May Lynn Quan

Biology of lymphatic metastases in breast cancer: Lessons learned from sentinel node biopsy

BackgroundThe evolution of sentinel node biopsy has placed new emphasis on the biology of lymphatic metastases in breast cancer. If radiocolloid mimics the migration of tumor cells, the nodes with the most uptake should also be the most likely to harbor metastatic cells. We attempted to correlate the frequency of metastatic disease to the greatest gamma uptake and to clarify the physiology of breast lymphatic drainage.MethodsData were collected from 152 patients undergoing sentinel node biopsy from January 1997 to June 1999. Localization was by injection of unfiltered99mTc-labeled sulfur colloid. Sentinel nodes were identified with an intraoperative gamma counter and the 10% rule. A completion level I/II axillary dissection was performed in all patients.ResultsFifty-four of 152 patients were positive for metastatic disease. There were no falsenegative sentinel nodes. In 46 (85%) of 54 cases, the node with the highest uptake was positive for metastatic disease. In the remaining eight (15%) cases, another node with a lower gamma count was positive.ConclusionsThe sentinel node with the highest uptake is not the one that contains metastatic disease in 15% of cases. This may reflect variations in lymphatic channels or technical variations in colloid properties and injection technique.

Measuring the Quality of Sentinel Lymph Node Biopsy in Breast Cancer Using Newly Developed Quality Indicators: A Feasibility Study

BackgroundMeasurement of the quality of sentinel lymph node biopsy (SLNB) has not been reported beyond the false-negative rate and sentinel lymph node identification rate. This study’s purpose is to determine the feasibility of measuring 11 quality indicators (QIs) that were recently developed using a modified Delphi process.MethodsAll patients who underwent SLNB for breast cancer at a tertiary health-care center from January 1st 2005 to December 31st 2007 were identified using a SLNB registry. Patient charts were reviewed retrospectively and the QIs were abstracted.ResultsNine of the 11 QIs were measurable: 7 required chart-level abstraction, 2 were confirmed at an institutional level, and 2 were immeasurable due to registry limitations. Of the 497 identified patients, 13 patients had failed SLNB, resulting in 484 SLNBs. The axillary positivity rate was 19%. The method of SLN identification was reported in 97% of cases, and in 388 (80%) more than one SLN was removed. All SLNs were serially sectioned according to protocol, though only 102 (21%) of pathology reports explicitly stated the cancer stage. Nearly all SLNBs were performed alongside the primary breast surgery. Among SLN-positive patients: 78 (87%) underwent axillary lymph node dissection, 10 patients refused, and chart data were missing in 2 others. No “ineligible” patients had SLNB.ConclusionMeasurement of newly developed QIs for SLNB is feasible for abstraction from inpatient charts at a single institution. These QIs can provide baseline measures for ongoing quality assessment of SLNB using hospital chart review.

Adoption of surgical innovations: factors influencing use of sentinel lymph node biopsy for breast cancer.

Purpose. Sentinel lymph node biopsy (SLNB) has been unevenly adopted into practice in Canada. In this qualitative study, the authors explored individual, institutional, and policy factors that may have influenced SLNB adoption. This information will guide interventions to improve SLNB implementation. Methods. Qualitative methodology was used to examine factors influencing SLNB adoption. Grounded theory guided data collection and analysis. Semistructured interviews were based on Roger’s diffusion of innovation theory. Purposive and snowball sampling was used to identify participants. Semistructured telephone interviews were conducted with urban, rural, academic, and community health care providers and administrators to ensure all perspectives and motivations were explored. Two individuals independently analyzed data and achieved consensus on emerging themes and their relationship. Results. A total of 43 interviews were completed with 21 surgeons, 5 pathologists, 7 nuclear medicine physicians, and 10 administrators. Generated themes included awareness of SLNB with the exception of some administrators, acknowledged advantage of SLNB, SLNB compatibility with beliefs regarding axillary staging, acknowledgment that SLNB was a complex innovation to adopt, extensive trialing of SLNB prior to adoption, observable benefits with SLNB, acknowledgment that hospital-level administrative support enabled adoption, desire for a provincial policy supporting SLNB to assist in hospital-level adoption, requirement of a local high-volume breast surgery champion who communicated extensively with team to facilitate local adoption, and need for credentialing of SLNB to ensure quality. Conclusions. SLNB is a complex innovation to adopt. Successful adoption was assisted by a high-volume breast cancer surgical champion, interprofessional communication, and administrative support.

A population-based assessment of melanoma: Does treatment in a regional cancer center make a difference?

Regionalization of care to specialized centers has improved outcomes for several cancer types. We sought to determine if treatment in a regional cancer center (RCC) impacts guideline adherence and outcomes for patients with melanoma.

Oncofertility Knowledge, Attitudes, and Practices of Canadian Breast Surgeons

BackgroundGuidelines recommend that oncologists discuss treatment-related fertility issues with young cancer patients as early as possible after diagnosis and, if appropriate, expedite referral for fertility preservation (FP). This study sought to determine the attitudes and practices of Canadian breast surgeons regarding fertility issues, as well as barriers to and facilitators of fertility discussion and referrals.MethodsSemistructured telephone interviews were conducted with 28 site lead surgeons (SLSs) at 28 (97 %) of 29 centers (25 % cancer centers, 64 % teaching hospitals) across Canada participating in RUBY, a pan-Canadian research program for young women with breast cancer. In addition, 56 (65 %) of 86 of their surgical colleagues (non-site lead surgeons [NSLSs]) completed an online survey of their oncofertility knowledge, attitudes, and practices.ResultsOf the 28 SLSs (43 % male, 36 % in practice <10 years), 46 % had inadequate oncofertility knowledge, 25 % discussed fertility only if mentioned by the patient, 21 % believed fertility discussion and referral were the mandate of the medical oncologist, and 45 % did not know of an FP center in their area. More than 80 % of the NSLSs (54 % male, 30 % in practice <10 years) were unfamiliar with oocyte or embryo cryopreservation; 36 % never or rarely discussed fertility issues; and 51 % thought referral to a fertility specialist was not their responsibility.ConclusionsOncofertility knowledge was low among the SLSs, especially the NSLSs, and barriers to referral were identified. An oncofertility knowledge translation intervention specifically for breast surgeons is being developed to increase surgeon knowledge and awareness of oncofertility issues and referral.

Quality indicators for ductal carcinoma in situ (DCIS) of the breast: Development using a multidisciplinary delphi process and its use in monitoring population-based treatment

Evaluation of the management of DCIS poses challenges, as standard breast cancer outcome measures such as mortality do not apply. We have developed quality indicators (QIs) to measure the quality of DCIS treatment in Alberta, Canada.

Effect of Multidisciplinary Case Conferences on Physician Decision Making: Breast Diagnostic Rounds

Purpose: To evaluate the utility of multidisciplinary case conferences (MCCs) on physician decision making in benign and malignant breast disease management. Methods: Patients with interesting or challenging diagnostic or management issues were discussed at biweekly diagnostic breast MCCs. Prior to discussion, a clinical summary and intended management plan prior to the MCC was presented. For each case, diagnostic images/histopathology were centrally reviewed after which group discussion achieved a management consensus which was documented prospectively. Initial management plans were compared to the post-MCC consensus. A change in a management plan was defined as a consensus plan different from the pre-MCC plan or no definite plan prior to the MCC. Results: From November 2014 to December 2015, 76 patients (43 malignant and 33 benign diagnoses) were discussed in 19 MCCs. All cases presented resulted in a consensus management recommendation. Thirty-one case discussions (41%) resulted in a changed management plan (20 malignant and 11 benign diagnoses). Management changes included avoidance of immediate surgery (9% of cases), change in the type of surgery (5%), non-invasive investigation to invasive/surgical intervention (7%), and detection of a new suspicious lesion (1%). Conclusion: MCCs had a substantial impact on physician decision making. Management plans changed in 41% of cases presented, the majority due to new/clarified diagnostic information. Presentation of cases at MCCs should be encouraged, especially for challenging diagnostic or management issues regarding malignant or benign breast diagnoses.

The Ever‐diminishing Role of Axillary Lymph Node Dissection in Breast Cancer

To the Editor: Over the past decade, high-quality studies have proven sentinel lymph node biopsy (SLNB) to be an accurate method of axillary staging for early-stage, clinically node-negative breast cancer (1–3). SLNB then became the standard initial axillary procedure, followed by a completion axillary lymph node dissection (cALND) in cases where sentinel nodes harbored cancer (4). The landmark American College of Surgeons Oncology Group Z0011 study (hereafter Z11) demonstrated that women with early-stage breast cancer, low-risk nodal metastases, and who undergo adjuvant therapy receive no benefit from cALND as compared with SLNB alone (5). Surgical management of the axilla has, therefore, progressed, such that SLNB is the sole staging procedure in select cases. Due to the emerging role of SLNB, we recently developed eight measurable SLNB quality indicators and examined SLNB implementation across a Canadian province (6). We considered SLNB cases for breast cancer performed in Ontario during the 2005 calendar year and found that SLNB was performed to a high degree of quality (7). Moreover, the data suggest that many Ontario surgeons, long before the publication by Giuliano et al., were already making changes to their practices that are consistent with the findings of Z11; namely, surgeons were performing significantly less cALNDs in older patients with low-burden axillary metastases (7). Our retrospective study identified certain barriers to SLNB implementation, notably, start-up equipment costs, as well as access to nuclear medicine and breast-dedicated pathology resources. The implication being that a minority of mainly smaller community hospitals have been unable to offer SLNB locally (8). The challenge of providing patient access to specialized radiology and pathology resources needs to be addressed at a regional level with effective planning and policy development. The cost of equipment for SLNB implementation, however, can be analyzed at an institutional level, as Canadian hospitals shoulder much of the budgetary burden when surgeons introduce technologies (8). We compared hospital-level costs of a pre-Z11 SLNB treatment algorithm (SLNB followed by cALND for positive sentinel nodes) to one that involved only ALND for axillary staging (as this reflected the practical reality of the surgical management of breast cancer in the rural centers). The comparison consisted of an economic analysis, using a deterministic decision-analysis model built with TreeAge Pro Suite 2010 (TreeAge Software, Williamstown, MA, USA). The competing treatment algorithms were populated with clinical probabilities derived from a systematic review of SLNB-associated clinical trials (2,8,9) and weighted-average costs (from 13 Ontario hospitals) were taken from the 2008 Ontario Case Costing Initiative (OCCI) data base (8). Case costing is less precise than microcosting, but is considered to be more generalizable (10). Known axillary surgery-associated complications of seroma formation, shoulder dysmobility, axillary pain and paresthesia, as well as lymphedema, were incorporated into the model as iterative loops known as Markov states (2,8,9). The results showed the SLNB treatment pathway to be less costly by CDN

Abstract P5-02-07: Effect of multidisciplinary case conferences on physician decision making: Breast diagnostic rounds

489.27 than the ALND option, with mean costs of

Contralateral mastectomy in young women with breast cancer: A population-based analysis of predictive factors and clinical impact.

3,295.21 [CI: