Melissa Anne Mallory

Estimating operative disease prevalence in a low-income country: results of a nationwide population survey in Rwanda.

BACKGROUND Operative disease is estimated to contribute to 11% of the global burden of disease, but no studies have correlated this figure to operative burden at the community level. We describe a survey tool that evaluates population-based prevalence of operative conditions and its first full-country implementation in Rwanda. METHODS The Surgeons OverSeas Assessment of Surgical Need (SOSAS) survey tool is a cross-sectional, cluster-based population survey designed to measure conditions that may necessitate an operative consultation or intervention. Household surveys in Rwanda were conducted in October 2011 in 52 clusters nationwide. Data were population-weighted and analyzed with the use of descriptive statistics. RESULTS A total of 1626 households (3175 individuals) were sampled with a 99% response rate. 41.2% (95% confidence interval [95 CI%] 38.8-43.6%) of the population has had at least one operative condition during their lifetime, 14.8% (95% CI 13.3-16.5%) had an operative condition during the previous 12 months, and 6.4% (95% CI 5.6-7.3%) of the population were determined to have a current operative condition. A total of 55.3% of the current operative need was found in female respondents and 40.3% in children younger than 15 years of age. A total of 32.9% of household deaths in the previous year may have been related to operative conditions, and 55.0% of responding households lacked funds for transport to the nearest hospital providing general practitioner operative services. CONCLUSION The SOSAS survey tool provides important insight into the burden of operative disease in the community. Our results show a high need for operative care, which has important implications for the global operative community as well as for local health system strengthening in Rwanda.

Survival Benefit of Breast Surgery for Low-Grade Ductal Carcinoma In Situ: A Population-Based Cohort Study

IMPORTANCE While the prevalence of ductal carcinoma in situ (DCIS) of the breast has increased substantially following the introduction of breast-screening methods, the clinical significance of early detection and treatment for DCIS remains unclear. OBJECTIVE To investigate the survival benefit of breast surgery for low-grade DCIS. DESIGN, SETTING, AND PARTICIPANTS A retrospective longitudinal cohort study using the Surveillance, Epidemiology, and End Results (SEER) database from October 9, 2014, to January 15, 2015, at the Dana-Farber/Brigham Womens Cancer Center. Between 1988 and 2011, 57,222 eligible cases of DCIS with known nuclear grade and surgery status were identified. EXPOSURES Patients were divided into surgery and nonsurgery groups. MAIN OUTCOMES AND MEASURES Propensity score weighting was used to balance patient backgrounds between groups. A log-rank test and multivariable Cox proportional hazards model was used to assess factors related to overall and breast cancer-specific survival. RESULTS Of 57,222 cases of DCIS identified in this study, 1169 cases (2.0%) were managed without surgery and 56,053 cases (98.0%) were managed with surgery. With a median follow-up of 72 months from diagnosis, there were 576 breast cancer-specific deaths (1.0%). The weighted 10-year breast cancer-specific survival was 93.4% for the nonsurgery group and 98.5% for the surgery group (log-rank test, P < .001). The degree of survival benefit among those managed surgically differed according to nuclear grade (P = .003). For low-grade DCIS, the weighted 10-year breast cancer-specific survival of the nonsurgery group was 98.8% and that of the surgery group was 98.6% (P = .95). Multivariable analysis showed there was no significant difference in the weighted hazard ratios of breast cancer-specific survival between the surgery and nonsurgery groups for low-grade DCIS. The weighted hazard ratios of intermediate- and high-grade DCIS were significantly different (low grade: hazard ratio, 0.85; 95% CI, 0.21-3.52; intermediate grade: hazard ratio, 0.23; 95% CI, 0.14-0.42; and high grade: hazard ratio, 0.15; 95% CI, 0.11-0.23) and similar results were seen for overall survival. CONCLUSIONS AND RELEVANCE The survival benefit of performing breast surgery for low-grade DCIS was lower than that for intermediate- or high-grade DCIS. A prospective clinical trial is warranted to investigate the feasibility of active surveillance for the management of low-grade DCIS.

Patient Prognostic Score and Associations With Survival Improvement Offered by Radiotherapy After Breast-Conserving Surgery for Ductal Carcinoma In Situ: A Population-Based Longitudinal Cohort Study

PURPOSE Radiotherapy (RT) after breast-conserving surgery (BCS) is a standard treatment option for the management of ductal carcinoma in situ (DCIS). We sought to determine the survival benefit of RT after BCS on the basis of risk factors for local recurrence. PATIENTS AND METHODS A retrospective longitudinal cohort study was performed to identify patients with DCIS diagnosed between 1988 and 2007 and treated with BCS by using SEER data. Patients were divided into the following two groups: BCS+RT (RT group) and BCS alone (non-RT group). We used a patient prognostic scoring model to stratify patients on the basis of risk of local recurrence. We performed a Cox proportional hazards model with propensity score weighting to evaluate breast cancer mortality between the two groups. RESULTS We identified 32,144 eligible patients with DCIS, 20,329 (63%) in the RT group and 11,815 (37%) in the non-RT group. Overall, 304 breast cancer-specific deaths occurred over a median follow-up of 96 months, with a cumulative incidence of breast cancer mortality at 10 years in the weighted cohorts of 1.8% (RT group) and 2.1% (non-RT group; hazard ratio, 0.73; 95% CI, 0.62 to 0.88). Significant improvements in survival in the RT group compared with the non-RT group were only observed in patients with higher nuclear grade, younger age, and larger tumor size. The magnitude of the survival difference with RT was significantly correlated with prognostic score (P < .001). CONCLUSION In this population-based study, the patient prognostic score for DCIS is associated with the magnitude of improvement in survival offered by RT after BCS, suggesting that decisions for RT could be tailored on the basis of patient factors, tumor biology, and the prognostic score.

Feasibility of Intraoperative Breast MRI and the Role of Prone Versus Supine Positioning in Surgical Planning for Breast‐Conserving Surgery

We assessed the feasibility of supine intraoperative MRI (iMRI) during breast‐conserving surgery (BCS), enrolling 15 patients in our phase I trial between 2012 and 2014. Patients received diagnostic prone MRI, BCS, pre‐excisional supine iMRI, and postexcisional supine iMRI. Feasibility was assessed based on safety, sterility, duration, and image‐quality. Twelve patients completed the study; mean duration = 114 minutes; all images were adequate; no complications, safety, or sterility issues were encountered. Substantial tumor‐associated changes occurred (mean displacement = 67.7 mm, prone–supine metric, n = 7). We have demonstrated iMRI feasibility for BCS and have identified potential limitations of prone breast MRI that may impact surgical planning.

A low cost training phantom model for radio-guided localization techniques in occult breast lesions

Radio‐guided localization (RGL) for identifying occult breast lesions has been widely accepted as an alternative technique to other localization methods, including those using wire guidance. An appropriate phantom model would be an invaluable tool for practitioners interested in learning the technique of RGL prior to clinical application. The aim of this study was to devise an inexpensive and reproducible training phantom model for RGL. We developed a simple RGL phantom model imitating an occult breast lesion from inexpensive supplies including a pimento olive, a green pea and a turkey breast. The phantom was constructed for a total cost of less than

25 – Examination Techniques: Roles of the Physician and Patient in Evaluating Breast Disease

20 and prepared in approximately 10 min. After the first models construction, we constructed approximately 25 additional models and demonstrated that the model design was easily reproducible. The RGL phantom is a time‐ and cost‐effective model that accurately simulates the RGL technique for non‐palpable breast lesions. Future studies are warranted to further validate this model as an effective teaching tool. J. Surg. Oncol. 2015; 112:449–451.

Label-free biomolecular characterization of human breast cancer tissue with stimulated Raman scattering (SRS) spectral imaging (Conference Presentation)

Abstract Screening and diagnosis for diseases of the breast involve coordination between patients and their multidisciplinary team of physicians. The roles of patients and physicians in the evaluation of breast disease are discussed, and the many modalities available for assisting in breast disease evaluation are examined and described, including breast self-examination, clinical breast examination, and breast imaging.

Implementation of a Breast/Reconstruction Surgery Coordinator to Reduce Preoperative Delays for Patients Undergoing Mastectomy With Immediate Reconstruction

Stimulated Raman scattering (SRS) microscopy has been used for rapid label-free imaging of various biomolecules and drugs in living cells and tissues (Science, doi:10.1126/science.aaa8870). Our recent work has demonstrated that lipid and protein mapping of cancer tissue renders pathology-like images, providing essential histopathological information with subcellular resolution of the entire specimen (Cancer Research, doi: 10.1158/0008-5472.CAN-16-027). We have also established the first SRS imaging Atlas of human brain tumors (Harvard Dataverse, doi: (doi:10.7910/DVN/EZW4EK). SRS imaging of tissue could provide invaluable information for cancer diagnosis and surgical guidance in two aspects: rapid surgical pathology and quantitative biomolecular characterization. In this work, we present the use of SRS microscopy for characterization of a few essential biomolecules in breast cancer. Human breast cancer tissue specimens at the tumor core, tumor margin and normal area (5 cm away from the tumor) from surgical cases will be imaged with SRS at multiple Raman shifts, including the peaks for lipid, protein, blood (absorption), collagen, microcalcification (calcium phosphates and calcium oxalate) and carotenoids. Most of these Raman shifts have relatively strong Raman cross sections, which ensures high-quality and fast imaging. This proof-of-principle study is sought to demonstrate the feasibility and potential of SRS imaging for ambient diagnosis and surgical guidance of breast cancer.

Computed Tomographic Imaging in the Diagnosis of Recurrent Ventral Hernia

PURPOSE Mastectomy with immediate reconstruction (MIR) requires coordination between breast and reconstructive surgical teams, leading to increased preoperative delays that may adversely impact patient outcomes and satisfaction. Our cancer center established a target of 28 days from initial consultation with the breast surgeon to MIR. We sought to determine if a centralized breast/reconstructive surgical coordinator (BRC) could reduce care delays. METHODS A 60-day pilot to evaluate the impact of a BRC on timeliness of care was initiated at our cancer center. All reconstructive surgery candidates were referred to the BRC, who had access to surgical clinic and operating room schedules. The BRC worked with both surgical services to identify the earliest surgery dates and facilitated operative bookings. The median time to MIR and the proportion of MIR cases that met the time-to-treatment goal was determined. These results were compared with a baseline cohort of patients undergoing MIR during the same time period (January to March) in 2013 and 2014. RESULTS A total of 99 patients were referred to the BRC (62% cancer, 21% neoadjuvant, 17% prophylactic) during the pilot period. Focusing exclusively on patients with a cancer diagnosis, an 18.5% increase in the percentage of cases meeting the target (P = .04) and a 7-day reduction to MIR (P = .02) were observed. CONCLUSION A significant reduction in time to MIR was achieved through the implementation of the BRC. Further research is warranted to validate these findings and assess the impact the BRC has on operational efficiency and workflows.

Tumor subtype and race in male breast cancer: A population-based cohort study.

Ventral hernias (VHs) are common in the United States, with more than 350 000 repairs performed annually.1 Nevertheless, consensus regarding the optimal technique for VH repair is lacking and recurrence rates remain high (approaching 50% in some series), suggesting we are not quite ready to close the book on VH management. Considerable debate persists in VH management, particularly in cases of recurrence. Although the treatment of symptomatic recurrence detected on physical examination is usually surgical repair, management dilemmas arise for symptomatic patients without palpable hernias and asymptomatic patients with detectable hernias. In these settings, computed tomography (CT) as an adjunct to physical examination may be beneficial. Although data suggest CT may be superior to examination, especially for obese patients or small hernias, no standardized criteria for diagnosis of recurrent herniation exist.2,3 In this month’s JAMA Surgery, Holihan et al2 address the value of CT by examining its reliability for detecting VH recurrence in 100 patients who received CT scans following VH repair. Because most patients were never subsequently explored, the accuracy of CT could not be fully assessed. Therefore, the authors examined the interobserver reliability of 6 radiologists and 3 surgeon reviewers. When reviewers were blinded to symptoms, physical examination, and details of the previous repair, discordance regarding CT interpretation existed in 73% of cases. This result is striking, although not unexpected in the absence of standardized diagnostic criteria. Although identifying recurrence on CT is straightforward when obvious organ or tissue protrusion is present, many hernias spontaneously reduce in the supine imaging position, requiring recurrence detection to be based solely on identification of the fascial defect. Additional challenges arise for mesh-based repairs because certain prostheses are not visible on CT, and when used to bridge defects without approximating fascia, they may be indistinguishable from recurrences.4 Finally, the presence of eventration, fluid collections, and/or scarring above intact repairs can complicate interpretation. The disagreement among observers in the unblinded consensus group who were given clinical history and allowed multidisciplinary discussion was considerably less (only 10%), and the interobserver reliability of CT for VH diagnosis significantly improved. Causes for persistent disagreement were discussed and the emerging trends provide some of the study’s most salient conclusions (Table 2 in the article2), offering insight into ways of improving VH diagnosis. The 90% agreement observed after multidisciplinary discussion and clinical history review in the consensus group suggests that CT can be a reliable method of diagnosing VH recurrence but should not be used in isolation. This study demonstrates the benefit of imaging to assist, not replace, patient examination and assessment for VH detection. The success of CT for recurrent VH diagnosis requires communication between surgeon and radiologist, and multidisciplinary care is again at the forefront of optimal patient management.