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Losk K, Freedman RA, Laws A, Kantor O, Mittendorf EA, Tan-Wasielewski Z, Trippa L, Lin NU, Winer EP, King TA. Oncotype DX testing in node-positive breast cancer strongly impacts chemotherapy use at a comprehensive cancer center. Breast Cancer Res Treat 2020; 185:215-227. [PMID: 32939592 DOI: 10.1007/s10549-020-05931-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 09/05/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE In 2016, we initiated standardized "reflex" Oncotype DX Recurrence Score (RS) testing for patients ≤ 65 years with pT1-2N0-1 HR+/HER2- breast cancer. Here, we examine RS testing patterns, RS distribution, and factors associated with chemotherapy use in patients with pN1 breast cancer. METHODS Patients with stage I-III HR+/HER2- pN1 breast cancer treated with upfront surgery from February 2016 to March 2019 were identified. Clinical characteristics were compared between patients meeting reflex RS testing criteria, those with RS ordered outside of reflex criteria, and those without RS testing. RS was categorized as low (< 18), intermediate (18-30), and high (≥ 31). Multivariate logistic regression was performed to identify factors associated with adjuvant chemotherapy receipt. We examined 3-year recurrence-free survival (RFS) and overall survival (OS) stratified by chemotherapy use. RESULTS We identified 347 HR+/HER2- pN1 patients; 272 (78.4%) received RS testing, and 194 (71.3%) met reflex criteria. RS was < 18 in 164 (61.4%) patients, 18-30 in 89 (32.7%) patients, and ≥ 31 in 16 (5.9%) patients. On multivariate analysis, RS < 18 (OR 0.47, 95% CI 0.24-0.92) was associated with lower odds of chemotherapy use, whereas presence of lymphovascular invasion (OR 1.77, 95% CI 1.03-3.07) and lobular subtype (OR 2.40, 95% CI 1.21-4.78) were associated with higher odds. No differences in 3-year RFS (p = 0.97) or OS (p = 0.19) based on chemotherapy receipt were observed. CONCLUSION Most RS-tested HR+/HER2- pN1 patients at our center had low genomic risk. A low RS independently influenced chemotherapy omission and in RS-tested patients, short-term outcomes were excellent. Our study demonstrates increased use of RS in guiding adjuvant treatment decisions in node-positive disease.
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Affiliation(s)
- Katya Losk
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA, 02215, USA. .,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.
| | - Rachel A Freedman
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA, 02215, USA.,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Alison Laws
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Olga Kantor
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Elizabeth A Mittendorf
- Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Lorenzo Trippa
- Department of Biostatistics, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Nancy U Lin
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA, 02215, USA.,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Eric P Winer
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA, 02215, USA.,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Tari A King
- Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
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Mallory MA, Valero MG, Hu J, Barry WT, Losk K, Nimbkar S, Golshan M. Bilateral mastectomy operations and the role for the cosurgeon technique: A Nationwide analysis of surgical practice patterns. Breast J 2019; 26:220-226. [PMID: 31498509 DOI: 10.1111/tbj.13522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 06/13/2019] [Accepted: 06/13/2019] [Indexed: 11/30/2022]
Abstract
Traditionally, bilateral mastectomy (BM) operations are performed by a single surgeon but a two-attending co-surgeon technique (CST) has been described. A questionnaire was sent to members of the American Society of Breast Surgeons to assess national BM practices and analyze utilization and perceived benefits of the CST. Among surgeons responding, most continue to use the single-surgeon approach for BMs; however, 14.1% utilize the CST and up to 31% are interested in future CST use. Time savings, mentorship, cost savings, and opportunity to learn new techniques were identified as perceived CST advantages.
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Affiliation(s)
- Melissa Anne Mallory
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Monica G Valero
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jiani Hu
- Department of Biostatistics & Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - William T Barry
- Department of Biostatistics & Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Katya Losk
- Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts
| | - Suniti Nimbkar
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Mehra Golshan
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
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Losk K, Freedman RA, Mittendorf EA, Tan-Wasielewski Z, Trippa L, King TA. Oncotype DX testing in early-stage node-positive breast cancer and impact on chemotherapy use at a comprehensive cancer center. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
549 Background: The 21-gene Oncotype DX Recurrence Score (RS) is widely used to guide adjuvant chemotherapy decisions in hormone receptor positive (HR+), HER2-negtive (HER2-), lymph node negative (LN-) breast cancer. It’s adoption in lymph node positive (LN+) disease remains controversial. In 2016, we implemented ‘reflex’ RS testing for patients ≤65 years with HR+/HER2- breast cancer including T1/T2 N1 (grade 1 or 2) tumors. Providers can also order Oncotype DX outside of reflex criteria. We sought to assess RS distribution and factors associated with chemotherapy use in HR+/HER2-/LN+ breast cancer patients at our center. Methods: Patients with non-metastatic HR+/HER2-/LN+ breast cancer who underwent primary surgery at our center were identified from our prospective database. We examined the distribution of low (RS < 18), intermediate (RS 18-30) and high (RS > 30) RS and identified characteristics for those who did not meet reflex criteria. A multinomial logistic regression model was performed to identify factors associated with chemotherapy receipt among all LN+ patients. Results: From 1/2016-3/2018, we identified 296 consecutive patients with HR+/HER2-/LN+ breast cancer. 200 (68%) patients had RS testing and 128 (64%) met reflex criteria. Reasons for not meeting RS reflex criteria included age > 65 (n = 35), grade III disease (n = 35) and N2/N3 tumors (n = 10). Among the 200 patients with RS, 122 (61%) had RS < 18, 67 (34%) had RS 18-30, and 11 (6%) had RS > 30. Only 68/200 (34%) patients with RS received chemotherapy as compared to 54/96 (56%) patients without RS (p = 0.0004). Compared to patients without RS testing, the odds of receiving chemotherapy were less with RS < 18 (OR = 0.46). The odds of receiving chemotherapy were greater with ≥3 positive LNs versus 1 positive LN (OR = 3.40). Conclusions: The majority of HR+/HER2-/LN+ patients undergoing upfront surgery at our center receive RS testing (200/296), with 122 (61%) resulting in low risk RS. Patients with low risk scores (RS < 18) were less likely to receive chemotherapy. While nodal involvement remains a common driver of chemotherapy use, our study demonstrates that RS testing provides clinically useful information in this population.
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Affiliation(s)
- Katya Losk
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Rachel A. Freedman
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Elizabeth A. Mittendorf
- Division of Breast Surgery, Department of Surgery, BWH, Breast Oncology Program, Dana-Farber/Brigham and Women’s Cancer Center, Boston, MA
| | | | - Lorenzo Trippa
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, MA
| | - Tari A. King
- Division of Breast Surgery, Department of Surgery, BWH; Breast Oncology Program, Dana-Farber/Brigham and Women’s Cancer Center, Boston, MA
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Whorms DS, Giess CS, Golshan M, Freedman RA, Bunnell CA, Alper EC, Losk K, Khorasani R. Clinical Impact of Second Opinion Radiology Consultation for Patients With Breast Cancer. J Am Coll Radiol 2018; 16:814-823. [PMID: 30579707 DOI: 10.1016/j.jacr.2018.10.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 10/06/2018] [Accepted: 10/14/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE To assess the incidence and clinical significance of discrepancy in subspecialty interpretation of outside breast imaging examinations for newly diagnosed breast cancer patients presenting to a tertiary cancer center. MATERIALS AND METHODS This Institutional Review Board-approved retrospective study included patients presenting from July 2016 to March 2017 to a National Cancer Institute-designated comprehensive cancer center for second opinion after breast cancer diagnosis. Outside and second opinion radiology reports of 252 randomly selected patients were compared by two subspecialty breast radiologists to consensus. A peer review score was assigned, modeled after ACR's RADPEERTM peer review metric: 1-agree; 2-minor discrepancy (unlikely clinically significant); 3-moderate discrepancy (may be clinically significant); 4-major discrepancy (likely clinically significant). Among cases with clinically significant discrepancies, rates of clinical management change (management alterations including change in follow-up, neoadjuvant therapy use, and surgical management as a direct result of image review), and detection of additional malignancy were assessed through electronic medical record review. RESULTS A significant difference in interpretation (scores = 3 or 4) was seen in 41 of 252 cases (16%, 95% confidence interval [CI], 11.7%-20.8%). The difference led to additional workup in 38 of 252 cases (15%, 95% CI 10.6%-19.5%) and change in clinical management in 18 of 252 cases (7.1%, 95% CI 4.0%-10.2%), including 15 of 252 with change in surgical management (6.0%, 95% CI, 3.0%-8.9%). An additional malignancy or larger area of disease was identified in 11 of 252 cases (4.4%, 95% CI, 1.8%-6.9%). CONCLUSION Discrepancy between outside and second-opinion breast imaging subspecialists frequently results in additional workup for breast cancer patients, changes in treatment plan, and identification of new malignancies.
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Affiliation(s)
- Debra S Whorms
- Center for Evidence-Based Imaging and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
| | - Catherine S Giess
- Center for Evidence-Based Imaging and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts; Dana-Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Mehra Golshan
- Dana-Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Rachel A Freedman
- Dana-Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Craig A Bunnell
- Dana-Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Emily C Alper
- Center for Evidence-Based Imaging and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Katya Losk
- Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Ramin Khorasani
- Center for Evidence-Based Imaging and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
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Natsuhara KH, Losk K, King TA, Lin NU, Camuso K, Golshan M, Pochebit S, Brock JE, Bunnell CA, Freedman RA. Impact of Genomic Assay Testing and Clinical Factors on Chemotherapy Use After Implementation of Standardized Testing Criteria. Oncologist 2018; 24:595-602. [PMID: 30076279 DOI: 10.1634/theoncologist.2018-0154] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 06/14/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND For clinically appropriate early-stage breast cancer patients, reflex criteria for Oncotype DX ordering ("the intervention") were implemented at our comprehensive cancer center, which reduced time-to-adjuvant chemotherapy initiation. Our objective was to evaluate Oncotype DX ordering practices and chemotherapy use before and after implementation of the intervention. MATERIALS AND METHODS We examined medical records for 498 patients who had definitive breast cancer surgery at our center. The post-intervention cohort consisted of 232 consecutive patients who had Oncotype DX testing after reflex criteria implementation. This group was compared to a retrospective cohort of 266 patients who were diagnosed and treated prior to reflex criteria implementation, including patients who did and did not have Oncotype DX ordered. Factors associated with Oncotype DX ordering pre- and post-intervention were examined. We used multivariate logistic regression to evaluate factors associated with chemotherapy receipt among patients with Oncotype DX testing. RESULTS The distribution of Oncotype DX scores, the proportion of those having Oncotype DX testing (28.9% vs. 34.1%) and those receiving chemotherapy (14.3% vs. 19.4%), did not significantly change between pre- and post-intervention groups. Age ≤65 years, stage II, grade 2, 1-3+ nodes, and tumor size >2 cm were associated with higher odds of Oncotype DX testing. Among patients having Oncotype DX testing, node status and Oncotype DX scores were significantly associated with chemotherapy receipt. CONCLUSION Our criteria for reflex Oncotype DX ordering appropriately targeted patients for whom Oncotype DX would typically be ordered by providers. No significant change in the rate of Oncotype DX ordering or chemotherapy use was observed after reflex testing implementation. IMPLICATIONS FOR PRACTICE This study demonstrates that implementing multidisciplinary consensus reflex criteria for Oncotype DX ordering maintains a stable Oncotype DX ordering rate and chemotherapy rate, mirroring what was observed in a specific clinical practice, while decreasing treatment delays due to additional testing. These reflex criteria appropriately capture patients who would likely have had Oncotype DX ordered by their providers and for whom the test results are predicted to influence management. This intervention serves as a potential model for other large integrated, multidisciplinary oncology centers to institute processes targeting patient populations most likely to benefit from genomic assay testing, while mitigating treatment delays.
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Affiliation(s)
| | - Katya Losk
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Tari A King
- Surgical Oncology, Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts, USA
| | - Nancy U Lin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Kristen Camuso
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Mehra Golshan
- Surgical Oncology, Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts, USA
| | - Stephen Pochebit
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jane E Brock
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Craig A Bunnell
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Rachel A Freedman
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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Moossdorff M, Nakhlis F, Hu J, Barry WT, Losk K, Haskett C, Smidt ML, King TA. The Potential Impact of AMAROS on the Management of the Axilla in Patients with Clinical T1-2N0 Breast Cancer Undergoing Primary Total Mastectomy. Ann Surg Oncol 2018; 25:2612-2619. [PMID: 29855827 DOI: 10.1245/s10434-018-6519-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Indexed: 01/25/2023]
Abstract
BACKGROUND Recent trials have demonstrated that axillary observation or axillary radiation therapy (AxRT) is equivalent to axillary node dissection (ALND) for patients with one or two positive sentinel lymph nodes (SLNs). These strategies have been widely adopted for patients having breast conservation. This report demonstrates the potential impact of the AMAROS trial on axillary therapy in a retrospective cohort of mastectomy patients. METHODS Patients undergoing primary mastectomy for cT1-2N0 breast cancer who had one or two positive SLNs were identified from institutional databases (2005-2015). Locoregional management strategies were evaluated, and variables predictive of the use of postmastectomy radiation therapy (PMRT) were identified. RESULTS Among 2594 mastectomies, 193 (7%) met the AMAROS eligibility criteria. The median patient age was 50 years (range 22-83 years). Locoregional treatment consisted of ALND + PMRT for 102 patients (53%), ALND alone for 66 patients (34%), PMRT alone for 11 patients (6%), and observation for 14 patients (7%). Overall, 59 ALND patients (35%) had additional positive nodes. In the multivariate analysis, age younger than 50 years (odds ratio [OR] 3.55; 95% confidence interval [CI] 1.57-8.45), lymphovascular invasion (LVI) (OR 5.78; 95% CI 2.53-4.78), macrometastases (OR 3.99; 95% CI 1.54-10.97), and extracapsular extension (OR 11.66; 95% CI 2.55-88.34) were associated with receipt of PMRT. CONCLUSION In this cohort of AMAROS-eligible patients, 168 (87%) underwent ALND, 102 (61%) of whom also received PMRT, suggesting that AxRT could have been used instead of ALND for a significant number of patients. Preoperative factors associated with the receipt of PMRT, such as young age and LVI, may be useful for defining a multidisciplinary decision-making framework for axillary management in this population.
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Affiliation(s)
- Martine Moossdorff
- Department of Surgery, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Faina Nakhlis
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.,Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Jiani Hu
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - William T Barry
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Katya Losk
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Courtney Haskett
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Marjolein L Smidt
- Department of Surgery, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Tari A King
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA. .,Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.
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Valero MG, Mallory MA, Losk K, Tukenmez M, Hwang J, Camuso K, Bunnell C, King T, Golshan M. Surgeon Variability and Factors Predicting for Reoperation Following Breast-Conserving Surgery. Ann Surg Oncol 2018; 25:2573-2578. [PMID: 29786129 DOI: 10.1245/s10434-018-6526-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND Reoperation after breast-conserving surgery (BCS) is common and has been partially associated with the lack of consensus on margin definition. We sought to investigate factors associated with reoperations and variation in reoperation rates across breast surgeons at our cancer center. METHODS Retrospective analyses of patients with clinical stage I-II breast cancer who underwent BCS between January and December 2014 were conducted prior to the recommendation of 'no ink on tumor' margin. Patient demographics and tumor and surgical data were extracted from medical records. A multivariate regression model was used to identify factors associated with reoperation. RESULTS Overall, 490 patients with stage I (n = 408) and stage II (n = 89) breast cancer underwent BCS; seven patients had bilateral breast cancer and underwent bilateral BCS procedures. Median invasive tumor size was 1.1 cm, reoperation rate was 22.9% (n = 114) and varied among surgeons (range 15-40%), and, in 100 (88%) patients, the second procedure was re-excision, followed by unilateral mastectomy (n = 7, 6%) and bilateral mastectomy (n = 7, 6%). Intraoperative margin techniques (global cavity or targeted shaves) were utilized in 50.1% of cases, while no specific margin technique was utilized in 49.9% of cases. Median total specimen size was 65.8 cm3 (range 24.5-156.0). In the adjusted model, patients with multifocal disease were more likely to undergo reoperation [odds ratio (OR) 5.78, 95% confidence interval (CI) 2.17-15.42]. In addition, two surgeons were found to have significantly higher reoperation rates (OR 6.41, 95% CI 1.94-21.22; OR 3.41, 95% CI 1.07-10.85). CONCLUSIONS Examination of BCS demonstrated variability in reoperation rates and margin practices among our breast surgeons. Future trials should look at surgeon-specific factors that may predict for reoperations.
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Affiliation(s)
- Monica G Valero
- Department of Surgery, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Melissa Anne Mallory
- Department of Surgery, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Katya Losk
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, MA, USA
| | - Mustafa Tukenmez
- Department of Surgery, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA, USA
| | | | - Kristen Camuso
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, MA, USA
| | - Craig Bunnell
- Harvard Medical School, Boston, MA, USA.,Department of Medical Oncology, Dana Farber Cancer Institute, Boston, MA, USA
| | - Tari King
- Department of Surgery, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Mehra Golshan
- Department of Surgery, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA, USA. .,Harvard Medical School, Boston, MA, USA.
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Losk K, Freedman RA, Lin NU, Golshan M, Pochebit SM, Lester SC, Natsuhara K, Camuso K, King TA, Bunnell CA. Implementation of Surgeon-Initiated Gene Expression Profile Testing (Onco type DX) Among Patients With Early-Stage Breast Cancer to Reduce Delays in Chemotherapy Initiation. J Oncol Pract 2017; 13:e815-e820. [PMID: 28858535 DOI: 10.1200/jop.2017.023788] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
PURPOSE Delays to adjuvant chemotherapy initiation in breast cancer may adversely affect clinical outcomes and patient satisfaction. We previously identified an association between genomic testing (Onco type DX) and delayed chemotherapy initiation. We sought to reduce the interval between surgery and adjuvant chemotherapy initiation by developing standardized criteria and workflows for Onco type DX testing. METHODS Criteria for surgeon-initiated reflex Onco type DX testing, workflows for communication between surgeons and medical oncologists, and a streamlined process for receiving and processing Onco type DX requests in pathology were established by multidisciplinary consensus. Criteria for surgeon-initiated testing included patients ≤ 65 years old with T1cN0 (grade 2 or 3), T2N0 (grade 1 or 2), or T1/T2N1 (grade 1 or 2) breast cancer on final surgical pathology. Medical oncologists could elect to initiate Onco type testing for cases falling outside the criteria. We then examined 720 consecutive patients with breast cancer who underwent Onco type DX testing postoperatively between January 1, 2014 and November 28, 2016 and measured intervals between date of surgery, Onco type DX order date, result received date, and chemotherapy initiation date (if applicable) before and after intervention implementation. RESULTS The introduction of standardized criteria and workflows reduced time between surgery and Onco type DX ordering, and time from surgery to receipt of result, by 7.3 days ( P < .001) and 6.3 days ( P < .001), respectively. The mean number of days between surgery and initiation of chemotherapy was also reduced by 6.4 days ( P = .004). CONCLUSION Developing consensus on Onco type DX testing criteria and implementing streamlined workflows has led to clinically significant reductions in wait times to chemotherapy decision making and initiation.
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Affiliation(s)
- Katya Losk
- Dana-Farber Cancer Institute; Dana-Farber/Brigham and Women's Cancer Center; Brigham and Women's Hospital; and Harvard Medical School, Boston, MA
| | - Rachel A Freedman
- Dana-Farber Cancer Institute; Dana-Farber/Brigham and Women's Cancer Center; Brigham and Women's Hospital; and Harvard Medical School, Boston, MA
| | - Nancy U Lin
- Dana-Farber Cancer Institute; Dana-Farber/Brigham and Women's Cancer Center; Brigham and Women's Hospital; and Harvard Medical School, Boston, MA
| | - Mehra Golshan
- Dana-Farber Cancer Institute; Dana-Farber/Brigham and Women's Cancer Center; Brigham and Women's Hospital; and Harvard Medical School, Boston, MA
| | - Stephen M Pochebit
- Dana-Farber Cancer Institute; Dana-Farber/Brigham and Women's Cancer Center; Brigham and Women's Hospital; and Harvard Medical School, Boston, MA
| | - Susan C Lester
- Dana-Farber Cancer Institute; Dana-Farber/Brigham and Women's Cancer Center; Brigham and Women's Hospital; and Harvard Medical School, Boston, MA
| | - Kelsey Natsuhara
- Dana-Farber Cancer Institute; Dana-Farber/Brigham and Women's Cancer Center; Brigham and Women's Hospital; and Harvard Medical School, Boston, MA
| | - Kristen Camuso
- Dana-Farber Cancer Institute; Dana-Farber/Brigham and Women's Cancer Center; Brigham and Women's Hospital; and Harvard Medical School, Boston, MA
| | - Tari A King
- Dana-Farber Cancer Institute; Dana-Farber/Brigham and Women's Cancer Center; Brigham and Women's Hospital; and Harvard Medical School, Boston, MA
| | - Craig A Bunnell
- Dana-Farber Cancer Institute; Dana-Farber/Brigham and Women's Cancer Center; Brigham and Women's Hospital; and Harvard Medical School, Boston, MA
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9
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Losk K, Freedman RA, Lin NU, Golshan M, Lester S, Pochebit S, Natsuhara K, Camuso K, King TA, Bunnell CA. Implementation of surgeon-initiated Oncotype DX ordering among patients with breast cancer to reduce chemotherapy wait times. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.8_suppl.166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
166 Background: Oncotype DX testing in breast cancer is associated with delayed chemotherapy initiation, which may adversely impact clinical outcomes and patient satisfaction. We sought to reduce delays between surgery and adjuvant chemotherapy initiation among patients who undergo Oncotype DX testing by developing standard ordering criteria and modifying surgical oncology, medical oncology, and pathology workflows. Methods: We implemented ‘reflex’ Oncotype DX testing for any patient ≤ 65 with the following tumor characteristics: T1cN0 (grade 2-3), T2N0 (grade 1-2), or T1/T2N1 (grade 1-2). A new process was developed whereby once pathology review is complete surgeons communicate the results to medical oncologists in real-time and initiate requests for Oncotype DX when appropriate. Medical oncologists can order Oncotype for cases outside the criteria. A streamlined pathology system for receiving and processing Oncotype DX requests was also developed. We then examined 649 consecutive breast cancer patients who received postoperative Oncotype DX testing and measured time intervals between surgery date, Oncotype DX order date, Oncotype DX result received date, and chemotherapy initiation date (if applicable) before and after intervention implementation. Results: The interventions reduced the turnaround time (TAT) from surgery to Oncotype DX order and time to when the results were available by 7.7 days and 6.3 days, respectively. A 6.5 day decrease in the mean time from surgery to chemotherapy initiation was observed. The decrease in the standard deviation also suggests a reduction in process variation. Conclusions: Developing Oncotype DX testing criteria and implementing streamlined workflows among providers has led to a significant reduction in Oncotype DX ordering TAT and wait times to chemotherapy initiation. [Table: see text]
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Affiliation(s)
- Katya Losk
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | | | | | - Mehra Golshan
- Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA
| | | | | | | | - Kristen Camuso
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Tari A. King
- Memorial Sloan Kettering Cancer Center, New York, NY
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10
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Losk K, Vaz-Luis I, Camuso K, Batista R, Lloyd M, Tukenmez M, Golshan M, Lin NU, Bunnell CA. Factors Associated With Delays in Chemotherapy Initiation Among Patients With Breast Cancer at a Comprehensive Cancer Center. J Natl Compr Canc Netw 2016; 14:1519-1526. [DOI: 10.6004/jnccn.2016.0163] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 08/08/2016] [Indexed: 11/17/2022]
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11
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Barroso-Sousa R, Paes FR, Vaz-Luis I, Batista RB, Costa RB, Losk K, Camuso K, Metzger-Filho O, Hughes ME, Bunnell CA, Golshan M, Winer EP, Lin NU. Variation in the use of granulocyte-colony stimulating factor for dose dense paclitaxel: A single institution retrospective study. Breast 2016; 30:136-140. [DOI: 10.1016/j.breast.2016.09.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 09/14/2016] [Accepted: 09/17/2016] [Indexed: 11/30/2022] Open
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12
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Golshan M, Losk K, Mallory MA, Camuso K, Cutone L, Caterson S, Bunnell CA. Implementation of a Breast/Reconstruction Surgery Coordinator to Reduce Preoperative Delays for Patients Undergoing Mastectomy With Immediate Reconstruction. J Oncol Pract 2016; 12:e338-43. [PMID: 26883406 PMCID: PMC4960471 DOI: 10.1200/jop.2015.008672] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Mastectomy with immediate reconstruction (MIR) requires coordination between breast and reconstructive surgical teams, leading to increased preoperative delays that may adversely impact patient outcomes and satisfaction. Our cancer center established a target of 28 days from initial consultation with the breast surgeon to MIR. We sought to determine if a centralized breast/reconstructive surgical coordinator (BRC) could reduce care delays. METHODS A 60-day pilot to evaluate the impact of a BRC on timeliness of care was initiated at our cancer center. All reconstructive surgery candidates were referred to the BRC, who had access to surgical clinic and operating room schedules. The BRC worked with both surgical services to identify the earliest surgery dates and facilitated operative bookings. The median time to MIR and the proportion of MIR cases that met the time-to-treatment goal was determined. These results were compared with a baseline cohort of patients undergoing MIR during the same time period (January to March) in 2013 and 2014. RESULTS A total of 99 patients were referred to the BRC (62% cancer, 21% neoadjuvant, 17% prophylactic) during the pilot period. Focusing exclusively on patients with a cancer diagnosis, an 18.5% increase in the percentage of cases meeting the target (P = .04) and a 7-day reduction to MIR (P = .02) were observed. CONCLUSION A significant reduction in time to MIR was achieved through the implementation of the BRC. Further research is warranted to validate these findings and assess the impact the BRC has on operational efficiency and workflows.
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Affiliation(s)
- Mehra Golshan
- Brigham and Women's Hospital; and Dana-Farber Cancer Institute, Boston, MA
| | - Katya Losk
- Brigham and Women's Hospital; and Dana-Farber Cancer Institute, Boston, MA
| | - Melissa A Mallory
- Brigham and Women's Hospital; and Dana-Farber Cancer Institute, Boston, MA
| | - Kristen Camuso
- Brigham and Women's Hospital; and Dana-Farber Cancer Institute, Boston, MA
| | - Linda Cutone
- Brigham and Women's Hospital; and Dana-Farber Cancer Institute, Boston, MA
| | - Stephanie Caterson
- Brigham and Women's Hospital; and Dana-Farber Cancer Institute, Boston, MA
| | - Craig A Bunnell
- Brigham and Women's Hospital; and Dana-Farber Cancer Institute, Boston, MA
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Losk K, Vaz Duarte Luis I, Camuso K, Lloyd M, Kadish S, Hirshfield-Bartek J, Cutone L, Golshan M, Lin N, Bunnell C. Abstract P1-12-08: Factors associated with delays in chemotherapy initiation among patients with breast cancer. Cancer Res 2016. [DOI: 10.1158/1538-7445.sabcs15-p1-12-08] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: National guidelines endorse time-dependent quality metrics for breast cancer care. We examined factors associated with delays in chemotherapy initiation at an NCI designated comprehensive cancer center.
Methods: We identified 523 patients who received post-operative adjuvant chemotherapy between January 2011 and December 2013 at our center. We defined 28 days from last definitive surgery (LDS) to chemotherapy as the target timeframe, and unacceptable delay in chemotherapy initiation (UCD) as more than 42 days from LDS. Multivariate regression models were used to identify factors associated with UCD and the impact of Oncotype testing in HR+ patients.
Results: Median days between LDS and chemotherapy initiation was 34 (IQR 15), with 30% of patients starting within 28 days of LDS and 23% having UCD (Table 1). Tumor characteristics such as subtype and stage affected UCD; patients with HR+ or HER2+ tumors were more likely to be delayed compared to those with TNBC. Patients with stage I disease were more likely to be delayed as well as patients undergoing mastectomy or mastectomy with reconstruction. Patients whose pathology sign-out was more than 10 days post-operatively were more likely to be delayed. A higher proportion of UCD was found in HR+ patients (31%) who received an Oncotype recurrence score compared to those who did not (20%).
Table 1: Factors associated with delays in chemotherapy initiation N% DelayOdds Ratio95% CITotal52323 Age<4068191.00.5-2.340 to 49165161.0--50 to 59150252.01.1-3.660 to 69113282.51.3-5.070+27374.11.4-12.3RaceWhite424221.0--Non-White79271.50.8-2.7Missing20251.10.4-3.3InsurancePrivate419211.0--Public104321.60.8-2.9StageI208211.0--II243281.30.8-2.1III72110.30.1-0.7Tumor SubtypeHER2-/HR-105151.0--HR+HER2-264242.11.1-4.2HER2+154272.01.0-3.9Surgery TypeLumpectomy265161.0--Mastectomy89292.51.3-4.5Mastectomy with Immediate Reconstruction169313.31.9-5.6Pathology Sign-Out (>10 days)No331191.0--Yes192322.01.3-3.2Post-Op ComplicationsNo506221.0--Yes17412.20.7-6.6Clinical trial considerationNo435231.0--Yes88240.90.5-17
Conclusions: This study provides insight into populations that may be at risk to experience delays in chemotherapy initiation, directing interventions to improve the timeliness of care.
Citation Format: Losk K, Vaz Duarte Luis I, Camuso K, Lloyd M, Kadish S, Hirshfield-Bartek J, Cutone L, Golshan M, Lin N, Bunnell C. Factors associated with delays in chemotherapy initiation among patients with breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-12-08.
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Affiliation(s)
- K Losk
- Dana-Farber Cancer Institute, Boston, MA
| | | | - K Camuso
- Dana-Farber Cancer Institute, Boston, MA
| | - M Lloyd
- Dana-Farber Cancer Institute, Boston, MA
| | - S Kadish
- Dana-Farber Cancer Institute, Boston, MA
| | | | - L Cutone
- Dana-Farber Cancer Institute, Boston, MA
| | - M Golshan
- Dana-Farber Cancer Institute, Boston, MA
| | - N Lin
- Dana-Farber Cancer Institute, Boston, MA
| | - C Bunnell
- Dana-Farber Cancer Institute, Boston, MA
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Losk K, Mallory M, Caterson S, Camuso K, Cutone L, Roberts P, Lin N, Bunnell C, Golshan M. Abstract P2-13-12: Implementation of a breast/reconstructive surgery coordinator to reduce preoperative delays for patients undergoing mastectomy with immediate reconstruction. Cancer Res 2016. [DOI: 10.1158/1538-7445.sabcs15-p2-13-12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background
The scheduling of mastectomy with immediate reconstruction (M-IR) procedures requires coordination between breast and plastic surgical teams that can contribute to delays in breast cancer treatment and subsequently impact patient outcomes and satisfaction. The breast center leadership at our comprehensive cancer center established a time-to-treatment target of 28 days from initial consultation with a breast surgical oncologist to M-IR. We sought to determine if a centralized breast surgical coordinator (BC) could reduce preoperative delays.
Methods
We initiated a 60-day pilot program to evaluate the impact of a BC on the workflow, efficiency, and timeliness for patients seen at our breast center. All reconstructive surgery candidates were referred to the BC, who had access to the clinic and operating room schedules of the breast and plastic surgeons. The BC worked with patients and both surgical services to identify the earliest consult and surgery dates and facilitated case booking. Interval days between initial surgical consult and M-IR were calculated. The median time to M-IR and the proportion of M-IR cases that met the time-to-treatment goal was determined. These results were compared to a reference cohort of breast cancer patients undergoing M-IR during the same time period (January-March) in 2013 and 2014, who had their consults and surgeries scheduled independently by breast surgery administrative staff. Patients who received neoadjuvant therapy or did not have a definitive cancer diagnosis at initial consultation were excluded from the time-to-treatment calculation.
Results
A total of 99 patients were referred to the BC (62% cancer, 21% neoadjuvant, and 17% prophylactic) during the pilot period. Focusing exclusively on patients with a definitive breast cancer diagnosis at initial consultation, an 18.5% increase in the percentage of cases that met the target (p=0.04), and a 7 day decrease in the median number of days to M-IR (p=0.02) was observed with the implementation of the BC (Table 1).
Table 1: Days to M-IR Pre and Post Implementation of BCPatients (N)Median Days to M-IR (IQR)% M-IR within 28 daysBaseline (59)40.0 (17.0)23.7%BC (45)33.0 (20.0)42.2%p-value0.020.04
Conclusion
The coordination of care between breast surgical and reconstructive services presents timeliness challenges which may be partially alleviated through the implementation of a BC role. Establishing a centralized position to coordinate co-surgeon cases has improved time-to-treatment for M-IR at our cancer center. Further research is warranted to validate these preliminary findings, and determine the impact the BC has on operational efficiency and workflows.
Citation Format: Losk K, Mallory M, Caterson S, Camuso K, Cutone L, Roberts P, Lin N, Bunnell C, Golshan M. Implementation of a breast/reconstructive surgery coordinator to reduce preoperative delays for patients undergoing mastectomy with immediate reconstruction. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-13-12.
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Affiliation(s)
- K Losk
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hopsital, Boston, MA
| | - M Mallory
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hopsital, Boston, MA
| | - S Caterson
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hopsital, Boston, MA
| | - K Camuso
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hopsital, Boston, MA
| | - L Cutone
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hopsital, Boston, MA
| | - P Roberts
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hopsital, Boston, MA
| | - N Lin
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hopsital, Boston, MA
| | - C Bunnell
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hopsital, Boston, MA
| | - M Golshan
- Dana-Farber Cancer Institute, Boston, MA; Brigham and Women's Hopsital, Boston, MA
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Mallory MA, Losk K, Camuso K, Caterson S, Nimbkar S, Golshan M. Does "Two is Better Than One" Apply to Surgeons? Comparing Single-Surgeon Versus Co-surgeon Bilateral Mastectomies. Ann Surg Oncol 2015; 23:1111-6. [PMID: 26514122 DOI: 10.1245/s10434-015-4956-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Indexed: 01/27/2023]
Abstract
BACKGROUND Bilateral mastectomies (BM) are traditionally performed by single surgeons (SS); a co-surgeon (CS) technique, where each surgeon concurrently performs a unilateral mastectomy, offers an alternative approach. We examined differences in general surgery time (GST), overall surgery time (OST), and patient complications for BM performed by CS and SS. METHODS Patients undergoing BM with tissue expander reconstruction (BMTR) between January 2010 and May 2014 at our center were identified through operative case logs. GST (incision to end of BM procedure), reconstruction duration (RST) (plastic surgery start to end of reconstruction) and OST (OST = GST + RST) was calculated. Patient age, presence/stage of cancer, breast weight, axillary procedure performed, and 30-day postoperative complications were extracted from medical records. Differences in GST and OST between CS and SS cases were assessed with a t test. A multivariate linear regression was fit to identify factors associated with GST. RESULTS A total of 116 BMTR cases were performed [CS, n = 67 (57.8 %); SS, n = 49 (42.2 %)]. Demographic characteristics did not differ between groups. GST and OST were significantly shorter for CS cases, 75.8 versus 116.8 min, p < .0001, and 255.2 versus 278.3 min, p = .005, respectively. Presence of a CS significantly reduces BMTR time (β = -38.82, p < .0001). Breast weight (β = 0.0093, p = .03) and axillary dissection (β = 28.69, p = .0003) also impacted GST. CONCLUSIONS The CS approach to BMTR reduced both GST and OST; however, the degree of time savings (35.1 and 8.3 %, respectively) was less than hypothesized. A larger study is warranted to better characterize time, cost, and outcomes of the CS-approach for BM.
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Affiliation(s)
- Melissa Anne Mallory
- Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA.,Department of Surgery, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Katya Losk
- Department of Quality and Patient Safety, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Kristen Camuso
- Department of Quality and Patient Safety, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Stephanie Caterson
- Division of Plastic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Suniti Nimbkar
- Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
| | - Mehra Golshan
- Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA. .,Department of Surgery, Dana-Farber Cancer Institute, Boston, MA, USA.
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16
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Nimbkar S, Mallory MA, Losk K, Camuso K, Golshan M. Does “two is better than one” apply to surgeons? Comparing single-surgeon and cosurgeon bilateral mastectomy outcomes. J Clin Oncol 2015. [DOI: 10.1200/jco.2015.33.28_suppl.35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
35 Background: Bilateral mastectomies (BM) are generally performed by a single surgeon (SS). A two-attending ‘co-surgeon’ (CS) technique, in which each surgeon concurrently performs a unilateral mastectomy, offers an alternative operative approach. We sought to examine differences in general surgery time (GST), overall surgery time (OST), and patient outcomes for BM performed by CS and SS at our institution. Methods: Patients undergoing BM with tissue expander reconstruction (BMTR) between January 2010 and May 2014 at our institution were identified and divided into SS and CS cases. Operative records were used to calculate GST (incision to end of BM procedure), reconstruction time (plastic surgery start time to end of reconstruction) and OST (OST = GST + reconstructive time). Patient age, presence and stage of cancer, breast weight, axillary procedure [sentinel node biopsy (SNB) or axillary dissection (ALND)], and 30-day postoperative complications were extracted from medical charts. Differences in GST and OST between CS and SS performed cases were assessed using a t-test. A linear regression was performed to identify factors contributing to GST. Results: We identified 116 BMTR cases performed by 8 breast surgeons, [CS, n = 67 (57.8%); SS, n = 49 (42.2%)]. Demographic characteristics did not significantly differ between groups. In the bivariate analyses, GST and OST for CS cases were significantly shorter than for SS, 75.8 vs 116.8 minutes, p < 0.0001, and 255.2 vs 278.3 minutes, p = 0.005, respectively. The linear regression demonstrated a significant decrease in GST when BMTR was performed by CS (β = -38.82, p < 0.0001); total breast weight (β = 0.0093, p = 0.03) and axillary dissection (β = 28.69, p = 0.0003) were found to significantly impact GST. Conclusions: The GST of BMTR is significantly decreased using a CS-approach without impacting complication rates. However, the degree of GST and OST-reduction suggests the addition of a CS does not proportionally impact surgical time as would be expected. A CS-approach may be more beneficial for patients with large total breast weight or those requiring ALND. A larger study is warranted to better characterize time, cost, and outcomes of the CS-approach for BM.
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Affiliation(s)
- Suniti Nimbkar
- Department of Surgery, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA
| | - Melissa Anne Mallory
- Department of Surgery, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA
| | - Katya Losk
- Department of Quality and Patient Safety, Dana-Farber Cancer Institute, Boston, MA
| | - Kristen Camuso
- Department of Quality and Patient Safety, Dana-Farber Cancer Institute, Boston, MA
| | - Mehra Golshan
- Department of Surgery, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA
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Golshan M, Losk K, Mallory MA, Camuso K, Troyan S, Lin NU, Kadish S, Bunnell CA. Variation in Additional Breast Imaging Orders and Impact on Surgical Wait Times at a Comprehensive Cancer Center. Ann Surg Oncol 2015; 22 Suppl 3:S428-34. [PMID: 26307233 DOI: 10.1245/s10434-015-4834-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND In the multidisciplinary care model, breast imagers frequently provide second-opinion reviews of imaging studies performed at outside institutions. However, the need for additional imaging and timeliness of obtaining these studies has yet to be established. We sought to evaluate the frequency of additional imaging orders by breast surgeons and to evaluate the impact of this supplementary imaging on timeliness of surgery. METHODS We identified 2489 consecutive women with breast cancer who underwent first definitive surgery (FDS) at our comprehensive cancer center between 2011 and 2013. The number of breast-specific imaging studies performed for each patient between initial consultation and FDS was obtained. χ (2) tests were used to quantify the proportion of patients undergoing additional imaging by surgeon. Interval time between initial consultation and additional imaging and/or biopsy was calculated. The delay of additional imaging on time to FDS was assessed by t test. RESULTS Of 2489 patients, 615 (24.7 %) had at least one additional breast-specific imaging study performed between initial consultation and FDS, with 222 patients undergoing additional biopsies (8.9 %). The proportion of patients receiving imaging tests by breast surgeon ranged from 15 to 39 % (p < 0.0001). Patients receiving additional imaging had statistically longer wait times to FDS for BCT (21.4-28.5 days, p < 0.0001). CONCLUSIONS Substantial variability exists in the utilization of additional breast-specific imaging and in the timeliness of obtaining these tests among breast surgeons. Further research is warranted to assess the sources and impact of this variation on patient care, cost, and outcomes.
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Affiliation(s)
- Mehra Golshan
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.
| | - Katya Losk
- Department of Quality and Patient Safety, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Melissa A Mallory
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Kristen Camuso
- Department of Quality and Patient Safety, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Susan Troyan
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Nancy U Lin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Sarah Kadish
- Department of Quality and Patient Safety, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Craig A Bunnell
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
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Mallory MA, Losk K, Lin NU, Sagara Y, Birdwell RL, Cutone L, Camuso K, Bunnell C, Aydogan F, Golshan M. The Influence of Radiology Image Consultation in the Surgical Management of Breast Cancer Patients. Ann Surg Oncol 2015. [PMID: 26202551 DOI: 10.1245/s10434-015-4663-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Patients referred to comprehensive cancer centers arrive with clinical data requiring review. Radiology consultation for second opinions often generates additional imaging requests; however, the impact of this service on breast cancer management remains unclear. We sought to identify the incidence of additional imaging requests and the effect additional imaging has on patients' ultimate surgical management. METHODS Between November 2013 and March 2014, 153 consecutive patients with breast cancer received second opinion imaging reviews and definitive surgery at our cancer center. We identified the number of additional imaging requests, the number of fulfilled requests, the modality of additional imaging completed, the number of biopsies performed, and the number of patients whose management was altered due to additional imaging results. RESULTS Of 153 patients, the mean age was 55 years; 98.9% were female; 23.5% (36) had in situ carcinoma (35 DCIS/1 LCIS), and 76.5% (117) had invasive carcinoma. Additional imaging was suggested for 47.7% (73/153) of patients. After multidisciplinary consultation, 65.8% (48/73) of patients underwent additional imaging. Imaging review resulted in biopsy in 43.7% (21/48) of patients and ultimately altered preliminary treatment plans in 37.5% (18/48) of patients (Fig. 1). Changes in management included: conversion to mastectomy or breast conservation, neoadjuvant therapy, additional wire placement, and need for contralateral breast surgery. Fig. 1 Impact of second-opinion imaging reviews on the management of breast cancer patients CONCLUSIONS Our analysis of second opinion imaging consultation demonstrates the significant value that this service has on breast cancer management. Overall, 11.7% (18/153) of patients who underwent breast surgery had management changes as a consequence of radiologic imaging review.
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Affiliation(s)
- Melissa Anne Mallory
- Department of Surgery, Dana Farber/Brigham and Women's Cancer Center, Boston, MA, USA
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Paes FR, Luis IMVD, Costa RB, Metzger Filho O, Hughes ME, Losk K, Camuso K, Bunnell CA, Golshan M, Winer EP, Lin NU. Variation in the use of granulocyte-colony stimulating factor (G-CSF) for dose dense paclitaxel: A single institution retrospective study. J Clin Oncol 2015. [DOI: 10.1200/jco.2015.33.15_suppl.561] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | | | | | - Katya Losk
- Dana-Farber Cancer Institute, Boston, MA
| | | | | | - Mehra Golshan
- Department of Surgery, Brigham and Women's Hospital, Boston, MA
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20
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Golshan M, Hergrueter CA, Camuso K, Lin NU, Cutone L, Hirshfield-Bartek J, Roberts P, Runkle W, Kadish S, Losk K, Bunnell CA. Standardizing coordination between surgical oncology and reconstructive surgery for breast cancer patients undergoing mastectomy with immediate reconstruction. J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.30_suppl.110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
110 Background: Timely diagnosis and treatment of breast cancer, endorsed by organizations such as ASCO and NCCN, are essential to ensure optimal clinical outcomes and patient satisfaction. Inefficient care coordination may adversely affect care quality. At our cancer center, 75% of patients who undergo mastectomy seek a reconstructive surgery consult and over 60% elect mastectomy with immediate reconstruction. We sought to evaluate and reduce the time to reconstructive surgery consult and first definitive surgery (FDS) by streamlining coordination between services. Methods: We studied 330 patients who underwent mastectomy with immediate reconstruction between January 2011 and April 2013. Time intervals between initial surgical consult, reconstruction consult, and FDS were calculated. After examining existing best practices in patient referral and scheduling, we established targets of 7 days from initial consult to reconstruction consult and 28 days from initial consult to FDS. To achieve these targets, facilitated sessions were held with administrative and clinical experts to create a standard referral and scheduling process, including a referral template and establishing surgical teams based on clinic and operating room alignment. The interventions were implemented over a 6-month period. Results: Mean days from initial consult to reconstructive surgery consult decreased, with significant improvement in reaching the 7 day target. No significant changes from time of initial consult to FDS were observed. Conclusions: Standardizing coordination has led to timelier reconstructive surgery consults for patients undergoing mastectomy with immediate reconstruction. Other factors, such as operating room availability, pre-operative testing and patient preference should be explored to reduce the time to FDS. [Table: see text]
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Affiliation(s)
- Mehra Golshan
- Dana-Farber Cancer Institute/Brigham and Women's Cancer Center at Milford Regional Medical Center, Boston, MA
| | | | | | | | | | | | | | | | | | - Katya Losk
- Dana-Farber Cancer Institute, Boston, MA
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Bunnell CA, Losk K, Kadish S, Lin N, Hirshfield-Bartek J, Cutone L, Camuso K, Golshan M, Weingart S. Measuring Opportunities to Improve Timeliness of Breast Cancer Care at Dana-Farber/Brigham and Women’s Cancer Center. J Natl Compr Canc Netw 2014; 12 Suppl 1:S5-9. [DOI: 10.6004/jnccn.2014.0215] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Golshan M, Weingart SN, Losk K, Hirshfield-Bartek J, Cutone L, Abeita J, Kadish S, Bunnell C. Abstract P5-13-15: Process-of-care: Elucidating delays in surgical treatment of breast cancer. Cancer Res 2013. [DOI: 10.1158/0008-5472.sabcs13-p5-13-15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: We examined the timeliness of breast cancer care at our cancer center, focusing on care processes that affect the time from surgical consultation to surgery, with the goal of identifying improvement opportunities.
Methods: We studied 584 women who underwent a mastectomy (with or without reconstruction) or breast conserving therapy at one of two Dana-Farber/Brigham and Women's Cancer Center (DF/BWCC) surgical sites between Jan. 1, 2011 and Feb. 28, 2012. We excluded patients who received a DF/BWCC consultation but received surgery elsewhere, those who required neo-adjuvant chemotherapy, and patients whose surgeons had no primary appointment at DF/BWCC.
We calculated the delay between consultation and surgery, defined as an interval of greater than two weeks for cases of mastectomy without reconstruction or breast conserving therapy, and four weeks for those with mastectomy with immediate reconstruction. We tabulated the number of patients with a delay, stratified by type of procedure and patient characteristics. We examined factors associated with a delay in bivariate analyses using Chi-square and multivariate logistic regression models with two-tailed tests and p<0.05. We examined provider-level variation in a subset of reconstructive surgery cases, and reviewed medical records of 50 patients with the greatest delays.
Results. The mean number of days from consultation to surgery was 21 (range 2-104, SD 14) for lumpectomy, 31 (5-230, 28) for mastectomy, and 41 (6-180, 26) for mastectomy with reconstruction. Of women undergoing breast conserving therapy or mastectomy without reconstruction, 296 (67%) experienced a delay compared to 102 (71%) undergoing mastectomy with immediate reconstruction. Although no statistically significant findings were obtained in the bivariate analyses, age over 60 was associated with a two-fold delay in the multivariable model. Delays were also more likely among mastectomy procedures compared to breast conserving therapy.
TableCharacteristicsNo Delay (n = 186)Delay (n = 398)OR (95% CI) No. (%)No. (%) Age 70-9528 (15)69 (17)2.6 (1.3-5.5)60-6943 (23)107 (27)2.0 (1.2-3.6)50-5951 (27)103 (26)1.3 (0.8-2.0)18-4964 (34)119 (30)1.0Race Non-White21 (11)43 (11)1.0 (0.6-1.9)White161 (89)346 (89)1.0Missing49 Primary Language Non-English7 (4)14 (4)1.0 (0.4-2.9)English179 (96)384 (97)1.0Insurance Medicare49 (26.3)97 (24)0.6 (0.3-1.0)Medicaid6 (3)8 (2)0.6 (0.2-1.7)Private131 (70)292 (74)1.0Missing01 Procedure Mastectomy with Recon41 (22)102 (26)1.6 (1.0-2.5)Mastectomy without Recon15 (8.1)53 (13)1.9 (1.0-3.6)Lumpectomy130 (70)243 (61)1.0
The 4 highest-volume breast surgeons (n>20 procedures each) varied in the time from initial consultation to plastic surgery consultation, from a mean of 7 to 22 days. Early screening and referral practices accounted for much of this variation. Delayed surgeries among the 50 patients with delays of at least 45 days included the need for additional testing or imaging, pre-operative medical evaluation, or “personal” reasons.
Conclusion. Analyses of the interval from consultation to breast surgery identified process variation that may be amenable to improvement initiatives. Cancer centers should invest in efforts to measure, monitor, and improve the timeliness of breast cancer care.
Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-13-15.
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Affiliation(s)
- M Golshan
- Dana-Farber/Brigham and Women's Cancer Center, Boston, MA
| | - SN Weingart
- Dana-Farber/Brigham and Women's Cancer Center, Boston, MA
| | - K Losk
- Dana-Farber/Brigham and Women's Cancer Center, Boston, MA
| | | | - L Cutone
- Dana-Farber/Brigham and Women's Cancer Center, Boston, MA
| | - J Abeita
- Dana-Farber/Brigham and Women's Cancer Center, Boston, MA
| | - S Kadish
- Dana-Farber/Brigham and Women's Cancer Center, Boston, MA
| | - C Bunnell
- Dana-Farber/Brigham and Women's Cancer Center, Boston, MA
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Losk K, Kadish S, Golshan M, Lin N, Hirshfield-Bartek J, Cutone L, Bunnell CA, Weingart S. Reducing breast cancer chemotherapy treatment delays by improving the transition from surgical to medical oncology. J Clin Oncol 2013. [DOI: 10.1200/jco.2013.31.31_suppl.51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
51 Background: Delayed chemotherapy is associated with adverse clinical outcomes for breast cancer patients. Few studies have examined the processes of care within administrative staff and providers’ control that might affect the timeliness of breast cancer care. Coordinating transitions of care from surgical to medical oncology to eliminate variation is essential in ensuring timely chemotherapy for patients after surgery. This study evaluated the time of transition from surgery to medical oncology when administrative change of practice was implemented. Methods: We studied 192 consecutive breast cancer patients who received adjuvant chemotherapy. The interval between last definitive surgery and initiation of chemotherapy was calculated by integrating billing and scheduling data. Using process improvement methods a multidisciplinary team identified the opportunity to reduce delays in care coordination by scheduling the surgery, surgical post-op appointment, and medical oncology follow-up appointments simultaneously. Furthermore, responsibility for scheduling the medical oncology follow-up appointment was shifted and standardized from medical to surgical oncology administrative staff. Criteria for acceptable timeliness of appointments and escalation pathways for when provider availability was limited were established. The intervention targeted patients whose initial consultation with a breast surgeon and medical oncologist occurred on the same day, the standard practice at our institution. Results: Implementation of the interventions decreased the time from surgery to chemotherapy by six days. The standard deviation also declined, suggesting that the intervention reduced process variability. Conclusions: Standardizing administrative practices between breast surgery and medical oncology has led to a significant decrease in the time from last definitive surgery to initiation of chemotherapy and in the variability of that delay. [Table: see text]
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Affiliation(s)
- Katya Losk
- Dana-Farber Cancer Institute, Boston, MA
| | | | - Mehra Golshan
- Dana-Farber Cancer Institute/Brigham and Women’s Cancer Center, Boston, MA
| | - Nancy Lin
- Dana-Farber Cancer Insitute, Boston, MA
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