Breast Angiosarcoma Surveillance Study: UK national audit of management and outcomes of angiosarcoma of the breast and chest wall

BACKGROUND

Breast angiosarcomas are rare tumours of vascular origin. Secondary angiosarcoma occurs following radiotherapy for breast cancer. Angiosarcomas have high recurrence and poor survival rates. This is concerning owing to the increasing use of adjuvant radiotherapy for the treatment of invasive breast cancer and ductal cancer in situ (DCIS), which could explain the rising incidence of angiosarcoma. Outcome data are limited and provide a poor evidence base for treatment. This paper presents a national, trainee-led, retrospective, multicentre study of a large angiosarcoma cohort.

METHODS

Data for patients with a diagnosis of breast/chest wall angiosarcoma between 2000 and 2015 were collected retrospectively from 15 centres.

RESULTS

The cohort included 183 patients with 34 primary and 149 secondary angiosarcomas. Median latency from breast cancer to secondary angiosarcoma was 6 years. Only 78.9 per cent of patients were discussed at a sarcoma multidisciplinary team meeting. Rates of recurrence were high with 14 of 28 (50 per cent ) recurrences in patients with primary and 80 of 124 (64.5 per cent ) in those with secondary angiosarcoma at 5 years. Many patients had multiple recurrences: total of 94 recurrences in 162 patients (58.0 per cent). Median survival was 5 (range 0-16) years for patients with primary and 5 (0-15) years for those with secondary angiosarcoma. Development of secondary angiosarcoma had a negative impact on predicted breast cancer survival, with a median 10-year PREDICT prognostic rate of 69.6 per cent, compared with 54.0 per cent in the observed cohort.

CONCLUSION

A detrimental impact of secondary angiosarcoma on breast cancer survival has been demonstrated. Although not statistically significant, almost all excess deaths were attributable to angiosarcoma. The increased use of adjuvant radiotherapy to treat low-risk breast cancer and DCIS is a cause for concern and warrants further study.

Oncoplastic breast surgery: A guide to good practice

Oncoplastic Breast Surgery has become standard of care in the management of Breast Cancer patients. These guidelines written by an Expert Advisory Group; convened by the Association of Breast Surgery (ABS) and the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS), are designed to provide all members of the breast cancer multidisciplinary team (MDT) with guidance on the best breast surgical oncoplastic and reconstructive practice at each stage of a patient's journey, based on current evidence. It is hoped they will also be of benefit to the wide range of professionals and service commissioners who are involved in this area of clinical practice.

The Exeter half-day release psychotherapy training scheme – a model for others?

Training in psychotherapy is a mandatory part of general professional training in psychiatry. The College produced guidelines in 1993 outlining the breadth and depth of training required (Royal College of Psychiatrists, 1993).

Abstract P4-17-03: Towards the standardisation of outcome reporting in reconstructive breast surgery: Initial results of the BRAVO (Breast Reconstruction and Valid Outcome) Study–A multicentre consensus process to develop a core outcome set for reconstructive breast surgery

Introduction: Appropriate outcome selection is essential if research is to guide decision-making for patients, professionals and policy makers. Systematic reviews evaluating the clinical, cosmetic and patient-reported outcomes of breast reconstruction, however, have demonstrated marked heterogeneity of outcome reporting such that results from individual studies cannot be compared or combined. Standardising end-points by developing and using core outcome sets - an agreed minimum set of outcomes that should be measured and reported in all research and audit studies – is one way by which outcome reporting may be improved. We therefore report the initial results of the BRAVO (Breast Reconstruction and Valid Outcomes) Study which aims to use a scientifically rigorous Delphi consensus process to develop a core outcome set for reconstructive breast surgery.

Methods: The Delphi process involves the sequential completion of questionnaires to allow stakeholder opinions to be synthesised using item responses to prioritise outcome domains.

The questionnaire was developed from a long list of 148 outcomes generated from literature reviews and qualitative work with stakeholders. The outcomes were categorised into 34 domains in six categories (short-term complications; late complications; symptoms; psychosocial issues; practical issues and cosmesis) and each domain operationalised.

Key stakeholders were identified as patients, surgeons, specialist nurses and psychologists and participants were sampled purposively to ensure a breadth of perspectives. Each participant was sent a questionnaire and asked to prioritise the outcomes on a nine-point likert scale from 1(not important) to 9(extremely important).

The number of respondents in each group rating each outcome as not important(scores 1–3); equivocal(scores 4–6) or very important(score 7–9) were calculated for each item and compared between groups. The proportions of respondents rating each item as very important(score 7–9) was used to rank the items.

Results: 213 of the 430 questionnaires were returned(126/274 patients and 87/156 professionals) giving a response rate of 49.5%.

Patient participants had a median age of 53.4 years(range 34–76) and had undergone a full range of reconstructive procedures. The professional group included 39 breast surgeons, 20 plastic surgeons and 18 clinical nurse specialists.

There was agreement between 7 of the 10 outcomes that each group rated most highly. Items with consensus included patient-reported cosmesis, cosmetic satisfaction and early complications. Patients, but not professionals, considered generic complications such as bleeding to be important while professionals valued psychosocial issues such as self-esteem more highly than patients.

Conclusions: Patients and professionals prioritise similar outcomes, but areas of discrepancy with regard to complications and psychosocial outcomes remain. A further Delphi round asking participants to re-prioritise outcomes and a consensus meeting to ratify the final decisions will be necessary to determine a final core outcome set for reconstructive breast surgery.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-17-03.

Investigating the mechanical shear-plane between core and sheath elements of peripheral nerves

The mechanical architecture of rat sciatic nerve has been described as a central core surrounded by a sheath, although the way in which these structures contribute to the overall mechanical properties of the nerve is unknown. We have studied the retraction responses of the core and sheath following transection, together with their tensile properties and the interface between them. Nerves were harvested and maintained at their in situ tension and then either transected entirely, through the sheath only, or through an exposed section of the core. The retraction of each component was measured within 5 min and again after 45 min. Post mortem loss of retraction was tested 0 min or 60 min after excision. For fresh nerves, immediate retraction was 12.68% (whole nerve), 5.35% (sheath) and 4% (core), with a total retraction of 15%, 7.21% and 5.26% respectively. For stored nerves, immediate retraction was 5.33% (whole nerve) and 5.87% (sheath), with an extension of 0.78% for core, and a total retraction of 6.71% and 7.87% and an extension of 1.74%, respectively. Tensile extension and pullout force profiles were obtained for the sheath, the core and the interface between them. These showed a consistent hierarchy of break strengths that would, under increasing load, result in failure of the interface, then the core and finally the sheath. These data reflect the contributions of material tension and fluid swelling pressure to total retraction, and the involvement of an energy-dependent process that runs down rapidly post mortem. This study increases our understanding of the composite nature of peripheral nerve tissue architecture and quantifies the material properties of the distinct elements that contribute to overall mechanical function.

Psychotherapy assessment and treatment selection

BACKGROUND

Current acceptance of the need for a wide range of treatments and growing pressure for cost-effectiveness suggest the need for a more discriminating approach to assessment of psychotherapy.

METHOD

Medline and manual literature searches, and personal experience of over 1000 assessments in a district psychotherapy service.

RESULTS

There is substantial evidence for the general efficacy of psychotherapy; differential benefits are beginning to be identified. Short-term treatments are appropriate in a wide variety of situations and can be surprisingly effective. Chronic/complex psychopathology is likely to need longer term therapy.

CONCLUSIONS

Effective use of scarce psychotherapy resources requires knowledge of the research evidence of treatment effectiveness, careful assessment of the patient and a logical and collaborative approach to treatment planning.

Gestalt therapy in theory and in practice

Gestalt therapy was developed by Frederick (Fritz) Perls, (1893–1970), a German psychoanalyst originally trained in the Freudian tradition; he left Germany in the 1930's for South Africa and emigrated to the United States in the immediate post-war years. Despite the publication of his book “Gestalt Therapy—Excitement and Growth in the Human Personality” (Perls, Hefferline and Goodman, 1950) his work remained relatively little known until Gestalt Therapy was taken up enthusiastically by the growth movement in the early 1960's. Although it is widely regarded as an established therapy in the United States, Gestalt remains relatively little known in the United Kingdom and there are probably few psychiatrists who are familiar with its theory and techniques. This paper is intended to present an introduction to Gestalt Therapy together with some idea of its application in clinical psychiatric practice.