Background
There are a number of studies in the literature that describe the prevalence, causes, and factors associated with chronic postoperative opioid use, but there is a lack of synthesis of the ...literature to guide clinicians in optimally managing postoperative pain while avoiding opioid dependence. Thus, the goal of this study was to perform a systematic review of the literature to investigate the prevalence of chronic postoperative opioid use and the associated risk factors.
Materials and methods
A systematic search was performed using Ovid Medline and Embase according to PRISMA guidelines. Data were collected on the following outcomes of interest: prevalence of opioid use at 3, 6, and 12 months postoperatively, and risk factors associated with chronic postoperative opioid use.
Results
Forty-three articles were included in the final analysis. The mean prevalence of chronic postoperative opioid use in all populations at 3, 6, and 12 months postoperatively was 30.5%, 25.6%, and 25.2%, respectively. The prevalence of patients who developed chronic opioid use at 3, 6, and 12 months postoperatively was 10.4%, 8.5%, and 9.8%, respectively. Forty of the articles analyzed risk factors associated with chronic postoperative opioid use. The most common associated risk factor identified was preoperative opioid use with 27 articles demonstrating a significant association with chronic postoperative opioid use.
Discussion
The current opioid crisis is in part secondary to the prevalence of chronic opioid use following surgery. This study identified associated risk factors with chronic postoperative opioid use, which may help identify patients at risk for developing chronic postoperative opioid use.
To reach a consensus about contralateral prophylactic mastectomy in unilateral breast cancer.
There has been a substantial increase in the number of North American women with unilateral breast cancer ...undergoing a therapeutic mastectomy and a contralateral prophylactic mastectomy (CPM) either simultaneously or sequentially. The purpose of this project was to create a nationally endorsed consensus statement for CPM in women with unilateral breast cancer using modified Delphi consensus methodology.
A nationally representative expert panel of 19 general surgeons, 2 plastic surgeons, 2 medical oncologists, 2 radiation oncologists, and 1 psychologist was invited to participate in the generation of a consensus statement. Thirty-nine statements were created in 5 topic domains: predisposing risk factors for breast cancer, tumor factors, reconstruction/symmetry issues, patient factors, and miscellaneous factors. Panelists were asked to rate statements on a 7-point Likert scale. Two electronic rounds of iterative rating and feedback were anonymously completed, followed by an in-person meeting. Consensus was reached when there was at least 80% agreement.
Our panelists did not recommend for average risk women with unilateral breast cancer. The panel recommended CPM for women with a unilateral breast cancer and previous Mantle field radiation or a BrCa1/2 gene mutation. The panel agreed that CPM could be considered by the surgeon on an individual basis for: women with unilateral breast cancer and a genetic mutation in the CHEK2/PTEN/p53/PALB2/CDH1 gene, and in women who may have significant difficulty achieving symmetry after unilateral mastectomy.
Contralateral prophylactic mastectomy is rarely recommended for women with unilateral breast cancer.
Background
Same-day surgery (SDS) following mastectomy is safe and well accepted. Overnight admission in patients fit for discharge is an inefficient use of health resources. In response to a ...national review highlighting SDS following mastectomy at 1.4% in Alberta, a perioperative pathway was conceived.
Methods
The pathway was implemented across Alberta at 13 hospitals beginning in 2016. A steering committee was assembled, and clinical and administrative leads at each site were identified. Opportunities along the patient care experience whereby action could be taken to promote uptake of SDS were identified. Provincially branded support materials including presentations, order sets, and standard operating procedures were developed. Nurse educators provided in-service teaching such as standardized drain care and discharge teaching. Educational booklets, group classes, and online resources were developed for patients and families. An audit of SDS rates, unscheduled return to the emergency department (ED), and readmission rates was reported to teams quarterly, allowing for iterative modifications. Patient-reported experience measures (PREMs) were collected.
Results
SDS following mastectomy increased from 1.7 to 47.8%, releasing an estimated 831 bed days per year. No differences in unexpected return to the ED or readmission to hospital existed between SDS patients and those admitted overnight. A total of 102 patients completed the PREM survey, of whom 90% felt “excellent or good” with the plan to go home, how to care for themselves once home, and who to contact should issues arise.
Conclusions
Implementation of a provincial perioperative pathway improved uptake of SDS following mastectomy and demonstrated favorable PREMs.
Recurrence is not explicitly documented in cancer registry data that are widely used for research. Patterns of events after initial treatment such as oncology visits, re-operation, and receipt of ...subsequent chemotherapy or radiation may indicate recurrence. This study aimed to develop and validate algorithms for identifying breast cancer recurrence using routinely collected administrative data.
The study cohort included all young (≤ 40 years) breast cancer patients (2007-2010), and all patients receiving neoadjuvant chemotherapy (2012-2014) in Alberta, Canada. Health events (including mastectomy, chemotherapy, radiation, biopsy and specialist visits) were obtained from provincial administrative data. The algorithms were developed using classification and regression tree (CART) models and validated against primary chart review.
Among 598 patients, 121 (20.2%) had recurrence after a median follow-up of 4 years. The high sensitivity algorithm achieved 94.2% (95% CI: 90.1-98.4%) sensitivity, 93.7% (91.5-95.9%) specificity, 79.2% (72.5-85.8%) positive predictive value (PPV), and 98.5% (97.3-99.6%) negative predictive value (NPV). The high PPV algorithm had 75.2% (67.5-82.9%) sensitivity, 98.3% (97.2-99.5%) specificity, 91.9% (86.6-97.3%) PPV, and 94% (91.9-96.1%) NPV. Combining high PPV and high sensitivity algorithms with additional (7.5%) chart review to resolve discordant cases resulted in 94.2% (90.1-98.4%) sensitivity, 98.3% (97.2-99.5%) specificity, 93.4% (89.1-97.8%) PPV, and 98.5% (97.4-99.6%) NPV.
The proposed algorithms based on routinely collected administrative data achieved favorably high validity for identifying breast cancer recurrences in a universal healthcare system in Canada.
Background
The breast surgeon, generally the first oncology specialist consulted, is ideally suited to offer fertility preservation (FP) referral to young women with breast cancer (YWBC). In the ...authors’ 2015 survey of 84 surgeons participating in the pan-Canadian RUBY study of YWBC, oncofertility knowledge and rates of FP referral were suboptimal. The authors designed an oncofertility knowledge-translation intervention for surgeons.
Methods
A customized oncofertility toolbox was created including a seminar/webinar, an option grid, a three-question FP survey sent upon registration of each RUBY patient, and a management checklist. In 2018, the 28 site lead surgeons were re-invited to participate in a follow-up telephone interview, and 85 non-site lead surgeons were invited to complete a follow-up online questionnaire.
Results
A total of 27 site lead surgeons consented to be re-interviewed. After the intervention, 85% indicated that they “routinely” initiated a fertility discussion compared with 54% at baseline (
p
< 0.005), with 56% stating that the toolbox had been helpful for making positive changes in their practice regarding oncofertility, and 44% stating that they found it easier to initiate a fertility discussion. Among the 55 non-site lead surgeons who completed the questionnaire, a significant improvement in oncofertility knowledge was found. The percentage reporting “rarely” or “never” discussing FP options decreased from 41 to 14% (
p
< 0.005), and 84% stated that they referred patients who had not completed their families and were at risk for infertility to FP consultation compared with 32% before the intervention (
p
< 0.001).
Conclusions
A multi-pronged but simple knowledge-translation intervention improved the attitudes, knowledge, and FP practice of Canadian breast surgeons.
Background
The incidence of breast biopsy following treatment for breast cancer is not well-characterized. We sought to determine the frequency and outcomes of breast biopsy and the need for ...subsequent surgery in patients treated with breast-conserving surgery (BCS).
Methods
Using a prospective database, we identified patients in Alberta, Canada, treated with BCS for screen-detected breast cancer or ductal carcinoma in situ (DCIS) from 2010 to 2014. Post-treatment breast procedures were identified from physician claims data. Multivariable analysis was performed to identify factors associated with biopsy.
Results
We included 2065 patients with a median of 6.4 years of follow-up; most had DCIS (
n
= 426, 20.6%) or stage I disease (
n
= 1385, 67.1%). Post-treatment core biopsy was performed in 389 (18.8%, 95% confidence interval CI 17.2–20.6%) patients, and excisional biopsy was performed in 19 (0.9%, 95% CI 0.6–1.4%) patients. The per-patient benign-to-malignant biopsy ratio was 3.2 to 1, and the overall malignancy rate was 6.1% (95% CI 5.1–7.2%). Younger age, proximity to a cancer center, positive margins, and the use of magnetic resonance imaging were associated with biopsy (
p
< 0.05). Additional surgery was performed in 150 (7.3%, 95% CI 6.2–8.5%) patients; 93 (4.5%, 95% CI 3.6–5.4%) patients underwent mastectomy. Surgery was performed for local recurrence/ipsilateral cancer in 62 (3.0%) patients, contralateral breast cancer in 60 (2.9%) patients, bilateral breast cancer in 3 (0.1%) patients, and benign indications/prophylaxis in 25 (1.2%) patients.
Conclusions
One in five patients required breast biopsy during post-treatment surveillance following BCS and most revealed benign findings. Rates of additional surgery, especially subsequent mastectomy due to ipsilateral or contralateral malignancy, were low. Patients can be reassured of these findings during pre-treatment counseling and post-treatment surveillance.
Background
Understanding occurrence and timing of second events (recurrence and second primary cancer) is essential for cancer specific survival analysis. However, this information is not readily ...available in administrative data.
Methods
Alberta Cancer Registry, physician claims, and other administrative data were used. Timing of second event was estimated based on our developed algorithm. For validation, the difference, in days between the algorithm estimated and the chart‐reviewed timing of second event. Further, the result of Cox‐regression modeling cancer‐free survival was compared to chart review data.
Results
Majority (74.3%) of the patients had a difference between the chart‐reviewed and algorithm‐estimated timing of second event falling within the 0–60 days window. Kaplan–Meier curves generated from the estimated data and chart review data were comparable with a 5‐year second‐event‐free survival rate of 75.4% versus 72.5%.
Conclusion
The algorithm provided an estimated timing of second event similar to that of the chart review.
Breast cancer survival among young women Brenner, Darren R.; Brockton, Nigel T.; Kotsopoulos, Joanne ...
CCC. Cancer causes & control/CCC, Cancer causes & control,
04/2016, Letnik:
27, Številka:
4
Journal Article, Book Review
Recenzirano
Odprti dostop
Almost 7 % of breast cancers are diagnosed among women age 40 years and younger in Western populations. Clinical outcomes among young women are worse. Early age-of-onset increases the risk of ...contralateral breast cancer, local and distant recurrence, and subsequent mortality. Breast cancers in young women (BCYW) are more likely to present with triple-negative (TNBC), TP53-positive, and HER-2 over-expressing tumors than among older women. However, despite these known differences in breast cancer outcomes and tumor subtypes, there is limited understanding of the basic biology, epidemiology, and optimal therapeutic strategies for BCYW. Several modifiable lifestyle factors associated with reduced risk of developing breast cancer have also been implicated in improved prognosis among breast cancer survivors of all ages. Given the treatment-related toxicities and the extended window for late effects, long-term lifestyle modifications potentially offer significant benefits to BCYW. In this review, we propose a model identifying three main areas of lifestyle factors (energy imbalance, inflammation, and dietary nutrient adequacy) that may influence survival in BCYW. In addition, we provide a summary of mechanisms of action and a synthesis of previous research on each of these topics.
Triple-negative breast cancer (TNBC) is more common among young women, although it frequently presents in older patients. Despite an aging population, there remains a paucity of data on the treatment ...of TNBC in elderly women. We conducted a systematic review of the peer-reviewed and unpublished literature that captures the management and breast-cancer-specific survival (BCSS) of women ≥70 years old with TNBC. Out of 739 papers, five studies met our inclusion criteria. In total, 2037 patients with TNBC treated between 1973 and 2014 were captured in the analysis. Women ≥70 years old were less likely to undergo surgical resection compared to those <70 (92.8% vs. 94.6%, p = 0.002). Adjuvant therapy, including radiation and chemotherapy, was also less likely to be utilized in women ≥70 years of age. These treatment differences were associated with more than a doubling of cancer-specific mortality in the elderly cohort (5.9% vs. 2.7% in ≤70 years old, p < 0.0001). Two of the five studies showed improved BCSS with adjuvant treatment while others showed no difference. Our systemic review questions the appropriateness of therapeutic de-escalation in this cohort and highlights the significant gap in our understanding of the optimal management for elderly patients with TNBC. Until more data are available, multidisciplinary treatment decision-making should carefully balance the available clinical evidence as well as the patient’s predicted life expectancy and goals-of-care preferences.
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