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Marie-Anne Durand,1– 3 Marie Bannier,4 Marie-Anastasie Aim,5,6 Julien Mancini7 1CERPOP, Université de Toulouse, Inserm, Université Toulouse III Paul Sabatier, Toulouse, France; 2The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College Lebanon, Lebanon, NH, USA; 3Unisanté, Centre universitaire de médecine générale et santé publique, Lausanne, Switzerland; 4Institut Paoli-Calmettes, Marseille, France; 5AP-HM, Délégation à la Recherche Clinique et à l’Innovation, Marseille, France; 6Aix-Marseille Univ, LPS, Aix-en-Provence, France; 7Aix-Marseille Univ, APHM, INSERM, IRD, ISSPAM, SESSTIM, “Cancer, Biomedicine & Society” Group, Equipe Labellisée LIGUE, Hop Timone, Marseille, FranceCorrespondence: Julien Mancini, SESSTIM (Aix-Marseille Univ, Inserm, IRD) “Cancer, Biomedicine & Society” group, Institut Paoli-Calmettes, 232 Bd Ste Marguerite, BP 156, Marseille Cedex 9, Marseille, 13273, France, Tel +33 491 22 35 01, Email julien.mancini@univ-amu.frPurpose: After a diagnosis of early-stage breast cancer, women of lower socioeconomic position (SEP) report worse outcomes than women of higher SEP. A pictorial conversation aid was shown to improve decision outcomes in controlled contexts. No such intervention existed in France. In Phase 1, our aim was to adapt, for use in France, two pictorial conversation aids for breast cancer surgery and reconstruction. In Phase 2, our aim was to implement them in a regional cancer center serving a diverse population.Patients and Methods: In phase 1, we used iterative qualitative methods to adapt the conversation aids with a convenience sample of patients and health professionals. In phase 2, we tested their implementation using PDSA cycles with volunteer surgeons.Results: In phase 1, we interviewed 10 health professionals and 5 patients to reach thematic data saturation. They found the conversation aids usable and very acceptable (especially patients) and suggested small changes to further simplify the layout and content (including a glossary). In phase 2, three surgeons started the first PDSA cycle, for 4 weeks. Only one additional surgeon agreed to take part in the second cycle. The third cycle was cancelled since no new surgeon agreed to take part. Time was a barrier for 2 out of 4 surgeons, potentially explaining the difficulty recruiting for the third cycle. The evaluation was otherwise positive. The surgeons found the conversation aids very useful during their consultations and all intended to continue using them in the future.Conclusion: It was possible to adapt, for use in France, pictorial conversation aids proven to be effective elsewhere. While the adapted conversation aids were deemed usable by health professionals and very acceptable to patients, their implementation using PDSA cycles proved slow.Plain Language Summary: After a diagnosis of early-stage breast cancer, women of lower health literacy and socioeconomic position report worse outcomes than women of higher health literacy and socioeconomic position. Pictorial conversation aids were shown to improve decision outcomes in controlled contexts. No such intervention existed in France. Our aims were to adapt, for use in France, two lower health literacy pictorial conversation aids for breast cancer surgery and reconstruction, and then to implement them in a regional cancer center. Health professionals and patients found the conversation aids usable and very acceptable (especially patients) and suggested changes. Regarding implementation, the evaluation was also positive but time was a barrier for surgeons, and it was difficult to recruit many volunteers to use such conversation aids during their consultations.Keywords: shared decision-making, decision support techniques, breast cancer disparities, lower socioeconomic position

Gilles Houvenaeghel,1 Eric Lambaudie,1 Marie Bannier,2 Sandrine Rua,2 Julien Barrou,2 Mellie Heinemann,1 Max Buttarelli,2 Jeanne Thomassin Piana,3 Monique Cohen2 1Department of Surgical Oncology, Paoli Calmettes Institute and CRCM, CNRS, INSERM, Aix Marseille Université, 13009 Marseille, France; 2Department of Surgical Oncology, Paoli Calmettes Institute, 13009 Marseille, France; 3Department of Pathology, Paoli Calmettes Institute and CRCM, CNRS, INSERM, 13009 Marseille, France Introduction: Reoperation after breast-conserving surgery (BCS) could be proposed for positive or close margins. Reoperation type, re-excision or mastectomy, depends on several factors in relation to patient’s and tumor’s characteristics. We have analyzed our breast cancer (BC) database in order to determine second and third attempts for BCS and mastectomy rates, as well as associated factors for type of surgery. Methods: All patients with BCS between 1995 and 2017 were included. Patient’s characteristics, pathologic results, and treatments were analyzed. Reoperation rate, type of reoperation, second reoperation, and associated factors of reoperation, mastectomy, and third intervention were determined. Three periods were determined: P1–P3. Results: We analyzed 10,761 patients: 1,161 with ductal carcinoma in situ (DCIS) and 9,600 with invasive BC. The reoperation rate was 41.4% for DCIS and 28.0% for invasive BC. Using multivariate analysis, we identified tumor size >20 mm as being a risk factor for reoperation, whereas age >50 years, P2–3, and some localization decreased reoperation rates. For invasive BC, age >40 years, triple-negative tumors, neoadjuvant chemotherapy, and noncentral tumors decreased reoperation rates and lobular tumor, multifocal tumors, lymphovascular invasion, DCIS component, and Her2-positive tumors increased reoperation rates. For patients requiring reoperation, re-excision was performed in 48.1% (1,523/3,168) and mastectomy was required after first re-excision in 13.46% (205/1,523). For DCIS, mastectomy rates were higher for grade 2 and tumor ≥20 mm. For invasive BC, mastectomy rates were higher for lobular, multifocal, ≥20 mm, Her2-positive tumors and diffuse positive margins and lower for age >50 years and during the last period. Even if interval time between surgery and adjuvant treatments was higher for patients with reoperation, survival rates were not different between patients with and without reoperation. Conclusion: A decrease in reoperation and mastectomy rates had been reported with several associated factors. A third intervention with mastectomy was required in 13.5% of patients. This information should be done in case of reoperation. Keywords: breast cancer, conservative surgery, mastectomy, reoperation, margins

Background: Nipple-sparing mastectomy (NSM) with immediate breast reconstruction (IBR) is used increasingly when performing a prophylactic mastectomy. Few prospective studies have reported on complication rates. This complementary trial to the French prospective multicentre MAPAM trial aimed to evaluate the nipple-areola complex (NAC) necrosis rate in prophylactic NSM with IBR. Methods: Patient characteristics and surgical data were recorded. Morbidity after prophylactic NSM with a focus on NAC necrosis was analysed. Results: Among 59 women undergoing prophylactic NSM, 19 (32 per cent) of the incisions were partly on the NAC. Reconstructions were performed with 46 definitive implants and 13 expanders. The crude rate of postoperative complications was 25 per cent (15 patients). Complete NAC necrosis was reported in two women (3 per cent) and partial or total necrosis in nine (15 per cent). No NAC resection was necessary. Median BMI was lower in women with total or partial NAC necrosis compared with the others (20.0 versus 21.3 kg/m2 respectively; P=0.034). Conclusion: Results of this prospective study confirm that prophylactic NSM with IBR is associated with a low risk of total NAC necrosis. [ABSTRACT FROM AUTHOR]

Background Mastectomy with immediate breast reconstruction ( IBR) is a surgical strategy in breast cancer when breast-conserving surgery is not an option. There is a lack of evidence showing an advantage of mastectomy plus IBR over mastectomy alone on health-related quality of life ( QoL). Methods A large prospective multicentre survey, STIC-RMI (support of innovative and expensive techniques - immediate breast reconstruction), was undertaken to study the changes in QoL in patients treated by mastectomy with or without IBR. Patients were recruited between 2007 and 2009. European Organisation for Research and Treatment of Cancer QLQ-C30 and QLQ-BR23 instruments were used to assess QoL before operation, and at 6 and 12 months after surgery. A propensity score was used to compare QoL between mastectomy alone and mastectomy plus IBR, with limited bias. Results A total of 595 patients were included from 22 French academic hospitals, of whom 407 (68·4 per cent) underwent IBR. One-year data were available for 71·1 per cent of patients. Factors associated with IBR were age, histological tumour type, palpable nodes and an attempt at breast-conserving surgery. At inclusion, QoL was significantly better in the IBR group ( P < 0·001) and there was no significant change in either group during 1 year compared with baseline. Results for the QLQ-BR23 functional dimension varied according to propensity score quartiles; IBR had no influence in the lowest quartile. In the upper quartiles, QoL increased slightly over the year among patients who had IBR, whereas it decreased among those who had mastectomy alone ( P = 0·037). Satisfaction with the cosmetic outcome strongly influenced QoL, especially in upper quartiles ( P < 0·001). However, an unsatisfactory outcome after IBR was still considered a better condition than simple mastectomy. Conclusion The QoL benefit provided by IBR depends on patients' life status at inclusion; young active women with an in situ tumour are more likely to preserve their QoL after IBR. [ABSTRACT FROM AUTHOR]