David Lucido

Early-Stage Breast Cancer Treated With 3-Week Accelerated Whole-Breast Radiation Therapy and Concomitant Boost

PURPOSE To report early outcomes of accelerated whole-breast radiation therapy with concomitant boost. METHODS AND MATERIALS This is a prospective, institutional review board-approved study. Eligibility included stage TisN0, T1N0, and T2N0 breast cancer. Patients receiving adjuvant chemotherapy were ineligible. The whole breast received 40.5 Gy in 2.7-Gy fractions with a concomitant lumpectomy boost of 4.5 Gy in 0.3-Gy fractions. Total dose to the lumpectomy site was 45 Gy in 15 fractions over 19 days. RESULTS Between October 2004 and December 2010, 160 patients were treated; stage distribution was as follows: TisN0, n = 63; T1N0, n = 88; and T2N0, n = 9. With a median follow-up of 3.5 years (range, 1.5-7.8 years) the 5-year overall survival and disease-free survival rates were 90% (95% confidence interval [CI] 0.84-0.94) and 97% (95% CI 0.93-0.99), respectively. Five-year local relapse-free survival was 99% (95% CI 0.96-0.99). Acute National Cancer Institute/Common Toxicity Criteria grade 1 and 2 skin toxicity was observed in 70% and 5%, respectively. Among the patients with ≥ 2-year follow-up no toxicity higher than grade 2 on the Late Effects in Normal Tissues-Subjective, Objective, Management, and Analytic scale was observed. Review of the radiation therapy dose-volume histogram noted that ≥ 95% of the prescribed dose encompassed the lumpectomy target volume in >95% of plans. The median dose received by the heart D05 was 215 cGy, and median lung V20 was 7.6%. CONCLUSIONS The prescribed accelerated schedule of whole-breast radiation therapy with concomitant boost can be administered, achieving acceptable dose distribution. With follow-up to date, the results are encouraging and suggest minimal side effects and excellent local control.

Multiple arterial bypass grafting should be routine

OBJECTIVE We sought to estimate the reduction in deaths and the number of additional person-years of life that could potentially be gained by nationwide adoption of routine multiple arterial bypass grafting (MABG). METHODS Propensity matching on 4883 patients undergoing primary, isolated coronary artery bypass grafting (CABG) using the left internal thoracic artery (LITA) from January 1995 to June 2011, resulted in 1023 matched pairs of LITA-radial artery and LITA-saphenous vein patients. Kaplan-Meier estimated survivals were used to calculate the potential number of lives that could be saved based on a 20% and an 80% rate of MABG, compared with the national 10% rate, when applied to a hypothetical national sample of 200,000 similar patients. RESULTS Our overall MABG rate was 40% with >80% rate for the past 3 years. Kaplan-Meier estimated 10-year survival was better for LITA-radial artery patients (83.1%) compared with LITA-saphenous vein patients (75.7%) (log rank test, P < .001). When compared with the current national 10% MABG rate, a 20% and an 80% MABG rate could potentially result in 1400 and 10,000 fewer annual deaths, respectively, among a hypothetical national cohort, yielding >9000 and >64,000 person-years of life over a 10-year period. CONCLUSIONS An 80% rate of MABG has the potential to prevent more than 10,000 deaths annually and add >64,000 person-years of life over the course of 10 years. The use of a second arterial graft during CABG should be routine in the majority of patients undergoing CABG.

Optimal Conduit for Diabetic Patients: Propensity Analysis of Radial and Right Internal Thoracic Arteries

BACKGROUND Multiple arterial grafts, in addition to the left internal thoracic artery, improve long-term survival after coronary artery bypass grafting (CABG); yet, the use of this procedure remains low for both the right internal thoracic artery (RITA) and the radial artery (RA). To identify the optimal arterial conduit to deploy for revascularization of diabetic patients, we compared the outcomes for RA and RITA grafts to the circumflex coronary. METHODS From January 1, 1995, to December 31, 2011, 908 consecutive diabetic patients underwent first-time, isolated CABG (99% on-pump), 659 with the RA and 502 with the RITA, respectively, in two affiliated hospitals. Data were prospectively collected, and late mortality was determined from the Social Security Death Index. Propensity matching, based on preoperative and operative variables, identified 202 matched pairs from each group. RESULTS Long-term survival was similar for matched patients. Mortality, myocardial infarction, reoperation for bleeding, stroke, sepsis, and renal failure were not significantly different between groups. However, deep sternal wound infection (p<0.035) and respiratory failure (p<0.048) favored the RA group, in which the total major adverse events were significantly fewer (p=0.002). CONCLUSIONS In diabetic patients undergoing multivessel revascularization with either RA or RITA grafts to the circumflex coronary, long-term survival is similar. However, RA patients experienced significantly fewer respiratory or sternal wound adverse events. The RA is the preferred conduit to extend to more diabetic patients the recognized survival benefit of a multiple arterial graft strategy.

Environmental Music Therapy: A Pilot Study on the Effects of Music Therapy in a Chemotherapy Infusion Suite

Environmental music therapy (EMT) is a noninvasive mind–body intervention that considers the physical, psychological, and cultural needs of patients, caregivers, and staff. Quantitative and qualitative analyses of the effect of EMT on patients, caregivers, and staff revealed that EMT, involving the purposeful use of live music, showed positive effects on stress level and reduced the perception of noise in patients and caregivers when applied in common and treatment areas of the Cancer Center and outpatient infusion facility at a large inner-city hospital. Environmental music therapy attended to the immediate needs of patients and caregivers in a culturally sensitive way both prior to and during treatment. The present study additionally evaluates the effect of EMT’s capacity to alleviate compassion fatigue and stress in oncologists, nurses, and other health professionals.

Factors influencing incidence and type of postmastectomy breast reconstruction in an urban multidisciplinary cancer center.

Background: On January 1, 2011, New York State amended the Public Health Law to ensure that patients receive “information and access to breast reconstruction surgery.” The purposes of this study were to investigate the early impact of this legislation on reconstruction rates and to evaluate the influence of patient variables versus physician variables on the incidence and type of breast reconstruction performed. Methods: A retrospective study was conducted on all patients who underwent mastectomy between January 1, 2010, and December 31, 2011. Reconstruction rates were analyzed in relation to timing of legislation, breast surgeon variables, plastic surgeon faculty status, type of reconstruction, and patient variables. Results: Two hundred fifty-eight patients met inclusion criteria. The overall reconstruction rate was 56.59 percent. There was no statistically significant increase in reconstruction rate after the 2011 legislation (OR, 0.45; p = 0.057). Patients whose breast surgeon was female were more likely to undergo reconstruction (OR, 5.17; p = 0.001). Patients who were Asian (OR, 0.22; p = 0.002), older than 60 years (OR, 0.09; p = 0.001), or had stage 3 and 4 cancer (OR, 0.04; p = 0.03) were less likely to undergo reconstruction. Patients reconstructed by a hospital-employed plastic surgeon were significantly more likely to undergo autologous versus implant reconstruction (OR, 6.85; p = 0.001) and to undergo microsurgical versus nonmicrosurgical autologous reconstruction (78.2 percent versus 0 percent; p = 0.001). Conclusions: Breast surgeon sex and plastic surgeon faculty status were the factors that most affected the rate and type of reconstruction, respectively. Legislation mandating the discussion of breast reconstruction options had no impact on reconstruction rate. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Disaster Preparedness and Awareness of Patients on Hemodialysis after Hurricane Sandy

BACKGROUND AND OBJECTIVES Patients with ESRD on dialysis live in a complex sociomedical situation and are dependent on technology and infrastructure, such as transportation, electricity, and water, to sustain their lives. Interruptions of this infrastructure by natural disasters can result in devastating outcomes. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Between November of 2013 and April of 2014, a cross-sectional survey was conducted of patients who received maintenance hemodialysis before and after the landfall of Hurricane Sandy on October 29, 2012 in lower Manhattan, New York. The primary outcome was the number of missed dialysis sessions after the storm. Dialysis-specific and general disaster preparedness were assessed using checklists prepared by the National Kidney Foundation and US Homeland Security, respectively. RESULTS In total, 598 patients were approached, and 357 (59.7%) patients completed the survey. Participants were 60.2% men and 30.0% black, with a median age of 60 years old; 94 (26.3%) participants missed dialysis (median of two sessions [quartile 1 to quartile 3 =1-3]), and 236 (66.1%) participants received dialysis at nonregular dialysis unit(s): 209 (58.5%) at affiliated dialysis unit(s) and 27 (7.6%) at emergency rooms. The percentages of participants who carried their insurance information and detailed medication list were 75.9% and 44.3%, respectively. Enhancement of the dialysis emergency packet after the hurricane was associated with a significantly higher cache of medical records at home at follow-up survey (P<0.001, Fishers exact test). Multivariate Poisson regression analysis showed that dialysis-specific preparedness (incidence rate ratio, 0.91; 95% confidence interval, 0.87 to 0.98), other racial ethnicity (incidence rate ratio, 0.34; 95% confidence interval, 0.20 to 0.57), dialysis treatment in affiliated units (incidence rate ratio, 0.69; 95% confidence interval, 0.51 to 0.94), and older age (incidence rate ratio, 0.98; 95% confidence interval, 0.97 to 0.99) were associated with a significantly lower incidence rate ratio of missed dialysis. CONCLUSIONS There is still room to improve the preparedness for natural disasters of patients with ESRD. Provider- or facility-oriented enhancement of awareness of the disease and preparedness should be a priority.

Rapid loss of vaccine-acquired hepatitis B surface antibody after three doses of hepatitis B vaccination in HIV-infected persons

HIV-infected individuals have poor responses to hepatitis B vaccine and may have decreased durability of post-vaccination immunity. Retrospective chart review was conducted for HIV-1 positive individuals aged ≥18 years who received hepatitis B vaccine at an urban HIV clinic. A total of 309 patients completed three doses and 178 had post-vaccine serology testing after the third dose. In multivariate analysis, time between the third dose and the first post-vaccine serology testing at 180–359 days (OR = 0.077, p = 0.049) and at ≥360 days (OR = 0.065, p = 0.019) were associated with poor vaccine responses. A significant decrease in seropositivity appeared as early as 180 days after the third vaccine dose, suggesting a rapid loss of vaccine-acquired hepatitis B surface antibody in HIV-infected persons. Our findings suggest that hepatitis B surface antibody should be tested at 6 to 12 months after completing primary vaccine series in order to detect early secondary vaccine failure.