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Introduction Breast conservation surgery (BCS) is the treatment of choice for unifocal, early-stage breast cancer. The ability to offer BCS to a wider subset of patients, including those with multifocal/multicentric cancer as well as extensive ductal carcinoma in situ, has emerged over time, especially in those undergoing joint oncoplastic reconstruction and those treated with neoadjuvant therapy. However, localization techniques using multiple radioactive seeds for bracketing in this patient subset have not been validated. Materials and Methods A single-institution retrospective review was conducted of all patients with breast cancer who underwent BCS, guided by multiple bracketed iodine I 125 radioactive seeds between January 2014 and April 2017. Results Bracketing of breast cancer using 2 or more radioactive seeds was performed in 157 breasts in 156 patients. Negative margins were achieved in 124 of 157 (79%) breasts, including 33 cases (21%) that underwent targeted margin reexcision at the time of surgery after intraoperative, multidisciplinary margin assessment. Thirty-three cases (21%) resulted in close or positive margins, of which 11 (7%) and 10 (6.4%) underwent completion mastectomy or repeat lumpectomy, respectively. Twelve patients (7.6%) did not undergo reexcision. En bloc resection was successful in 134 of 157 (85.4%) lumpectomies. Eighty-nine percent of the procedures were coupled with oncoplastic reconstruction. Conclusion Bracketing techniques using multiple radioactive seeds expands the indications for breast conservation therapy in patients who would have traditionally required mastectomy. Intraoperative margin assessment improves surgical and pathologic success. Larger defects created by multifocal resection are optimally managed in concert with oncoplastic reconstruction to minimize asymmetries and aesthetic defects.

PURPOSE: Patients with cancer frequently encounter financial hardship, yet systematic strategies to identify at-risk patients are not established in care delivery. We assessed sensitivity of distress-based screening to identify patients with cancer-related financial hardship and associated care delivery outcomes. METHODS: A survey of 225 patients at a large cancer center assessed cancer-related financial hardship (0-10 Likert scale; highest quintile scores ≥ 5 defined severe hardship). Responses were linked to electronic medical records identifying patients’ distress screening scores 6 months presurvey (0-10 scale) and outcomes of missed cancer care visits and bad debt charges (unrecovered patient charges) within 6 months postsurvey. A positive screen for distress was defined as score ≥ 4. We analyzed screening test characteristics for identifying severe financial hardship within 6 months and associations between financial hardship and outcomes using logistic models. RESULTS: Although patients with positive distress screens were more likely to report financial hardship (odds ratio [OR], 1.21; 1.08-1.37; P < .001), a positive distress screen was only 48% sensitive and 70% specific for identifying severe financial hardship. Patients with worse financial hardship scores were more likely to miss oncology care visits within 6 months (for every additional point in financial hardship score from 0 to 10, OR, 1.28; 1.12-1.47; P < .001). Of patients with severe hardship, 72% missed oncology visits versus 35% without severe hardship ( P = .006). Patients with worse hardship were more likely to incur any bad debt charges within 6 months (OR, 1.32; 1.13-1.54; P < .001). CONCLUSION: Systematic financial hardship screening is needed to help mitigate adverse care delivery outcomes. Existing distress-based screening lacks sensitivity.

Purpose: Surgeon and patient-related factors have been shown to influence patient experiences, quality of life (QoL), and surgical outcomes. We examined the association between surgeon-patient race- and gender-concordance with QoL after breast reconstruction. Methods: We conducted a retrospective cross-sectional analysis of patients who underwent lumpectomy or mastectomy followed by breast reconstruction over a 3-year period. We created the following categories with respect to the race and gender of a patient-surgeon triad: no-, intermediate-, and perfect-concordance. Multivariable regression was used to correlate post-operative global (SF-12) and condition-specific (BREAST-Q) QoL performance with patient-level covariates, gender- and race-concordance. Results: We identified 375 patients with a mean (±SD) age of 57.6±11.9 years, median (IQR) body mass index of 27.5 (24.0, 32.0), and median morbidity burden of 3 (2, 4). The majority of encounters were of intermediate concordance for gender (70%) and race (52%). Compared with gender discordant triads, intermediate gender concordance was associated with higher SF-Mental scores (b, 2.60; 95% CI, 0.21 to 4.99, p=0.003). Perfect race concordance (35% of encounters) was associated with significantly higher adjusted SF-Physical scores (b, 2.14; 95% CI, 0.50 to 4.22, p=0.045) than the race-discordant group. There were no significant associations observed between race- or gender-concordance and BREAST-Q performance. Conclusions: Race concordant relationships following breast cancer surgery were more likely to have improved global QoL. Perfect gender concordance was not associated with variation in QoL outcomes. Policy-level interventions are needed to facilitate personalized care and optimize breast cancer surgery outcomes.

Surgeon- and patient-related factors have been shown to influence patient experiences, quality of life (QoL), and surgical outcomes. We examined the association between patient-surgeon race and gender concordance with QoL after breast reconstruction.We conducted a retrospective cross-sectional analysis of patients who underwent lumpectomy or mastectomy followed by breast reconstruction over a 3-year period. We created the following categories with respect to the race and gender of a patient-surgeon triad: no, intermediate, and perfect concordance. Multivariable regression was used to correlate postoperative global (SF-12) and condition-specific (BREAST-Q) QoL performance with patient-level covariates, gender and race concordance.We identified 375 patients with a mean (± SD) age of 57.6 ± 11.9 years, median (IQR) body mass index of 27.5 (24.0, 32.0), and median morbidity burden of 3 (2, 4). The majority of encounters were of intermediate concordance for gender (70%) and race (52%). Compared with gender-discordant triads, intermediate gender concordance was associated with higher SF-Mental scores (β, 2.60; 95% CI, 0.21-4.99, p = 0.003). Perfect race concordance (35% of encounters) was associated with significantly higher adjusted SF-Physical scores (β, 2.14; 95% CI, 0.50-4.22, p = 0.045) than the race-discordant group. There were no significant associations observed between race or gender concordance and BREAST-Q performance.Race-concordant relationships following breast cancer surgery were more likely to have improved global QoL. Perfect gender concordance was not associated with variation in QoL outcomes. Policy-level interventions are needed to facilitate personalized care and optimize breast cancer surgery outcomes.

Objectives This study sought to evaluate advanced psychometric properties of the 15-item Economic Strain and Resilience in Cancer (ENRICh) measure of financial toxicity for cancer patients. Methods We surveyed 515 cancer patients in the greater Houston metropolitan area using ENRICh from March 2019 to March 2020. We conducted a series of factor analyses alongside parametric and non-parametric item response theory (IRT) assessments using Mokken analysis and the graded response model (GRM). We utilized parameters derived from the GRM to run a simulated computerized adaptive test (CAT) assessment. Results Among participants, mean age was 58.49 years and 278 (54%) were female. The initial round factor analysis results suggested a one-factor scale structure. Negligible levels of differential item functioning (DIF) were evident between eight items. Three items were removed due to local interdependence (Q3>+0.4). The original 11-point numerical rating scale did not function well, and a new 3-point scoring system was implemented. The final 12-item ENRICh had acceptable fit to the GRM (p Conclusion These CAT and 4-item versions provide options for quick screening in clinical practice and low-burden assessment in research.

PURPOSE: To evaluate the acceptability and impact of 3D printed breast models (3D-BM) on treatment-related decisional conflict (DC) of breast cancer patients. METHODS: Patients with breast cancer were accrued in a prospective IRB-approved trial. All patients underwent contrast-enhanced breast MRI (MRI). A personalized 3D-BM was derived from MRI. DC was evaluated pre and post 3D-BM review. 3D-BM acceptability was assessed post 3D-BM review. RESULTS: DC surveys before and after 3D-BM review and 3D-BM acceptability surveys were completed by 25 patients. 3D-BM were generated in 2 patients with bilateral breast cancer. The mean patient age was 48.8 years (28–72). Tumor stage was Tis (7), 1 (8), 2 (8) and 3 (4). Nodal staging was 0 (19), 1 (7), 3 (1). Tumors were unifocal (15), multifocal (8) or multicentric (4). Patients underwent mastectomy (13) and segmental mastectomy (14) with (20) or without (7) oncoplastic intervention. Neoadjuvant therapy was given to 7 patients. Patients rated the acceptability of the 3D-BM as good/excellent in understanding their condition (24/24), understanding disease size (25/25), 3D-BM detail (22/25), understanding their surgical options (24/25), encouraging to ask questions (23/25), 3D-BM size (24/25) and impartial to surgical options (17/24). There was significant reduction in overall DC post 3D-BM review, indicating patients became more assured of their treatment choice (p=0.002). Reduction post 3D-BM review was also observed in the uncertainty (p=0.012), feeling informed about options (p=.005), clarity about values (p=0.032) and effective (p=0.002) DCS subscales. CONCLUSIONS: 3D-BMs are an acceptable tool to decrease decisional conflict in breast cancer patients. CLINICAL RELEVANCE: Breast cancer patients may experience decisional conflict when considering their surgical options. 3D-BM are an acceptable, impartial tool that reduces decisional conflict in patients with breast cancer.

Contralateral prophylactic mastectomy (CPM) is increasingly performed in average-risk patients despite the lack of survival benefit. In an era of heightened awareness of healthcare costs, we sought to determine the impact of CPM on financial toxicity in breast cancer. A single-institution propensity-matched analysis of female patients who underwent unilateral mastectomy (UM) with or without CPM for breast cancer over an 18-month period. Patients with a history of genetic predisposition or bilateral cancer were excluded. The validated Comprehensive Score for financial Toxicity (COST) evaluated financial toxicity among participants. Multivariable regression analysis evaluated the relationship between CPM and financial toxicity. Relevant domains of the Breast Q and SF12 instruments were examined as secondary outcomes. Sensitivity analysis was performed using propensity-weighting to examine robustness of results and increase our sample size. Overall, 104 patients were identified, equally distributed across UM and CPM. CPM was not associated with financial toxicity, as evidenced by comparable COST scores (adjusted difference, 1.53 [− 3.24 to 6.29]). Minor complications were significantly lower in UM patients (UM, 8%; CPM, 31%). CPM was associated with significantly higher Breast Q psychosocial well-being score (adjusted difference, 10.58 [1.34 to 19.83]). BREAST Q surgeon satisfaction, SF12 mental and physical component scores were comparable. Similar results were noted on sensitivity analysis involving 194 patients. Choice for CPM was associated with higher minor complications, but led to improved psychosocial well-being without a higher degree of patient-reported financial toxicity. Prospective studies are needed to discern the influence of CPM on the incidence and trajectory of financial toxicity.

Background: The low uptake of antiestrogen preventive therapy among women at high risk of developing breast cancer remains a challenge. We implemented a performance improvement program to increase the uptake of preventive therapy among women with atypical hyperplasia (AH) and lobular cancer in situ (LCIS). Methods: A performance improvement program was implemented at the MD Anderson Cancer Center (Houston, TX), November 2015 to February 2017, for patients with a new ( Results: Baseline uptake of preventive therapy was 44%. The program registered 408 patients with a new (n = 87) or existing diagnosis (n = 321) of AH/LCIS; mean age was 57 and 71% were non-Hispanic white. Ninety-eight percent of patients received a recommendation for preventive therapy. The overall prescribing of preventive therapy to patients with a new or existing diagnosis was 82% (monthly range, 40%–100%; Ptrend = 0.76) and 48% (monthly range, 27%–57%; Ptrend < 0.01), respectively. Adherence among patients with a new or existing diagnosis was 76% and 48% (P < 0.01) at 6 months, respectively. Conclusion: A system-level approach improved the uptake of preventive therapy. Identifying women at the time of diagnosis of AH/LCIS and offering a strong recommendation are key components for improving acceptance and adherence with preventive therapy. Cancer Prev Res; 11(5); 295–302. ©2018 AACR.

Background Traditional 2-stage breast reconstruction involves placement of a textured-surface tissue expander (TTE). Recent studies have demonstrated textured surface devices have higher propensity for bacterial contamination and biofilm formation. Objectives The purpose of this study was to evaluate the safety and efficacy of smooth surface tissue expanders (STE) in immediate breast reconstruction. Methods The authors retrospectively reviewed consecutive women who underwent STE breast reconstruction from 2016 to 2017 at 3 institutions. Indications and outcomes were evaluated. Results A total 112 patients underwent STE reconstruction (75 subpectoral, 37 prepectoral placement), receiving 173 devices and monitored for a mean follow-up of 14.1 months. Demographics of patients included average age of 53 years and average BMI of 27.2 kg/m2, and 18.6% received postmastectomy radiation therapy. Overall complication rates were 15.6% and included mastectomy skin flap necrosis (10.4%), seroma (5.2%), expander malposition (2.9%), and infection requiring intravenous antibiotic therapy (3.5%). Six (3.5%) unplanned reoperations with explantation were reported for 3 infections and 3 patients requesting change of plan with no reconstruction. Conclusions STEs represent a safe and efficacious alternative to TTE breast reconstruction with at least equitable outcomes. Technique modification including tab fixation, strict pocket control, postoperative bra support, and suture choice may contribute to observed favorable outcomes and are reviewed. Early results for infection control and explantation rate are encouraging and warrant comparative evaluation for potential superiority over TTEs in a prospective randomized trial. Level of Evidence: 4

153 Background: Financial toxicity is a patient-reported outcome reflecting burdens of cancer treatment costs. There is a need to assess financial toxicity in cancer care, as its unique domains—upstream factors like direct medical costs or downstream economic impact like bankruptcy—predict worse QOL, adherence, and mortality. Socioeconomically disadvantaged patients bear disparate financial toxicity burdens. We thus developed and report performance of a new measure, the Economic StraiN and Resilience in Cancer (ENRICh), to assess all financial toxicity domains in economically diverse patients. Methods: We studied 238 patients with Stage I-IV cancer from a tertiary academic comprehensive cancer center (MDA) and county safety-net hospital serving socioeconomically disadvantaged patients (LBJ). Financial toxicity domains and corresponding subscales were developed from qualitative/cognitive (n = 104) interviews. ENRICh and Comprehensive Score for Financial Toxicity (COST) questions were administered (n = 127; MDA = 71, LBJ = 56). To demonstrate known-group validity, we compared ENRICh scores between centers; for concurrent validity, we correlated ENRICh and COST; for reliability, we calculated Cronbach's coefficient α for ENRICh subscales (range 0, none, to 10, high burden). Results: There were 4 distinct, valid financial toxicity domains/subscales: 1) Burden of cost; 2) Disruption of financial stability; 3) Depletion of financial coping; 4) Depletion of instrumental coping. Patients from the 2 centers significantly differed in subscale and overall ENRICh scores. Socioeconomically disadvantaged patients had worse mean scores (4.9 vs 2.1, 95%CI -3.6,-2.1, effect size 1.4, P < .001). ENRICh significantly correlated with COST (r = -0.82, 95%CI -0.87,-0.77, P < .001). Subscales were reliable with excellent internal consistency (Cronbach α = 0.78 to 0.94). The 4 ENRICh domains collectively had synergistic impact on overall financial toxicity burden. Conclusions: ENRICh is valid, reliable, and identifies and 4 novel domains of financial toxicity. Future utility of this tool is to guide assessment/interventions targeting financial toxicity domains affecting diverse cancer patients, to mitigate disparities.

e18799Background: Post-operative analgesia requirements vary, but no guidelines exist for opioid prescription (Rx) after breast surgical oncology (BSO) procedures. Given the national opioid epidemi...