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Introduction: Inflammatory breast cancer (IBC) is an aggressive form of breast cancer with best outcomes result-ing from trimodality therapy: neoadjuvant chemotherapy (NAC), modified radical mastectomy (MRM), and radiation (PMRT). Contralateral prophylactic mastectomy (CPM) is generally discour-aged at the time of MRM due to poor prognosis. Our aim was to identify factors associated with CPM for IBC and determine its relationship with overall survival (OS). Methods: The National Cancer Database was used to identify female patients with AJCC stage IIIC unilateral IBC (cT4d and inflammatory histology code) treated 2004-2018. Patients were stratified by mastec-tomy type: unilateral mastectomy (UM) was defined as MRM or simple mastectomy, and CPM was defined as UM + CPM. Logistic regression identified factors associated with mastectomy type, and multivariable proportional Cox hazards regression identified factors associated with OS. A subset analysis of patients receiving NAC compared complete pathologic response (pCR) between mastec-tomy groups. Results: Of the 2,837 patients with non-metastatic IBC, 2,013 (70.2%) underwent UM and 855 (29.8%) had CPM. The CPM group was significantly younger than the UM group (mean age 52 vs. 56.6 years, p=0.028), more frequently identified as Non-Hispanic White (79.7% vs. 70.1%, p< 0.001), and had private insurance (66.9% vs. 55.6%, p< 0.001). Nearly all patients received chemotherapy and over 80% were treated with NAC. Receipt of PMRT did not differ by mastectomy type (80% for UM and CPM). On multivariable logistic regression, patients age < 40 were more likely to undergo CPM than UM (OR 3.7, 95% CI 1.61-8.5, p< 0.002). Patients with age >70, Hispanic ethnicity, and public insur-ance were significantly less likely to receive CPM (all p≤0.002). On multivariable Cox regression ad-justed for patient, tumor, and treatment factors, CPM was not associated with OS benefit (HR 0.86, 95% CI 0.73-1.02, p=0.08). Higher histologic grade, node-positive disease, and greater co-morbidity were associated with poorer OS, while receipt of chemotherapy and PMRT improved OS. In the subset of NAC patients, overall pCR did not differ significantly by mastectomy type (CPM 22.3%, UM 19.4%, p=0.26). When included in multivariable models, pCR rates were not predictive of CPM de-spite being associated with improved OS. Conclusion: Nearly 30% of IBC patients undergo CPM despite discouragement by guidelines. Demographic char-acteristics – particularly age < 40 – predicted CPM, suggesting patient preferences and access to care affect surgical decisions. As expected, trimodality therapy and favorable NAC response im-proved oncologic outcomes, but CPM had no association with OS. While CPM may be chosen for risk reduction and symmetry, patients should be counseled that it does not improve survival for IBC. Citation Format: Lauren M. Drapalik, Amanda L. Amin, Ashley Simpson, Lisa Rock, Mary Freyvogel, Robert Shenk, Megan E. Miller. Patient rather than tumor factors predict contralateral prophylactic mastectomy for inflammatory breast cancer [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P2-14-05.

Despite evidence that early-stage male breast cancer (MBC) can be treated the same as in females, we hypothesized that men undergo more extensive surgery.Patients with clinical T1-2 breast cancer were identified in the National Cancer Database 2004-2016. Trends in surgery type and overall survival were compared between sexes.Of 9,782 males and 1,078,105 females, most were cN0 with AJCC stage I/II disease. Unilateral mastectomy was most common in men (67.1% vs. 24.1%, p 0.001) and partial mastectomy in women (64.7% vs. 26.4%, p 0.001), with no significant change over time. Over 1/3 of men received ALND in 2016. While overall survival was superior in females (HR 0.83, 95% CI 0.73-0.94, p = 0.003), partial mastectomy was associated with a 42% reduction in mortality risk for males (HR 0.58, 95% CI 0.4-0.8, p = 0.003).De-escalation of surgery could be considered for MBC to improve survival and align with current standards of care.

Previous studies have identified racial-ethnic differences in the diagnostic patterns and recurrence outcomes of women with phyllodes tumors (PT). However, these studies are generally limited in size and generalizability. We therefore sought to explore racial-ethnic differences in age, tumor size, subtype, and recurrence in a large US cohort of women with PT.We performed an 11-institution retrospective review of women with PT from 2007 to 2017. Differences in age at diagnosis, tumor size and subtype, and recurrence-free survival according to race-ethnicity.Women of non-White race or Hispanic ethnicity were younger at the time of diagnosis with phyllodes tumor. Non-Hispanic Other women had a larger proportion of malignant PT. There were no differences in recurrence-free survival in our cohort.Differences in age, tumor size, and subtype were small. Therefore, the workup of young women with breast masses and the treatment of women with PT should not differ according to race-ethnicity. These conclusions are supported by our finding that there were no differences in recurrence-free survival.

Transitioning from trainee to attending surgeon requires learners to become educators. The purpose of this study is to evaluate educational strategies utilized by surgeons, define gaps in preparation for operative teaching, and identify opportunities to support this transition.A web-based, Association of Surgical Education approved survey was distributed to attending surgeons.There were 153 respondents. Narrating actions was the most frequently reported educational model, utilized by 74% of junior faculty [JF] (0-5yrs) and 63% of senior faculty [SF] (6yrs). Other models used included educational time-outs (29% JF, 27% SF), BID teaching model (36% JF, 51% SF), and Zwisch model (13% JF, 25% SF). Compared with 91% JF, 65% SF reported struggling with instruction (p 0.001). Five themes emerged as presenting difficulty during the resident to attending transition: lack of relationships, ongoing learning, systems-based, cognitive load, impression management.Our results represent a needs assessment in the transition from learner to educator in the OR.

Background: Triple-negative breast cancer (TNBC) is an aggressive breast cancer subtype with a higher risk of locoregional and distance recurrence. Consequently, this population was considered poor candidate for breast conservation (BCT). Our study aim was to determine whether BCT plus radiotherapy (RT) was equivalent to mastectomy for TNBC after adjustment of selection bias of demographic and clinical characteristics. Methods: The National Cancer Database was queried for women diagnosed as primary unilateral invasive clinical T1-2N0-2 TNBC from 2004-2016. Patients who underwent mastectomy or breast conservation (partial mastectomy plus radiation) were included. A 1:1 propensity match with replacement was performed to compare breast conservation vs. mastectomy. Overall survival was analyzed using stratified multivariable Cox proportional hazard regression analysis.Results: Of 59,599 clinical T1-2N0-2 TNBC patients, 26,325 (44.2%) underwent mastectomy and 33,274 (55.8%) were treated with BCT. BCT patients were older (median age 59 vs. 54, p Citation Format: Lifen Cao, Christopher W Towe, Megan E Miller, Alberto J Montero, Robert Shenk. Breast conservation plus radiotherapy provides superior survival benefit than mastectomy in triple negative breast cancer: A propensity matched national cancer database analysis [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-18-02.

Wastewater surveillance of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may be useful for monitoring population-wide coronavirus disease 2019 (COVID-19) infections, especially given asymptomatic infections and limitations in diagnostic testing. We aimed to detect SARS-CoV-2 RNA in wastewater and compare viral concentrations to COVID-19 case numbers in the respective counties and sewersheds. Influent 24-hour composite wastewater samples were collected from July to December 2020 from two municipal wastewater treatment plants serving different population sizes in Orange and Chatham Counties in North Carolina. After a concentration step via HA filtration, SARS-CoV-2 RNA was detected and quantified by reverse transcription droplet digital polymerase chain reaction (RT-ddPCR) and quantitative PCR (RT-qPCR), targeting the N1 and N2 nucleocapsid genes. SARS-CoV-2 RNA was detected by RT-ddPCR in 100 % (24/24) and 79 % (19/24) of influent wastewater samples from the larger and smaller plants, respectively. In comparison, viral RNA was detected by RT-qPCR in 41.7 % (10/24) and 8.3 % (2/24) of samples from the larger and smaller plants, respectively. Positivity rates and method agreement further increased for the RT-qPCR assay when samples with positive signals below the limit of detection were counted as positive. The wastewater data from the larger plant generally correlated (⍴ ~0.5, p0.05) with, and even anticipated, the trends in reported COVID-19 cases, with a notable spike in measured viral RNA preceding a spike in cases when students returned to a college campus in the Orange County sewershed. Correlations were generally higher when using estimates of sewershed-level case data rather than county-level data. This work supports use of wastewater surveillance for tracking COVID-19 disease trends, especially in identifying spikes in cases. Wastewater-based epidemiology can be a valuable resource for tracking disease trends, allocating resources, and evaluating policy in the fight against current and future pandemics.

Boxwood blight is caused by Calonectria henricotiae (Che) and C. pseudonaviculata (Cps). Unrecognized symptoms on Buxus cuttings used for propagation could potentially serve as a source of inoculum and result in pathogen spread. In this study, cuttings of boxwood (Buxus spp.) cultivars ‘Justin Brouwers', ‘Nana', ‘Green Beauty', and ‘Green Velvet' were assessed for root production after exposure to 45 C (113 F) or 47.5 C (118 F) water for 0 to 60 minutes in 5 minute increments. The number of roots greater than 1 cm (0.4 in) in length produced by cuttings of all cultivars three months after treatment in 45 C water for up to 60 minutes was not statistically different from the non-immersed control. A similar response was observed for cuttings of all cultivars treated in 47.5 C water for up to 60 minutes, except for cv. ‘Nana,' which produced fewer roots than the non-immersed control after 35 minutes of exposure to heated water. Experiments conducted on diseased, detached boxwood leaves of susceptible cultivar ‘Justin Brouwers' at 47.5 C, 50 C (122 F) or 52.5 C (127 F) showed significantly reduced production of conidia and viability of Che and Cps after 25 to 30 minute exposure to 47.5 C water (44%) or 12 minute exposure to 50 C water (22%). After 8 minutes of exposure to 52.5 C water, little or no sporulation was observed for either pathogen.Index words: Boxwood blight, Calonectria pseudonaviculata, Calonectria henricotiae, Buxus, hot water treatment, rooting, cuttings, plant propagation.Species used in this study: Boxwood blight [Calonectria henricotiae Gehesquière, Heungens and J.A. Crouch and C. pseudonaviculata (Crous J.Z. Groenewald & C.F. Hill) L. Lombard, M.J. Wingf & Crous] Boxwood [Buxus sempervirens L. ‘Justin Brouwers'; Buxus sinica (Rehder & E. H. Wilson) M. Cheng var. insularis (Nakai) M. Cheng ‘Nana'; B. sempervirens ‘Suffruticosa'×B. sinica var. insularis ‘Green Beauty', and B. sempervirens ‘Suffruticosa' × B. sinica var. insularis ‘Green Velvet'].

Background: The benefit of axillary lymph node dissection (ALND) in patients with pN1 disease on sentinel lymph node biopsy (SLNB) following neoadjuvant chemotherapy for invasive breast cancer in patients receiving regional nodal irradiation (RNI) is unclear, even in patients with high risk histologic features such as triple negative disease. We sought to determine any association of ALND with improved survival, as well as patterns of care in this cohort using the National Cancer Database (NCDB). Methods: The NCDB was queried for women ages 18-75 with cT1-3N1 and ypT0-T3N1M0 breast cancer that underwent definitive surgical resection with axillary staging followed by adjuvant regional nodal irradiation, with triple negative receptor status. Only patients who were treated from 2012 - 2015 were included for appropriate coding of the extent of axillary surgery. Overall survival was estimated using the Kaplan-Meier method and Cox proportional hazards models. An analysis of the number of lymph nodes removed, rate of RNI utilization, and rate of ALND was performed using the Wilcoxon rank-sum test, proportions of RNI utilization compared using the Chi-squared test, and correlation of these to year of diagnosis was evaluated with the Pearson correlation coefficient. Results: A total of 572 women were identified that met inclusion criteria. The median age was 53 (range 24-75) years. 67 (11.7%) of women had SLNB alone and 505 (88.3%) had ALND with or without SLNB. Four year OS was 66.7% in patients undergoing ALND compared to 70.6% in those that had SLNB alone (p = 0.47). Charlson-Deyo comorbidity index (CDCC) (p = 0.01) and clinical T3 stage (p = 0.03) were significantly associated with survival. After adjusting for age, histology, clinical and pathologic T-stage, and CDCC, there was no significant relationship between receipt of ALND and overall survival (OS), however CDCC (p = 0.01) and cT3 or pT3 (p = 0.02 and p =0.01) remained significantly associated with OS. The mean number of lymph nodes sampled from 2012 to 2015 increased from 11.68 to 13.46 (p = 0.07). The rate of RNI increased from 55.6% in 2012 of patients to 58.4% in 2015 (p = 0.6). The rate of ALND increased from 83.9% in 2012 to 90.8% in 2015 (p = 0.2). Pearson correlation coefficients between mean number of lymph nodes sampled, rate of RNI, and rate of ALND were 0.83. 0.13, and 0.95 respectively. Conclusions: There was no difference in overall survival between patients with cT1-3N1M0 and ypT0-3N1M0 triple negative breast cancer receiving SLNB compared to ALND with adjuvant RNI, even when adjusting for tumor size and comorbidities, which remained significant risk factors. There was a trend towards an increase in the mean number of lymph nodes sampled and increased utilization of ALND, though these failed to reach statistical significance. We await the results of the Alliance 011202 randomized trial to provide prospective guidance of the utility of ALND in this high risk subgroup. Table 1. Baseline Characteristics For Triple-Negative PatientsSLNB (n=67)ALND (n=505)Median Age (Years)5353Histology (n, %)Ductal61 (91%)452 (90%)Lobular2 (3%)15 (3%)Other4 (6%)38 (7%)T-Stage (n,%)cT111 (16%)73 (15%)cT234 (51%)290 (57%)cT322 (33%)142 (28%)CDCC (n,%)054 (81%)441 (87%)19 (13%)51 (10%)24 (6%)8 (2%)30 (0%)5 (1%)Mean CDCC0.250.16Facility Type (n,%)Community5 (7%)36 (7%)Comprehensive Community27 (40%)171 (34%)Academic/Research13 (19%)160 (32%)Integrated Network13 (19%)72 (14%)Other/Unknown9 (14%)66 (13%)Lymphovascular Invasion (%)32.84%32.48%Median Tumor Size (cm)3.63.3Median Nodes Examined412Median Nodes Positive12 Citation Format: Michael Kharouta, Nicholas Damico, Megan Miller, Eleanor Harris, Janice Lyons. Impact of axillary dissection and patterns of care in patients with ypN1 triple negative breast cancer receiving regional nodal irradiation [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 PS1-14.

Introduction: MammaPrint, a 70-gene assay used to predict breast cancer recurrence, is typically obtained on the surgical specimen to guide the use of adjuvant chemotherapy. However, MammaPrint results obtained at the time of diagnosis on core biopsy specimen could allow consideration of neoadjuvant chemotherapy (NAC), particularly for tumors that may not traditionally be considered for NAC such as invasive lobular carcinoma (ILC). We hypothesized that MammaPrint scores correlate with pathologic complete response (pCR) and can predict NAC response independent of histology type. Methods: The National Cancer Database was used to identify patients with AJCC Stage I-III unilateral HR+/HER2- breast cancer with MammaPrint scores treated 2010-2018. Patients were stratified by histology: invasive ductal carcinoma (IDC) and ILC; and by MammaPrint score for 5-year breast cancer recurrence: Low Risk (1%) and High Risk (12%). Descriptive statistics identified clinical and treatment differences between groups. Logistic regression was used to identify factors associated with chemotherapy receipt and sequence. A subset analysis of patients receiving NAC compared pCR rates by MammaPrint score and histology type. Results: Of 10,999 patients, 9,351 (85%) were diagnosed with IDC and 1,648 (15%) with ILC. ILC were larger at presentation: 40% of ILC were cT2 or greater vs. 29% of IDC (p< 0.001). However, 90% of patients in both groups had cN0 disease. The majority of ILC were grade II (67% ILC vs. 52% IDC, p< 0.001). High Risk MammaPrint scores were significantly more common in IDC tumors: 44% IDC vs 25% ILC (p< 0.001). Mastectomy and axillary lymph node dissection (ALND) were performed more often for ILC than IDC (unilateral mastectomy 32% vs. 21%, bilateral mastectomy 17% vs. 12%, ALND 29% vs. 24%; all p< 0.001). Conversely, chemotherapy (38% vs. 30%, p< 0.001) and radiation (69% vs. 64%, p< 0.001) were more frequently used to treat IDC than ILC. In the subset analysis of patients who received NAC (n = 715), tumors with High Risk MammaPrint scores had more favorable in-breast and axillary responses than those with Low Risk scores for both ILC and IDC (Table 1). Furthermore, only tumors with High Risk Mammaprint scores achieved an overall pCR: 7% IDC and 5% ILC. There were no significant differences in pCR rates by histology type. On multivariable logistic regression, High Risk MammaPrint score was positively associated with the receipt of NAC (OR 4.3, p< 0.001) and adjuvant chemotherapy (OR 24.8, p< 0.001). NAC, adjuvant chemotherapy, and any chemotherapy were also strongly associated with node-positive disease and tumor size >2cm, but not IDC vs. ILC histology. Conclusions: Superior response to NAC was observed in tumors with High Risk MammaPrint score regardless of histology type, indicating a correlation between pCR rates and genomic assay results. Greater use of NAC guided by High Risk Mammaprint score obtained on core needle biopsy may allow patients with invasive breast cancer to undergo less extensive breast and axillary surgery. Further prospective studies using MammaPrint testing on core biopsy specimens could validate these findings in clinical practice. Table 1. Response to neoadjuvant chemotherapy by MammaPrint score for patients with Invasive breast carcinoma, NCDB 2010–2018 Citation Format: Lauren M. Drapalik, Rashi Singh, Ashley Simpson, Lisa Rock, Robert Shenk, Amanda L. Amin, Megan E. Miller. Using MammaPrint on Core Needle Biopsy to Guide Neoadjuvant Chemotherapy for Invasive Breast Carcinoma [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P6-01-02.

It was suggested that stereotactic radiation (SBRT) is an "alternative if no surgical capacity is available" for non-small cell lung cancer (NSCLC) care during the COVID-19 pandemic. The purpose of this study was to compare the oncologic outcomes of delayed surgical resection and early SBRT among operable patients with early stage lung cancer.The National Cancer Database was queried for patients with cT1aN0M0 NSCLC who underwent surgery or SBRT (2010-2016) with no comorbidity. Patients with any comorbidities or age80 were excluded. The outcome of interest was overall survival. Delays in surgical care were modeled using different times from diagnosis to surgery. A 1:1 propensity match was performed and survival was analyzed using multivariable Cox regression.Of 6720 healthy cT1aN0M0 NSCLC patients, 6008 (89.4%) received surgery and 712 (10.6%) received SBRT. Among surgery patients, time to surgery30 d was associated with inferior survival (HR 1.4, P ≤ 0.013) compared with patients receiving surgery ≤14 d. Relative to SBRT, surgery demonstrated superior survival at all time points evaluated: 0-30 d, 31-60 d, 61-90 d, and90 d (all P 0.001). Among a propensity-matched cohort of 256 pairs of patients, delayed surgery (90 d) remained association with better overall survival relative to early SBRT (5-year survival 76.9% versus 32.3%, HR = 0.266, P 0.001).Although longer time to surgery is associated with inferior survival among surgery patients, delayed surgery is superior to early SBRT. Surgical resection should remain the standard of care to treat operable early stage lung cancer despite delays imposed by the COVID-19 pandemic.

Race, access to care, and molecular features result in outcome disparities in triple-negative breast cancer (TNBC). We sought to determine the role of age in TNBC disparity by hypothesizing that younger patients receive more comprehensive treatment, resulting in survival differences.The National Cancer Database was used to identify women with unilateral TNBC treated from 2005 through 2017. Patients were stratified by age (≤40, 41-70,70); demographics, clinical characteristics, and treatment factors were compared. Logistic regression determined factors associated with treatment received. Survival outcomes were analyzed using a stratified log-rank test.Of the 168,715 patients, 16,287 (9.6%) were ≤40 years. Patients ≤40 were significantly more likely to present at higher clinical stage (P.001) and receive neoadjuvant chemotherapy (NAC, P.001). Bilateral mastectomy was the most common surgery for patients ≤40 (37%), whereas partial mastectomy was most often used in patients 41 to 70 years old (48%) and those70 (49%) (P.001). Patients ≤40 years were significantly more likely to undergo both NAC and mastectomy than those40 (odds ratio 1.5, both P.05) despite a greater in-breast tumor response in the youngest patients. Patients treated with mastectomy and axillary lymph node dissection had inferior survival outcomes compared to those treated with partial mastectomy and sentinel lymph node biopsy across all 3 age groups (P.001).The clinical characteristics of TNBC differ significantly at the extremes of age, likely driving treatment decisions. Although patients ≤40 present with a more advanced disease and appropriately receive NAC, they also undergo more extensive surgery that does not yield a survival benefit. Further research is needed to determine if age disparity is due to oncologic factors or patient and provider preferences.

Background Molecular testing of thyroid nodules with indeterminate fine-needle aspiration (FNA) cytology is commonly used to guide patient management and is typically performed on freshly collected FNA samples. In this study, the authors evaluated the performance of the ThyroSeq test in cytology smear slides. Methods Air-dried Diff-Quik (DQ)-stained and alcohol-fixed Papanicolaou (Pap)-stained smears were used to determine required cellularity and sensitivity of mutation detection and to compare ThyroSeq v3 Genomic Classifier (GC) results obtained in cytology smears and fresh FNA samples from the same nodules. Results ThyroSeq testing of 31 cytology smears revealed that 25 smears (81%) were adequate for ThyroSeq analysis, including 14 Pap-stained smears (100%) and 11 DQ-stained smears (65%), whereas 6 DQ-stained smears (35%) failed RNA sequencing. The overall accuracy for detecting molecular alterations was 98%, with 100% concordance for mutations and gene expression alterations, 96% concordance for fusions, and 94% concordance for copy number alterations. Cytology smears were adequate for ThyroSeq analysis when at least 200 to 300 cells were present in 1 to 3 slides. ThyroSeq detected all studied mutations down to 5% allele frequency and BRAF mutations down to 1% allele frequency. Testing of smears yielded a positive ThyroSeq GC result in all nodules originally classified as positive. Conclusions Thyroid FNA cytology smear slides with adequate cellularity can be successfully used for ThyroSeq GC testing in approximately 80% of cases, with an even higher success rate in Pap-stained smears. Compared with FNA samples collected into preservative solution, 94% to 100% of different genetic alterations could be accurately detected in smears, validating cytology smears as an alternative for ThyroSeq testing in patients with indeterminate thyroid cytology.

Surgical residents receive limited formal training in education, yet they are expected to teach medical students and one another. A "Residents as Teachers" curriculum was developed and implemented to improve residents' knowledge of educational strategies, confidence in teaching abilities, and quality of feedback given to learners.A 6-hour workshop was delivered at an academic general surgery residency program. It included 3 interactive sessions: "Teaching on the wards", "How to give and receive feedback", and "Teaching in the operating room (OR)". Pre- and postsession surveys were administered to evaluate participants' knowledge and confidence regarding teaching skills. Standard statistical analyses were used to compare pre- and postcurriculum scores.General surgery residents at Case Western Reserve University/University Hospitals Cleveland Medical Center Program attended a 6-hour educational seminar entitled "Residents as Teachers". Three attending surgeons with expertise in surgical education administered the curriculum.Twenty-four residents completed the course and surveys (5 PGY-5s, 6 PGY-4s, 4 PGY-3s, 5 PGY-2s, and 4 PGY-1s).On a 5-point Likert scale, residents' self-rating of teaching skills (pre = 1.8, post = 3.04, p0.001) and understanding of adult learning (pre = 1.88, post = 4.42, p0.001) improved significantly. The greatest gain was in describing effective strategies for teaching in the OR (pre = 1.75, post = 4.38, p0.001). Residents reported improved understanding of effective feedback characteristics (pre = 2.5, post = 4.33, p0.001), and felt more prepared to provide feedback to learners (pre = 2.73, post = 3.17, p = 0.01). Scores on 5 of 10 knowledge-based questions significantly improved following the intervention. All participants agreed or strongly agreed that the workshop improved the program's surgical education curriculum (mean score 4.42 of 5).A "Residents as Teachers" workshop improved resident confidence in teaching and feedback skills, particularly for intraoperative instruction, and improved knowledge in the 3 specific educational domains included in the session.

Viruses are major contributors to the annual 1.3 million deaths associated with the global burden of diarrheal disease morbidity and mortality. While household-level water treatment technologies reduce diarrheal illness, the majority of filtration technologies are ineffective in removing viruses due to their small size relative to filter pore size. In order to meet the WHO health-based tolerable risk target of 10−6 Disability Adjusted Life Years per person per year, a drinking water filter must achieve a 5 Log10 virus reduction. Ceramic pot water filters manufactured in developing countries typically achieve less than 1 Log10 virus reductions. In order to overcome the shortfall in virus removal efficiency in household water treatment filtration, we (1) evaluated the capacity of chitosan acetate and chitosan lactate, as a cationic coagulant pretreatment combined with ceramic water filtration to remove lab cultured and sewage derived viruses and bacteria in drinking waters, (2) optimized treatment conditions in waters of varying quality and (3) evaluated long-term continuous treatment over a 10-week experiment in surface waters. For each test condition, bacteria and virus concentrations were enumerated by culture methods for influent, controls, and treated effluent after chitosan pretreatment and ceramic water filtration. A &gt, 5 Log10 reduction was achieved in treated effluent for E.coli, C. perfringens, sewage derived E. coli and total coliforms, MS2 coliphage, Qβ coliphage, ΦX174 coliphage, and sewage derived F+ and somatic coliphages.

Purpose: Approximately 20% of all breast cancers (BC) are HER2 amplified. In the APT trial, weekly paclitaxel/ trastuzumab in node negative HER2+ BC with tumors Methods: In the National Cancer Database (2004-2017), patients with a primary diagnosis of pT1N0M0 HER2+ BC, were separated into two groups: (i) HER2 monotherapy, i.e. trastuzumab, and (ii) chemo-HER2 therapy. A 3:1 propensity match was performed to balance patient selection bias between the two different cohorts. Long-term overall survival (OS) was compared between both groups. Results: A total of 23, 281 patients met the criteria. 22,268 (96.7%) received chemo-HER2 therapy and 1,013 (4.4%) received HER2 monotherapy. Propensity match identified 1,995 patients who received chemo-HER2 therapy, and 666 who received HER2 monotherapy. After match, adjuvant chemo-HER2 therapy was associated with a modest survival advantage over HER2 monotherapy (5-year OS 94.1% vs. 90.6%, P=0.041). Conclusions: Even though there is a modest OS advantage favoring adjuvant chemo-HER2 therapy in pT1N0 HER2+ BC, HER2 monotherapy was associated with 5-year OS >90%. Therefore, in select patients who have contraindications for cytotoxic chemotherapy, or decline adjuvant chemotherapy, adjuvant trastuzumab monotherapy appears to be a reasonable alternative.

Background: Routine sentinel lymph node biopsy (SLNB) has been recommended against by Choosing Wisely© Foundation due to its low value in clinical node negative, hormone receptor positive breast cancer patients age≥70 years old. We used the National Cancer Database (NCDB) to examine the effect of SLNB omission and outcomes in this population. We hypothesized that SLNB would be beneficial in this population.Methods: The National Cancer Database was queried for women diagnosed with primary unilateral invasive clinical stage T1N0M0 hormone receptor positive, HER-2 negative breast cancer from 2012-2017. Patients age ≥ 70 years old with Charlson Score ≥1 who underwent partial mastectomy and received hormonal therapy were included in the study cohort. Patients received neoadjuvant therapy or underwent upfront axillary lymph node dissection (ALND) were excluded. A 1:3 propensity match with replacement was performed to compare SLNB omission vs. SLNB group controlling age, race, comorbidities, insurance and facility. Overall survival was analyzed using stratified multivariable Cox proportional hazard regression analysis.Results: Of 14,150 patients, 1,928 (13.6%) omitted SLNB and 12,222 (86.4%) underwent SLNB, including 1,545/12,222 (12.6%) who proceeded to ALND. Central portion tumor location (OR=1.77, P=0.001), clinical T1c (OR= 2.49, P Citation Format: Lifen Cao, Megan E Miller, Luke D Rothermel, Alberto J Montero, Christopher W Towe, Robert Shenk. Less is not necessarily more: A propensity matched national analysis on effect and outcome of sentinel lymph node biopsy omission [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr PD7-08.

Neoadjuvant chemotherapy (NAC) downstages breast cancer and provides prognostic information. Males with breast cancer are known to receive less treatment overall and have poorer outcomes relative to females. We hypothesized that males would be less likely to receive NAC. Patients with a primary diagnosis of cN1–3 breast cancer were identified in the National Cancer Database (2004–2016). Multivariable logistic regression determined the association between NAC utilization and sex, and the relationship between sex and NAC response, controlling for demographic and tumor factors. Overall survival was analyzed using a multivariable Cox model. In total, 196,027 patients (194,010 females, 2017 males) met inclusion criteria. A significantly greater proportion of males underwent mastectomy (80% vs. 60%, P < 0.001), and axillary lymph node dissection (76% vs. 74%, P = 0.022). Overall fewer men received chemotherapy than women (73% vs. 84%, P < 0.001); men also received NAC at a significantly lower rate (26% men vs. 45% women, P < 0.001). After accounting for demographic and oncologic factors including hormone receptor (HR) subtype, females remained more likely to undergo NAC (OR 1.84, P < 0.001). On multivariable analysis, sex was not associated with pathologic response or overall survival after NAC. Although oncologic outcomes after NAC were similar, males with node-positive breast cancer received less NAC and more aggressive surgery than females. These data suggest men achieve outcomes comparable to women with cN1–3 disease, and NAC should be used in appropriate male patients to downstage the breast and axilla.

Simple Summary The welfare of animals in human care should be taken into consideration by both the scientific community and members of the public who are able to view animals in a zoo setting. One component of individual welfare is how groups of animals and the individuals within groups may be affected by the presence of zoo guests. At the Buffalo Zoo in New York, we studied the behavioral differences of six gorillas in two conditions: heavy guest presence and the complete absence of guests. We found few significant behavioral differences between the conditions, with the greatest behavioral change observed in the adult silverback male. We stress the importance of not over-generalizing our findings, and suggest an inter-institutional study of the nuanced ways that zoo guests interact with gorillas in managed care. Abstract Research conducted on the effects that zoo visitors have on primate behavior has yielded inconsistent patterns. This study aims to contribute to the growing body of literature regarding visitor effects on zoo-housed primate’s activity budgets, with the purpose of quantifying the behavioral variability under two conditions: guest presence and guest absence. Due to the COVID-19 pandemic, many zoos were closed to the public for varying lengths of time. The Buffalo Zoo was closed to guests for an 18-week period including the summer of 2020, which allowed us to effectively control for zoo guest presence. This case report compares data on the zoo’s gorilla troop from the same time period in 2019. We found inconsistent results, similar to prior studies conducted with zoo-housed gorilla troops. Most gorillas were observed foraging less and exhibiting more inactivity in 2020, whereas the adult male silverback showed the opposite pattern. Abnormal or undesirable behaviors were performed less frequently when guests were absent however, these differences were not significant. We encourage others to compare behavior patterns during the pandemic shutdown to add to our knowledge base of visitor effects. We suggest that researchers do not try and generalize their individual and troop results to the entire population of gorillas in managed care, as both intrinsic and extrinsic factors contribute to individual differences in behavioral response.

Lobular carcinoma in situ (LCIS) is a risk factor for breast cancer, but the effect of LCIS found in association with ductal carcinoma in situ (DCIS) is unknown. In this study, we compared contralateral breast cancer (CBC) and ipsilateral breast tumor recurrence (IBTR) rates among women with DCIS with or without synchronous ipsilateral LCIS treated with breast-conserving surgery (BCS). DCIS patients undergoing BCS from 2000 to 2011 with a contralateral breast at risk were stratified by the presence or absence of synchronous ipsilateral LCIS with the index DCIS (DCIS + LCIS vs. DCIS). Those with contralateral, bilateral, or prior ipsilateral LCIS were excluded. Associations of patient, tumor, and treatment factors with CBC and IBTR were evaluated. Of 1888 patients identified, 1475 (78%) had DCIS and 413 (22%) had DCIS + LCIS. At median follow-up of 7.2 (range 0–17) years, 307 patients had a subsequent first breast event; 207 IBTR and 100 CBC. The 10-year cumulative incidence of IBTR was similar in both groups: 15.0% vs. 14.2% (log-rank, p = 0.8) for DCIS + LCIS vs. DCIS, respectively. The 10-year cumulative incidence of CBC was greater in the DCIS + LCIS group: 10.9% vs. 6.1% for DCIS (log-rank, p

Background: LCIS is considered a risk factor for bilateral breast cancer, but the effect of LCIS diagnosed concurrently with DCIS is not known. We sought to compare CBC and ipsilateral breast tumor recurrence (IBTR) rates in women with DCIS with and without synchronous LCIS treated with breast conserving surgery (BCS). Methods: A prospectively maintained database of DCIS patients undergoing BCS from 2000-2011 was used to identify women with a contralateral breast at risk. Patients with synchronous ipsilateral LCIS found at core needle biopsy or surgical excision were included in the “DCIS + LCIS” group; those with contralateral or bilateral LCIS were excluded. Associations of patient, tumor, and treatment factors with CBC and IBTR were evaluated using logistic regression. Results: Of the 1888 patients identified, 1475 (78%) had DCIS only and 413 (22%) had DCIS with synchronous LCIS. Median follow-up was 7.5 years (range 0-17 years). 305 patients had a subsequent breast event; 216 IBTR and 89 CBC. The 5 and 10-year cumulative incidence of IBTR was similar in both groups: 6.3% and 14.4% for DCIS only, compared with 5.9% and 14.0% for DCIS + LCIS (p = 0.94), respectively. The 5 and 10-year cumulative incidence of CBC was significantly greater in the DCIS + LCIS group: 5.7% and 10.0%, compared with 2.4% and 5.0% for DCIS only (p < 0.001). Table 1 summarizes uni-and multi-variable analyses of risk factors associated with CBC and IBTR among women with DCIS treated with BCS. After adjustment for other factors, CBC risk was more than 2-fold higher in the DCIS + LCIS group compared with the DCIS only group (HR 2.37, 95% CI 1.54-3.65, p < 0.001). There was no difference in IBTR risk based on presence of synchronous LCIS. Younger age and receipt of endocrine therapy were significantly associated with decreased risk of CBC. Table 1:Risk factors associated with CBC and IBTR in patients with DCIS treated with BCS Univariate Analysis Multivariate Analysis Hazard Ratio (95% CI) Hazard Ratio (95% CI) CBC IBTR CBC IBTRAge (continuous)1.02 (1.01-1.04) *0.99 (0.98-1.0)1.02 (1.0-1.04) *0.99 (0.97-1.0) *Presentation Radiologic1111Clinical0.36 (0.11-1.14)1.56 (1.05-2.3) *0.41 (0.13-1.31)1.67 (1.12-2.47) *Family history Yes1.32 (0.87-2.01)1.0 (0.76-1.32)1.33 (0.87-2.03)1.03 (0.78-1.35)Grade Low1111Intermediate/high1.83 (1.0-3.37)1.32 (0.93-1.88)1.74 (0.92-3.29)1.62 (1.11-2.35) *Radiation Yes1.16 (0.75-1.8)0.7 (0.54-0.92) *1.14 (0.71-1.82)0.64 (0.48-0.86) *Endocrine Therapy Yes0.43 (0.23-0.81) *0.51 (0.35-0.74) *0.42 (0.22-0.8) *0.53 (0.36-0.77) *DCIS group DCIS only1111DCIS + LCIS2.28 (1.49-3.5) *0.99 (0.71-1.36)2.37 (1.54-3.65) *0.99 (0.71-1.37)* p < 0.05 Conclusions: LCIS diagnosed concurrently with DCIS is not associated with IBTR, but increases the risk of CBC two-fold. Endocrine therapy should be considered both for the index DCIS and for prevention of subsequent CBC. Citation Format: Miller ME, Muhsen S, Zabor EC, Flynn J, Olcese C, Giri D, Van Zee KJ, Pilewskie M. Risk of contralateral breast cancer (CBC) in women with ductal carcinoma in situ (DCIS) with and without and synchronous lobular carcinoma in situ (LCIS) [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 P5-18-01.

Background Neoadjuvant chemotherapy (NCT) is considered more effective in downstaging hormone receptor-positive (HR+) breast cancer than neoadjuvant endocrine therapy (NET), particularly in node-positive disease. This study compared breast and axillary response and survival after NCT and NET in HR+ breast cancer. Methods Based on American College of Surgeons Oncology Group (ACOSOG) Z1031 criteria, women age 50 years or older with cT2-4 HR+ breast cancer who underwent NET or NCT and surgery were identified in the National Cancer Database 2010–2016. Chi-square and logistic regression analysis determined differences between the NCT and NET groups and therapy response, including downstaging and pathologic complete response (pCR, ypT0/is and ypN0). Results Of 19,829 patients, 14,025 (70.7%) received NCT and 5804 (29.3%) received NET. The NET patients were older (mean age, 68.9 vs. 60.3; P < 0.001) and had greater comorbidity (1+ Charlson–Deyo score, 21% vs. 16%; P < 0.001). Therapy achieved T downstaging (any) for 58% of the patients with NCT versus 40.5% of the patients with NET, and in-breast pCR was achieved for 9.3% of the NCT versus 1.3% of the NET patients (P < 0.001). Approximately half of the mastectomy procedures could have been potentially avoided for the patients with in-breast pCR (53.6% of the NCT and 43.8% of the NET patients). For the cN+ patients, N downstaging (any) was 29% for the NCT patients versus 18.3% for the NET patients (P < 0.001), and nodal pCR was achieved for 20.3% of the NCT versus 13.5% of the NET patients (P < 0.001). Among those with nodal pCR, axillary lymph node dissection (ALND) still was performed for 56% of the patients after NCT and 45% of the patients after NET. Conclusions Although the response rates after NCT were higher, NET achieved both T and N downstaging and pCR. Neoadjuvant endocrine therapy can be used to de-escalate surgery for patients who cannot tolerate NCT or when chemotherapy may not be effective based on genomic testing. Supplementary Information The online version contains supplementary material available at 10.1245/s10434-021-10459-3.

PURPOSE Phyllodes tumors (PTs) are rare breast neoplasms, which have little granular data on margins. Current guidelines recommend ≥ 1 cm margins; however, recent data suggest narrower margins are sufficient, and for benign PT, a negative margin may not be necessary. METHODS We performed an 11-institution contemporary (2007-2017) review of PT practices. Demographics, surgical, and histopathologic data were captured. Logistic regression was used to estimate the association of select covariates with local recurrence (LR). RESULTS Of 550 PT patients, the majority underwent excisional biopsy (55.3%, n = 302/546) or lumpectomy (wide excision) (38.5%, n = 210/546). Median tumor size was 30 mm, 68.9% (n = 379) were benign, 19.6% (n = 108) borderline, and 10.5% (n = 58) malignant. Surgical margins were positive in 42% (n = 231) and negative in 57.3% (n = 311). A second operation was performed in 38.0% (n = 209) of the total cohort, including 51 patients with an initial negative margin (82.4% with < 2 mm), and 157 with an initial positive margin, with residual disease only found in six (2.9%). Notably, 32.0% (n = 74) of those with an initial positive margin did not undergo a second operation, among whom only 2.7% (n = 2) recurred. Recurrence occurred in 3.3% (n = 18) of the total cohort (n = 15 LR, n = 3 distant), at median follow-up of 36.7 months. LR (all PT grades) was not reduced with wider negative margin width (≥ 2 mm v < 2 mm: odds ratio [OR] = 0.39; 95% CI, 0.07 to 2.10; P = .27) or final margin status (positive v negative: OR = 0.96; 95% CI, 0.26 to 3.52; P = .96). CONCLUSION In current practice, many patients are managed outside of current guidelines. For the entire cohort, a wider margin width was not associated with a reduced risk of LR. We do not recommend re-excision of a negative margin for benign PT, regardless of margin width, as a progressively wider surgical margin is unlikely to reduce LR.

Background Immune checkpoint inhibitors (ICI) and targeted therapies (TT) have improved the survival outcomes in patients with advanced melanoma. However, less is known about their impact on Asian patients with melanoma. In this study, we hypothesize that patients of Asian ancestry would have improved survival for advanced melanoma since the introduction of ICI and TT in 2011. Methods Asian patients with melanoma were identified in the National Cancer Database (NCDB) from 2004–2016. Patient, tumor, and treatment characteristics were compared for populations treated before and after 2011 using Chi-square analyses. Overall survival (OS) was analyzed using Kaplan-Meier estimates. Results 1,411 Asian patients with melanoma were identified. Overall, 21% were melanoma in situ, and 79% were invasive melanomas. 62% of patients did not have a documented histologic subtype. The most common reported histologies were superficial spreading (14%) and acral lentiginous (10%) melanomas. Primary locations included 41% lower extremity, 17% upper extremity, and 11% head and neck. The age at diagnosis has increased during the study period - 38% over 60 years old in 2004, to 54% in 2016 (P Conclusions Asian patients with melanoma are receiving diagnoses at older ages. Despite decreases in OS for all Asian patients with melanoma, advanced stage IV of the diseases have improved outcomes for the group treated in the era of ICI and TT. Further investigation is warranted to understand the treatment, patient, and tumor characteristics that predict response in this demographic of patients.

BackgroundA paucity of data exists regarding inherited mutations associated with phyllodes tumors (PT); however, some are reported (TP53, BRCA1, and RB1). A PT diagnosis does not meet NCCN criteria for testing, including within Li-Fraumeni Syndrome (TP53). We sought to determine the prevalence of mutations associated with PT.MethodsWe performed an 11-institution review of contemporary (2007-2017) PT practice. We recorded multigenerational family history and personal history of genetic testing. We identified patients meeting NCCN criteria for genetic evaluation. Logistic regression estimated the association of select covariates with likelihood of undergoing genetic testing.ResultsOf 550 PT patients, 59.8% (n = 329) had a close family history of cancer, and 34.0% (n = 112) had ≥ 3 family members affected. Only 6.2% (n = 34) underwent genetic testing, 38.2% (n = 13) of whom had only BRCA1/BRCA2 tested. Of 34 patients tested, 8.8% had a deleterious mutation (1 BRCA1, 2 TP53), and 5.9% had a BRCA2 VUS. Of women who had TP53 testing (N = 21), 9.5% had a mutation. Selection for testing was not associated with age (odds ratio [OR] 1.01, p = 0.55) or PT size (p = 0.12) but was associated with grade (malignant vs. benign: OR 9.17, 95% CI 3.97-21.18) and meeting NCCN criteria (OR 3.43, 95% confidence interval 1.70-6.94). Notably, an additional 86 (15.6%) patients met NCCN criteria but had no genetic testing.ConclusionsVery few women with PT undergo germline testing; however, in those selected for testing, a deleterious mutation was identified in ~ 10%. Multigene testing of a PT cohort would present an opportunity to discover the true incidence of germline mutations in PT patients.

As an alternative to traditional wire localization, an inducible magnetic seed system can be used to identify and remove nonpalpable breast lesions and axillary lymph nodes intraoperatively. We report the largest single-institution experience of magnetic seed placement for operative localization to date, including feasibility and short-term outcomes. Patients who underwent placement of a magnetic seed in the breast or lymph node were identified from July 2017 to March 2019. Imaging findings, core needle biopsy, surgical pathology results, and type of surgery were collected. Outcomes included procedural complications, magnetic seed and biopsy clip retrieval rates, and need for additional surgery. A total of 842 magnetic seeds were placed by nine radiologists in 673 patients and retrieved by six surgeons at six operative locations. The majority of breast lesions were malignant (395/659, 59.9%); 136 seeds were placed for lymph node localization. The overall magnetic seed retrieval rate was 98.6%, whereas the biopsy clip retrieval rate was 90.9%. Only six patients (0.7%) experienced a complication from magnetic seed placement. Reexcision was performed in 15.2% of patients with breast cancer; 9.6% of benign/high risk lesions were upgraded to malignancy at surgical excision. The magnetic seed technique is safe, effective, and accurate for localization of breast lesions and lymph nodes, and importantly uncouples surgery from the localization procedure. The high magnetic seed retrieval rate and low reexcision rate may reflect the accuracy of magnetic marker placement as a “second chance” localization procedure, especially in cases with biopsy clip migration.

Background Surgical residencies use variable structures for formal training in education. We hypothesized that a one-day workshop intervention would improve resident teaching ability measured by self-assessment and learner evaluation. Materials and Methods Faculty educators delivered a Residents as Teachers (RAT) workshop to general surgery residents on setting expectations, positive learning environment, difficult feedback and the 1-min preceptor model. For three months before and after the workshop, junior residents and medical students evaluated their supervising residents’ teaching skill monthly using a Likert scale questionnaire. Pre- and postworkshop surveys were administered to resident participants to assess their knowledge of the material and teaching confidence. Results were analyzed using Wilcoxon rank sum tests. This study was conducted at a tertiary academic center with a large surgical residency program. Results Thirty-nine PGY 1-5 residents participated in the Residents as Teachers workshop and were included in the study. Pre- and post- workshop survey results demonstrated significant improvements in participants’ knowledge and teaching confidence. On monthly assessments of seniors by junior residents, significant improvements were noted in three domains. Medical student ratings did not reflect significant improvements in resident teaching skill. Conclusions This is the first study using learner evaluation of a comprehensive surgical RAT program. Despite a significant increase in surgery residents’ self-assessment following participation in an education workshop, no improvement was seen in resident teaching skill as perceived by medical students.

Background The Accreditation Council for Graduate Medical Education Clinical Learning Environment Review recommends that quality improvement/patient safety (QI/PS) experts, program faculty, and trainees collectively develop QI/PS education. Objective Faculty, hospital leaders, and resident and fellow champions at the University of Chicago designed an interdepartmental curriculum to train postgraduate year 1 (PGY-1) residents on core QI/PS principles, measuring outcomes of knowledge, attitudes, and event reporting. Methods The curriculum consisted of 3 sessions: PS, quality assessment, and QI. Faculty and resident and fellow leaders taught foundational knowledge, and hospital leaders discussed institutional priorities. PGY-1 residents attended during protected conference times, and they completed in-class activities. Knowledge and attitudes were assessed using pretests and posttests; graduating residents (PGY-3–PGY-8) were controls. Event reporting was compared to a concurrent control group of nonparticipating PGY-1 residents. Results From 2015 to 2017, 140 interns in internal medicine (49%), pediatrics (33%), and surgery (13%) enrolled, with 112 (80%) participating and completing pretests and posttests. Overall, knowledge scores improved (44% versus 57%, P Conclusions An interdepartmental curriculum was acceptable to residents and feasible across 3 specialties, and it was associated with increased event reporting by participating PGY-1 residents.

e13034 Background: Current ASCO guidelines recommend endocrine therapy as preferred primary treatment for hormone receptor positive (HR+) metastatic breast cancer (MBC). We assessed survival outcomes of HR+/HER2- MBC patients undergoing endocrine therapy with and without chemotherapy. Methods: The National Cancer Database was queried 2004-2016 for patients with de novo HR+/HER2- MBC. Exclusion criteria were treatment with surgery or radiation at the primary site and missing oncologic and follow up data. Overall survival was compared between systemic treatment groups using multivariable cox proportional hazards regression modes. Results: 19,317 patients met inclusion criteria, among whom 2,360 (12%) received no systemic therapy, 2,617 (14%) received chemotherapy only, 10,078 (52%) received endocrine therapy only and 4,262 (22%) received both chemotherapy and endocrine therapy. Patients treated with chemotherapy only more frequently had lung (38%, p