Ambulatory surgery for breast cancer patients

Outcomes of a same day discharge protocol in patients undergoing mastectomy and implant reconstruction

BACKGROUND

Finite hospital resources has required a closer look at resource allocation. This has prompted a shift toward same day surgeries and a focus on reducing hospital readmissions. Following the institution of a same day discharge protocol for mastectomy and mastectomy with immediate reconstruction, we sought to assess differences in the length of stay and readmission rates.

METHODS

This retrospective review evaluates all cases of mastectomy with or without immediate reconstruction performed at a single high-volume center between June 2019 and March 2021. Average length of stay, 30-day readmission rates, Anesthesia Society Assessment class, and type of immediate reconstruction were assessed. Autologous reconstructions were excluded.

RESULTS

A total of 413 patients underwent mastectomy with or without reconstruction (n = 148 pre protocol and n = 265 during protocol) between June 2019 and March 2021. Of those 413 patients, 180 underwent reconstruction (n = 62 pre protocol and n = 118 during protocol). The average length of stay after mastectomy following the implementation of the same day discharge protocol was decreased at 0.6 days (n = 265) compared to preimplementation at 1.02 days (n = 148), p < 0.001. The 30-day readmission rate was not significant between the groups, p = 0.13. A total of 180 patients underwent immediate reconstruction after mastectomy. The average length of stay after mastectomy with immediate reconstruction following implementation of the same day discharge protocol was shorter than preimplementation at 1.05 days preimplementation (n = 62) versus 0.58 days following implementation (n = 118), p < 0.001; this finding was significant for both prepectoral and subpectoral implants, p < 0.001. There was no significant difference in 30-day readmission rates between the groups with immediate reconstruction, p = 0.34.

CONCLUSION

Same day discharge for mastectomy with reconstruction is as safe as the more widely recognized same day discharge practice for patients with mastectomy alone.

Investigating Factors Associated with Postmastectomy Emergency Department Visits: A Population-Based Analysis

BACKGROUND

In 2016, a multi-pronged pathway was implemented across 13 hospitals to improve the mastectomy perioperative care experience with one objective being to safely allow same day surgery mastectomy. While the pathway successfully increased same day mastectomy rates from 1.7 to 73.0%, the rate of postoperative emergency department (ED) visits remained high at > 20%, despite focused interventions to enhance perioperative support.

AIM

To investigate potential factors associated with high postoperative ED visits following mastectomies in Alberta, Canada.

METHODS

Data was collected using the Discharge Abstract Database and the National Ambulatory Care Reporting System database. Eligible patients included all women over 18 years old who underwent a mastectomy province-wide between 2004 and 2020. Patient demographics were collected. Primary outcome of interest was ED visit within 30 days of mastectomy. Univariate and multivariable analyses were performed to identify independent predictors for post-operative ED visits.

RESULTS

A total of 19,974 patients had mastectomy during the study period, of which 4590 (23%) had an ED visit within 30 days of surgery. Independent factors associated with ED visits were increasing age, overnight stay mastectomy, reconstruction, certain comorbidities, and living rurally.

CONCLUSIONS

Post-operative ED visits remain high despite initiating a province-wide surgical pathway in 2016 which emphasizes patient education and improved perioperative care and supports. Currently, the majority of ED visits are manageable in non-emergent settings. Patient populations at higher risk for ED visits groups may benefit from additional targeted support and resources to reduce unplanned ED visits.

Breast Sarcomas-How Different Are They from Breast Carcinomas? Clinical, Pathological, Imaging and Treatment Insights

Breast sarcoma (BS) is a very rare and poorly studied condition. This has led to a lack of studies with a high level of evidence and to low efficacy of current clinical management protocols. Here we present our experience in treating this disease in the form of a retrospective case series study including discussion of clinical, imaging, and pathological features and treatment. We also compare the main clinical and biological features of six cases of BS (phyllodes tumors were excluded) with a cohort of 184 patients with unilateral breast carcinoma (BC) from a previous study performed at our institution. Patients with BS were diagnosed at a younger age, presented no evidence of lymph node invasion or distant metastases, had no multiple or bilateral lesions, and underwent a shorter length of hospital stay versus the breast carcinoma group. Where recommended, adjuvant chemotherapy consisted of an anthracycline-containing regimen, and adjuvant external radiotherapy was delivered in doses of 50 Gy. The comparison data obtained from our BS cases and the ones with BC revealed differences in diagnosis and treatment. A correct pathological diagnosis of breast sarcoma is essential for the right therapeutic approach. We still have more to learn about this entity, but our case series could add value to existing knowledge in a meta-analysis study.

Outcomes of the same-day discharge following mastectomy before, during and after COVID-19 pandemic

BACKGROUND AND OBJECTIVES

The majority of patients undergoing mastectomy before the COVID-19 pandemic were admitted for 23-h observation to the hospital. Indications for observation included drain care education, pain control and observation for possible early surgical complications. This study compared the rates of outpatient mastectomy before, during, and after the COVID-19 pandemic and indirectly evaluated the safety of same-day discharge.

METHODS

We retrospectively analyzed patients undergoing mastectomy using Current Procedural Terminology code 19303.

RESULTS

A total of 357 patients were included: 113 were treated pre-COVID-19, 82 patients during COVID-19 and 162 post-COVID-19. The rate of outpatient mastectomies tripled during the pandemic from 17% to 51% (p < 0.001); after the pandemic remain high at 48%. The rate of bilateral mastectomies decreased during the pandemic to 30% from 48% prepandemic (p = 0.015). Pectoralis muscle block utilization increased during the COVID-19 period from 36% to 59% (p = 0.002). No difference in complication rates, including surgical site infections, hematomas, and readmissions, pre and during COVID.

CONCLUSIONS

The rate of outpatient mastectomy increased during the COVID-19 pandemic. During this timeframe, perioperative complications did not increase, suggesting the safety of this practice. After the pandemic, the rate of outpatient mastectomy continued to be significantly higher than pre-COVID.

Worth the trip? The effect of hospital clinic closures for patients undergoing scheduled surgery

Recent decades' hospital closures and consolidations have been rationalized with reference to arguments of efficiency and quality returns to scale and scope. However, closures are met with public outcry from patients living in areas affected by such closures if accompanying increases in travel time are not offset by a higher quality of care. It is broadly established that increases in patients' travel time to acute care lower the probability of survival, but in non-acute and scheduled care we lack knowledge about the quality of care that patients living in closure-affected areas receive. In the non-acute setting of scheduled breast cancer surgery, this study examines how hospital clinic closures affect the quality of care that closure-affected patients receive. The effects are identified using closures of breast cancer clinics in Denmark from 2000 to 2011, during which time the number of clinics was more than halved. Using event study designs on population-wide Danish register data from 1996 to 2014, this study examine changes in surgical outcomes for 9790 patients living in municipalities where the nearest clinic has been closed. The results show that closures have reduced the number of hospitalization days and shifted surgical procedures to state-of-the-art breast-conserving techniques without generating adverse health effects and without causing crowding in non-closing clinics. An examination of the mechanisms suggests that added volume returns at non-closing clinics were of less importance than simply reallocating patients to higher-quality clinics. Closures of clinics performing scheduled surgery may be an effective policy instrument if the goal is to reduce variation in the delivery of hospital care. Increased access to state-of-the-art care may counterbalance patients' concerns of losing their local clinic. However, if the clinics to be closed are small compared to non-closing clinics then there is no potential for added economies of scale or scope in non-closing clinics.

One-Year Experience of Same-Day Mastectomy and Breast Reconstruction Protocol

BACKGROUND

The prevalence of same-day mastectomy with reconstruction has continued to increase across the United States in recent years. Prior studies have shown that same-day mastectomy with reconstruction leads to increased patient satisfaction and allows hospitals to use resources better. This study sought to evaluate the implementation of same-day mastectomy with a reconstruction recovery protocol for patients undergoing mastectomy at our institution.

METHODS

Under an institutional review board-approved protocol, a retrospective cohort analysis compared patients who underwent mastectomy April 2016 through April 2017 with those who had mastectomy March 2020 through March 2021. Length of stay, postoperative intravenous (IV) opioid administration, safety end points, and cost were the main variables examined.

RESULTS

The study compared 457 patients in 2016-2017 with 428 patients in 2020-2021. The median hospital length of stay decreased from 24.6 h in 2016-2017 to 5.5 h in 2020-2021 (p < 0.001). The percentage of patients requiring postoperative IV opioids decreased from 69.1 % in 2016-2017 to 50 % in 2020-2021 (p < 0.001). The rates of unplanned readmissions within 30 days after mastectomy did not differ between the two groups, with a rate of 3.7 % in 2016-2017 and a rate of 5.1 % in 2020-2021 (p = 0.30). Reducing the rate of overnight admissions after mastectomy by 65.8 % resulted in a cost reduction of 65.8 %.

CONCLUSIONS

Implementation of same-day mastectomy with a reconstruction protocol across a large academic center and two satellite sites was a safe alternative to conventional mastectomy recovery plans.

Same‐day mastectomy and axillary lymph node dissection is safe for most patients with breast cancer

Background and Objective

The aim of this study was to evaluate the safety of same‐day mastectomy, with or without a sentinel node biopsy (SNB) and/or axillary lymph node dissection (ALND).

Methods

In this retrospective study, we reviewed 913 consecutive women who underwent a simple mastectomy for breast cancer between the years 2014 and 2019 and were treated either with same‐day surgery (SDS) or an overnight stay (OS) regime. We reviewed all surgical complications, any unplanned return to care (RTC) and the rehospitalization rate for 30 postoperative days.

Results

A total of 259 patients (28%) were treated with SDS and 654 patients (72%) with an OS regime. There was no difference in RTC (odds ratio: 0.79 [95% confidence interval: 0.53–1.18], p = 0.26) or any major complications between the groups. None of the investigated subgroups, such as patients with previous neoadjuvant therapy, diabetes, obesity (up to a body mass index of 40 kg/m²), the American Society of Anaesthesiologist Class of 3, or elderly patients aged 75–84 years, showed an increased complication rate when treated with the SDS regime.

Conclusion

A same‐day simple mastectomy is safe with SNB and/or ALND. It can be performed safely for most patients with stable co‐morbidities.

Same-day Discharge Is Safe and Effective After Implant-Based Breast Reconstruction

BACKGROUND

Same-day discharge after mastectomy is a recently described treatment approach. Limited data exist investigating whether same-day discharge can be successfully implemented in patients undergoing mastectomy with immediate implant-based breast reconstruction (IBR).

METHODS

Patients having mastectomy with IBR from 2013 to 2019 were reviewed. Enhanced recovery with same-day discharge was implemented in 2017. Patient characteristics, oncologic treatments, surgical techniques, and 90-day postoperative complications and reoperations were analyzed comparing enhanced recovery patients with historical controls.

RESULTS

A total of 363 patients underwent nipple-sparing (214, 59%) or skin-sparing (149, 41%) mastectomy with 1-stage (270, 74%) or tissue expander (93, 26%) IBR. Enhanced recovery was used for 151 patients, with 79 of these patients (52%) discharged same-day. Overall, enhanced recovery patients experienced a significantly lower rate of 90-day complications (21% vs 41%, P < 0.001), including hematoma (3% vs 11%, P = 0.002), mastectomy flap necrosis (7% vs 15%, P = 0.02), seroma (1% vs 9%, P < 0.001), and wound breakdown (3% vs 9%, P = 0.05). Postoperative complication rates did not significantly differ among enhanced recovery patients discharged same day. Postoperative admissions significantly decreased after enhanced recovery implementation (100% to 48%, P < 0.001), and admitted enhanced recovery patients experienced a lower length of stay (1.2 vs 1.8, P < 0.001). Enhanced recovery patients experienced a lower incidence of ≥1 unplanned reoperation (22% vs 33%, P = 0.01); overall average unplanned and total reoperations did not significantly differ between groups.

CONCLUSIONS

In conjunction with enhanced recovery practices, same-day discharge after mastectomy with IBR is a safe and feasible treatment approach.

Outpatient Mastectomy: Factors Influencing Patient Selection and Predictors of Return to Care

Background

After implementation of the Surgical Home Recovery (SHR) initiative for mastectomy within a large, integrated health delivery system, most patients are discharged on the day of the procedure. We sought to identify predictors of SHR and unplanned return to care (RTC).

Study Design

Mastectomy cases with and without reconstruction from October 2017 to August 2019 were analyzed. Patient characteristics, operative variables, and multimodal pain management were compared between admitted patients and SHR patients using logistic regression. We identified predictors of RTC in SHR patients, defined as 7-day readmission, reoperation, or emergency department visit.

Results

Of 2,648 mastectomies, 1,689 (64%) were outpatient procedures and the mean age of patients was 58.5 years. Predictors of SHR included perioperative IV acetaminophen (odds ratio [OR] 1.59; 95% CI, 1.28 to 1.97), perioperative opiates (OR 1.47; 95% CI, 1.06 to 2.02), and operation performed by a high-volume breast surgeon (OR 2.12; 95% CI, 1.42 to 3.18). Bilateral mastectomies (OR 0.70; 95% CI, 0.54 to 0.91), immediate reconstruction (OR 0.52; 95% CI, 0.39 to 0.70), and American Society of Anesthesiologists class 3 to 4 (OR 0.69; 95% CI, 0.54 to 0.87) decreased the odds of SHR. Of SHR patients, 111 of 1,689 patients (7%) experienced RTC. Patients with American Society of Anesthesiologists class 3 to 4 (OR 2.01; 95% CI, 1.29 to 3.14) and African American race (OR 2.30; 95% CI, 1.38 to 4.91) were more likely to RTC; receiving IV acetaminophen (OR 0.56; 95% CI, 0.35 to 0.88) and filling an opiate prescription (OR 0.51; 95% CI, 0.34 to 0.77) decreased the odds of RTC.

Conclusions

Surgeon volume and multimodal pain medication increased the odds of SHR. Within the SHR group, American Society of Anesthesiologists Class 3 to 4 and African American patients increased the likelihood of RTC. This study helps optimize patient selection and perioperative practice for successful SHR.

Quality of life, anxiety, and postoperative complications of patients undergoing breast cancer surgery as ambulatory surgery compared to non-ambulatory surgery: A prospective non-randomized study

PURPOSE

According to the latest recommendations a minimally invasive approach should be used to manage breast cancer and a global policy for minimizing costs encourages shorter periods of hospitalization. The aim of this study was to investigate the impact of length of hospitalization on quality of life, anxiety and depression and postoperative complications.

METHODS

This is a prospective observational study of 412 female patients with breast cancer requiring a first mastectomy or lumpectomy to assess the impact of the length of hospitalization on quality of life (using the European Organization for Research and Treatment of Cancer Quality of Life QLQ30 and BR23 questionnaires) at postoperative day 14 (D+14), levels of anxiety at d-1 and D+1 (according to the Hospital Anxiety and Depression scale) and postoperative state at D+21.

RESULTS

Our study included 244 patients that had ambulatory surgery and 124 that had non-ambulatory surgery. Global health status was significantly better for ambulatory surgery patients (adjusted p-value=0.014). There were no significant differences between the two groups for levels of anxiety, pain, lymphoceles and postoperative complications. No cases of nausea and vomiting requiring medical treatment were reported for either group.

CONCLUSIONS

Breast cancer surgery can be performed using ambulatory surgery with no significant differences compared to non-ambulatory surgery in terms of quality of life, perioperative anxiety, and postoperative complications. Indeed, our study suggests that ambulatory surgery improves patient outcome. It should be determined whether the mode of hospitalization has any long-term impact on the patient, as a shorter hospitalization period would allow decreasing waiting times.

Implementation of a Post-mastectomy Home Recovery Program in a Large, Integrated Health Care Delivery System

BACKGROUND

The number of outpatient mastectomies, with and without reconstruction, has increased nationwide. In well-selected patient populations, same-day surgery for mastectomy is a safe option. A pilot project was initiated within the Kaiser Permanente Northern California healthcare system to facilitate surgical home recovery (SHR) for mastectomy patients, including patients undergoing implant-based reconstruction and bilateral mastectomies.

METHODS

Surgical home recovery for mastectomy patients was implemented in October 2017. Specific measures in this initiative included management of patient expectations at initial consultation, education about postoperative home care, multimodality pain management, and timely post-discharge follow-up. All patients undergoing mastectomy were included, except those undergoing autologous tissue reconstructions. After a 6-month implementation period, rate of same day discharge over 6 months was compared before and after the SHR initiative. We also compared emergency department (ED) visits, reoperations, and readmissions within 7 days.

RESULTS

Twenty-one medical centers participated in this initiative. Before implementing SHR, 164 of the 717 (23%) mastectomies were outpatient procedures, compared with 403 of the 663 (61%) after the implementation period. Although the rate of outpatient mastectomy increased significantly, there were no statistically significant differences in ED visits (5.2% vs. 5.1%, p = 0.98), reoperation (3.5% vs. 3.5%, p = 0.99), or readmission rates (1.4% vs. 2.7%, p = 0.08).

CONCLUSIONS

By implementing standard expectations and sharing best practices, there was a significant increase in the rate of home recovery for mastectomy without compromising quality of patient care. The success of this pilot program supports SHR for mastectomy.

[Outpatient breast cancer surgery: Patient satisfaction study and the role of the attending physician]

OBJECTIVES

To evaluate the satisfaction of patients with breast cancer treated surgically in an outpatient setting and the role of the attending physician.

METHODS

This prospective satisfaction study focused on patients who had a breast cancer surgery as an outpatient procedure, between February and October 2018, at the CHU and Clinique Mutualiste chirurgicale de Saint-Étienne, Loire, France. The data were collected via a satisfaction survey, which was given to the patients during the postoperative visit.

RESULTS

One hundred and four patients were included. The most frequent surgery was partial mastectomy with sentinel lymph node (63.5%). On overall breast cancer surgery, 47.6% were performed on an outpatient basis. Ninety-seven percent of the patients were satisfied, 96.9% would have recommended this procedure to a friend and 47% could resume their daily activities as early as the second day. Among the patients, 16.2% would have preferred to stay on day more in hospital after the surgery. This preference was related to the complexity (P=0.035) and duration of the surgery (P=0.025), fatigue (P=0.03) and feeling of isolation (P=0.016). Among the patients, 25.5% saw their doctor for organic, psychological, administrative, monitoring and informational issues.

CONCLUSIONS

Outpatient breast cancer surgery seems safe and qualitative. Standardized procedures, relevant information about the outpatient procedure and specificities of this type of care, as well as the transmission of information with the attending physician are the keys to success.

Same-Day Surgery for Mastectomy Patients in Alberta: A Perioperative Care Pathway and Quality Improvement Initiative

BACKGROUND

Same-day surgery (SDS) following mastectomy is safe and well accepted. Overnight admission in patients fit for discharge is an inefficient use of health resources. In response to a national review highlighting SDS following mastectomy at 1.4% in Alberta, a perioperative pathway was conceived.

METHODS

The pathway was implemented across Alberta at 13 hospitals beginning in 2016. A steering committee was assembled, and clinical and administrative leads at each site were identified. Opportunities along the patient care experience whereby action could be taken to promote uptake of SDS were identified. Provincially branded support materials including presentations, order sets, and standard operating procedures were developed. Nurse educators provided in-service teaching such as standardized drain care and discharge teaching. Educational booklets, group classes, and online resources were developed for patients and families. An audit of SDS rates, unscheduled return to the emergency department (ED), and readmission rates was reported to teams quarterly, allowing for iterative modifications. Patient-reported experience measures (PREMs) were collected.

RESULTS

SDS following mastectomy increased from 1.7 to 47.8%, releasing an estimated 831 bed days per year. No differences in unexpected return to the ED or readmission to hospital existed between SDS patients and those admitted overnight. A total of 102 patients completed the PREM survey, of whom 90% felt "excellent or good" with the plan to go home, how to care for themselves once home, and who to contact should issues arise.

CONCLUSIONS

Implementation of a provincial perioperative pathway improved uptake of SDS following mastectomy and demonstrated favorable PREMs.

Major ambulatory surgery for the treatment of breast cancer: Factors conditioning conversion to conventional hospitalization

INTRODUCTION

The main step in curative treatment for breast cancer is surgery. Its use in an ambulatory setting can contribute towards more efficient healthcare, providing additional benefits for patients. In this study, we analyze the results obtained with this treatment method and identify factors related with conversion to hospitalization.

METHODS

Results were analyzed from the 206 surgeries performed for breast cancer in 2016, using three different methods: day surgery, overnight ambulatory (23h) and conventional hospitalization. The ambulatory success and conversion rates were calculated for the global sample and stratified, distinguishing between conservative surgery, mastectomy and axillary surgery. A univariate analysis was performed to identify the factors involved in conversion.

RESULTS

For the global sample, the ambulatory surgery rate was 61.2%, 16.5% conversions and a success rate of 83.4%. For conservative surgery, ambulatory, success and conversion rates were 78.8%, 88.6 and 11.4%, respectively. For mastectomies, the ambulatory rate was 28.6%, with 62.9% success and 37.1% conversions. The 11 axillary surgeries were performed as day surgeries. Factors associated with conversion were mastectomy vs. vs. conservative surgery and the appearance of postoperative complications.

CONCLUSIONS

Ambulatory surgery for the surgical treatment of breast cancer should be standard care. Optimized results require adequate patient selection and the performance of surgical technique that needs to be as careful and as conservative as possible.

Distress and Psychosocial Needs in Patients Accessing a Cancer Day Surgery Division: Implications for Clinical Decision Making

Introduction: The Distress Thermometer (DT) was built and validated for screening cancer patients for distress, as suggested by the National Comprehensive Cancer Network. The current work was designed to measure the rates of distress in a sample of patients being hospitalized in a multidisciplinary outpatient surgery clinic.

OBJECTIVE

To measure the rates of distress in a sample of patients referring to a multidisciplinary day surgery division in a comprehensive cancer center based in Northern Italy. Methods: A total of 177 patients were asked to fill in the (DT) before surgery. Results: Out of 177 patients, 154 (87%) patients completed the DT. While 13% of the patients indicated a total absence of distress, more than half of the sample declared a moderate or high distress. A total of 55% of patients presented at least three difficulties in the Problem List Checklist. Distress was not correlated with age or other medical and clinical variables. Number of emotional problems was the best predictor of distress at admission (β = 0.655, p = 0.000). Conclusion: Screening for distress in a day surgery multidisciplinary oncology division is feasible and a relevant percentage of patients can be identified as clinically distressed. Outcomes also highlight the impact of age and precise physical and psycho-social signs as prognostic indicators of clinically significant distress. Measurement of distress and associated problems list represent the preliminary endpoint toward adequate recommendations that contribute to taking care of distress in cancer patients in cost-effective clinical setting.

Autonomic nervous infiltration positively correlates with pathological risk grading and poor prognosis in patients with lung adenocarcinoma

Background

Perineural invasion has been found in several types of human tumors, and is associated with poor prognosis; however, few studies have examined perineural invasion in lung cancer. We evaluated the relationship between autonomic nervous densities, pathological risk grading, and prognosis in patients with lung adenocarcinoma (LADC).

Methods

Neural fiber expression was examined by immunofluorescence in resected lung specimens in control patients (n = 30), and low‐risk (n = 22), and high‐risk LADC patients (n = 43). The nerve densities of normal lung tissue and abnormal lung tissues in the tumor and surrounding tissues were evaluated by a semi‐quantitative score method.

Results

Increased sympathetic fibers mainly infiltrated the paratumoral area, while increased parasympathetic fibers were largely restricted to the tumor (paratumor vs. tumor, P = 0.000 in high, P = 0.034 in low; each). In addition, high‐risk patients presented the highest density of neural fibers, followed by low‐risk and control patients (P = 0.000; each). In Kaplan–Meier survival analysis, the densities of sympathetic fibers in paratumoral tissue and parasympathetic fibers in the tumor, respectively, correlated with poor recurrence‐free survival in patients who were not treated with adjuvant therapy (P < 0.001; each). Further multivariate analysis showed that these two factors were associated with poor prognosis in all LADC patients (P = 0.024 sympathetic fibers; P = 0.037 parasympathetic fibers).

Conclusion

These findings reveal a positive correlation between nervous infiltration and risk of poor prognosis in patients with LADC.

Same-Day Major Breast Cancer Surgery is Safe: An Analysis of Short-Term Outcomes Using NSQIP Data

INTRODUCTION

Most patients undergoing significant breast cancer surgery stay in hospital postoperatively. We sought to determine whether there was a difference in complication rates among patients undergoing same-day surgery (SDS) versus overnight or inpatient stay.

METHODS

Analysis of the American College of Surgeons, National Surgical Quality Improvement Program participant user files was performed. Patients with breast cancer undergoing mastectomy and/or axillary lymph node dissection between 2005 and 2012 were examined (high-risk comorbidities and concurrent surgery were excluded). Thirty-day postoperative morbidity was analyzed. Multivariable regression was performed identifying independent predictors of complications.

RESULTS

The final population consisted of 40,575 patients; 8365 had SDS, 23,252 stayed overnight, and 8958 stayed in hospital longer postoperatively. Those admitted to hospital were older, more obese, had higher American Society of Anesthesiology (ASA) class, medical comorbidities, or had bilateral surgery. The overall 30-day morbidity was 4.7 %. On univariate analysis, patients undergoing SDS had significantly lower 30-day morbidity (2.4 %) compared with overnight (3.9 %) or inpatient stay (8.8 %) (p < 0.0001). After controlling for the above differences between groups, patients staying overnight had a higher odds of postoperative complications [1.37, 95 % confidence interval (CI) 1.16-1.63, p = 0.004] and inpatients had over twice the odds of postoperative complications (2.65, 95 % CI 2.21-3.18, p < 0.0001) compared with SDS patients.

CONCLUSION

This is the largest study examining the safety of SDS for breast cancer. Complication rates were significantly higher for patients admitted to hospital postoperatively, even after controlling for baseline differences. These data suggest that, with appropriate selection, it is safe to perform major breast cancer surgery on a same-day basis.

Factors Affecting the Postsurgical Length of Hospital Stay in Patients with Breast Cancer

OBJECTIVE

Breast cancer is the most common malignancy and the most common cause of mortality in women worldwide. In addition to the increasing incidence of breast cancer, the length of hospital stay (LOS) after breast cancer surgery has been decreasing. Because LOS is key in determining hospital usage, the decrease in the use of hospital facilities may have implications on healthcare planning. The purpose of this study was to evaluate the factors affecting postoperative LOS in patients with breast cancer.

MATERIALS AND METHODS

Seventy-six in patients with breast cancer, who had been treated between July 2013 and December 2014 in the General Surgery Clinic of Dicle University, were included in the study. The demographic characteristics of the patients, treatment methods, histopathological features of the tumor, concomitant diseases, whether they underwent neoadjuvant chemotherapy or not, and the length of drain remaining time were retrospectively recorded.

RESULTS

There was a correlation between drain remaining time, totally removed lymph node, the number of metastatic lymph node, and LOS. LOS of patients treated with neoadjuvant chemotherapy was longer. The patients who underwent breast-conserving surgery had a shorter LOS. Linear regression analysis revealed that the drain remaining time and the number of metastatic lymph nodes were independent risk factors for LOS.

CONCLUSION

Consideration should be given to cancer screening to diagnose the patients before lymph node metastasis occurs. In addition, drains should be avoided unless required and, if used, they should be removed as early as possible for shortening LOS.

Patients' perspective on day case breast surgery

BACKGROUND

This study assessed the views of patients undergoing breast surgery for breast cancer with a planned overnight stay, asking whether they would be happy to be discharged home on the same day of surgery.

METHODS

A structured questionnaire sent out in the 6 weeks following surgery was used to ascertain the patients' views.

RESULTS

The majority of patients undergoing mastectomy and axillary node clearance preferred an overnight stay, primarily for psychological reasons.

CONCLUSIONS

Patients undergoing breast-conserving surgery were more prepared to go home on the day of surgery.

Feasibility of Day Surgery in Patients With Breast Conservation and Sentinel Node Biopsy: A Randomized Controlled Trial

Background and Aims:

The aim of this study was to analyze feasibility of day surgery in breast cancer patients with breast conserving surgery and sentinel node biopsy.

Material and Methods:

The study was a randomized controlled trial comparing day surgery with one night hospital stay in breast cancer patients with breast conserving surgery and sentinel node biopsy. A total of 40 patients with ⩽3-cm tumor and clinically N0 were randomized to one night stay group and 38 patients to day surgery group. Within discharge, patients and their relatives were given questionnaires in order to evaluate their experience regarding the duration of hospital stay.

Results:

Randomized groups were similar regarding patient age and tumor stage. A total of 18 (47%) day surgery group patients were discharged the same day. The most common reason for overnight hospital stay was axillary clearance, 9 (24%). None of the patients in the day surgery group, but 2 patients in the overnight hospital stay group had re-operation due to complications. Perception and preference results were analyzed both according to randomization and actual treatment groups. Patients in both groups had rather similar experiences on the first postoperative day. Also, spouse’s or relative’s perception after discharge was similar in both groups.

Conclusion:

Day surgery was well received by the patients and their relatives. Day surgery appears as feasible in patients with breast conservation and sentinel node biopsy.

Adopting ambulatory breast cancer surgery as the standard of care in an asian population

Introduction. Ambulatory surgery is not commonly practiced in Asia. A 23-hour ambulatory (AS23) service was implemented at our institute in March 2004 to allow more surgeries to be performed as ambulatory procedures. In this study, we reviewed the impact of the AS23 service on breast cancer surgeries and reviewed surgical outcomes, including postoperative complications, length of stay, and 30-day readmission. Methods. Retrospective review was performed of 1742 patients who underwent definitive breast cancer surgery from 1 March 2004 to 31 December 2010. Results. By 2010, more than 70% of surgeries were being performed as ambulatory procedures. Younger women (P < 0.01), those undergoing wide local excision (P < 0.01) and those with ductal carcinoma-in situ or early stage breast cancer (P < 0.01), were more likely to undergo ambulatory surgery. Six percent of patients initially scheduled for ambulatory surgery were eventually managed as inpatients; a third of these were because of perioperative complications. Wound complications, 30-day readmission and reoperation rates were not more frequent with ambulatory surgery. Conclusion. Ambulatory breast cancer surgery is now the standard of care at our institute. An integrated workflow facilitating proper patient selection and structured postoperativee outpatient care have ensured minimal complications and high patient acceptance.

Racial disparities in the use of outpatient mastectomy

BACKGROUND

Racial disparities exist within many domains of cancer care. This study was designed to identify differences in the use of outpatient mastectomy (OM) based on patient race.

METHODS

We identified patients in the American College of Surgeons National Surgical Quality Improvement Program Participant Use File (during the years 2007-2010) who underwent a mastectomy. The association between mastectomy setting, patient race, patient age, American Society of Anesthesiology physical status classification, functional status, mastectomy type, and hospital teaching status was determined using the chi-square test. A multivariable logistic regression analysis was developed to assess the relative odds of undergoing OM by race, with adjustment for potential confounders.

RESULTS

We identified 47,318 patients enrolled in the American College of Surgeons National Surgical Quality Improvement Program Participant Use File who underwent a mastectomy during the study time frame. More than half (62.6%) of mastectomies were performed in the outpatient setting. All racial minorities had lower rates of OM, with 63.8% of white patients; 59.1% of black patients; 57.4% of Asian, Native Hawaiian, or Pacific Islander patients; and 43.9% of American Indian or Alaska Native patients undergoing OM (P < 0.001). After adjustment for multiple confounders, black patients, American Indian or Alaska Native patients, and those of unknown race were all less likely to undergo OM (odds ratio [OR], 0.86; 95% confidence interval [CI], 0.80-0.93; OR, 0.55; 95% CI, 0.41-0.72; and OR, 0.70; 95% CI, 0.64-0.76, respectively) compared with white patients.

CONCLUSIONS

Disparities exist in the use of OM among racial minorities. Further studies are needed to identify the role of cultural preferences, physician attitudes, and insurer encouragements that may influence these patterns of use.

Early hospital discharge following breast cancer surgery in the West Indies: a Trinidad study

PURPOSE

To examine the outcome of a policy of early hospital discharge (<24 hours) after breast cancer surgery in a Third World setting, where health care resources and support services are very limited.

DESIGN

Prospective enrollment into a plan of early hospital discharge within 24 hours following breast surgery. Followup was conducted for wound infections; seroma formation; flap dehiscence; and readmission, if any.

SUBJECTS

All patients over a 15-year period who underwent wide local excision or mastectomy and axillary clearance were enrolled.

RESULTS

A total of 331 patients were entered into the study. Of these, 148 had modified radical mastectomy and 183 had wide local excision plus axillary dissection. Each patient had a drain placed and output was recorded. Follow-up revealed that there was no increase in the complication rates.

CONCLUSION

Early hospital discharge following breast cancer surgery is a feasible option for most patients and can be safely implemented even in a resource-limited setting where cost containment is essential.

Enhancing the clinical pathway for patients undergoing axillary lymph node dissection

BACKGROUND

Day-case axillary lymph node dissection (ALND) is not standard practice. Here we assess the feasibility of converting this traditional inpatient procedure to an outpatient procedure without compromising the quality or continuity of patient care, identify barriers to introducing an enhanced clinical pathway based on this conversion, and report strategies employed to overcome these barriers.

METHODS

Consecutive patients (n=282) undergoing ALND alone or with a concurrent breast procedure (excluding mastectomy/reconstruction) over a 12-month period were recorded in a prospective database. Assessed outcomes were successful discharge the day of surgery, early postoperative complication rates, and readmission rates.

RESULTS

From July 2009 to June 2010, 282 ALNDs were performed at Memorial Sloan-Kettering Cancer Center. 240 (85.1%) were performed as an outpatient procedure and 42 (14.9%) had inpatient ALND. The readmission rate was 0.8% (2/240), and the reoperation rate was 0.7% (2/282). Outpatient ALND procedure implementation created 240 additional beds over the 12-month study period. Identified barriers to implementing this new clinical pathway included patient expectations, reducing narcotic administration while optimizing postoperative pain control, and facilitating preoperative patient education.

CONCLUSION

ALND may be safely performed as a day-case procedure. The key to successfully implementing ALND as a day-case procedure is a multidisciplinary team approach combined with enhanced pre and postoperative patient education. In addition, changes in the mindsets of patients and health care providers are essential.

Initial experiences with a multidisciplinary approach to decreasing the length of hospital stay for patients undergoing unilateral mastectomy

BACKGROUND

We hypothesized that the introduction of a short-stay pathway would result in a significant reduction in length of stay for patients undergoing unilateral mastectomy, without a negative impact on patient safety.

MATERIALS AND METHODS

As part of a quality improvement project, a multidisciplinary committee designed a 1-day stay program for unilateral mastectomy patients. The study period was the first year after the 1-day pathway had routinely been implemented. We report on consecutive patients undergoing unilateral mastectomy ± tissue expander at Memorial Sloan-Kettering Cancer Center from July 1, 2009 to June 30, 2010. The primary endpoint was the percentage of patients discharged on postoperative day 1. Secondary endpoints included the incidence of postoperative complications within 30 days of surgery, reoperations, readmissions, and urgent-care visits within 7 days.

RESULTS

Over a 12-month period, 537 patients underwent unilateral mastectomy. Of those, 82.7% (444/537) were performed on a 1-day hospitalization basis, compared with 9.6% in 2008, before implementation of the 1-day plan. The 30-day complication rate was 6.1% (33/537). Overall, 2.6% of all patients had reoperation for hematoma (14/537), 0.9% had to be readmitted (5/537), and 1.5% (8/537) attended the urgent-care department. If all patients had stayed in the hospital for more than 1 day, none of the readmissions and only 2 urgent-care visits would have been prevented.

CONCLUSIONS

This study shows that a 1-day stay following mastectomy is easy to implement and safe for patients if a multidisciplinary team is involved in planning and implementation.

Relationships between roles and mental states and role functional QOL in breast cancer outpatients

OBJECTIVE

To evaluate the degrees of role accomplishment, the importance of and satisfaction with roles, and to assess their relationships with mental states and role functional quality of life, in breast cancer patients receiving treatment on an outpatient basis.

METHODS

The study was designed as a cross-sectional study. Thirty patients with primary breast cancer were evaluated using the Self-Rating Frenchay Activities Index, the Role Checklist, the Profile of Mood States and the Medical Outcome Study Short-Form 36-Item Health Survey. Spearman's rank correlation coefficients were used to analyze the relationships between each role-related item and each Profile of Mood States and Short-Form 36 subscale.

RESULTS

A higher number of roles played was positively associated with the score for Vigor but was negatively associated with the score for physical quality of life. A higher degree of the importance of roles was negatively correlated with the score for Confusion and positively correlated with the score for mental quality of life. A higher degree of satisfaction with roles was negatively correlated with depression, tension-anxiety, confusion and the total mood disturbances score, and was positively correlated with both the physical and negative quality of life scores. No significant correlations were apparent between the degrees of role accomplishment (Self-Rating Frenchay Activities Index scores) and the Profile of Mood States and Short-Form 36 scores.

CONCLUSIONS

The results indicated that qualitative and subjective factors (i.e. the degrees of importance of and satisfaction with roles) are associated more closely with emotional states and role functional quality of life in breast cancer outpatients than quantitative and objective factors (i.e. degree of role accomplishment and the number of roles).

Same-day breast cancer surgery: a qualitative study of women's lived experiences

PURPOSE/OBJECTIVES

To understand the experiences of women having same-day breast cancer surgery and make recommendations to assist healthcare professionals effect change to enhance quality of care.

RESEARCH APPROACH

Thematic analysis of audiotaped interviews.

SETTING

Outpatient departments of two city hospitals on the east coast of Canada.

PARTICIPANTS

Purposive sample of 13 women who had undergone same-day breast cancer surgery.

METHODOLOGIC APPROACH

A constructivist approach with in-depth interviews and comparative analysis to develop and systemically organize data into four major interrelated themes and a connecting essential thread.

MAIN RESEARCH VARIABLES

Women's experiences with same-day breast cancer surgery.

FINDINGS

The themes of preparation, timing, supports, and community health nursing intervention were of paramount importance for effective coping and recovery. Women who had a positive experience with same-day breast cancer surgery also reported having adequate preparation, appropriate timing of preparation, strong support systems, and sufficient community health nursing intervention. Those reporting a negative experience encountered challenges in one or more of the identified theme areas.

CONCLUSIONS

Same-day surgery is a sign of the times, and the approach to it is changing. Healthcare systems need to be responsive to such changes. Although same-day surgery for breast cancer is not suitable for every patient, women undergoing this type of surgery should be assessed individually to determine whether it is appropriate for them.

INTERPRETATION

Women undergoing breast cancer surgery should be screened for same-day surgery suitability. Those having same-day breast cancer surgery should be prepared adequately with timely education. Most importantly, such women should receive community health nursing follow-up for assessment, continuing education, and psychosocial support.

Implementation of a short-stay programme after breast cancer surgery

BACKGROUND

: Short-stay breast cancer surgery (24 h or day case) is not common practice in Europe. This before-after comparative study was carried out to test the feasibility of systematically implementing a care programme incorporating short-stay admission using strategies tailored to individual hospital needs, and to assess safety and facilitating factors.

METHODS

: Patients with breast cancer from four Dutch hospitals participated. The intervention concerned the programme developed by the Maastricht University Medical Centre. This was implemented through local multidisciplinary meetings and educational outreach visits.

RESULTS

: Of 421 eligible patients, 324 (77.0 per cent) gave consent to participate. The proportion of patients who had short-stay treatment increased from 45.3 per cent before to 82.2 per cent after implementation of the programme (P < 0.001). No increase was observed in the rate of complications, readmissions, reoperations or number of visits to the emergency department. Factors associated with an increased chance of short-stay treatment were: breast-conserving surgery, having children and being employed. Being aged over 64 years showed a trend towards a decreased chance.

CONCLUSION

: Introducing a care programme incorporating short stay following breast cancer surgery in four hospitals was feasible and safe.

Incidence of Complications in Outpatient Mastectomy with Immediate Reconstruction

BACKGROUND

Although breast surgery, including mastectomy, is increasingly being performed on an outpatient basis, skepticism remains about the safety of outpatient mastectomy with immediate breast reconstruction. Studies have demonstrated a psychologic benefit to outpatient breast surgery in addition to the clear financial benefit. We sought to determine whether or not the postoperative complication rate after outpatient mastectomy with immediate reconstruction is low enough to consider the procedure safe and effective.

STUDY DESIGN

Charts were retrospectively reviewed for all patients who underwent outpatient mastectomies with immediate breast reconstruction at St Vincent's Comprehensive Cancer Center between December 2000 and June 2004. The presence or absence of postoperative complications was determined from records during the postoperative period and subsequent office visit.

RESULTS

Of 29 outpatient mastectomies with immediate reconstruction performed on 28 patients (one had independent procedures on each breast), only one procedure (3%) required subsequent admission to the hospital (for bleeding). Other complications included three seromas, two cases of cellulitis requiring antibiotics, and one hematoma. The overall complication rate was 24% (7 of 29), with only 14% (1 of 7) of the complications requiring hospitalization.

CONCLUSIONS

These results demonstrate that outpatient mastectomy with immediate reconstruction is a safe and effective procedure for carefully selected patients. The complication rates for our patient population are similar to those in other published reports on outpatient operations, most notably, those of outpatient mastectomy without immediate reconstruction.

[Nursing care in women with breast disease: organization of a specific nurses' clinic]

Breast surgery can be highly stressful for women due to the high symbolic value that it represents in bio-psycho-social terms. Before setting up a nurses' breast disease clinic, nurses felt that women were being discharged after surgery with excessive worries and doubts. The aim of this study was to describe the organization, structure, functions, and activities of the nurses' breast disease clinic in Hospital Palmós (Gerona, Spain) between 2002-2005, as well as to promote this kind of clinic. The clinic provides postsurgical care, health education, and psychological support, thus contributing to the integral care of women with this important health problem. The clinic is a resource for the follow-up of patients with breast disease. Moreover, it facilitates outpatient surgical treatment and early discharge and reduces mean length of hospital stay.

Introduction of a breast cancer care programme including ultra short hospital stay in 4 early adopter centres: framework for an implementation study

Background

Whereas ultra-short stay (day care or 24 hour hospitalisation) following breast cancer surgery was introduced in the US and Canada in the 1990s, it is not yet common practice in Europe. This paper describes the design of the MaDO study, which involves the implementation of ultra short stay admission for patients after breast cancer surgery, and evaluates whether the targets of the implementation strategy are reached. The ultra short stay programme and the applied implementation strategy will be evaluated from the economic perspective.

Methods/design

The MaDO study is a pre-post-controlled multi-centre study, that is performed in four hospitals in the Netherlands. It includes a pre and post measuring period of six months each with six months of implementation in between in at least 40 patients per hospital per measurement period.

Primary outcome measure is the percentage of patients treated in ultra short stay. Secondary endpoints are the percentage of patients treated according to protocol, degree of involvement of home care nursing, quality of care from the patient's perspective, cost-effectiveness of the ultra short stay programme and cost-effectiveness of the implementation strategy. Quality of care will be measured by the QUOTE-breast cancer instrument, cost-effectiveness of the ultra short stay programme will be measured by means of the EuroQol (administered at four time-points) and a cost book for patients. Cost-effectiveness analysis will be performed from a societal perspective. Cost-effectiveness of the implementation strategy will be measured by determination of the costs of implementation activities.

Discussion

This study will reveal barriers and facilitators for implementation of the ultra short stay programme. Moreover, the results of the study will provide information about the cost-effectiveness of the ultra short stay programme and the implementation strategy.

Trial registration

Current Controlled Trials ISRCTN77253391.

Evaluation of a Telephone Call Service for Ambulatory Surgery Patients in Taiwan

The purpose of this study was to evaluate the outcomes of a telephone call service (TCS) for ambulatory surgery patients. Three outcomes were evaluated: patient satisfaction, patients' perceptions of the value of a TCS intervention, and nurses' perceptions of difficulties in implementing it. The results indicated that patients were satisfied with the TCS intervention and were positive about its value. Nurses indicated that the main difficulties in implementing the TCS were their lack of knowledge in answering patients' questions and time limitations.

Differences in prevalence rates of psychological distress and mental disorders in inpatients and outpatients with breast and gynaecological cancer

Research has demonstrated that in a significant number of patients, mental disorders occur with cancer. However, it is not known whether there is a difference for comorbidity in patients who are treated in hospitals versus outpatient care. The present study initially screened patients for psychological distress and quality of life with breast and gynaecological cancer. Instruments used were the General Health Questionnaire-12 and the Hospital Anxiety and Depression Scale, and for quality of life, the SF-36 Health Survey was used. In the next stage, a subsample of patients was assessed with standardized clinical interview (Composite International Diagnostic Interview) for the detection of mental disorders according to the Diagnostic and Statistical Manual of Mental Disorders, 4(th) Edn. The frequency of psychologically distressed patients in inpatient care is about 10% higher than in outpatient care. A higher risk (OR = 1.2-2.0) for mental disorders is found for inpatients compared with outpatients in all prevalence periods. Although differences in psychological distress, quality of life and prevalences of mental disorders failed to achieve statistical significance, the descriptive results indicate that inpatients with breast or gynaecological cancer suffer more often from psychological distress and comorbid mental disorders than outpatients. Outpatient treatment can therefore be considered as an important alternative to inpatient care, as patients with comparable disease severity adjust similarly or even better without full hospital care.

Omission of fentanyl during sevoflurane anesthesia decreases the incidences of postoperative nausea and vomiting and accelerates postanesthesia recovery in major breast cancer surgery

PURPOSE

Our purpose was to investigate the effect of omission of fentanyl during sevoflurane anesthesia on the incidences of postoperative nausea and vomiting and on postanesthesia recovery in female patients undergoing major breast cancer surgery.

METHODS

Female patients (American Society of Anesthesiologists [ASA] physical status [PS] class I-II; age, 28-84 years) undergoing major breast cancer surgery were randomized to one of two anesthesia maintenance groups: sevoflurane-fentanyl anesthesia (SF; n = 25) or fentanyl-free sevoflurane anesthesia (S; n = 26). All patients were administered with propofol 2 mg x kg(-1) intravenously for anesthesia induction, a laryngeal mask airway was placed, and they received rectal diclofenac and local infiltration anesthesia. Anesthesia was maintained with sevoflurane in oxygen-air and they breathed spontaneously. The patients in group SF received fentanyl 0.1 mg intravenously and those in group S received normal saline during anesthesia.

RESULTS

Group SF revealed higher incidences of postoperative nausea (68% vs 27%) and vomiting (32% vs 8%) in the first 24 postoperative hours than group S. The median (25th-75th percentile) length of time from postanesthesia care unit (PACU) admission to ambulation was significantly longer in group SF (n = 23) at 195 min (158-219 min), than in group S, at 141 min (101-175 min). Two patients in group SF could not walk during the PACU stay.

CONCLUSION

Omission of fentanyl during sevoflurane anesthesia, combined with diclofenac and local infiltration anesthesia, decreases the incidences of postoperative nausea and vomiting and accelerates postanesthesia recovery in patients undergoing major breast cancer surgery.

Nocturnal episodic hypoxemia after ambulatory breast cancer surgery: comparison of sevoflurane and propofol-fentanyl anesthesia

PURPOSE

To study the incidence and severity of nocturnal episodic hypoxemia after ambulatory breast cancer surgery and its differences with sevoflurane and propofol anesthesia.

METHODS

Sixty-one adult female patients (ASA PS I-II; age, 32-77 years) without an apparent history of sleep apnea and respiratory disease undergoing major breast cancer surgery on an outpatient basis and with planned overnight admission were randomized to one of two anesthesia maintenance groups: sevoflurane anesthesia (SEV, n = 31) or intravenous propofol, fentanyl, and vecuronium anesthesia (TIVA, n = 30). All patients were administered propofol 2 mg x kg(-1) intravenously for anesthesia induction, had a laryngeal mask airway placed, and received rectal diclofenac and local infiltration anesthesia for pain relief. No opioid analgesic or oxygen was administered after discharge from the postanesthesia care unit (PACU). Oxygen saturation (Sp(O) (2)) was recorded continuously during the first postoperative night. Sp(O) (2) <90% that lasted >10 s was regarded as hypoxemia, and the percentage of effective recording time with Sp(O) (2) <90% (%time with Sp(O) (2) <90) was evaluated.

RESULTS

Six patients (SEV3/TIVA3) had >1% of %time with Sp(O) (2) <90 (S-hypoxemia group), 17 (SEV7/TIVA10) had >0% and <or=1% (M-Hypoxemia group), and 38 (SEV21/TIVA17) had 0% (no-hypoxemia group). There were no statistical differences in age, ASA PS, anesthesia technique, and duration of anesthesia among groups. The S-hypoxemia group had higher body mass index (BMI) and incidence of oxygen supplementation in the PACU than the no-hypoxemia group. No patient had major complications.

CONCLUSION

Nocturnal episodic hypoxemia occurs frequently after ambulatory breast cancer surgery. The incidence was not different between SEV and TIVA. Hypoxic patients had a higher BMI and needed oxygen therapy in PACU more frequently.

Conservative treatment for infiltrating breast cancer. Ten years follow-up experience

INTRODUCTION

We retrospectively analyze our experience in conservative treatment for infiltrating advanced breast cancer before implementation of selective sentinel node biopsy, specially focusing on characteristics, incidence, treatment and evolution of local-regional recurrences, disease-free survival time, overall survival and patient's satisfaction.

MATERIAL AND METHODS

From January 1984 to 31st December 1998, 739 female patients were operated in our institution, diagnosed as having infiltrating breast cancer. One hundred and eighty-eight patients (25.43%) received conservative treatment and they were followed up until December 2003.

RESULTS

Average age when diagnosed was 50.42 years old (24-87 years). 53.19% of the patients were premenopausal. After a median follow-up of 129 months (60-198 months), 13 women (6.91%) presented local -regional recurrence and the disease-free time was 48.4 months (8-108 months). Global survival rate was 83.5% and disease free survival rate was 80.85%.

CONCLUSIONS

The management of choice for early stage (I and II) infiltrating breast cancer is nowadays conservative, with a low local-regional recurrence rate and survival rate that are comparable to radical mastectomy, according to the literature. It's a safe and efficient method that let us preserve the breast with a good esthetical result. In selected cases, when a regional recurrence occurs, a second conservative management is possible with a good control of the disease, although the most widely accepted treatment in these cases is total mastectomy.

Post-operative care and patient satisfaction after ambulatory surgery for breast cancer patients

AIM

This study aimed to evaluate patient information provided, the management of post-operative symptoms and post-operative care, and patient satisfaction with ambulatory breast surgery over a 1-year period.

METHODS

From January to December 2000, all breast cancer patients undergoing conservative breast surgery were offered surgery as an outpatient procedure at the Ambulatory Surgery Unit.

RESULTS

Two hundred and thirty six patients underwent outpatient surgery. None were readmitted during the first night or the first week. Two hundred and nineteen patients completed a questionnaire. One hundred and sixty nine patients (group 1) underwent wide local excision (WLE) and 50 (group 2), WLE and axillary lymphadenectomy. Patients in group 2 experienced more pain at discharge from the hospital (p < or = 0.01) and during the first week after discharge (p < or = 0.00001) than patients in group 1. The mean overall satisfaction score was 8.97 on a scale of 1-10. Post-operative information provided by the surgeon before discharge from the hospital was rated 8.90 on a scale of 1-10 while information provided by the nurse was rated 9.33 (p < 0.0001).

CONCLUSION

Ambulatory surgery for breast cancer patients is safe and popular with patients, however, post-operative pain presents problem.

Seroma formation after axillary lymphadenectomy with and without the use of drains

Seroma formation after axillary lymphadenectomy is common. We performed a randomised controlled trial comparing seroma rate and volume after axillary lymphadenectomy with and without use of drains. In this study, there was no difference in incidence of seroma formation between patients who did and did not have a drain inserted after axillary lymphadenectomy for breast cancer. Undrained patients, however, had larger volume seromas of longer duration which required more aspirations. There was a tendency for undrained patients to have fewer complications when compared to patients with drains.

Experiences and resources of breast cancer patients in short-stay surgery

Aimed at increasing the understanding and improving the quality of nursing care for breast cancer patients in short-stay surgery, this qualitative study set out to describe the experiences and, the intra- and extra-personal coping resources these patients. The data were collected among eight breast cancer patients (n = 8). On the whole the patients described short-stay surgery as a positive experience. They felt they had been discharged at the right time. The patients thought they had coped well and received valuable emotional, informational and instrumental support from health care personnel at each phase of the illness process. The breast cancer coordinator, in particular, served as a safety net for the patients. Informational support from health care personnel was considered adequate at the illness phase, but there was evidence of some lack of information at the care phase and current phase. Lack of knowledge about follow-up treatment was a major source of fear and anxiety for the patients. Later on, family members and friends served as important extra-personal coping resources, providing emotional and instrumental support. In addition, the patients' own intra-personal coping resources were essential during all the phases.