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Background: The transition from surgical residency to independent practice is a challenging period that has not been well studied. Methods: An email invitation to complete a 55-item survey and the Maslach Burnout Inventory–Human Services Survey (MBI-HSS) was sent to early career general surgeons across Canada. The chi-square test or Fisher’s exact test was used to compare demographic and survey characteristics with burnout. Multivariable logistic regression was performed. Results: Of the 586 surgeons contacted, 88 responded (15%); 51/88 surgeons (58.0%) were classified as burnt out according to the MBI-HSS. Most surgeons (68.2%) were not confident in their abilities to handle the business aspect of practice. The majority (60.2%) believed that a transition to independent practice program would be beneficial to recent surgical graduates. Conclusions: Our data showed high prevalence of burnout among recently graduated general surgeons across Canada. Further, respondents were not confident in their managerial and administrative skills required to run a successful independent practice.

Rates of bilateral mastectomy are rising in women with unilateral, nonhereditary breast cancer. We aim to characterize how psychosocial outcomes evolve after breast cancer surgery. We performed a prospective cohort study of women with unilateral, sporadic stage 0–III breast cancer at University Health Network in Toronto, Canada between 2014 and 2017. Women completed validated psychosocial questionnaires (BREAST-Q, Impact of Event Scale, Hospital Anxiety & Depression Scale) preoperatively, and at 6 and 12 months following surgery. Change in psychosocial scores was assessed between surgical groups using linear mixed models, controlling for age, stage, and adjuvant treatments. P < .05 were significant. A total of 475 women underwent unilateral lumpectomy (42.5%), unilateral mastectomy (38.3%), and bilateral mastectomy (19.2%). There was a significant interaction (P < .0001) between procedure and time for breast satisfaction, psychosocial and physical well-being. Women having unilateral lumpectomy had higher breast satisfaction and psychosocial well-being scores at 6 and 12 months after surgery compared with either unilateral or bilateral mastectomy, with no difference between the latter two groups. Physical well-being declined in all groups over time; scores were not better in women having bilateral mastectomy. While sexual well-being scores remained stable in the unilateral lumpectomy group, scores declined similarly in both unilateral and bilateral mastectomy groups over time. Cancer-related distress, anxiety, and depression scores declined significantly after surgery, regardless of surgical procedure (P < .001). Psychosocial outcomes are not improved with contralateral prophylactic mastectomy in women with unilateral breast cancer. Our data may inform women considering contralateral prophylactic mastectomy.

Purpose: To evaluate patient-reported outcomes of adolescents and young adults (AYAs) with breast cancer treated with curative intent. Methods: AYA breast cancer patients (defined as diagnosed between 18 to 39 years of age) treated at a large tertiary cancer centre between January 2014 and December 2016 were identified. Patients routinely complete the validated symptom screening tool, the Edmonton Symptom Assessment System-revised (ESAS-r) prior to their clinical encounter. Scores from diagnosis up to 24 months post-diagnosis were obtained from our internal database, with elevated scores defined as > 4 for each individual symptom (rated 0-10). Patient, clinical and treatment characteristics were extracted from medical records. Descriptive statistics were used to describe patient, clinical and treatment characteristics, and ESAS-r scores. Time to recurrence was calculated from diagnosis to local or regional recurrence, distant metastasis or death (whichever occurred first). Kaplan-Meier survival analysis and log-rank tests were used to compare time to recurrence between women with vs. without elevated symptom scores. Chi-squared test was used to test the change in number of patients with elevated symptom scores over time. Univariable and multivariable logistic regression models were carried out to assess association between various factors and ESAS-r symptoms of depression, anxiety and well-being within 24 months of diagnosis. Results: Among 258 patients identified, 211 (82%) had accompanying ESAS-r and were eligible for analysis. Median follow-up was 3.9 years. Median age at diagnosis was 35 (20-39), most were clinical stage 2/3 at diagnosis (63%), 20% had triple negative disease, 76% received chemotherapy and 81% received radiotherapy. Overall, symptom burden was the highest (scores > 4) for decreased well-being (52%), tiredness (48%) and anxiety (44%). Although symptom burden significantly improved over time, 43%, 38% and 33% of patients, respectively, reported elevated symptoms 24 months post-diagnosis. Multivariable analysis found that elevated anxiety was significantly associated with younger age at diagnosis (p=0.036), receipt of chemotherapy (p=0.01) and presence of long-term toxicity (p=0.0032). Elevated depression, anxiety and well-being were significantly associated with referral to Psychosocial Oncology (p=0.024, p=0.036 and p=0.019, respectively), whereas well-being was also associated with referral to Survivorship Clinic (p=0.043). However, overall rates of referral (24-36%) were much lower than symptom prevalence. There was no association between elevated symptoms and time to recurrence. Conclusion: AYAs diagnosed with breast cancer report high symptom burden that continues to persist up to 24-months post-diagnosis. Patients with elevated psychosocial distress are more likely to be referred to Psychosocial Oncology and Survivorship clinics, indicating that the ESAS-r is a useful screening tool in a real-world setting. However, a gap between symptom burden and intervention exists, providing opportunities for future research. Citation Format: Revathy Krishnamurthy, Tulin Cil, Philippe Bedard, Robin Forbes, Madeline Li, Zhihui (Amy) Liu, Jennifer Croke. Patient-reported outcomes of adolescents and young adults with breast cancer treated with curative intent [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PD12-09.

BACKGROUND: Changes in access to breast imaging and suspension of mammographic screening during the COVID-19 pandemic had the potential to significantly delay breast cancer diagnostic pathways. The Gattuso Rapid Diagnostic Centre (GRDC) is an innovative clinic that provides a patient-centered approach for investigation of suspicious breast abnormalities and sees approximately 1200 patients per year. The aim of this study was to assess the impact of the pandemic on patient volumes and imaging at this high-volume breast rapid diagnostic centre. METHODS: A retrospective review of consecutive patients who presented to the GRDC from the start of the pandemic (March 12, 2020) until May 31, 2020 was performed. The number of patients, reason for referral, cancer detection rate (CDR), and waiting time from appointment to diagnosis were evaluated and compared to a corresponding time period in 2019. RESULTS: A total of 168 new patients presented to the GRDC during the study period, corresponding to a 32.3% decrease in the number of patients compared to 2019 (n=248). Seventy-eight patients (46.4%) were referred due to the presence of a clinical palpable abnormality, which represented an increase of 13.8% (n=81 [32.7%] in 2019; p=0.005). Out of 168 patients, 69 were diagnosed with a breast malignancy, yielding a CDR of 41.1% during the pandemic versus 111 patients in 2019 (CDR of 44.8%; p= 0.456). The average time from appointment at GRDC to diagnosis was lower at 0.76 days vs 1.21 days in 2019. The rate of same day diagnosis was significantly higher at 39.5% vs 27.0% in 2019 (p=0.008). Twenty-five patients (14.9%) received neoadjuvant systemic therapy compared to 16 patients (6.5%) in 2019 (p=0.005). CONCLUSION: There were fewer patients presenting for breast investigations during the pandemic period and a significant increase in the percentage of patients with palpable masses as the cause for referral with no appreciable change in the CDR. The presence of a rapid diagnostic breast center enabled patients with concerning breast symptoms to access and receive expedited assessment. This ensured patients did not undergo diagnostic delays despite the health care restrictions that emerged during the COVID-19 pandemic. Citation Format: Gary Ko, Sharmy Sarvanantham, Sangita Sequeira, Vrutika Prajapati, David R. McCready, Vivianne Freitas, Tulin D. Cil. Benefits of a rapid diagnostic centre for breast cancer care during the COVID-19 pandemic [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS2-27.

Background Full-thickness chest wall resection (FTCWR) is an underused modality for treating locally advanced primary or recurrent breast cancer invading the chest wall, for which little data exist regarding morbidity and mortality. We examined the postoperative complication rates in breast cancer patients undergoing FTCWR using a large multinational surgical outcomes database. Methods A retrospective cohort analysis was conducted using the American College of Surgeons National Surgical Quality Improvement Program database. All patients undergoing FTCWR for breast cancer between 2007 and 2016 were identified (n = 137). Primary outcome measures included 30-d postoperative morbidity, composite respiratory complications, and hospital length of stay (LOS). The secondary aim was to compare the postoperative morbidity of FTCWR to those of patients undergoing mastectomy. One-to-one coarsened exact matching was conducted between two groups, which were then compared with respect to morbidity, mortality, reoperations, readmissions, and LOS. Results The overall rate of postoperative morbidity was 11.7%. Two patients (1.5%) had respiratory complications requiring intubation. Median hospital LOS was 2 d. In the coarsened exact matching analysis, 122 patients were included in each of the two groups. Comparison of matched cohorts demonstrated an overall morbidity for the FTCWR group of 11.5% compared with 8.2% for the mastectomy group (8.2%) (P = 0.52). Conclusions FTCWR for the local treatment of breast cancer can be performed with relatively low morbidity and respiratory complications. This is the largest study looking at postoperative complications for FTCWR in the treatment of breast cancer. Future studies are needed to determine the long-term outcomes of FTCWR in this patient population.

BACKGROUND Despite the recent surge in rates of immediate breast reconstruction, there is a paucity of large multicenter studies to compare differences in morbidity after immediate versus delayed breast reconstruction. This study used the National Surgical Quality Improvement Program (NSQIP) to study the association between timing of breast reconstruction and complication rates, stratified by reconstructive modality. STUDY DESIGN The NSQIP database was used to identify breast reconstructions from 2005 to 2012. Rates of major complications were compared by timing within each reconstructive modality (implant vs autologous). Cohort differences in baseline characteristics and variables associated with increased complication rates were identified in bivariate analyses. A multivariable model was created to compare the association between the timing of reconstruction and major complications. RESULTS Of 24,506 postmastectomy reconstructions, 85.8% were immediate, 14.2% were delayed, 84% were implant, and 16% were autologous reconstructions. Overall, 10.0% of patients suffered a major complication. After stratification, only implant reconstructions showed a statistically higher complication rate with immediate (8.8%) reconstruction compared with delayed (5.3%) (odds ratio, 1.7, P < 0.01). There was no significant difference in complication rates between autologous immediate (18.4%) or delayed (19.0%) reconstructions. After controlling for baseline cohort differences and other risk factors, immediate reconstruction remained as an independent significant predictor of major complications in implant reconstructions (odds ratio, 1.8, P < 0.01). CONCLUSIONS Immediate rather than delayed breast reconstruction is associated with a significantly higher rate of major complications in implant reconstruction but not in autologous reconstruction. It is important to include these findings in the routine preoperative surgeon-patient discussion of reconstructive options.

Many women with early-onset breast cancer experience adverse psychological sequelae which impact on their quality of life. We sought to correlate levels of anxiety and cancer-related distress in women with breast cancer shortly after surgery and one year after treatment with the estimated risk of death. We studied 596 women with Stage I to III breast cancer. For each woman we estimated the five-year risk of death based on SEER data from 2010 to 2019. For each woman we measured anxiety and cancer-related distress levels shortly after surgery and one year later. The mean estimated five-year survival was 95%. At one week post-surgery, 59% of women had a clinically significant level of anxiety and 74% had a clinically significant level of cancer-related distress. There was no correlation between the objective risk of death and the level of anxiety or distress, at one week or at one year. Many women diagnosed with early-stage breast cancers experience significant levels of anxiety and distress. The emotional response to a breast cancer diagnosis is not related to the risk of death per se and other factors should be explored.

The Ontario High Risk Breast Screening program follows women aged 30–69 at an increased risk of breast cancer, using a yearly mammography and breast MRI. The aim of this study is to determine the clinical outcomes for the enrolled women. Observational cohort study following 2081 participants in the high-risk screening program 2011–2017. The participants were divided into three subgroup according to their risk criteria: (a) known carriers of pathogenic variants (PV) in hereditary breast cancer genes. (b) Previous chest radiotherapy. (c) Estimated life time risk (ELR) ≥ 25%, calculated using the International Breast Cancer Intervention Study (IBIS) tool, with no known mutation or previous radiation. All Breast Cancer (BC) diagnosed during the follow-up time were recorded. 673 women carried PVs in hereditary breast cancer genes, 159 had a history of chest radiotherapy, and 1249 had an ELR ≥ 25%. The total cohort of screening years was 8126. Median age at BC diagnosis was 41 for the first group, 47 for the second group and 51 for the third. BC incidence rate was 18.2 for PV mutation carriers, 17.9 for the chest radiotherapy group and 6.2 for ELR ≥ 25%. Hazard ratio was similar for the first two groups, but significantly lower for the ELR ≥ 25% group. When stratifying by age, the incidence rate in the ELR ≥ 25% increased over time, until it became similar to that of the other subgroups after age 50. Our findings question the need to screen women with an elevated lifetime risk using the same screening practices used for women who are PV mutation carriers, or with a history of chest radiation, prior to the age of 50.

Women continue to be underrepresented in academic anesthesiology, especially in leadership positions. Possible reasons for this gender disparity include family responsibilities, inadequate mentorship, lack of desire for leadership, the leaky pipeline effect (i.e., attrition of women physicians over the course of their career trajectories), and discrimination. Our objective was to understand the lived experiences of Canadian anesthesiologists in leadership positions. In this constructivist grounded theory-inspired study, we used purposeful sampling to identify women anesthesiologists in leadership positions at one Canadian institution. Each participant underwent a one-on-one semi-structured interview of 40-60 min in length, sampling until theoretical saturation was reached. We included questions about the participant’s practice setting, influences on their career, and advice the participant would provide to other women in leadership. We used an iterative approach to theoretical sampling and data analysis. The audio-recorded semi-structured interviews were transcribed and coded. NVivo12 was used for open and axial coding, and cross-referencing. Eight women anesthesiologists were recruited and interviewed. Our iterative process identified four interconnected themes: difficulty internalizing a leadership identity, identifying systemic barriers and biases, dissonance between agentic traits and communal social gender roles, and mentorship as shaping lived experiences. Participants consistently expressed experiencing discrimination, articulated barriers related to family responsibilities and ingrained societal expectations, and discussed how typical leadership traits are applied differently to women and men. Women perceived themselves as more compassionate and communicative than men. Despite these traits, these women have expressed barriers to obtaining mentorship. We identified consistent interconnected themes among the experiences of our sample of women anesthesiologists in academic leadership and found that academic anesthesiology is a gendered profession as experienced by these women leaders. Further research should focus on strategies to remove barriers to participation in academic anesthesiology for women.

PURPOSETo provide recommendations on the best strategies for the management and on the best timing and treatment (surgical and radiotherapeutic) of the axilla for patients with early-stage breast cancer.METHODSOntario Health (Cancer Care Ontario) and ASCO convened a Working Group and Expert Panel to develop evidence-based recommendations informed by a systematic review of the literature.RESULTSThis guideline endorsed two recommendations of the ASCO 2017 guideline for the use of sentinel lymph node biopsy in patients with early-stage breast cancer and expanded on that guideline with recommendations for radiotherapy interventions, timing of staging after neoadjuvant chemotherapy (NAC), and mapping modalities. Overall, the ASCO 2017 guideline, seven high-quality systematic reviews, 54 unique studies, and 65 corollary trials formed the evidentiary basis of this guideline.RECOMMENDATIONSRecommendations are issued for each of the objectives of this guideline: (1) To determine which patients with early-stage breast cancer require axillary staging, (2) to determine whether any further axillary treatment is indicated for women with early-stage breast cancer who did not receive NAC and are sentinel lymph node–negative at diagnosis, (3) to determine which axillary strategy is indicated for women with early-stage breast cancer who did not receive NAC and are pathologically sentinel lymph node–positive at diagnosis (after a clinically node-negative presentation), (4) to determine what axillary treatment is indicated and what the best timing of axillary treatment for women with early-stage breast cancer is when NAC is used, and (5) to determine which are the best methods for identifying sentinel nodes. Additional information is available at www.asco.org/breast-cancer-guidelines .

Background Presentation to multidisciplinary cancer conferences (MCCs) supports optimal treatment of young women with breast cancer (YWBC). However, research shows barriers to MCC practice, and variation in professional attendance and referral patterns. A checklist may help overcome these barriers and support MCC practice with YWBC. Methods We developed, piloted and evaluated an MCC checklist in sites participating in a pan-Canadian study (RUBY; Reducing the bUrden of Breast cancer in Young women). A survey assessed checklist processes and impacts, and checklist data were analysed for checklist uptake, MCC presentation rates and MCC processes including staff attendance. Results Fifteen RUBY sites used the checklist (~50%), mostly for data collection/tracking. Some positive effects on clinical practice such as increased presentation of YWBC at MCC were reported, but most survey participants indicated that MCC processes were sufficient without the checklist. Conversely, checklist data show that only 31% of patients were presented at MCC. Of those, 41% were recommended treatment change. Conclusion Despite limited checklist uptake, there was evidence of its clinical practice benefit. Furthermore, it supported data collection/quality monitoring. Critically, checklist data showed gaps in MCC practice and low MCC presentation rates for YWBC. This contrasts with overall provider perceptions that MCCs are working well. Findings suggest that supports for MCC are needed but may best take the form of clear national practice recommendations and audit and feedback cycles to inform awareness of good MCC practice and outcomes. In this setting, tools like the MCC checklist may become helpful in supporting MCC practice.

The safety of immediate breast reconstruction (IBR) in older women is largely unknown. This study aimed to determine the 30-day postoperative complication rates following IBR (implant-based or autologous) in older women (≥ 70 years) with breast cancer and to compare them to younger women (18–69 years). The National Surgical Quality Improvement Program (NSQIP) database was used to identify women with in situ or invasive breast cancer who underwent IBR (2005–2016). Outcomes included 30-day postoperative morbidity and mortality, which were compared across age groups stratified by type of reconstruction. Of 28,850 women who underwent implant-based and 9123 who underwent autologous reconstruction, older women comprised 6.5% and 5.7% of the sample, respectively. Compared to younger women, older women had more comorbidities, shorter operative times, and longer length of hospital stay. In the implant-based reconstruction group, the 30-day morbidity rate was significantly higher in older women (7.5% vs 5.3%, p

Objective. Breast-conserving therapy with external beam radiotherapy (EBRT) is currently the standard of care for women with early breast cancer. Our aim was to determine if early-stage breast cancers treated with lumpectomy and primary intraoperative radiotherapy (IORT) have comparable local recurrence rates. This is the first study examining the Canadian experience with IORT. Methods. Patients who underwent breast-conserving therapy with pre-pathology IORT between 2007- 2017 were retrospectively identified. The primary outcome measure was ipsilateral breast tumor recurrence (IBRT). A time to event analysis was performed; Kaplan-Meier estimates report the fraction of patients living free of recurrence. Secondary outcomes included acute and chronic wound complications. Results. 106 patients with a median age of 70 (IQR 65-75) were included. Median follow-up was 33 months. The majority of patients had screen-detected (94.3%), estrogen-receptor positive (96.2%), HER2neu negative (93.4%), invasive ductal carcinomas (92.5%). Only 50 (47.6%) were prescribed adjuvant endocrine blockade. IBTR occurred in 5 (4.7%) patients. Five and ten-year local recurrence-free rates were 0.95 and 0.81, respectively. The superficial skin infection rate was 9.4%. Acute symptomatic seromas occurred in 23 (21.7%), while only 10 (9.4%) persisted chronically. Conclusion. In this cohort of Canadian post-menopausal women treated with breast-conserving surgery and IORT, the IBTR approached 5%. Despite selection of low-risk patients, the local recurrence rate is higher than what is reported in the literature with EBRT. The low rates of prescribed adjuvant systemic therapy may have contributed to this outcome. Citation Format: Elmi M, Tigert A, Escallon J, Zagorski B, Leong W, Vranic M, Fyles A, Vitkin A, Cil T, McCready D. Intraoperative radiotherapy outcomes in early-stage breast cancer: A study in elderly Canadian women [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-12-02.

Background:Less than 14% of older women undergo post-mastectomy breast reconstruction. A major reason for the low rate is the concern about post-operative complications. A thorough analysis of surgical complications by age group is limited in previous studies. The aim of this study is to determine the surgical complication rates of older women (≥70 years old) with breast cancer who underwent breast reconstruction and compare them to younger women (18–69 years old). Methods: Data from the National Surgical Quality Improvement Program (NSQIP) database were used to identify women with carcinoma in situ and invasive breast cancer who underwent delayed or immediate breast reconstruction (2005-2016). The primary outcome was 30-day post-operative surgical complications; the secondary outcome was 30-day mortality.Patient demographics, comorbidities, and 30-day postoperative complications and mortality rates were compared across age groups and each type of reconstruction. Results: Of 42,929 women who underwent breast reconstruction, 2,615 (6.1%) were older women. Although compared to young women, older women were more likely to have medical comorbidities their American Society of Anesthesiologists' (ASA) classification was lower.Tumor histology distribution was similar in both groups. Lymph node surgery and neoadjuvant chemotherapy was significantly less frequent among older women. Compared to young women, older women more frequently underwent immediate breast reconstruction (IBR) [n=2,405 (92%) versus n=33,580 (88.3%), p Conclusions: Overall, 30-day postoperative complications in older women who undergo breast reconstruction are extremely low. Infection rates were slightly higher in the older group however; severe complications such as flap failure, bleeding, reoperation, and death were more common in young women. Age alone did not confer an increased risk of complications after breast reconstruction. Breast reconstruction can be safely offered to older women undergoing breast cancer treatment. Citation Format: Angarita FA, McCready DR, Cil T. Is breast reconstruction safe in women over 70? An analysis of the national surgical quality improvement program (NSQIP) database [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-16-01.

Racial disparities in breast cancer are well established. However, there is a paucity of literature assessing the interaction of patient, socioeconomic, and community factors on breast cancer care. The objective of this study was to determine the influence of race/ ethnicity, socioeconomic status (SES), and insurance status on disease presentation, access to care, and survival in breast cancer. A retrospective analysis was conducted of patients of Non-Hispanic White (NHW), Hispanic, and Non-Hispanic Black (NHB) patients with non-metastatic breast cancer in a large American national cancer registry. A total of 382,975 patients were identified. We demonstrated that NHB and Hispanic patients are more likely to present with more advanced stage disease, less likely to undergo surgery, and less likely to undergo breast reconstruction than their NHW counterparts. We also demonstrated worse survival for NHB patients compared to NHW patients. Furthermore, we demonstrated that these disparities were compounded across worsening socioeconomic status and insurance coverage.

The assessment of a patient with breast cancer involves taking a focused history. This includes identification of both the modifiable and non-modifiable risk factors for breast cancer that the patient carries. Most of the modifiable risk factors are related to estrogen. Non-modifiable risk factors include family history and precursor lesions. Physical examination of the breasts and lymph nodes must be performed. Both mammography and ultrasound are typically utilized to image the breasts, with higher diagnostic accuracy associated with concomitant use. Breast MRI is generally reserved for high-risk patients, with its use not otherwise shown to increase survival. Staging imaging to assess for metastatic disease is recommended for locally advanced and recurrent breast cancer and those with symptoms of metastatic disease. Lesions suspicious for cancer on imaging, as classified by the BI-RADS scoring system, should be biopsied. Core-needle biopsy is preferred over fine-needle aspiration because of its higher diagnostic accuracy. The results of the biopsy should be concordant with imaging and clinical findings or must be repeated. The AJCC Breast Cancer staging system can then be used to clinically stage and prognosticate the patient based on the results from the clinical exam, imaging, and biopsy.

Deep serratus anterior plane block has been widely adopted as an analgesic adjunct for patients undergoing breast surgery, but robust supporting evidence of efficacy is lacking. We randomly allocated 40 patients undergoing simple or partial mastectomy with sentinel node biopsy to receive either a pre-operative deep serratus anterior plane block (serratus group) or a placebo injection (sham group), in addition to systemic analgesia. The primary outcome measure was the quality of recovery score at discharge, as assessed by the quality of recovery-15 questionnaire at various time-points. Secondary analgesic outcomes included: pain severity; postoperative opioid consumption; opioid-related side-effects; patient satisfaction up to 7 days postoperatively; and persistent postoperative pain up to 3 months after surgery. All patients who were recruited completed the study. There were no differences in the quality of recovery-15 scores between patients in the serratus and control groups, with mean (SD) scores of 96 (14) and 102 (20) for the control and serratus groups, respectively. We were also unable to detect differences in any of the secondary analgesic outcomes examined. The addition of a deep serratus anterior plane block to systemic analgesia does not enhance quality of recovery in patients undergoing ambulatory breast cancer surgery.

BACKGROUND Whether to undergo postmastectomy breast reconstruction (PMBR) is a challenging, preference-sensitive decision. It is therefore paramount to optimize decision quality through ensuring patients' knowledge and aligning treatments with their personal preferences. This study assessed the effects of a preconsultation educational group intervention (PEGI) on patient knowledge, state-trait anxiety, and decisional conflict (patient uncertainty in decision making) during the decision-making process. METHODS This phase 3 randomized controlled trial assessed effects of a PEGI in women without active breast cancer undergoing delayed PMBR, or prophylactic mastectomy with immediate PMBR. Both groups underwent routine education before consultation. In addition, the intervention group underwent a PEGI composed of presentations from a plastic surgeon and nurse, a value clarification exercise, and shared experiences from PMBR patients before the consultation with the plastic surgeon. Before and 1-week after consultation, outcome measures were assessed using the Decisional Conflict Scale, State-Trait Anxiety Inventory, and the BREAST-Q. RESULTS Of the 219 women deemed eligible, a total of 156 women were recruited and randomized. Treatment fidelity was 96% and retention was 88%. At baseline, there were no significant differences in terms of demographic or clinical status, knowledge, state-trait anxiety, and decisional conflict. Patient knowledge about PMBR improved in both groups; however, the degree of knowledge attainment was significantly greater in the PEGI group (24.5% improvement in the intervention group compared with 13.5% in the routine education group, P < 0.001). The reduction in decisional conflict from baseline to follow-up was greater in the intervention group compared with the routine education; however, the difference only approached significance (P = 0.09). CONCLUSIONS The provision of a preconsultation educational group intervention has been shown to significantly close the knowledge gap on PMBR in patients seeking delayed breast reconstruction or prophylactic mastectomy with immediate breast reconstruction compared with routine education alone.

The goal of this study is to evaluate the frequency and imaging features of lobular neoplasia (LN) diagnosed on MRI-guided biopsy, determine the upgrade rate to malignancy, and assess for any features that may be associated with an upgrade on surgical excision. Research ethical board approved the review of consecutive patients with MRI-detected LN between January 2009 and December 2018 with differentiation between pure LN and LN with associated other high-risk lesions. The final outcome was determined by final pathology results from surgical excision or 24 months of follow-up. Appropriate statistical tests were used. Out of 1250 MRI-guided biopsies performed, 76 lesions (6%) fulfilled the inclusion criteria and formed the study cohort. Of the 76 lesions, 54 (71%) were pure LN while the rest had coexistent high-risk lesion. Non-mass enhancement (NME) was the most common lesion type (62, 82%). Fifty-nine lesions (78%) were surgically excised, the other 17 had benign follow-up. Overall, 8 lesions (11%) were upgraded to malignancy on final pathology. Malignant outcome was associated with larger lesion size (5.5 versus 1.9 cm, P

This study aimed to evaluate the impact of rapid genetic testing (RGT) for BRCA1 and BRCA2 at the time of breast cancer diagnosis on treatment choices. Bilateral mastectomy for the treatment of breast cancer in women with a BRCA1 or BRCA2 mutation offers a reduction in the risk of contralateral breast cancer. It is unclear whether offering RGT at the time of breast cancer diagnosis has an impact on women’s surgical decision-making. Women with breast cancer diagnosed between June 2013 and May 2018 were recruited from four academic health sciences centers in Toronto, Canada. The participants completed a questionnaire before genetic testing, then one week and one year after disclosure of the genetic test result. Before surgery, RGT was performed. Diagnostic, pathologic, and treatment data were compared between those with and those without a BRCA mutation. The study enrolled 1007 women who consented to RGT. The mean age of the participants was 46.3 years, and the median time to result disclosure was 10 days. A BRCA mutation was found in 6% of the women. The women with a BRCA mutation were significantly more likely to elect for bilateral mastectomy than the women without a BRCA mutation (p

Summary Surgeons are frequently perceived by medical students to be uncompassionate, resolute and individualistic. Surgical education often prioritizes teaching and learning approaches that perpetuate these perceptions. In other specialties, engaging patients in education has shown promise in refocusing attention from the technical and procedural aspects of care toward the humanistic and social aspects. Despite proven favourable outcomes for both patients and students in many clinical areas, a "patient as teacher" approach to surgical education has yet to be adopted widely in Canada. A patient as teacher program was developed for surgical clerks at the University of Toronto with the goal of emphasizing the humanity of the patient, the psychosocial impact of a surgical diagnosis of breast cancer on patients and their families, and the social and humanistic roles for surgeons in providing patient-centred care. We report on the program's development process and pilot session.

Neoadjuvant chemotherapy (NAC) is standard of care for locally advanced breast cancer. There is wide variation in radiation therapy (RT) practice and limited data describing locoregional relapse (LRR) after NAC. We hypothesized a low LRR risk with modern NAC, surgery, and RT and aimed to elucidate patterns of LRR and predictors of disease-free survival (DFS) and overall survival (OS) in these patients.Data from 416 patients with stage II/III breast cancer treated between 2008 and 2015 with NAC, surgery, and adjuvant RT were reviewed retrospectively. DFS and OS rates were calculated using the Kaplan-Meier method. The LRR rate was estimated using the cumulative incidence function, treating death as a competing risk. Multivariable survival analysis was performed using Cox regression.Median follow-up was 4.7 years. Most patients had cT2/3 (74%) cN1 (61%) disease and underwent mastectomy (75%) and axillary dissection (84%). Pathologic complete response (pCR) was achieved in 22% of patients. There were 27 LRRs (including 4 isolated LRRs) and 89 distant failures. Two patients developed LRR 2 months after surgery, before adjuvant RT. LRR could be mapped in 23 patients: most (20) recurred within the RT field; 1 in- and out-of-field; and 2 out-of-field. Five-year LRR, DFS, and OS were 6.4%, 77%, and 90%, respectively. On multivariable analysis, triple-negative subtype (hazard ratio [HR] 2.82; 95% confidence interval [CI], 1.78-4.47; P.001), stage III disease (HR 1.72; 95% CI, 1.11-2.69; P = .016), and non-pCR (HR 4.76; 95% CI 2.13-10.0; P.001) were associated with poor DFS and OS (HR 4.13 [95% CI, 2.21-7.72; P.001]; HR 1.94 [95% CI, 1.001-3.75; P = .049]; and HR 2.38 [95% CI, 0.98-5.88; P = .055], respectively).Patients with breast cancer treated with modern NAC, surgery, and RT have a low 5-year LRR risk, with the majority occurring in-field. Triple-negative subtype, stage III disease, and non-pCR were associated with inferior DFS and OS.

Patients with genetic susceptibility to breast and ovarian cancer are eligible for risk-reduction surgery. Surgical morbidity of risk-reduction mastectomy (RRM) with concurrent bilateral salpingo-oophorectomy (BSO) is unknown. Outcomes in these patients were compared to patients undergoing RRM without BSO using a large multi-institutional database. A retrospective cohort analysis was conducted using the American College of Surgeon’s National Surgical Quality Improvement Program (NSQIP) 2007–2016 datasets, comparing postoperative morbidity between patients undergoing RRM with patients undergoing RRM with concurrent BSO. Patients with genetic susceptibility to breast/ovarian cancer undergoing risk-reduction surgery were identified. The primary outcome was 30-day postoperative major morbidity. Secondary outcomes included surgical site infections, reoperations, readmissions, length of stay, and venous thromboembolic events. A multivariate analysis was performed to determine predictors of postoperative morbidity and the adjusted effect of concurrent BSO on morbidity. Of the 5470 patients undergoing RRM, 149 (2.7%) underwent concurrent BSO. The overall rate of major morbidity and postoperative infections was 4.5% and 4.6%, respectively. There was no significant difference in the rate of postoperative major morbidity (4.5% vs 4.7%, p = 0.91) or any of the secondary outcomes between patients undergoing RRM without BSO vs. those undergoing RRM with concurrent BSO. Multivariable analysis showed Body Mass Index (OR 1.05; p

Postoperative complication rates for elderly women undergoing breast cancer surgery have not been well studied. We describe the postoperative complication rates of elderly (≥ 70 years) women with breast cancer and compare them with young (40–69 years) women. Data were extracted from the National Surgical Quality Improvement Program database (2004–2014). We included women with invasive breast cancer who underwent surgery. Outcomes were 30-day postoperative morbidity and mortality (complications), which were compared between young and elderly women. Morbidity was categorized using the Surgical Risk Preoperative Assessment System (SURPAS) clusters. We identified 100,037 women of which 26.7% were elderly. Compared to young women, elderly women were more likely to have more comorbidities and undergo breast-conserving surgery, but less likely to undergo lymph node surgery, breast reconstruction, and neoadjuvant chemotherapy. While the 30-day overall morbidity rate was not significantly different between young and elderly women (3.9 vs. 3.8%, p = 0.2), elderly women did have significantly higher rates of pulmonary, cardiac (arrest and myocardial infarction), venous thromboembolic, and neurological morbidity. Specific morbidities that showed significantly lower rates among elderly women included wound disruption and deep and organ space surgical site infection. Any cause death was significantly higher in elderly compared to young women (0.2 vs. 0.05%, p

Background. Text messaging has become ubiquitous and is being increasingly used within the health care system. The purpose of this study was to understand texting practices for clinical communication among staff surgeons at a large academic institution. Methods. Staff surgeons in 4 subspecialties (vascular, plastics, urology, and general surgery) were surveyed electronically. Results. A total of 62 surgeons from general surgery (n = 33), vascular surgery (n = 6), plastic surgery (n = 13), and urology (n = 10) completed the study (response rate 30%). When conveying urgent patient-related information, staff surgeons preferred directly calling other staff surgeons (61.5%) and trainees (58.8%). When discussing routine patient information, staff surgeons used email to reach other staff surgeons (54.9%) but preferred texting (62.7%) for trainees. The majority of participants used texting because it is fast (65.4%), convenient (69.2%) and allows transmitting information to multiple recipients simultaneously (63.5%). Most felt that texting enhances patient care (71.5%); however, only half believed that it enhanced trainees’ educational experiences. The majority believed that texting identifiable patient information breaches patient confidentiality. Conclusions. Our data showed high adoption of text messaging for clinical communication among surgeons, particularly with trainees. The majority of surgeons acknowledge security concerns inherent in texting for patient care. Existing mobile communication platforms fail to meet the needs of academic surgeons. Further research should include guidelines related to texting in clinical practice, educational implications of texting, and technologies to better meet the needs of clinicians working in an academic surgical settings.

The armamentarium of the modern breast surgeon includes the time-tested procedures of modified radical mastectomy and lumpectomy with sentinel lymph node biopsy with postoperative radiation, but has evolved to include several options that produce excellent oncologic endpoints and improved cosmesis. These options include skin- and nipple-sparing mastectomies with immediate reconstruction as well as oncoplastic procedures that allow larger excisions and better postoperative breast shape. This article provides an overview of these modern surgical approaches for breast cancer treatment.

There have been recent reports in the breast imaging literature of unilateral axillary lymphadenopathy following COVID-19 vaccination. It is unclear whether the reactive lymphadenopathy may impact the sentinel lymph node biopsy procedure. In this article, we provide guidelines regarding the timing of the COVID-19 vaccine and breast cancer surgery which were formulated after a review of the available literature and in consultation with infectious disease specialists.

We sought to examine the safety of same-day breast reconstructive (BR) surgery.An analysis of the American College of Surgeons, National Surgical Quality Improvement Program (ACS-NSQIP) files was performed. Patients undergoing BR for breast cancer were examined, excluding those with high-risk co-morbidities or concurrent surgery. A propensity score was calculated and a multivariable logistic regression analysis was used to calculate the difference in 30-day complications between those undergoing SDS versus longer hospital stay.The study consisted of 21,539 patients; 17,449 had implant and 4090 had autologous breast reconstruction. 1195 (5.5%) underwent SDS, whereas 20,344 (94.5%) were admitted at least overnight. On unadjusted analysis, the rate of post-operative complications was nearly three times higher in those admitted compared to those undergoing SDS (6.7% vs. 2.5%; p 0.001). On propensity score adjusted multivariable regression there was no significant difference in complications amongst those undergoing SDS versus staying in hospital (OR 1.4 (95%CI: 0.9, 2.2)).These results suggest that admitting BR patients does not prevent short-term complications and same day BR surgery is safe when co-morbidities are accounted for.

Alloplastic breast reconstruction is safe in well-selected older women. The impact of timing of surgery on complication rates is unknown. This study aimed to determine the immediate (30-day) postoperative complication rates of older women who underwent immediate (IBR) and delayed breast reconstruction (DBR) with alloplastic techniques.The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was used to identify women ≥70 years old with in situ or invasive breast cancer who underwent either IBR or DBR (2005-2016). Outcomes included 30-day postoperative morbidity and mortality.A total of 2,085 older women underwent alloplastic breast reconstruction of which 90% and 10% were IBR and DBR, respectively. Both groups had similar median age, body mass index, and frequency of smoking, diabetes mellitus, and steroid use. Tumors were mainly invasive in the IBR group (83.5%) and in situ in the DBR group (83.3%). IBR had significantly longer operative times (median 154 min vs 98 min, p 0.0001), but equal length of stay (median 3 days vs 3 days, p = 0.1). The 30-day overall morbidity (medical or surgical complication) rate was significantly higher in the IBR group (7.5% vs 1.0%, p 0.0004). Women with IBR were significantly more likely to develop infectious complications (6% vs 1%, p = 0.002). Cardiac/transfusion, pulmonary, thromboembolic, renal, and neurological morbidity rates were equal between groups. Thirty-day mortality rates were similar across both groups (IBR: 0.05% vs DBR: 0%, p = 0.74).While overall thirty-day postoperative complication rates in older women who undergo breast reconstruction were low, there were higher rates of infectious complications in the IBR cohort. The risks and benefits of alloplastic breast reconstruction should be discussed with older women undergoing mastectomy for breast cancer treatment.

BACKGROUND The rates of contralateral prophylactic mastectomy (CPM) are increasing in women with breast cancer. Previous retrospective research has examined clinical and demographic predictors of the uptake of CPM. However, to the authors' knowledge, there has been very little prospective research to date that has examined psychosocial functioning prior to breast cancer surgery to determine whether psychosocial functioning predicts uptake of CPM. The current study was conducted to evaluate demographic, clinical, and psychosocial predictors of the uptake of CPM in women with unilateral breast cancer without a BRCA1 or BRCA2 mutation. METHODS Women with unilateral non-BRCA-associated breast cancer completed questionnaires prior to undergoing breast cancer surgery. Participants completed demographic and psychosocial questionnaires assessing anxiety, depression, cancer-related distress, optimism/pessimism, breast satisfaction, and quality of life. Pathological and surgical data were collected from medical charts. RESULTS A total of 506 women consented to participate, 112 of whom (22.1%) elected to undergo CPM. Age was found to be a significant predictor of CPM, with younger women found to be significantly more likely to undergo CPM compared with older women (P

e18551 Background: Racial disparities in breast cancer are well established. However, there is a paucity of literature assessing the interaction of patient, socioeconomic, and community factors on outcomes. The objective of this study was to determine the influence of race/ ethnicity, socioeconomic status (SES), and insurance status on disease presentation, access to care, and survival in breast cancer. Methods: A retrospective analysis was performed of Non-Hispanic Black (NHB), Non-Hispanic White (NHW), and Hispanic patients with non-metastatic breast cancer in the SEER cancer registry between 2007 and 2016. Multivariable binary logistic regression and Cox regression analyses were conducted. Results: A total of 382,975 patients were identified; 289,074 (75.5%) NHW, 45,821 (12.0%) NHB, and 48,080 (12.6%) Hispanic patients. On multivariate analysis (see table), NHB (OR 1.18, 95%CI: 1.15-1.20) and Hispanic (OR 1.20, 95%CI: 1.17-1.22) patients were more likely to present with higher stage disease than NHW patients. There was an increased likelihood of not undergoing primary resection in NHB (OR 1.56, 95%CI: 1.49-1.65) and Hispanic (OR 1.41, 95%CI: 1.34-1.48) patients compared to NHWs. Similarly, NHB and Hispanic patients had increased odds of not undergoing breast reconstruction following mastectomy (OR 1.07, 95%CI: 1.03-1.11 and OR 1.60, 95%CI 1.54-1.66, respectively). NHB patients had increased hazard for all-cause mortality (HR: 1.13, 95%CI 1.10-1.16) and breast cancer-specific mortality (HR: 1.20, 95%CI 1.16-1.24). All-cause mortality increased across SES categories (lower SES: HR 1.33, 95%CI 1.30-1.37, middle SES: HR 1.20, 95%CI 1.17-1.23) in NHBs. Conclusions: This population-based analysis confirms worse disease presentation, access to surgical therapy, and survival across racial, ethnic, and socioeconomic factors. These disparities were compounded across worsening SES, suggesting structural racism may partly account for our findings.[Table: see text]

568 Background: In breast cancer, clinicians aim to improve survival while patients value quality of life. We aim to delineate the impact of patient, tumour and treatment factors on psychosocial outcomes after treatment. Methods: A prospective cohort of women with unilateral stage I-III breast cancer were recruited at University Health Network in Toronto, Canada between 2014-2017. Validated questionnaires (BREAST-Q, Impact of Event, Hospital Anxiety & Depression Scales) were completed pre-operatively, and 6 and 12 months after surgery. Change in psychosocial scores over time by surgical procedure was assessed using linear mixed models, controlling for age, pathologic stage, hormone (HR) and HER2 receptor, and treatments. Predictors of psychosocial outcomes at 12 months were assessed using multivariable linear regression models. P values

Most patients undergoing significant breast cancer surgery stay in hospital postoperatively. We sought to determine whether there was a difference in complication rates among patients undergoing same-day surgery (SDS) versus overnight or inpatient stay. Analysis of the American College of Surgeons, National Surgical Quality Improvement Program participant user files was performed. Patients with breast cancer undergoing mastectomy and/or axillary lymph node dissection between 2005 and 2012 were examined (high-risk comorbidities and concurrent surgery were excluded). Thirty-day postoperative morbidity was analyzed. Multivariable regression was performed identifying independent predictors of complications. The final population consisted of 40,575 patients; 8365 had SDS, 23,252 stayed overnight, and 8958 stayed in hospital longer postoperatively. Those admitted to hospital were older, more obese, had higher American Society of Anesthesiology (ASA) class, medical comorbidities, or had bilateral surgery. The overall 30-day morbidity was 4.7 %. On univariate analysis, patients undergoing SDS had significantly lower 30-day morbidity (2.4 %) compared with overnight (3.9 %) or inpatient stay (8.8 %) (p

Background The purpose of this study was to explore career satisfaction and advancement for women in academic surgery. Methods A 48-item web-based survey was emailed to women surgeons in academic centers across Canada, exploring career advancement, family planning, mentorship, discrimination, and career satisfaction. Results The survey response rate was 38% (81 of 212); 18% of participants felt they experienced gender discrimination in medical school, 36% in residency, 12% in fellowship, and 41% as staff surgeons. More than half felt that their gender had played a role in the career challenges they faced. Responses to open-ended questions suggested that many surgeons struggled to balance their academic careers with family life. Despite this, participants rated their career satisfaction very highly. Conclusions There remain ongoing challenges for women in academic surgery including lack of gender equality, appropriate mentorship, and accommodations for surgeons with families. Continued advancement of women in academic surgery is dependent on addressing these concerns.

570 Background: Rates of bilateral mastectomy continue to rise in average-risk women with unilateral breast cancer. We aim to characterize psychosocial predictors of surgical procedure and how psychosocial outcomes change over time after surgery for breast cancer. Methods: A prospective cohort of women with unilateral, nonhereditary breast cancer were recruited at University Health Network in Toronto, Canada between 2014-2017. Women completed validated psychosocial questionnaires (BREAST-Q) pre-operatively, and 6 and 12 months after surgery. Outcomes were assessed between three surgical groups (unilateral lumpectomy, unilateral mastectomy, bilateral mastectomy). Predictors of surgical procedure were identified using a multinomial logistic regression model. Change in psychosocial scores over time according to procedure was assessed using linear mixed models. All models control for age, stage, reconstruction and treatment. P values < .05 were considered statistically significant. Results: 506 women underwent surgery as follows: 216 unilateral lumpectomy (43%), 181 unilateral mastectomy (36%) and 109 bilateral mastectomy (22%). In the multinomial regression model, younger age (p < .01), and lower chest physical (p = .03) and sexual well-being (p = .02) predicted having bilateral mastectomy over unilateral lumpectomy while younger age (p < .01) and lower disease stage (p = .02) predicted bilateral mastectomy over unilateral mastectomy. The mixed model demonstrates that breast satisfaction follows a non-linear pattern of change over time, with 6- but not 12-month scores being significantly different from baseline (p = .015). Procedure predicts baseline satisfaction (p = .016), with bilateral mastectomy having worse satisfaction than unilateral lumpectomy. Procedure also predicts change in satisfaction, with unilateral and bilateral mastectomy having lower scores across time than lumpectomy. While a significant improvement in psychological well-being is detected by 12 months (p = .02), those with unilateral and bilateral mastectomy have worse psychological well-being over time compared to lumpectomy. Women having mastectomy start with worse physical well-being than those in the lumpectomy group, but their physical well-being does not decline as much as the lumpectomy group over time (p < .01). Conclusions: Definitive surgical procedure affects the trajectory of psychosocial functioning over time. This emerging data may be used to further facilitate surgical decision-making in women considering contralateral prophylactic mastectomy.

Male breast cancer (MBC) is a rare malignancy, and gender-specific treatment outcomes are currently lacking. The use of a large, multi-national surgical-outcomes database may provide a better understanding of treatment patterns and postoperative morbidity in men who undergo oncological breast surgery. A retrospective cohort analysis was conducted between 2007 and 2016 using the American College of Surgeons National Surgical Quality Improvement Program database (NSQIP), examining MBC treatment patterns and postoperative complication rates. All men undergoing surgery for the treatment of invasive or in situ carcinoma of the breast were identified. Clinical characteristics, demographics, and surgical treatment options most frequently used for this population were described. In addition, the 30-day postoperative complication rates in the surgical treatment of male breast cancer were evaluated. A total of 1773 MBC patients with a median age of 65 years (IQR 56–74 years) were included in this analysis. Mean body mass index (BMI) was 29.1 (IQR 25.4–33.8). In this study population, 177 (10.0%) had a diagnosis of in situ breast cancer, while the remaining 1596 (90.0%) had invasive disease. While most men underwent mastectomy, 282 (15.9%) had breast-conserving surgery. There were 74 (4.2%) patients who underwent immediate breast reconstruction. In addition, 118 (6.7%) patients elected to have a contralateral prophylactic mastectomy. Overall, the rate of morbidity was 4.6%, comprising mostly of wound complications (3.2%). Analysis of this large, prospective multi-institutional cohort revealed that complication rates are low and comparable to reported rates in the female breast cancer population. What is also significant about this analysis is that the cohort demonstrated the importance of cosmetic considerations in MBC patients, as some men decide to undergo breast-conserving surgery or immediate breast reconstruction. Contralateral prophylactic mastectomy in the treatment of MBC is also performed.

Background Mental practice has been successfully applied in professional sports for skills acquisition and performance enhancement. The goals of this review are to describe the literature on mental practice within sport psychology and surgery and to explore how the specific principles of mental practice can be applied to the improvement of surgical performance—both in novice and expert surgeons. Method The authors reviewed the sports psychology, education, and surgery literatures through Medline, PubMed, PsycINFO, and Embase. Results In sports, mental practice is a valuable tool for optimizing existing motor skill sets once core competencies have been mastered. These techniques have been shown to be more advantageous when used by elite athletes. Within surgery, mental practice studies have focused on skill acquisition among novices with little study of how expert surgeons use it to optimize surgical preparation. Conclusions We propose that performance optimization and skills acquisition should be viewed as 2 separate domains of mental practice. Further understanding of this phenomenon has implications for changing how we teach and train not only novice surgeons but also how experienced surgeons continue to maintain their skills, acquire new ones, and excel in surgery.

Background:Regional anesthesia improves postoperative analgesia and enhances quality of recovery (QoR) after ambulatory surgery. This randomized, double-blinded, parallel-group, placebo-controlled trial examines the effects of multilevel ultrasound-guided paravertebral blocks (PVBs) and total intravenous anesthesia on QoR after ambulatory breast tumor resection.Methods:Sixty-six women were randomized to standardized general anesthesia (control group) or PVBs and propofol-based total intravenous anesthesia (PVB group). The PVB group received T1–T5 PVBs with 5 ml of 0.5% ropivacaine per level, whereas the control group received sham subcutaneous injections. Postoperative QoR was designated as the primary outcome. The 29-item ambulatory QoR tool was administered in the preadmission clinic, before discharge, and on postoperative days 2, 4, and 7. Secondary outcomes included block success, pain scores, intra- and postoperative morphine consumption, time to rescue analgesia, incidence of nausea and vomiting, and hospital discharge time.Results:Data from sixty-four patients were analyzed. The PVB group had higher QoR scores than control group upon discharge (146 vs. 131; P < 0.0001) and on postoperative day 2 (145 vs. 135; P = 0.013); improvements beyond postoperative day 2 lacked statistical significance. None of the PVB group patients required conversion to inhalation gas–based general anesthesia or experienced block-related complications. PVB group patients had improved pain scores on postanesthesia care unit admission and discharge, hospital discharge, and postoperative day 2; their intraoperative morphine consumption, incidence of nausea and vomiting, and discharge time were also reduced.Conclusion:Combining multilevel PVBs with total intravenous anesthesia provides reliable anesthesia, improves postoperative analgesia, enhances QoR, and expedites discharge compared with inhalational gas- and opioid-based general anesthesia for ambulatory breast tumor resection.

Management of breast disease is an integral component of general surgery. This study was performed to describe the exposure to breast disease by residents in Canadian general surgery programs.This study involved a 20-item survey and pilot semistructured interviews. Surgical trainees at 12 training programs in Canada participated in the survey. Results were used to characterize resident experience with breast surgery and clinics.Residents across all post-graduate training years and from 12 Canadian medical schools responded (n = 162, 44 %). Residents had the most breast surgery experience in PGY2 and PGY3 years. One third of trainees performed ≤ 1 breast procedure per month. Only 25 % had attended more than one breast clinic per month. Lumpectomies were the most common procedure (20.7/year) and 94 % of residents performed sentinel lymph node biopsy. Four pilot semistructured interviews were performed. The greatest stated barriers to breast training were "lack of time" and the impression that these were "lower priority cases."Achieving competence in breast disease management is a key requirement for general surgery trainees. Surgical educators must ensure that the quality and quantity of residency training in breast diseases is sufficient for future surgeons to provide optimal patient care.

Recent studies indicate that women with unilateral breast cancer are choosing contralateral prophylactic mastectomy (CPM) at an increasing rate. There is limited literature evaluating the postoperative complication rates associated with CPM without breast reconstruction. The objective of this study was to compare postoperative complications in women undergoing unilateral mastectomy (UM) and sentinel lymph node biopsy (SLNB) to those undergoing bilateral mastectomy (BM) and SLNB for the treatment of their breast cancer.The American College of Surgeons National Surgery Quality Improvement Program (ACS NSQIP) Participant Use Files between 2007 and 2010 were used to identify women with breast cancer undergoing UM or BM with SLNB. Individual and composite end points of 30-day complications were used to compare both groups by univariate and multivariate analyses.We identified 4,219 breast cancer patients who had a SLNB: 3,722 (88.2 %) had UM and 497 (11.8 %) had BM. The wound complication rate was significantly higher in the BM group versus the UM group, 5.8 % versus 2.9 % [unadjusted odds ratio (OR) 2.1, 95 % confidence interval (CI) 1.3-3.3, P0.01]. The overall 30-day complication rate in UM patients was 4.2 % versus 7.6 % in the BM group (unadjusted OR 1.9, 95 % CI 1.3-2.7, P0.01). The adjusted OR for overall complications adjusting for important patient characteristics was 1.9 (95 % CI 1.3-2.8, P0.01). Independent predictors of overall postoperative complications were body mass index (OR 1.1, P0.01) and smoking (OR 2.2, P0.01).For patients with breast cancer, bilateral mastectomy is associated with an increased risk of wound and overall postoperative complications. Discussion of these outcomes is imperative when counseling women contemplating CPM.

BACKGROUND: A family history of breast cancer has been shown to affect psychosocial functioning. However, the majority of research has focused on the daughters of patients with breast cancer and families with multiple relatives with the disease. The purpose of the current study was to examine cancer-related distress and breast cancer risk perception, and further examine the predictors of these outcomes, in the sisters of newly diagnosed patients with breast cancer without a previous family history of the disease. METHODS: Sisters of newly diagnosed index breast cancer patients were identified and asked to complete a study-specific questionnaire (demographics and cancer risk perception) and the Impact of Events Scale. Pathological information was abstracted from the medical chart for the index breast cancer patients. RESULTS: A total of 205 sisters completed the questionnaires. The mean time between breast cancer diagnosis and the sisters' completion of the questionnaire was 9.8 months. Approximately one-half of the women scored in the moderate or severe distress range. The most significant predictor of cancer-related distress was perceived lifetime breast cancer risk (P = .04). Women with a lifetime risk of breast cancer > 20% were more than twice as likely to have moderate or severe distress compared with those with a lifetime risk of < 20%. CONCLUSIONS: Cancer-related distress is high in the sisters of newly diagnosed patients with breast cancer in whom there is no other family history of breast cancer. Specifically, women with a perceived lifetime risk of breast cancer of > 20% experienced the highest levels of distress. Future interventions that target this group should be considered. Cancer 2013. © 2013 American Cancer Society.

Objectives The information needs of cancer patients are highly variable. Literature suggests an improved ability to modulate personalised stress, increased patient involvement with decision making, greater satisfaction with treatment choices and reduced anxiety levels in cancer patients who have access to information. The aim of this project was to evaluate the effects of a mobile information application on anxiety levels of patients undergoing surgery for breast cancer. Materials and methods An application was developed for use with Apple iPad containing information on basic breast cancer biology, different treatments used and surgical techniques. Content and face validity studies were performed. A randomized control trial was designed, with a 1:2 allocation. Data collected include basic demographics and type of surgery. Questionnaires used included: the HADS, Mini-MAC, information technology familiarity and information satisfaction. Results A total of 39 women participated. 13 women had access to an iPad containing additional information and 26 women acted as controls. The mean age was 54 and technology familiarity was similar among both groups. Anxiety and depression scores at seven days were significantly lower in control patients without access to the additional information provided by the mobile application (p = 0.022 and 0.029 respectively). Conclusion Anxiety and depression in breast cancer patients is both multifactorial and significant, with anxiety levels directly correlating with reduced quality of life. Intuitively, information should improve anxiety levels, however, we have demonstrated that surgical patients with less information reported significantly lower anxiety. We advise the thorough testing and auditing of information initiatives before deployment.

Despite the safety and popularity of oncoplastic surgery, there is limited data examining utilization and barriers associated with its incorporation into practice. This study examines the use of oncoplastic techniques in breast conserving surgery and determines the barriers associated with their implementation. A 13-item survey was mailed to all registered general surgeons in Ontario, Canada. The survey assessed surgeon demographics, utilization of specific oncoplastic techniques, and perceived barriers. A total of 234 survey responses were received, representing a response rate of 32.2 % (234 of 725). Of the respondents, 166 surgeons (70.9 %) reported a practice volume of at least 25 % breast surgery. Comparison was made between general surgeons performing oncoplastic breast surgery (N = 79) and those who did not use these techniques (N = 87). Surgeon gender, years in practice, fellowship training, and access to plastic surgery were similar across groups. Both groups rated the importance of breast cosmesis similarly. General surgeons with a practice volume involving >50 % breast surgery were more likely to use oncoplastic techniques (OR 8.82, p