Abstract P6-19-06: Breast conservation surgery in male breast cancer: A systematic literature review

BACKGROUND

Male breast cancer (BC) incidence is low and management is extrapolated from female BC. Breast conservation surgery (BCS) is commonly used for female BC, however, mastectomy remains the most frequently used surgical procedure for male breast cancer. We performed a literature review to assess the use of BCS in male BC as well as outcomes following BCS.

METHODS

A systematic literature review identified peer-reviewed articles in PubMed evaluating male BC and surgery. Abstracts were screened to identify studies that measured overall survival (OS), disease-free survival (DFS), or local recurrence (LR) in patients undergoing BCS. For all studies, we extracted the total number of patients and number of BCS cases. Of patients undergoing BCS, we further extracted mean age, mean follow-up time, clinical stage, type of axillary surgery [sentinel lymph node biopsy (SLNB), axillary lymph node dissection (ALND)], radiation therapy, hormonal therapy, and chemotherapy. Weighted averages, based on number of patients in each study, were performed for LR, DFS and 5-year OS. The time period for LR and DFS was the duration of follow-up time for each study.

RESULTS

The literature search yielded 4341 articles. Twelve studies published from 1998 to 2016 met the inclusion criteria and were selected for the systematic literature review. Among the 12,616 male breast surgery cases included, 1,633 (12.9%) underwent BCS. Only patients who underwent BCS were included in our analysis. The mean follow-up time was 54.4 months and mean age was 62.4 with stage II as the most common presentation. Two studies reported that 50-71.4% of patients underwent SLNB and 4 studies reported ALND in 14.3-100%. Seven studies reported that adjuvant radiation therapy was administered in 12.0-100% of 474 total patients undergoing BCS. Four studies reported use of hormonal therapy in 73.8-100% of patients. Four studies reported use of chemotherapy in 25-66.7% of patients. Seven studies reported LR among 122 patients, with a weighted average 11.8%. Four studies reported on 5-year OS in 1511 patients, with a weighted average of 85.8%.

CONCLUSION

While less commonly used than mastectomy, BCS can be considered a safe alternative in the surgical treatment of male BC. We have demonstrated that the use of adjuvant radiation following BCS is variable in this patient group. Future research should focus on better standardization of local therapy for male BC and improved reporting of outcomes.

Citation Format: Fisher CS, de la Cruz L, Joshi S, Mah T-J, Blankenship S, Thiruchelvam P. Breast conservation surgery in male breast cancer: A systematic literature review [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-19-06.

Patient-level costs in margin re-excision for breast-conserving surgery

BACKGROUND

High rates of reoperation following breast-conserving surgery (BCS) for positive margins are associated with costs to healthcare providers. The aim was to assess the quality of evidence on reported re-excision costs and compare the direct patient-level costs between patients undergoing successful BCS versus reoperations after BCS.

METHODS

The study used data from women who had BCS with or without reoperation at a single institution between April 2015 and March 2016. A systematic review of health economic analysis in BCS was conducted and scored using the Quality of Health Economic Studies (QHES) instrument. Financial data were retrieved using the Patient-Level Information and Costing Systems (PLICS) for patients. Exchange rates used were: US $1 = £0·75, £1 = €1·14 and US $1 = €0·85.

RESULTS

The median QHES score was 47 (i.q.r. 32·5-79). Only two of nine studies scored in the upper QHES quartile (score at least 75). Costs of initial lumpectomy and reoperation were in the range US $1234-11786 and $655-9136 respectively. Over a 12-month interval, 153 patients had definitive BCS and 59 patients underwent reoperation. The median cost of reoperations after BCS (59 patients) was £4511 (range 1752-18 019), representing an additional £2136 per patient compared with BCS without reoperation (P < 0·001).

CONCLUSION

The systematic review demonstrated variation in methodological approach to cost estimates and a paucity of high-quality cost estimate studies for reoperations. Extrapolating local PLICS data to a national level suggests that getting BCS right first time could result in substantial savings.

Best-practice care pathway for improving management of mastitis and breast abscess

BACKGROUND

Surgical subspecialization has resulted in mastitis and breast abscesses being managed with unnecessary admission to hospital, prolonged inpatient stay, variable antibiotic prescribing, incision and drainage rather than percutaneous aspiration, and loss to specialist follow-up. The objective was to evaluate a best-practice algorithm with the aim of improving management of mastitis and breast abscesses across a multisite NHS Trust. The focus was on uniformity of antibiotic prescribing, ultrasound assessment, admission rates, length of hospital stay, intervention by aspiration or incision and drainage, and specialist follow-up.

METHODS

Management was initially evaluated in a retrospective cohort (phase I) and subsequently compared with that in two prospective cohorts after introduction of a breast abscess and mastitis pathway. One prospective cohort was analysed immediately after introduction of the pathway (phase II), and the second was used to assess the sustainability of the quality improvements (phase III). The overall impact of the pathway was assessed by comparing data from phase I with combined data from phases II and III; results from phases II and III were compared to judge sustainability.

RESULTS

Fifty-three patients were included in phase I, 61 in phase II and 80 in phase III. The management pathway and referral pro forma improved compliance with antibiotic guidelines from 34 per cent to 58·2 per cent overall (phases II and III) after implementation (P = 0·003). The improvement was maintained between phases II and III (54 and 61 per cent respectively; P = 0·684). Ultrasound assessment increased from 38 to 77·3 per cent overall (P < 0·001), in a sustained manner (75 and 79 per cent in phases II and III respectively; P = 0·894). Reductions in rates of incision and drainage (from 8 to 0·7 per cent overall; P = 0·007) were maintained (0 per cent in phase II versus 1 per cent in phase III; P = 0·381). Specialist follow-up improved consistently from 43 to 95·7 per cent overall (P < 0·001), 92 per cent in phase II and 99 per cent in phase III (P = 0·120). Rates of hospital admission and median length of stay were not significantly reduced after implementation of the pathway.

CONCLUSION

A standardized approach to mastitis and breast abscess reduced undesirable practice variation, with sustained improvements in process and patient outcomes.

Abstract P3-14-07: Neoadjuvant radiotherapy in mastectomy and immediate autologous free flap reconstruction. Findings from the primary radiotherapy and DIEP flap (PRADA) pilot study

Background:

The need for post mastectomy radiotherapy (PMRT), may preclude reconstructive surgeons from offering patients immediate, autologous reconstruction. This is due to historical evidence suggesting high rates of short- and long-term complications as well as poorer aesthetic outcomes. As the indications for PMRT broaden this practice denies an ever-increasing number of women the benefit of an immediate reconstruction.

Aim:

This pilot study evaluates the safety of offering radiotherapy prior to mastectomy and immediate DIEP flap reconstruction.

Methods:

Women planned for neoadjuvant chemotherapy (NAcT), mastectomy (following unsuccessful breast conservation surgery (BCS) or upfront selection) and PMRT were offered a change in sequencing of RT at two academic breast surgery units in London, UK. Data was prospectively captured on 19 women, including: patient demographics, treatment details, tumour characteristics, oncological and post-operative outcomes. Operative parameters included unplanned return to theatre [RTT] &lt;30 days, mastectomy skin flap necrosis, and evidence of wound infection at 5 days, 4 and 12 weeks post-operatively. All mastectomies, were performed by one of 3 breast surgeons (DH, FAM, DRL) using a circumareolar incisions with one patient undergoing a vertical pattern incision for skin reduction.

Results:

The cohort demonstrated a broad range of age, body mass index (BMI) and mastectomy weight [mean (range): age=46 years (28-72); BMI = 28.4 kg/m2 (23-37.6) and specimen weight=678gm (257-1040)]. The mean time from completion of NAcT to neoadjuvant radiotherapy (NART) was 31.1 days (9-49 days), and time from completion of NART to mastectomy and DIEP was 17.8 days (13-24 days). There was one unplanned RTT at 72 hours for an evacuation of haematoma, 1 revision of micro-vascular anastomosis, 1 clinical fat necrosis requiring formal excision and 1 wound debridement and primary closure for poor wound healing (vertical pattern skin reduction). There were no flap failures and no mastectomy envelope necrosis. With a mean follow-up of 16.2 months, there were no loco-regional recurrences, 5 distant relapses with mean presentation at 13.7 months and 2 breast-cancer related deaths at 13.9 and 22.2months respectively.

Conclusion:

This pilot study suggests that mastectomy and DIEP reconstruction is surgically feasible within 4 weeks of completing NART. In this small cohort of oncologically high-risk women with altered sequencing of RT we did not observe flap failure or post-mastectomy skin flap necrosis. A larger multicentre study with aesthetic assessment, PROMS and translational aspects is planned.

Citation Format: Thiruchelvam P, Hadjiminas D, Cleator S, Wood S, Leff D, Jallali N, James S, MacNeill F. Neoadjuvant radiotherapy in mastectomy and immediate autologous free flap reconstruction. Findings from the primary radiotherapy and DIEP flap (PRADA) pilot study [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-14-07.

The importance of a medical chaperone: a quality improvement study exploring the use of a note stamp in a tertiary breast surgery unit

OBJECTIVES

The project aim was to determine current use and documentation of medical chaperones within a major breast service unit. It explored ways of improving adherence to professional guidelines concerning chaperones.

SETTING

The single centre quality improvement project was completed in a tertiary breast service unit in North West London. It was a three-stage project with initial audit in October 2013, 1st postintervention cycle in November 2013 and 2nd postintervention cycle in October 2014.

PARTICIPANTS

In each study cycle, data were collected from entries in clinic notes until at least 155 encounters with documented clinical examination were analysed. All notes were of female patients.

INTERVENTIONS

(1) Intervention 1st cycle: presentation and discussion of chaperone guidelines alongside reminder posters and introduction of note stamp. (2) Intervention 2nd cycle: note stamp alone.

PRIMARY AND SECONDARY OUTCOME MEASURES

Documentation of chaperone offer, documentation of patient preference regarding chaperone, identifier (name or signature) of chaperone present and gender of examining clinician.

RESULTS

In the 1st postintervention cycle, 69.95% documentation of chaperone offer was recorded, p<0.001, CI (59.04% to 80.76%). This result was replicated in the 2nd postintervention cycle a year later with 74.86% documentation of chaperone offer recorded, p<0.001, CI (66.41% to 83.31%). The 4.91% difference was insignificant; p=0.294, CI (14.03% to 4.21%).

CONCLUSIONS

The authors suggest that a proforma approach to medical chaperones is an effective means of ensuring adherence to best practice guidelines. A stamp, or similar, that can be embedded into documentation structure is an effective example of such an approach. Improved documentation allows any problems with adherence to guidelines to be more easily identified, helping to ensure the safeguarding of patients and staff involved in intimate examinations.