specialization Matter?

Credentials That Matter While Selecting a Surgeon for Major Surgical Treatment

Purpose

The credentials of surgeons, which include elements such as medical degree and length of practice, are vital information that forms a perception of their expertise in the patients' minds. The specific credentials that matter to patients and how important they are have not been sufficiently studied. The objective of this study was to assess the relative importance that patients assign to the specific credentials of a surgeon while selecting one for surgical treatment.

Methods

This study was conducted using the constant-variable-value vignette (CVVV) method. Four credentials- medical degrees, duration of practice, medical college attended, and type of surgeries performed - were assessed for their relative importance to patients. The participants were provided with vignettes of medical situations that required major surgical intervention and profiles of surgeons who could perform the required surgery, each dominating the others in a specific credential. The participants allocated a total of 10 points across the four surgeons proportionate to their preferences. The response data were analyzed using descriptive statistics, ANOVA and t-tests.

Results

The highest mean score of 3.73 (SD 2.21) was observed for the surgeon with focused experience, followed by 2.55 (1.57) for the surgeon with the best medical degrees, 2.17 (1.65) for the surgeon with the longest practice experience, and 1.54 (1.47) for the surgeon from a higher-ranked medical college. The mean of the surgeon with focused experience was significantly higher than that of other surgeons, and the mean of the surgeon with the best medical degrees was significantly higher than that of surgeons with the longest practice experience and the surgeon from the topmost medical college (p < 0.05). Preference did not vary with respondents' age or gender.

Conclusion

Patients seem to prioritize the focused surgical experience and superior medical degrees in their selection of surgeons.

Surgeon Factors Influencing Breast Surgery Outcomes: A Scoping Review to Define the Modern Breast Surgical Oncologist

BACKGROUND

Modern breast surgical oncology incorporates many aspects of care including preoperative workup, surgical management, and multidisciplinary collaboration to achieve favorable oncologic outcomes and high patient satisfaction. However, there is variability in surgical practice and outcomes. This review aims to identify modifiable surgeon factors influencing breast surgery outcomes and provide a definition of the modern breast surgical oncologist.

METHODS

A systematic literature search with additional backward citation searching was conducted. Studies describing modifiable surgeon factors with associated breast surgery outcomes such as rates of breast conservation, sentinel node biopsy, re-excision, complications, acceptable esthetic outcome, and disease-free and overall survival were included. Surgeon factors were categorized for qualitative analysis.

RESULTS

A total of 91 studies met inclusion criteria describing both modifiable surgeon factor and outcome data. Four key surgeon factors associated with improved breast surgery outcomes were identified: surgical volume (45 studies), use of oncoplastic techniques (41 studies), sub-specialization in breast surgery or surgical oncology (9 studies), and participation in professional development activities (5 studies).

CONCLUSIONS

On the basis of the literature review, the modern breast surgical oncologist has a moderate- to high-volume breast surgery practice, understands the use and application of oncoplastic breast surgery, engages in additional training opportunities, maintains memberships in relevant societies, and remains up to date on key literature. Surgeons practicing in breast surgical oncology can target these modifiable factors for professional development and quality improvement.

Decision Aids for Decision Making about Locally Advance Breast Cancer: A Systematic Review

Locally advanced breast cancer (LABC) is a subset of breast cancer with locoregional progression without distant metastasis. The multimodality treatment (surgery, chemotherapy, radiotherapy, hormonal and targeted therapy if required) could significantly improve results in this specific group of patients. The complex and multiple options of treatment with similar mortality rates but different outcomes depending on the patient's desires, preferences and social environment require aid to facilitate the individual patient's decisions (e.g. Decision Aids (DAs) targeting patients considering primary or adjuvant treatment in LABC). In this context, DAs have been proven fundamental to help patients and clinicians share and agree on the best value option. The current systematic review aimed to evaluate the existing DAs related to these patients with LABC and identify current status and possible improvement areas (possible scarcity and heterogeneity of instruments, the status of their development, explanation of their purpose,…). No previous systematic reviews have been published on this topic. Following Prospero registration no: CRD42021286173, studies about LABC DAs were identified, without data or language restrictions, through a systematic search of bibliographic databases in December 2021. Quality was assessed using Qualsyst criteria (range 0.0-1.0). The quality of the 17 selected studies ranged from 0.46 to 0.95. Of them, 14/17 (82%) were DAs about treatment, only one (6%) about diagnosis, and 2/17 (12%) about the employment of DAs. No screening or follow-up DAs were retrieved. Twelve (70.6%) DAs were online tools. They varied broadly regarding their characteristics and purposes. Most of the studies focused on developing and testing different DAs (5/17; 29.4%) and their impact (7/17; 41.2%). Only 4/17 (23.5%) analysed their implementation and cost. These instruments have proven to improve patient's knowledge and decision-making, decrease patient anxiety, and patients tend to undergo treatment. However, nowadays, there is still a need for further research and consensus on methodology to develop practical DAs.

Does Surgeon Training Affect Patient Perception of Surgeon Skill in DIEP Flap Breast Reconstruction?

BACKGROUND

 The aim of this study is to investigate whether a surgeon's training background and years of experience advertised on a social media platform influences perception of surgeon competence, patient recruitment likelihood, and referral likelihood.

METHODS

 A mockup of an Instagram post was created using a before and after picture of a deep inferior epigastric perforator (DIEP) flap patient. The caption under each post was changed to reflect one of six possible training categories: 1 year of experience, 10 years of experience, 20 years of experience, fellowship, Ivy League training, and a null case (with no training information against which all other cases were compared). Surveys asked female responders to evaluate surgeon competence, likelihood of becoming a patient, and likelihood of making a referral to their friends or family. Amazon MTurk crowdsourcing platform was used to distribute the survey.

RESULTS

 A total of 1,878 responses were recorded, with the majority identifying as Caucasian (59%). The surgeon with 20 years of experience had the highest patient recruitment scores when compared with the null, 1 year, 10 year, and Ivy League training backgrounds (p = 0.0314, p = 0.0065, p = 0.0207, and p = 0.0244, respectively). The majority of responders (67%) preferred a female surgeon. Responders with a history of breast reconstruction assigned lower surgeon competence scores compared with women without a history of breast cancer (p <0.0001). Women who underwent breast reconstruction were also less likely to make referrals to their family and friends (p <0.0001).

CONCLUSION

 Surgeon's experience influences whether a patient is likely to seek care from a plastic surgeon. Personal history of breast cancer has a negative impact on perceived surgeon competence as well as patient recruitment likelihood and referral likelihood. Emphasizing fewer years of training or Ivy League training did not make an appreciable difference in patient perception of competence or likelihood of recruiting a new patient.

"Going Flat" After Mastectomy: Patient-Reported Outcomes by Online Survey

BACKGROUND

The Going Flat movement aims to increase awareness and acceptance of mastectomy alone as a viable option for patients. Little is known about motivations and satisfaction with surgical outcomes in this population.

METHODS

An online survey was administered to 931 women who had a history of uni- or bilateral mastectomy for treatment of breast cancer or elevated breast cancer risk without current breast mound reconstruction. Satisfaction with outcome and surgeon support for the patient experience were characterized using 5-level scaled scores.

RESULTS

Mastectomy alone was the first choice for 73.7% of the respondents. The top two reasons for going flat were desire for a faster recovery and avoidance of a foreign body placement. Overall, the mean scaled satisfaction score was 3.72 ± 1.17 out of 5. In the multivariable analysis, low level of surgeon support for the decision to go flat was the strongest predictor of a satisfaction score lower than 3 (odds ratio [OR], 3.85; 95% confidence interval [CI], 2.59-5.72; p < 0.001). Dissatisfaction also was more likely among respondents reporting a body mass index (BMI) of 30 kg/m2 or higher (OR, 2.74; 95% CI, 1.76-4.27; p < 0.001) and those undergoing a unilateral procedure (OR, 1.99; 95% CI, 1.29-3.09; p = 0.002). Greater satisfaction was associated with receiving adequate information about surgical options (OR, 0.48; 95% CI, 0.32-0.69; p < 0.0001) and having a surgeon with a specialized breast surgery practice (OR, 0.56; 95% CI, 0.38-0.81; p = 0.002).

CONCLUSIONS

Most patients undergoing mastectomy alone are satisfied with their surgical outcome. Surgeons may optimize patient experience by recognizing and supporting a patient's decision to go flat.

Variations in Persistent Use of Low-Value Breast Cancer Surgery

Importance

Through the Choosing Wisely campaign, surgical specialties identified 4 low-value breast cancer operations. Preliminary data suggest varying rates of deimplementation and have identified patient-level and clinician-level determinants of continued overuse. However, little information exists about facility-level variation or determinants of differential deimplementation.

Objective

To identify variation and determinants of persistent use of low-value breast cancer surgical care.

Design, Setting, and Participants

Retrospective cohort study in which reliability-adjusted facility rates of each procedure were calculated using random-intercept hierarchical logistic regression before and after evidence demonstrated that each procedure was unnecessary. The National Cancer Database is a prospective cancer registry of patients encompassing approximately 70% of all new cancer diagnoses from more than 1500 facilities in the United States. Data were analyzed from November 2019 to August 2020. The registry included women 18 years and older diagnosed as having breast cancer between 2004 and 2016 and meeting inclusion criteria for each Choosing Wisely recommendation.

Main Outcomes and Measures

Rate of each low-value breast cancer procedure based on facility type and breast cancer volume categories before and after the release of data supporting each procedure's omission.

Results

The total cohort included 920 256 women with a median age of 63 years. Overall, 86% self-identified as White, 10% as Black, 3% as Asian, and 4.5% as Hispanic. Most women in this cohort were insured (51% private and 47% public), were living in a metropolitan or urban area (88% and 11%, respectively), and originated from the top half of income-earning households (65.5%). While there was significant deimplementation of axillary lymph node dissection and lumpectomy reoperation in response to guidelines supporting omission of these procedures, rates of contralateral prophylactic mastectomy and sentinel lymph node biopsy in older women increased during the study period. Academic research programs and high-volume facilities overall demonstrated the greatest reduction in use of these low-value procedures. There was significant interfacility variation for each low-value procedure. Facility-level axillary lymph node dissection rates ranged from 7% to 47%, lumpectomy reoperation rates ranged from 3% to 62%, contralateral prophylactic mastectomy rates ranged from 9% to 67%, and sentinel lymph node biopsy rates ranged from 25% to 97%. Pearson correlation coefficient for each combination of 2 of the 4 procedures was less than 0.11, suggesting that hospitals were not consistent in their deimplementation performance across all 4 procedures. Many were high outliers in one procedure but low outliers in another.

Conclusions and Relevance

Interfacility variation demonstrates a performance gap and an opportunity for formal deimplementation efforts targeting each procedure. Several facility-level characteristics were associated with differential deimplementation and performance.

Shared decision making in breast cancer treatment guidelines: Development of a quality assessment tool and a systematic review

BACKGROUND

It is not clear whether clinical practice guidelines (CPGs) and consensus statements (CSs) are adequately promoting shared decision making (SDM).

OBJECTIVE

To evaluate the recommendations about SDM in CPGs and CSs concerning breast cancer (BC) treatment.

SEARCH STRATEGY

Following protocol registration (Prospero no.: CRD42018106643), CPGs and CSs on BC treatment were identified, without language restrictions, through systematic search of bibliographic databases (MEDLINE, EMBASE, Web of Science, Scopus, CDSR) and online sources (12 guideline databases and 51 professional society websites) from January 2010 to December 2019.

INCLUSION CRITERIA

CPGs and CSs on BC treatment were selected whether published in a journal or in an online document.

DATA EXTRACTION AND SYNTHESIS

A 31-item SDM quality assessment tool was developed and used to extract data in duplicate.

MAIN RESULTS

There were 167 relevant CPGs (139) and CSs (28); SDM was reported in only 40% of the studies. SDM was reported more often in recent publications after 2015 (42/101 (41.6 %) vs 46/66 (69.7 %), P = .0003) but less often in medical journal publications (44/101 (43.5 %) vs 17/66 (25.7 %), P = .009). In CPGs and CSs with SDM, only 8/66 (12%) met one-fifth (6 of 31) of the quality items; only 14/66 (8%) provided clear and precise SDM recommendations.

DISCUSSION AND CONCLUSIONS

SDM descriptions and recommendations in CPGs and CSs concerning BC treatment need improvement. SDM was more frequently reported in CPGs and CSs in recent years, but surprisingly it was less often covered in medical journals, a feature that needs attention.

Effect of Surgeon Factors on Long-Term Patient-Reported Outcomes After Breast-Conserving Therapy in Older Breast Cancer Survivors

BACKGROUND

The effect of surgeon factors on patient-reported quality-of-life outcomes after breast-conserving therapy (BCT) is unknown and may help patients make informed care decisions.

METHODS

We performed a survey study of women aged ≥ 67 years with non-metastatic breast cancer diagnosed in 2009 and treated with guideline-concordant BCT, to determine the association of surgeon factors with patient-reported outcomes. The treating surgeon was identified using Medicare claims, and surgeon factors were identified via the American Medical Association Physician Masterfile. The primary outcome was patient-reported cosmetic satisfaction measured by the Cancer Surveillance and Outcomes Research Team (CanSORT) Satisfaction with Breast Cosmetic Outcome instrument, while secondary outcomes included BREAST-Q subdomains. All patient, treatment, and surgeon covariables were included in a saturated multivariable linear regression model with backward elimination applied until remaining variables were p < 0.1.

RESULTS

Of 1650 women randomly selected to receive the questionnaire, 489 responded, of whom 289 underwent BCT. Median age at diagnosis was 72 years and the time from diagnosis to survey was 6 years. The mean adjusted CanSORT score was higher for patients treated by surgical oncologists than patients treated by non-surgical oncologists (4.01 [95% confidence interval [CI] 3.65-4.38] vs. 3.53 [95% CI 3.28-3.77], p = 0.006). Similarly, mean adjusted BREAST-Q Physical Well-Being (91.97 [95% CI 86.13-97.80] vs. 83.04 [95% CI 80.85-85.22], p = 0.006) and Adverse Radiation Effects (95.28 [95% CI 91.25-99.31] vs. 88.90 [95% CI 86.23-91.57], p = 0.004) scores were better among patients treated by surgical oncologists.

CONCLUSIONS

Specialized surgical oncology training is associated with improved long-term patient-reported outcomes. These findings underscore the value of specialized training and may be useful to patients choosing their care team.

Education and Training in Breast Cancer Surgery in Europe

BACKGROUND

The substantial increase in the complexity of breast cancer care in the last few decades has resulted in significant improvements in survival rates and also in the quality of life of breast cancer survivors. However, across Europe there are variations in outcomes and access to the latest techniques. Whilst much of this variance is due to differences in health economies between European member states, training variation may also play a part. Training in breast cancer surgery varies greatly across Europe, not only in its basal discipline (general surgery, gynaecology or plastic surgery) but also in the length of training and whether there is any requirement for specialist training. Several countries have been leading the way in training breast specialist surgeons (the USA, the UK, Australia and New Zealand) with dedicated 1- or 2-year fellowships either within or in addition to standard training. Access to such training is limited and consequently many women in Europe are still treated by generalists, potentially denying them access to the best care. This paper reviews the issues surrounding training provision in breast surgery and some of the challenges which need to be addressed to improve the current situation.

SUMMARY

Breast surgery training in Europe is of variable quality and duration, which may result in variations in the quality of care received by patients with breast cancer. Specialist training standards are urgently required which should be adopted by all European member states. Excellent models are available in the USA, the UK and Australia and New Zealand on which to base this training.

KEY MESSAGES

The quality of training in breast surgery needs to be upgraded and harmonised across Europe.

Effect of 21-gene recurrence score in decision-making for surgery in early stage breast cancer

Aim

We aimed to assess the role of 21-gene recurrence score (RS) in the decision-making for surgical treatment in early stage breast cancer and compared the outcomes between breast-conserving surgery (BCS) and mastectomy (MAST) among various 21-gene RS groups.

Methods

We included patients with stage T1-2M0M0 and estrogen receptor-positive breast invasive ductal carcinoma who underwent BCS + radiotherapy or MAST between 2004 and 2012 as part of the Surveillance, Epidemiology, and End Results program. Data were analyzed using binomial logistic regression, multivariate Cox proportional hazards models, and propensity score matching (PSM).

Results

We enrolled 34,447 patients including 22,681 (65.8%) and 11,766 (34.2%) who underwent BCS and MAST, respectively. Patients with high-risk RS were more likely to receive MAST. Multivariate analysis indicated that patients with intermediate-risk (P<0.001) and high-risk (P<0.001) RS had poor breast cancer-specific survival (BCSS), as compared to those with low-risk RS. Moreover, patients who underwent MAST also exhibited poor BCSS (P<0.001), as compared to those who underwent BCS. In low-risk (P<0.001) and intermediate-risk (P=0.020) RS groups, patients who underwent MAST had poor BCSS, as compared to those treated with BCS. However, BCSS was comparable between patients who underwent MAST and BCS (P=0.952); similar trends were also observed after PSM.

Conclusion

The 21-gene RS may impact the decision-making for surgery in early stage breast cancer. Our study provides additional support for a shared decision-making process for BCS when both local management options are appropriate choices regardless of the 21-gene RS.

The impact of spine disease, relative to cranial disease, on perception of health and care experience: an analysis of 1484 patients in a tertiary center

OBJECTIVEPatient-reported outcomes have been increasingly mandated by regulators and payers to evaluate hospital and physician performance. The purpose of this study is to delineate the differences in patient-reported experience of hospital care for cranial and spinal operations.METHODSThe authors selected all patients who underwent inpatient, elective cranial or spinal procedures and completed the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey at a single, high-volume, tertiary care institution between October 2012 and September 2015. The association of the surgical procedure and diagnosis with various HCAHPS composite measures, calculated across 9 domains using standard top-box methodology, was investigated. Multivariable logistic regression models were fitted for outcomes that were significant with procedure type and diagnosis group on univariate analysis, adjusting for age, sex, case complexity, overall health rating, and education level.RESULTSA total of 1484 patients met criteria and returned an HCAHPS survey. Overall, patients undergoing a cranial procedure gave top-box (most favorable) scores more often in pain management measure (66.3% vs 59.6%, p = 0.01) compared with those undergoing spine surgery. Furthermore, despite better discharge scores (93.1% vs 87.1%, p < 0.001), spinal patients were less likely to report excellent health (7.4% vs 12.7%). Lastly, patients with a primary diagnosis of brain or spinal tumor compared with those with degenerative spinal disease and those with other neurosurgical diagnoses provided top-box scores more often regarding communication with doctors (82.7% vs 76.4% vs 75.2%, p = 0.04), pain management (71.8% vs 60.9% vs 59.1%, p = 0.002), and global rating (90.4% vs 84.0% vs 87.3%, p = 0.02). On multivariable analysis, spinal patients had significantly lower odds of reporting top-box scores in pain management (OR 0.67, 95% CI 0.52-0.85; p = 0.001), staff responsiveness (OR 0.68, 95% CI 0.53-0.87; p = 0.002), and global rating (OR 0.59, 95% CI 0.42-0.82; p = 0.002), and significantly higher odds of top-box scoring in discharge information (OR 2.15, 95% CI 1.45-3.18; p < 0.001) than cranial patients. Similarly, brain tumor cases were associated with significantly higher odds of top-box scoring in communication with doctors (OR 1.46, 95% CI 1.01-2.12; p = 0.04), pain management (OR 1.81, 95% CI 1.29-2.55; p < 0.001), staff responsiveness (OR 1.88, 95% CI 1.33-2.66; p < 0.001), and global rating (OR 2.00, 95% CI 1.26-3.17; p = 0.003) compared with degenerative spine cases.CONCLUSIONSSignificant differences in patient-reported experience with hospital care exist across different cranial and spine surgery patient populations. Overall, spinal patients, particularly those with degenerative spine disease, rated their health and their hospital experience lower relative to cranial patients. Identifying weaker areas of hospital performance in target populations can stimulate quality initiatives that aim to increase the overall hospital score.

Training oncoplastic breast surgeons: the Canadian fellowship experience

BACKGROUND

Oncoplastic breast surgery combines traditional oncologic breast conservation with plastic surgery techniques to achieve improved aesthetic and quality-of-life outcomes without sacrificing oncologic safety. Clinical uptake and training remain limited in the Canadian surgical system. In the present article, we detail the current state of oncoplastic surgery (ops) training in Canada, the United States, and worldwide, as well as the experience of a Canadian clinical fellow in ops.

METHODS

The clinical fellow undertook a 9-month audit of breast surgical cases. All cases performed during the fellow's ops fellowship were included. The fellowship ran from October 2015 to June 2016.

RESULTS

During the 9 months of the fellowship, 67 mastectomies were completed (30 simple, 17 modified radical, 12 skin-sparing, and 8 nipple-sparing). The fellow participated in 13 breast reconstructions. Of 126 lumpectomies completed, 79 incorporated oncoplastic techniques.

CONCLUSIONS

The experience of the most recent ops clinical fellow suggests that Canadian ops training is feasible and achievable. Commentary on the current state of Canadian ops training suggests areas for improvement. Oncoplastic surgery is an important skill for breast surgical oncologists, and access to training should be improved for Canadian surgeons.

Therapeutic mammoplasty combining partial mastectomy with nipple-areola grafting for patients with early breast cancer: a case series

PURPOSE

Therapeutic mammoplasty (TM) for breast cancer is a widely practiced oncoplastic technique. Intraductal spread towards the nipple or the location of the cancerous lesion on the central breast may become a contraindication for breast-conserving surgery. We herein report the results of TM in such cases.

METHODS

Six patients underwent TM that combined partial mastectomy with free nipple-areola (NA) grafting. The nipple was removed together with the cancerous lesions, and the areola was preserved for NA reconstruction. The tumors were located in the lower quadrant (n = 1), the central area (n = 1), the upper-outer area (n = 2), and the upper-inner area (n = 2). The types of mammoplasty that were performed included: amputation (n = 1), inverted T mammoplasty (n = 3), and L mammoplasty (n = 2). With the exception of one patient, all patients underwent inverted T mammoplasty on the contralateral breast in order to achieve symmetry.

RESULTS

The total surgical and plastic periods ranged from 155 to 235 min (mean 207 min) and 100 to 150 min (mean 121 min), respectively. Oncological safety and excellent cosmetic results were achieved.

CONCLUSIONS

TM combining partial mastectomy with NA grafting was successfully performed in patients with early-stage cancer in all quadrant areas.

A Review of the Effectiveness of Breast Surgical Oncology Fellowship Programs Utilizing Kirkpatrick's Evaluation Model

It has been 10 years since the first class of Society of Surgical Oncology (SSO) fellowship trained Breast Surgical Oncologist entered practice. To date, there has been no publications examining the effectiveness of these training programs that are today throughout North America and Europe. This evaluative review examines the effectiveness of these fellowship training programs through the lens of the Kirkpatrick Evaluation Model. An extensive review of the literature was performed, and articles were categorized to capture how fellows are reacting to the program, what they are learning, and how the program is effecting their career path and impacting their patients. We can conclude that there is both direct and indirect evidence to support the effectiveness of this training program, but there is a paucity of direct evidence as one progresses from a level 1 Kirkpatrick analysis to a level 4. This review sets the framework for program evaluation in surgical fellowships and should encourage stakeholders to constantly evaluate the impact their program is having on trainees and oncology patients.

Understanding and Optimizing the Patient Experience in Breast Reconstruction

BACKGROUND

Optimizing the patient experience is a central pillar in healthcare quality. Although this may be recognized as important in breast reconstruction, surgeons are often unaware of how well they and members of their team achieve this goal. The objective of our study was to evaluate patient satisfaction with the experience of care in a multicenter, prospective cohort of patients undergoing breast reconstruction. Specifically, we sought to determine which aspects of the care experience might be most amenable to quality improvement.

METHODS

As part of the Mastectomy Reconstruction Outcomes Consortium Study, 2093 patients were recruited from 11 centers in North America. Of these, 1534 (73.3%) completed the BREAST-Q Satisfaction with Care scales (satisfaction with information, surgeon, medical team, and office staff) at 3 months after reconstruction and were included in the analysis.

RESULTS

Patients scored lowest on 'Satisfaction with Information' (mean = 72.8) compared to all other Satisfaction with Care scales (mean, 89.5-95.5). Patients with immediate reconstruction were less satisfied with their plastic surgeon compared to those with delayed reconstruction. The racial category, "Other" (Asians, Pacific Islanders, Hawaiians, American Indians), was the least satisfied group across all Satisfaction with Care scales.

CONCLUSIONS

Patients undergoing breast reconstruction perceive significant gaps in their knowledge and understanding of expected outcomes. Immediate reconstruction patients and minority racial groups may require additional resources and attention. As a means to improve quality of care, these findings highlight an important unmet need and suggest that improving patient education may be central to providing patient-centered care.

Decision-Making in the Surgical Treatment of Breast Cancer: Factors Influencing Women's Choices for Mastectomy and Breast Conserving Surgery

One of the most difficult decisions a woman can be faced with when choosing breast cancer treatment is whether or not to undergo breast conserving surgery or mastectomy. The factors that influence these treatment decisions are complex and involve issues regarding access to health care, concerns for cancer recurrence, and the impact of surgery on body image and sexuality. Understanding these factors will help practitioners to improve patient education and to better guide patients through this decision-making process. Although significant scientific and societal advances have been made in improving women’s choices for the breast cancer treatment, there are still deficits in the decision-making processes surrounding the surgical treatment of breast cancer. Further research is needed to define optimal patient education and shared decision-making practices in this area.

Residents' Experience in Breast Cancer Care

OBJECTIVE

General surgeons commonly treat breast cancer (BC), hence necessitating adequate training during residency. We examined surgery residents' exposure to these conditions across postgraduate years (PGYs) to assess the proximity of involvement to commencement.

STUDY DESIGN

We examined the BC operative profile by PGY using the American College of Surgeons National Surgical Quality Improvement Program Participant Use File (ACS NSQIP PUF, 2008-2011). Operations were classified using the Surgical Council on Resident Education curriculum complexity categories. Univariate analysis was performed using chi-square, Fisher exact, analysis of variance, and Kruskal-Wallis tests, as appropriate.

RESULTS

Of 58,413 BC operations, 23,996 involved PGY1 to PGY5 residents. A Surgical Council on Resident Education complexity was assigned to 97.7% of operations studied (n = 23,432). PGY was inversely proportional to the number of operations performed. PGY1 to PGY3 residents covered most essential-common operations (PGY1-3, 72% vs PGY4-5, 28%; p < 0.001). PGY1 and PGY2 residents covered more than half of the complex operations (PGY1-2, 55% [n = 359] vs PGY3-5, 45% [n = 288]; p = 0.033).

CONCLUSIONS

Although junior residents perform most of the BC cases in surgical residency, residents do participate in operations for BC across the continuum of the training years. Program directors should consider trainees' career aspirations to ensure adequate exposure to the operative and nonoperative management of this common disease before the transition to independent practice.

Toolbox to Reduce Lumpectomy Reoperations and Improve Cosmetic Outcome in Breast Cancer Patients: The American Society of Breast Surgeons Consensus Conference

BACKGROUND

Multiple recent reports have documented significant variability of reoperation rates after initial lumpectomy for breast cancer. To address this issue, a multidisciplinary consensus conference was convened during the American Society of Breast Surgeons 2015 annual meeting.

METHODS

The conference mission statement was to "reduce the national reoperation rate in patients undergoing breast conserving surgery for cancer, without increasing mastectomy rates or adversely affecting cosmetic outcome, thereby improving value of care." The goal was to develop a toolbox of recommendations to reduce the variability of reoperation rates and improve cosmetic outcomes. Conference participants included providers from multiple disciplines involved with breast cancer care, as well as a patient representative. Updated systematic reviews of the literature and invited presentations were sent to participants in advance. After topic presentations, voting occurred for choice of tools, level of evidence, and strength of recommendation.

RESULTS

The following tools were recommended with varied levels of evidence and strength of recommendation: compliance with the SSO-ASTRO Margin Guideline; needle biopsy for diagnosis before surgical excision of breast cancer; full-field digital diagnostic mammography with ultrasound as needed; use of oncoplastic techniques; image-guided lesion localization; specimen imaging for nonpalpable cancers; use of specialized techniques for intraoperative management, including excisional cavity shave biopsies and intraoperative pathology assessment; formal pre- and postoperative planning strategies; and patient-reported outcome measurement.

CONCLUSIONS

A practical approach to performance improvement was used by the American Society of Breast Surgeons to create a toolbox of options to reduce lumpectomy reoperations and improve cosmetic outcomes.

Psychometric properties of a brief measure of autonomy support in breast cancer patients

Background

The Health Care Climate Questionnaire measures patient perceptions of their clinician’s autonomy supportive communication. We sought to evaluate the psychometric properties of a modified brief version of the Health Care Climate Questionnaire (mHCCQ) adapted for breast cancer patients.

Methods

We surveyed 235 women aged 20–79 diagnosed with breast cancer within the previous 18 months at two cancer specialty centers using a print questionnaire. Patients completed the mHCCQ for their surgeon, medical oncologist, and radiation oncologist separately, as well as the overall treatment experience. Exploratory factor analysis (EFA) using principal components was used to explore the factor structure.

Results

One hundred sixty out of 235 (68.1 %) women completed the survey. Mean age was 57 years and time since diagnosis was 12.6 months. For surgeon, medical oncologist, and radiation oncologist ratings separately, as well as overall treatment, women rated 6 dimensions of perceived physician autonomy support. Exploratory factor analysis indicated a single factor solution for each clinician type and for the overall experience. Further, all six items were retained in each clinician subscore. Internal consistency was 0.93, 0.94, 0.97, and 0.92 for the overall, surgeon, medical oncologist, and radiation oncologist scales, respectively. Hierarchical factor analysis demonstrated that a summary score of the overall treatment experience accounts for only 52 % of the total variance observed in ratings of autonomy support for the three provider types.

Conclusions

These results describe the first use of the mHCCQ in cancer patients. Ratings of the overall treatment experience account for only half of the variance in ratings of autonomy support, suggesting that patients perceive and report differences in communication across provider types. Future research is needed to evaluate the relationship between physician communication practices and the quality of decision making, as well as other outcomes among cancer patients.

Development and psychometric properties of a brief measure of subjective decision quality for breast cancer treatment

Background

Breast cancer patients face several preference-sensitive treatment decisions. Feelings such as regret or having had inadequate information about these decisions can significantly alter patient perceptions of recovery and recurrence. Numerous objective measures of decision quality (e.g., knowledge assessments, values concordance measures) have been developed; there are far fewer measures of subjective decision quality and little consensus regarding how the construct should be assessed. The current study explores the psychometric properties of a new subjective quality decision measure for breast cancer treatment that could be used for other preference sensitive decisions.

Methods

320 women aged 20–79 diagnosed with AJCC stage 0 – III breast cancer were surveyed at two cancer specialty centers. Decision quality was assessed with single items representing six dimensions: regret, satisfaction, and fit as well as perceived adequacy of information, time, and involvement. Women rated decision quality for their overall treatment experience and surgery, chemotherapy, and radiation decisions separately. Principle components was used to explore factor structure. After scales were formed, internal consistency was computed using Cronbach’s alpha. The association of each of the four final scales with patient characteristics scores was examined by Pearson correlation.

Results

For overall breast cancer treatment as well as surgery, chemotherapy, and radiation decisions, the six items yielded a single factor solution. Factor loadings of the six decision items were all above .45 across the overall and treatment-specific scales, with the exception of “Right for You” for chemotherapy and radiation. Internal consistency was 0.77, 0.85, 0.82, and 0.78 for the overall, surgery, chemotherapy, and radiation decision quality scales, respectively.

Conclusions

Our measure of subjective appraisal of breast cancer treatment decisions includes 5 related elements; regret and satisfaction as well as perceived adequacy of information, time, and involvement. Future research is needed to establish norms for the measure as is further psychometric testing, particularly to examine how it is associated with outcomes such as quality of life, psychological coping and objective decision quality.

Variation in the Use of Therapy following Distal Radius Fractures in the United States

Background:

Distal radius fractures (DRFs) are one of the most common injuries among the elderly, resulting in significant expense and disability. The specific aims of this study are (1) to examine rates of therapy following DRFs and (2) to identify those factors that influence utilization of therapy and time span between DRF treatment and therapy among a national cohort of elderly patients.

Methods:

We examined national use of physical and occupational therapy among all Medicare beneficiaries who suffered DRFs between January 1, 2007, and October 1, 2007, and assessed the effect of treatment, patient-related, and surgeon-related factors on utilization of therapy.

Results:

Overall, 20.6% of patients received either physical or occupational therapy following DRF. Use of therapy varied by DRF treatment, and patients who underwent open reduction and internal fixation were more likely to receive therapy compared with patients who received closed reduction. Patients who received open reduction and internal fixation were also referred to therapy earlier compared with patients who received external fixation, percutaneous pinning, and closed reduction. Surgeon specialization is associated with greater use of postoperative therapy. Patient predictors of therapy use include younger age, female sex, higher socioeconomic status, and fewer comorbidity conditions.

Conclusion:

Use of therapy following DRF varies significantly by both patient- and surgeon-related factors. Identifying patients who benefit from postinjury therapy can allow for better resource utilization following these common injuries.

Body image struggles and breast cancer care: an under-recognized and undertreated issue with important implications for all patients

SUMMARY 

Body image encompasses the relationship between perceptions, cognitions, behaviors and emotions regarding the body and its functions. Breast cancer treatment can have a profound impact on body image, with body image issues occurring throughout diagnosis, treatment and survivorship. Despite this, a potential disconnect exists between breast cancer care providers and patients with respect to understanding and addressing body image difficulties. This article provides an overview of body image issues related to breast cancer treatment and offers recommendations that will enable healthcare providers to assist patients who are struggling with body image issues. More emphasis must be placed on the importance of body image as a means of improving the quality of care for all breast cancer patients.

Surgeon specialization and use of sentinel lymph node biopsy for breast cancer

IMPORTANCE

Sentinel lymph node biopsy (SLNB) is the standard of care for axillary staging in patients with clinically node-negative breast cancer. It is not known whether SLNB rates differ by surgeon expertise. If surgeons with less breast cancer expertise are less likely to offer SLNB to these patients, this practice pattern could lead to unnecessary axillary lymph node dissections and lymphedema.

OBJECTIVE

To explore potential measures of surgical expertise (including a novel objective specialization measure: percentage of a surgeon's operations performed for breast cancer determined from Medicare claims) on the use of SLNB for invasive breast cancer.

DESIGN, SETTING, AND POPULATION

A population-based prospective cohort study was conducted in California, Florida, and Illinois. Participants included elderly (65-89 years) women identified from Medicare claims as having had incident invasive breast cancer surgery in 2003. Patient, tumor, treatment, and surgeon characteristics were examined.

MAIN OUTCOME AND MEASURE

Type of axillary surgery performed.

RESULTS

Of 1703 women who received treatment by 863 surgeons, 56.4% underwent an initial SLNB, 37.2% initial axillary lymph node dissection, and 6.3% no axillary surgery. The median annual surgeon Medicare volume of breast cancer cases was 6.0 (range, 1.5-57.0); the median surgeon percentage of breast cancer cases was 4.5% (range, 0.4%-100.0%). After multivariable adjustment of patient and surgeon factors, women operated on by surgeons with higher volumes and percentages of breast cancer cases had a higher likelihood of undergoing SLNB. Specifically, women were most likely to undergo SLNB if the operation was performed by high-volume surgeons (regardless of percentage) or by lower-volume surgeons with a high percentage of breast cancer cases. In addition, membership in the American Society of Breast Surgeons (odds ratio, 1.98; 95% CI, 1.51-2.60) and Society of Surgical Oncology (1.59; 1.09-2.30) were independent predictors of women undergoing an initial SLNB.

CONCLUSIONS AND RELEVANCE

Patients who receive treatment from surgeons with more experience with and focus on breast cancer are significantly more likely to undergo SLNB, highlighting the importance of receiving initial treatment by specialized providers. Factors relating to specialization in a particular area, including our novel surgeon percentage measure, require further investigation as potential indicators of quality of care.

Surgeons' knowledge and practices regarding the role of radiation therapy in breast cancer management

PURPOSE

Population-based studies suggest underuse of radiation therapy, especially after mastectomy. Because radiation oncology is a referral-based specialty, knowledge and attitudes of upstream providers, specifically surgeons, may influence patients' decisions regarding radiation, including whether it is even considered. Therefore, we sought to evaluate surgeons' knowledge of pertinent risk information, their patterns of referral, and the correlates of surgeon knowledge and referral in specific breast cancer scenarios.

METHODS AND MATERIALS

We surveyed a national sample of 750 surgeons, with a 67% response rate. We analyzed responses from those who had seen at least 1 breast cancer patient in the past year (n=403), using logistic regression models to identify correlates of knowledge and appropriate referral.

RESULTS

Overall, 87% of respondents were general surgeons, and 64% saw >10 breast cancer patients in the previous year. In a scenario involving a 45-year-old undergoing lumpectomy, only 45% correctly estimated the risk of locoregional recurrence without radiation therapy, but 97% would refer to radiation oncology. In a patient with 2 of 20 nodes involved after mastectomy, 30% would neither refer to radiation oncology nor provide accurate information to make radiation decisions. In a patient with 4 of 20 nodes involved after mastectomy, 9% would not refer to radiation oncology. Fewer than half knew that the Oxford meta-analysis revealed a survival benefit from radiation therapy after lumpectomy (45%) or mastectomy (32%). Only 16% passed a 7-item knowledge test; female and more-experienced surgeons were more likely to pass. Factors significantly associated with appropriate referral to radiation oncology included breast cancer volume, tumor board participation, and knowledge.

CONCLUSIONS

Many surgeons have inadequate knowledge regarding the role of radiation in breast cancer management, especially after mastectomy. Targeted educational interventions may improve the quality of care.

Developing a theoretical framework to illustrate associations among patient satisfaction, body image and quality of life for women undergoing breast reconstruction

Within the field of breast reconstruction there is increasing focus on patient-reported outcomes related to satisfaction, body image, and quality of life. These outcomes are deemed highly relevant because the primary goal of breast reconstruction is to recreate the appearance of a breast (or breasts) that is satisfying to the patient. Prominent researchers have suggested the need to develop improved standards for outcome evaluation which can ultimately benefit patients as well as physicians. The purpose of this article is to summarize key findings in the area of patient-reported outcomes for breast reconstruction and introduce a theoretical framework for advancing research in this field. We conducted an extensive literature review of outcome studies for breast reconstruction focusing on patient-reported results. We developed a theoretical framework illustrating core patient-reported outcomes related to breast reconstruction and factors associated with these outcomes. Our theoretical model highlights domains and distinguishing features of patient satisfaction, body image, and quality of life outcomes for women undergoing breast reconstruction. This model further identifies a broad range of variables (e.g., historical/premorbid influences, disease and treatment-related factors) that have been found to influence patient-reported outcomes and need to be taken into consideration when designing future research in this area. Additional attention is given to examining the relationship between patient reported outcomes and outside evaluation of breast reconstruction. Our proposed theoretical framework suggests key opportunities to expand research in this area with the goal of optimizing body image adjustment, satisfaction, and psychosocial outcomes for the individual patient.

An evaluation of patient reported outcomes following breast reconstruction utilizing Breast Q

INTRODUCTION

Breast Q questionnaire measures patient's perceptions following breast reconstruction using quality of life and satisfaction. This study assessed patient reported outcomes following mastectomy and reconstruction utilizing Breast Q.

METHODS

All consecutive Letterkenny Hospital patients undergoing mastectomy and breast reconstruction between August 2008 and February 2011 were invited to complete Breast Q evaluation of their care. Collected data included: age; presenting complaint, height, weight; type of operation. RUMM 2020 program evaluated satisfaction where 0 is very dissatisfied to 100 very satisfied.

RESULTS

30/33 (91%) patients completed Breast Q; mean age 43 ± 11 (range 29-64); mean BMI 27.3 ± 5 (range 21.7-43.1). 27 patients were symptomatic, and 3 were image detected. 23 had a latissimus dorsi reconstruction, 11 of these with implant augmentation, 5 had a DIEP and 2 implant only reconstruction. The mean satisfaction score of 79.7 indicating good to excellent results. Post reconstructive outcomes were not statistically different from pre-operative perceptions in key areas such as satisfaction with breasts, psychosocial and sexual well-being.

CONCLUSION

This study identified outcomes as good as if not superior to international averages with preservation of satisfaction with breast and psychosocial well-being. Breast Q could help form a template for national benchmarks in patients undergoing mastectomy and reconstruction.

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.

Mechanisms of improved outcomes for breast cancer between surgical oncologists and general surgeons

BACKGROUND

Prior multi-institutional studies have reported a survival benefit of breast cancer treatment by surgical oncologists (SO) over general surgeons (GS).

METHODS

Retrospective review tumor registry data of all breast cancer patients receiving primary treatment at a single institution from January 1, 1995, to December 31, 2008.

RESULTS

During the time period, there were 2192 patients who received primary breast cancer treatment at this institution. The mean age was 57 years and the mean follow-up was >55 months. Stage distribution was similar between GS and SO. Overall survival (SO 83.8% vs. GS 75.6%) and disease-free survival (SO 80.7% vs. GS 72.0%) was highly statistically significant (P<0.0001). For stages 1, 2a, 2b, 3a, and 3b there were statistically significant (P<0.05) differences for overall and disease-free survival. Overall, the use of breast conservation was more likely by SO-52.6 vs. 38.3% all stages and 65.8 vs. 54.0% for stage 0-2. The compliance with all systemic therapies (chemotherapy and hormone therapy) was more likely if being treated by SO-77.3 vs. 68.5% (P<0.02). The use of radiotherapy for breast conservation and in stage 3 mastectomy patients was higher for SO (P<0.001). Participation in clinical trials was far higher for SO patients-56.2 vs. GS 7.0% (P<0.001).

CONCLUSIONS

The value added by having primary breast cancer treatment by a SO seems to arise from the more successful completion of multidisciplinary care in a timely fashion and higher rates of clinical trial involvement.

Measuring quality of life in oncologic breast surgery: a systematic review of patient-reported outcome measures

Multiple randomized trials demonstrate equivalent survival between BCT and mastectomy, but clinical outcomes research must also evaluate patient satisfaction and quality of life. This review analyzes existing patient-reported outcome (PRO) measures in oncologic breast surgery to assess utility and make recommendations for future research. We performed a systematic literature review to identify PRO measures used in oncologic breast surgery patients. After applying inclusion and exclusion criteria, qualifying instruments were assessed for adherence to international guidelines for health outcomes instrument development and validation. Ten measures underwent development and psychometric evaluation in an oncologic breast surgery population. Five of ten measures (EORTC QLQ BR-23, FACT-B, HBIS, BIBCQ, and BREAST-Q) reported an adequate development and validation process. Three of these 5 measures (EORTC QLQ BR-23, FACT-B, HBIS) focused on non-surgical treatment issues. A fourth instrument (BIBCQ) did not address aesthetic concerns after breast reconstruction. The fifth instrument (BREAST-Q) was developed for use in patients undergoing mastectomy ± reconstruction, but did not address breast-conserving therapy. Overall, two key limitations were noted: 1) surgery-specific issues of breast-conserving surgery patients were not well represented and 2) measures were largely developed without the aid of newer psychometric methods that may improve their clinical utility. Reliable and valid PRO measures in breast cancer patients exist, but even the best instruments do not address all important surgery-specific and psychometric issues of oncologic breast surgery patients. Newer psychometric methods would facilitate development of scales for use in individual patient care as well as group level comparisons.

Challenges and economics of private breast cancer surgery practice

The role of the breast cancer surgeon has changed from one with performance of one operation, to a position in which the surgeon is the patient's initial contact, leader of a multidisciplinary team, the clinical leader who ensures that the patient receives the most appropriate breast cancer treatment and then also receives follow up and surveillance services. Breast conservation rates, patient satisfaction rates, clear margins, use of oncoplastic surgical techniques, appropriate referral to other consultants, clinical trial referral, and survival rates are all higher when patients are cared for by breast-focused surgeons. This new role requires greater time both before and after surgery to provide the proper planning and care for these patients. Women with breast cancer should have access to these dedicated breast-focused surgeons. Recognition of this expanding responsibility and reimbursement for this time and expertise is needed so that women with breast cancer can be offered the highest quality of care.

Coordinating cancer care: patient and practice management processes among surgeons who treat breast cancer

OBJECTIVES

The Institute of Medicine has called for more coordinated cancer care models that correspond to initiatives led by cancer providers and professional organizations. These initiatives parallel those underway to integrate the management of patients with chronic conditions.

METHODS

We developed 5 breast cancer patient and practice management process measures based on the Chronic Care Model. We then performed a survey to evaluate patterns and correlates of these measures among attending surgeons of a population-based sample of patients diagnosed with breast cancer between June 2005 and February 2007 in Los Angeles and Detroit (N = 312; response rate, 75.9%).

RESULTS

Surgeon practice specialization varied markedly with about half of the surgeons devoting 15% or less of their total practice to breast cancer, whereas 16.2% of surgeons devoted 50% or more. There was also large variation in the extent of the use of patient and practice management processes with most surgeons reporting low use. Patient and practice management process measures were positively associated with greater levels of surgeon specialization and the presence of a teaching program. Cancer program status was weakly associated with patient and practice management processes.

CONCLUSION

Low uptake of patient and practice management processes among surgeons who treat breast cancer patients may indicate that surgeons are not convinced that these processes matter, or that there are logistical and cost barriers to implementation. More research is needed to understand how large variations in patient and practice management processes might affect the quality of care for patients with breast cancer.

Factors that determine satisfaction with surgical treatment of low-income women with breast cancer

OBJECTIVE

To analyze the relationship between patient satisfaction with surgical treatment and 4 consultation skills and processes of the surgeons (time spent, listens carefully, explains concepts in a way the patient can understand, and shows respect for what the patient has to say), controlling for a range of patient, surgeon, and treatment characteristics.

DESIGN

Cross-sectional survey.

SETTING

The Breast and Cervical Cancer Treatment Program for the state of California.

PATIENTS

A statewide sample of 789 low-income women who received treatment for breast cancer from February 1, 2003, through September 31, 2005.

MAIN OUTCOME MEASURE

Satisfaction with surgical treatment.

RESULTS

Three of every 4 women reported being extremely satisfied with the treatment they received from their surgeon. African American women and those with arm swelling were less likely to be satisfied, whereas those reporting that the surgeon always spent enough time and explained concepts in a way they could understand were more likely to report greater satisfaction.

CONCLUSION

Our findings highlight the importance of 2 relatively simple behaviors that surgeons can easily implement to increase patient satisfaction, which can be of potential benefit in the litigious world of today.

What do breast surgeons do?

BACKGROUND

There are an increasing number of fellowship-trained breast surgeons and surgical oncologists who dedicate their clinical practice exclusively to breast disease. However, there are little published data regarding characteristics of a breast surgical practice.

METHODS

All patient visits at a university-based breast surgery practice were reviewed for calendar years 2006 and 2007.

RESULTS

There were 10,381 patient visits, of which 2,334 (22%) represented new patients. Of these, 11% were referred with a diagnosis of cancer. Out of the remainder, 29% had a needle biopsy (8% by the surgeon and 21% by radiology), 29% underwent surgery, and 13% were ultimately diagnosed with cancer. After completion of initial therapy, 6 months or 1 year follow-up was recommended for 59% of the patients.

CONCLUSIONS

The specialty of breast surgery is unique in its nonoperative volume and extensive duration of follow-up. Strategies need to be designed to make this process more time-efficient for the surgeon.

Impact of MRI-evaluated neoadjuvant chemotherapy response on change of surgical recommendation in breast cancer

OBJECTIVE

To investigate how MRI imaging of neoadjuvant chemotherapy (NAC) tumor response affects the recommendation for optimal breast cancer surgery, both before and after NAC.

SUMMARY BACKGROUND DATA

Understanding how imaging findings are incorporated into surgeons' decision-making processes will help establish appropriate imaging guidelines for recommending breast conservation surgery (BCS) after the NAC.

METHODS

Seventy-six breast cancer patients undergoing NAC with MRI follow-up studies were analyzed. Two experienced breast surgeons reviewed all cases. An initial surgical recommendation was made based on the pre-NAC lesion presentation; a subsequent surgical recommendation was made based on the post-NAC tumor response. Finally, the pathology results were disclosed and the surgeons were asked to decide on the optimal definitive surgical procedure. MRI findings throughout the entire course of the NAC were analyzed to understand how they affected different recommendations.

RESULTS

Before the NAC, a large tumor size or extent of disease were the primary determinant factors for mastectomy. In this study, the mean tumor size was 5.3 +/- 3.4 cm (RECIST) in the mastectomy group and 3.2 +/- 1.6 cm in the lumpectomy group (P = 0.0001). After the NAC, based on consensus recommendations, 21 mastectomy candidates remained for mastectomy, with tumor size decreasing from 7.4 +/- 4.5 to 1.5 +/- 2.5 cm, and 22 mastectomy candidates were changed to lumpectomy, with tumor size decreasing from 4.2 +/- 2.1 to 0.4 +/- 0.6 cm. When the final pathology revealed pCR or minimal residual disease, the surgeons agreed that BCS is the optimal procedure. On the other hand, for a large extent of residual disease, mastectomy should be performed.

CONCLUSION

In patients who had more extensive pretreatment disease, despite an excellent response to NAC, the surgeons still tended to apply an aggressive approach and recommended mastectomy. Given that the confirmation of pCR or minimal residual disease would change surgeons' recommendations for less aggressive, conservation surgery, the maturity of MRI for NAC response prediction may provide reliable staging information to aid in the recommendation of the optimal surgical procedure.

Racial/ethnic disparities in knowledge about risks and benefits of breast cancer treatment: does it matter where you go?

OBJECTIVE

To evaluate the association between provider characteristics and treatment location and racial/ethnic minority patients' knowledge of breast cancer treatment risks and benefits.

DATA SOURCES/DATA COLLECTION

Survey responses and clinical data from breast cancer patients of Detroit and Los Angeles SEER registries were merged with surgeon survey responses (N=1,132 patients, 277 surgeons).

STUDY DESIGN

Cross-sectional survey. Multivariable regression was used to identify associations between patient, surgeon, and treatment setting factors and accurate knowledge of the survival benefit and recurrence risk related to mastectomy and breast conserving surgery with radiation.

PRINCIPAL FINDINGS

Half (51 percent) of respondents had survival knowledge, while close to half (47.6 percent) were uncertain regarding recurrence knowledge. Minority patients and those with lower education were less likely to have adequate survival knowledge and more likely to be uncertain regarding recurrence risk than their counterparts (p<.001). Neither surgeon characteristics nor treatment location attenuated racial/ethnic knowledge disparities. Patient-physician communication was significantly (p<.001) associated with both types of knowledge, but did not influence racial/ethnic differences in knowledge.

CONCLUSIONS

Interventions to improve patient understanding of the benefits and risks of breast cancer treatments are needed across surgeons and treatment setting, particularly for racial/ethnic minority women with breast cancer.

Correlates of patient satisfaction and provider trust after breast-conserving surgery

BACKGROUND

Although breast-conserving therapy (BCS) is considered the standard of care for early-stage breast cancer, up to 20% of patients are dissatisfied. The effect of treatment-related factors on patient satisfaction with their healthcare experiences is unclear.

METHODS

All BCS patients at the University of Michigan Medical Center who were treated between January 2002 and May 2006 were surveyed (n=714; response rate, 79.5%). Patients were queried regarding 4 aspects of their decision for surgery: satisfaction with the decision, decision regret, decisional conflict, and trust in surgeons. Independent variables included the number of re-excisions, the occurrence of postoperative complications, and postoperative breast appearance, which was assessed by using the Breast Cancer Treatment and Outcomes scale. Multiple logistic regression was used to assess the effect of the independent variables on each outcome controlling for demographic and clinical characteristics.

RESULTS

Breast asymmetry after BCS was correlated significantly with patient satisfaction with their treatment experiences and patient distrust in surgeons. Women who reported pronounced asymmetry were significantly less likely to be satisfied with the decision for surgery compared with women who reported minimal asymmetry (odds ratio [OR], 0.43; 95% confidence interval [95% CI], 0.21-0.89). Women with pronounced asymmetry were less likely to be certain about their surgical decision (OR, 0.36; 95% CI, 0.21-0.60) and to believe that they were prepared to make the decision for surgery (OR, 0.25; 95% CI, 0.14-0.43). Increasing breast asymmetry was associated with higher surgeon distrust scores (2.14 vs 2.30 vs 2.35; P= .04) and with the occurrence of postoperative complications (distrust score: 2.23 vs 2.35; P= .03). Reoperation after BCS was not associated with patient satisfaction or trust in providers.

CONCLUSIONS

Esthetic result after BCS was associated more profoundly with aspects of satisfaction than either surgical therapy or the occurrence of postoperative complications. The current findings indicated that surgeons who care for patients with breast cancer should identify the women at an increased risk for breast asymmetry preoperatively to effectively address their expectations of treatment outcomes.