Zenon Rayter

A Prospective Analysis of Implementation of Multi-Disciplinary Team Decisions in Breast Cancer

Abstract:  Multi‐disciplinary teams (MDTs) management of patients with cancer is mandatory in the United Kingdom, and auditing team decision‐making by examining rates of decision implementation and reasons for nonimplementation may inform this practice. Consecutive breast cancer MDT decisions, subsequent decision implementation, and reasons for nonimplementation were prospectively recorded. Factors associated with nonimplementation of the MDT decision were analyzed with logistic regression. Of 289 consecutive MDT decisions involving 210 women, 20 (6.9%, 95% CIs 4.3%–10.5%) were not implemented. Most changed MDT decisions did so because of patient preferences (n = 13, 65%), with the discovery of new clinical information (n = 3) and individual doctor’s views (n = 4) also leading to decision nonimplementation. MDT decisions were significantly less likely to be adhered to in patients with confirmed malignant disease compared to those with benign or ‘unknown’ disease categories (p < 0.001) and MDT decisions in older patients were significantly more likely not to be implemented than in younger patients (p = 0.002). Auditing nonimplementation of MDT recommendations and examining reasons for changed decisions is a useful process to monitor team performance and to identify factors that need more attention during the MDT meeting to ensure that the process makes optimal patient centered decisions.

A prospective analysis of implementation of multi-disciplinary team decisions in breast cancer

Abstract:  Multi‐disciplinary teams (MDTs) management of patients with cancer is mandatory in the United Kingdom, and auditing team decision‐making by examining rates of decision implementation and reasons for nonimplementation may inform this practice. Consecutive breast cancer MDT decisions, subsequent decision implementation, and reasons for nonimplementation were prospectively recorded. Factors associated with nonimplementation of the MDT decision were analyzed with logistic regression. Of 289 consecutive MDT decisions involving 210 women, 20 (6.9%, 95% CIs 4.3%–10.5%) were not implemented. Most changed MDT decisions did so because of patient preferences (n = 13, 65%), with the discovery of new clinical information (n = 3) and individual doctor’s views (n = 4) also leading to decision nonimplementation. MDT decisions were significantly less likely to be adhered to in patients with confirmed malignant disease compared to those with benign or ‘unknown’ disease categories (p < 0.001) and MDT decisions in older patients were significantly more likely not to be implemented than in younger patients (p = 0.002). Auditing nonimplementation of MDT recommendations and examining reasons for changed decisions is a useful process to monitor team performance and to identify factors that need more attention during the MDT meeting to ensure that the process makes optimal patient centered decisions.

P2-16-07: A Randomised Controlled Trial To Evaluate the Role of Tisseel, a Fibrin Sealant on Seroma Formation in Latissimus dorsi Breast Reconstruction.

Introduction: Donor site seromas are common complications following Latissimus dorsi breast reconstructions (LDBR), as shown in the UK National Mastectomy and Breast Reconstruction audit. Level I clinical evidence following the performance of an RCT supports ‘fixation’ of the back skin flaps by quilting sutures 1 . Fibrin sealants (Tisseel) have been postulated to reduce seromas after simple mastectomy and axillary dissections 2 , but their role in reducing donor site seromas after breast reconstruction has yet to be performed in a ‘robust’ clinical trial. The aim of this RCT was to compare Tisseel against Control (no Tisseel) on the incidence of seromas after LDBR. Methods: In an ethics approved single centre, single-blinded study comprising 2 surgeons from 2005–2010; 106 women were randomised to either Control (52) or Tisseel (54) interventions after immediate or delayed breast reconstructions. Sixteen patient9s were excluded as follows due to incomplete data at 3 months or re-operations of the donor site for complications. The types of breast reconstructions comprised implant-assisted LD (LDI) in 45 women, 23 extended LD flaps (ELD) and 23 ELD with implant (ELDI). Immediate breast reconstructions (n=87) comprised the majority compared to only 4 delayed procedures. Intraoperative drains were placed to the breast, axilla and donor site (x two) as per standard practice. A 0.5% fibrinogen concentration was used in a hydraulic hand-held Tisseel spray application to the donor site chest wall over 60 seconds. Two stay sutures were pre-placed 2 cm adjacent to the donor wound skin edges above and below prior to the Tisseel application. In the control group, 2 drains only were placed. The primary outcome measure was the total seroma volumes from all the sites over 3 months. This was used for the power calculation of the sample size and showed a requirement for a minimum of 95 women. Secondary outcomes included the volumes of the donor site seromas, and the frequency of post-drain removal donor site aspirations of all symptomatic seromas by patient self-report. Results: The effect of Tisseel glue was to reduce the mean total drain (breast, axilla and back) volume from 2170ml to 1919ml (P=0.05, Mann-Whitney) within 7–10 days. The donor site seroma volumes were similar between the 2 groups over 3 months. The mean donor site total drain volumes (LD donor site drain volume and symptomatic donor site aspirations) were 5412ml in the Control group (840-6252), compared to the Tisseel group producing 4646ml (5384-738). There were no statistical differences between the frequencies or volumes of patient reported seromas aspirated post-drain removal between the two groups. This comprised a mean of 4 aspirations (range 0–13) in the Control group compared to a mean of 9 aspirations (range 0–11) after the use of Tisseel (P=0.548). Conclusion: Tisseel glue may reduce the ‘early’ effect of seroma development, but has not shown any significant role in minimising the potential ‘shearing’ of the donor site skin flaps causing later seroma formation. Current evidence recommends quilting sutures as the gold-standard in reducing this complication. 1. Daltrey I et. al. BJS 2006; 93(7):825–830. 2. Jain PK et. al. BJS 2004; 91:54–60. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-16-07.

A Multi Centre Prospective Longitudinal Study Establishing Level II Evidence of Health Related Quality of Life after Types of Immediate Latissimus Dorsi (LD) Breast Reconstruction.

Introduction: NICE recommends that the majority of women undergoing mastectomy should be offered immediate breast reconstruction with its potential benefits to improve health related quality of life (HRQL). A systematic review shows poor and conflicting evidence with a lack of 9hard9 data to best inform both clinicians and their patients. Our aim was to evaluate the effects of implant-assisted LD (LDI) versus autologous LD (ALD) breast reconstruction on HRQL over 36 months. Recently, with the exception of the USA Breast-Q module there is a lack of a validated Breast reconstruction questionnaire. Methods: An MREC approved prospective longitudinal cohort study involving 6 centres commenced in early 2007. Serial patient reported outcome measures using the EORTC C30 (global QoL, physical functioning, fatigue, pain), BR-23 (breast and arm symptoms), 10 item Body Image Scale (BIS) and HADS, were completed pre-operatively and at 3, 6, 12, 24 and 36 months after surgery. Overall cosmetic satisfaction of the breast reconstruction was measured by a study-specific question on a 5 point Likert scale. Generalised estimating equations were used to assess change over time and differences between treatment groups.The Spearman9s rank correlation coefficient was used to assess associations between patient reported cosmetic satisfaction with BIS and breast symptoms. Results: 118 patients (65 – ALD, 53 – LDI) were recruited to the study with a mean age of 50 years (range 22-70). Compliance with questionnaires at all time points was between 85-90%. There were no significant differences in HRQL domains between LDI and ALD, except a tendency for worse pain with ALD (p=0.06). Significant improvements over time were seen for overall HRQL (p Conclusion: There is an important need for cumulative clinical evidence in this field on which to base patient informed consent and clinical recommendations. Further analyses will assess whether there is an independent effect of RT on HRQL. A validated EORTC breast reconstruction module is in development. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3106.