Kelsey E. Larson

Fifteen-Year Decrease in General Surgery Resident Breast Operative Experience: Are We Training Proficient Breast Surgeons?

OBJECTIVE The goal of the study was to evaluate trends in general surgery resident breast cases over the past 15 years. STUDY DESIGN The Accreditation Council for Graduate Medical Education (ACGME) Case Logs Statistics Reports from 2000 to 2015 were reviewed for average breast-specific case numbers and trends over time. ACGME data were available for all cases and breast-specific cases including the following: excisional biopsy/lumpectomy, simple mastectomy, modified radical mastectomy, and sentinel lymph node excision. SETTING The study evaluation was conducted at Cleveland Clinic, Cleveland, Ohio. PARTICIPANTS No individuals directly participated in this project. However, all general surgery residents at ACGME-accredited programs are represented in this analysis by virtue of the ACGME Case Logs Statistics Reports. RESULTS Total residency case volume increased by 2% (2000-2015, p = 0.0159), with 2015 graduates logging 985.5 cases. In contrast, breast cases decreased by 17.1%. The largest drops were in modified radical mastectomy (61.5% decrease, p = 0.0001) and excisional biopsy/lumpectomy (25.8% decrease). Simple mastectomy increased from 6.0 to 10.8 cases (p = 0.0001). Sentinel lymph node excision fluctuated, but has been down-trending recently (67.3% decrease from 2010 to 2015, p = 0.0001). Decreased experience is occurring at both junior and senior resident levels. CONCLUSIONS Breast case operative experience for general surgery residents decreased by 17% between 2000 and 2015, despite increase in overall operative volume. Residents have less experience in more advanced cases including axillary management, raising concern about the proficiency of graduating surgeons with respect to these procedures. It is reasonable to set national minimums for resident breast operative experience to ensure that individuals are appropriately trained to perform these cases in practice.

Milk Fistula: Diagnosis, Prevention, and Treatment.

Milk fistula is an uncommon condition which occurs when there is an abnormal connection that forms between the skin surface and the duct in the breast of a lactating woman, resulting in spontaneous and often constant drainage of milk from this path of least resistance. A milk fistula is usually a complication that results from a needle biopsy or surgical intervention in a lactating patient. Here, the authors present an unusual case of a spontaneous milk fistula which developed from an abscess in the breast of a lactating woman. The patient initially presented to the office with a large open wound on her breast, formed from skin breakdown, within which milk was pooling. She was treated with local wound care and cessation of breastfeeding, with appropriate healing of the wound and closure of the fistula with 6 weeks. Diagnosis, prevention, and treatment of milk fistula were reviewed.

Do Primary Care Physician Perform Clinical Breast Exams Prior to Ordering a Mammogram

Both the American Cancer Society and National Comprehensive Cancer Network recommend annual clinical breast examination (CBE) along with screening mammogram (SM) for patients starting at 40 years of age. However, patients with a palpable breast mass should have a diagnostic mammogram (DM) during workup. Review at our institution demonstrated that 11% of patients with newly diagnosed breast cancer and self‐identified breast mass had SM instead of DM. This led us to question whether primary care physicians (PCP) perform CBE prior to ordering mammography. As part of the routine preimaging screening, patients were asked if they had undergone breast examination by a medical provider prior to mammogram order. Data on mammogram type, ordering physician specialty, and presence of symptoms on day of mammogram were recorded. Of 6,109 mammograms, 4,823 were ordered by PCPs. CBE was performed prior to 67.2% SM and 64.8% DM (p = 0.12). OB/GYN performed statistically significantly higher CBE (81.6%) compared to internal (45.4%) and family (50.5%) medicine physicians (p < 0.001). Of patients with self‐reported breast symptoms, 8.7% had SM ordered rather than DM. Despite recommendations, approximately 1/3 of women report not having CBE prior to mammogram. The chances of having a CBE varied significantly by PCP specialty. Lack of CBE can lead to incorrect type of mammogram, with possibly increased cost and delay in diagnosis. Further evaluation is needed to understand why CBE was not performed in some patients.

Surgeon-associated variation in breast cancer staging with sentinel node biopsy

Background: Sentinel lymph node biopsy is the gold standard for axillary staging in early‐stage, clinically node‐negative breast cancer, so it is paramount that this operation be both precise and accurate, because excessive sentinel lymph node removal increases morbidity, whereas understaging risks inadequate treatment. The goal of this study was to assess surgeon variation in the number of sentinel lymph nodes removed and the oncologic yield of sentinel lymph node biopsy for breast cancer. Methods: All patients in the Surveillance, Epidemiology, and End Results–Medicare database who underwent operative treatment for breast cancer from 2007–2011 were eligible for inclusion. Deidentified provider codes were used to track operations performed by individual surgeons. Only records in which an individual surgeon could be linked to a specific breast cancer operation were analyzed. The total number of sentinel lymph nodes removed and the number that were pathologically positive (oncologic yield) were recorded. Surgeon variation by T stage was analyzed using linear mixed‐effects regression and logistic mixed‐effects regression models. Results: Query of the database identified 15,571 patients who met inclusion criteria, representing 2,478 providers. The mean number of sentinel lymph node procedures performed per provider per year was 1.3 (range 1–103). The lowest quartile of providers performed 1 or fewer sentinel lymph node procedures per year. The highest quartile of providers performed >8 sentinel lymph node procedures per year. The average number of sentinel lymph node removed per operation increased with increasing T stage for all providers (P < .001), including when N0 (P < .001) and node‐positive (P=.003) patients were evaluated separately. There was surgeon‐associated variation in the number of sentinel lymph node removed for each T stage (P < .001). In addition, there was surgeon‐associated variation in the oncologic yield (sentinel lymph node positivity rate) by T stage (P < .001). Conclusion: This study found surgeon‐associated variation in axillary sentinel lymph node staging of breast cancer patients, which suggests the need to improve standardization of surgical practices to optimize the oncologic yield of these procedures and ensure accurate staging.

Oncotype testing in patients undergoing intraoperative radiation for breast cancer

Oncotype DX recurrence score (RS) predicts risk of distant disease recurrence, and can guide chemotherapy recommendations in hormone positive, human epidermal growth factor 2-negative, early stage breast cancer. The present study aimed to evaluate the pattern of oncotype testing, RS and adjuvant treatment in patients undergoing intraoperative radiotherapy (IORT). Single center prospective data registry was queried for patients receiving IORT between October 2011 and February 2017. Patient demographics, tumor characteristics, RS, systemic therapy and recurrence information were analyzed. A total of 150 women with mean age of 70.8 years were included. The majority had invasive ductal cancer (60.6%) with 1.0 cm average tumor size and no lymph node involvement (99%). Oncotype testing was performed in 36 patients (24.3%). Low risk score (<18) was confirmed in 19 women (53%); intermediate risk score (18-30) in 16 women (44%); and high risk score (>30) in one woman (3%). Patients with RS testing had significantly increased tumor sizes (1.2 vs. 1.0 cm; P<0.001) and were younger (68.5 vs. 71.3 years; P=0.02) compared with those not tested. A total of 4/150 patients (2.6%) received chemotherapy; two received chemotherapy based on RS testing. Based on the current selection criteria for IORT, oncotype testing rarely results in a high-risk score or utilization of chemotherapy for IORT patients. The present study supports selective use of RS testing in IORT patients and confirms that biologically low-risk patients are being selected for IORT based on current guidelines.

Evaluation of recurrence patterns and survival in modern series of young women with breast cancer

The data on oncologic outcomes in young women with breast cancer (BC) are dated as it relates to recurrences and mortality. Our goal was to assess these outcomes in a modern series of young women with BC. A retrospective chart review identified women ≤40 years old with stage I‐III BC diagnosed from 2006 to 2013 at our institution. Demographics, tumor biology, type of operation, recurrence, and survival were analyzed. Overall, 322 women were identified. Most had ER+(70%) infiltrating ductal tumors (88%) with low stage (42% T1; 41% T2; 56% N0). Follow‐up was 4.2 years with 5.6% local‐regional recurrence (LRR), 15.2% metastatic recurrence (MR), and 8% mortality. There was no survival difference based on demographics, tumor biology, or type of operation. T3 tumors (P < .001) and node positivity (P < .001) were associated with worse disease‐free survival. In this modern series of young women with BC, stage rather than tumor biology or surgical choice has more effect on recurrence‐free survival. MR was more common than LRR, with most MR occurring within the first 2 years after surgery.

Radiographically guided shave margins may reduce lumpectomy re-excision rates

Minimizing margin re‐excision optimizes patient care by providing appropriate oncologic resection and reducing costs. This study aims to assess margin positivity rate in two groups: shave margin based on gross specimen (control group, CG) vs shave margin based on intraoperative imaging (radiographic group, RG). A total of 182 patients who underwent lumpectomy for stage O‐III breast cancer at a single institution from January 2013 to January 2014 were evaluated. There was statistically significant decrease in margin re‐excision rate with intraoperative mammography but not with ultrasound. Surgeons are ideally equipped to use intraoperative imaging to guide margin excision, thus, improving care and reducing costs.

Are Patients Traveling for Intraoperative Radiation Therapy

Purpose One benefit of intraoperative radiation therapy (IORT) is that it usually requires a single treatment, thus potentially eliminating distance as a barrier to receipt of whole breast irradiation. The aim of this study was to evaluate the distance traveled by IORT patients at our institution. Methods Our institutional prospective registry was used to identify IORT patients from 10/2011 to 2/2017. Patients home zip code was compared to institution zip code to determine travel distance. Characteristics of local (<50 miles), regional (50–100 miles), and faraway (>100 miles) patients were compared. Results 150 were patients included with a median travel distance of 27 miles and mean travel distance of 121 miles. Most were local (68.7%), with the second largest group living faraway (20.0%). Subset analysis of local patients demonstrated 20.4% traveled <10 miles, 34.0% traveled 10–20 miles, and 45.6% traveled 20–50 miles. Six patients traveled >1000 miles. The local, regional, and faraway patients did not differ with respect to age, race, tumor characteristics, or whole breast irradiation. Conclusions Breast cancer patients are traveling for IORT, with 63% traveling >20 miles for care. IORT is an excellent strategy to promote breast conservation in selected patients, particularly those who live remote from a radiation facility.