Association Of Breast Surgeons Research Articles

OPTIMISING HOLISTIC CARE OF WOMEN AT RISK OF OR LIVING WITH BIA‐ALCL: A SURVEY OF UK HEALTH CARE PROFESSIONALS

Introduction: Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) was classified by the World Health Organisation in 2016. As of December 2021 there have been 86 reported cases within the UK. Raising awareness amongst clinicians of this novel entity is crucial in order to provide effective clinical care. Psycho-social support forms a vital arm of care, both for affected women but also for the now millions at risk or those considering new implants. This survey aims to assess the current awareness and experiences of health care providers potentially involved in the care of patients with BIA-ALCL with a particular focus on psycho-social support requirements. Methods: We performed an online survey using categorical and open-ended questions. The questionnaire was distributed amongst professional associations that have an interest in the topic researched, e.g., The Association of Breast Surgeons (ABS), British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS). In addition the survey was distributed amongst multidisciplinary teams that are likely to encounter these patients, e.g. Breast and Lymphoma. The survey was designed in Qualtrics and sent via a link. Data has been collated and analysed within SPSS. Research approval was obtained from Leeds Beckett University. Results: There were a total of 78 respondents who completed the survey. Breast surgeons made up the largest proportion of respondents (36%, 28/78) with over half of respondents having cared for a patient with BIA-ALCL (58% 42/78). The largest proportion of respondents reporting using ABS/BAPRAS joint guidelines in their clinical practice (46%, 36/78). High median confidence scores were reported in both diagnosing/managing, 7/10 (3) and having conversations with patients regarding BIA-ALCL, 7/10 (5) although a large range in responses was noted. The most frequently selected test to work up a case of suspected BIA-ALCL was ‘core biopsy of any associated peri-implant mass’ (82%, 64/78) with mammography the least selected (42%, 33/78). 45% (35/78) reported seeing women requesting reassurance or implant removal despite an absence of symptoms or signs of BIA-ALCL. The average degree of distress upon receiving a diagnosis was reported as 7/10 (2). 70% (54/77) of respondents felt patients diagnosed with BIA-ALCL or those awaiting test results would benefit from psychological support. Only 38 (29/76) % of respondents however, confirmed that breast implant patients have access to any psychological support as part of routine care. Conclusion: This survey demonstrates that although there is relatively high confidence in managing and conducting discussions with patients regarding BIA-ALCL, there is a large variability amongst healthcare providers. The findings suggest there is urgent need for psycho-social support for both patients diagnosed with BIA-ALCL and asymptomatic women seeking reassurance. Keyword: Aggressive T-cell non-Hodgkin lymphoma Conflicts of interests pertinent to the abstract D. Cunningham Consultant or advisory role Ovibio on scientific advisory board Research funding: Medimmune/AZ, Clovis, Eli Lilly, 4SC, Bayer, Celgene, Roche - institution recipient

Breast Density Notification: Current UK National Practice

Increased breast density is a risk factor for breast cancer and can mask cancer on mammography. This survey attempts to understand clinician views regarding breast density notification in the United Kingdom. Two separate breast density surveys were distributed to radiologists and breast surgeons between May 2019 and May 2020. Invited participants were members of the British Society of Breast Radiology and the Association of Breast Surgeons. We received 232 completed questionnaires from 109 surgeons (71%) and 123 radiologists (41%). Fourteen percent of the surgeons reported discussing the increased risk of developing cancer with their patients, and 20% of the surgeons recommended further imaging compared with 50% of the radiologists. Fifty-two percent of surgeons and 28% of radiologists felt women should not be informed of their breast density scores considering the lack of National Health Service–funded supplementary imaging. Almost all respondents of this survey called for guidelines regarding the reporting and management of UK patients with increased breast density (90%). Density notification is becoming increasingly central to breast screening, and our results highlight an urgent need for a national consensus.

Ambulatory day case oncoplastic and reconstructive breast surgery during the peak of COVID 19 pandemic

Background: The World Health Organization (WHO) declared a novel coronavirus disease 2019 (COVID 19) pandemic on the 11 March 20. In response to this, the United Kingdom (UK) Association of Breast Surgeons (ABS) released guidelines on breast cancer management during the pandemic on the 15 March 20. The UK was in lockdown on the 23 March 20. Whilst the UK breast units adapted to deliver safe cancer services, many limited and some stopped all oncoplastic and reconstructive breast surgery (OPRBS). With careful stratification and prioritisation of cases, coupled with our existing successful integrated ambulatory day case surgery pathway, our unit continued to perform OPRBS safely and we present the outcomes of our OPRBS during the pandemic.

Behavioural text message reminders to improve participation in breast screening: a randomised controlled trial

BackgroundBreast screening coverage in London, UK, consistently falls below the national average (69·3% vs 75·6% in 2016). West London has among the lowest coverage rates nationally. Text message reminders (SMS-R) can improve screening rates. Evidence shows that message content can further improve the impact of SMS-R on hospital appointment attendance. This randomised controlled trial aimed to test the effect of SMS-R message manipulations on breast screening participation. MethodsWomen aged 47–73 years in the West of London Breast Screening Service (WoLBSS) catchment area, who were due for screening between Aug 10, 2016, and Nov 2, 2016, and who had provided their mobile number to the service, were eligible. Two intervention messages were tested against the current SMS-R (appendix). A survey of 1000 women informed the content, which indicated that women who prioritised or planned to attend breast screening were more likely to attend. Participants were randomised to control, planning, and priority arms (1:1:1) by the SMS provider platform iPLATO using a Mersenne twister algorithm and sent two SMS-R before their appointment. Participants and the routine care team, but not researchers, were masked to allocation. The primary outcome was uptake of screening by trial arm. Analysis was by intention to treat. Ethics approval was obtained from IRAS (IRAS project ID 185492, REC reference 16/YH/0276). This trial is registered with ClinicalTrials.gov, number NCT02872363. Findings2696, 2614, and 2634 women were allocated to the control, planning, and priority arms, respectively (mean age 58·8 years, SD 6·09), with 854, 883, and 860 women analysed after exclusions for opt-outs, self-referrals, and SMS-R cross-contamination. Uptake was 82·8% (n=707), 84·4% (745), and 82·7% (711), respectively (χ2 [df 2]=1·131, p=0·568). No adverse events were observed. InterpretationAlthough no statistical difference between trial arms was noted, the target sample size (11 496) was not achieved because of a reconfiguration of services prematurely ending the trial. A large number of participants received different SMS-R messages or more than two SMS-R in total, probably because of appointment rescheduling, which re-entered women into the randomisation process. These participants were excluded. Owing to information governance regulations, women who provided their mobile number to their general practitioner but not directly to WoLBSS could not be sent an SMS-R. Consequently, the sample is likely to represent highly motivated women, reflected in the high participation rate. Therefore, first-time attenders and non-attenders may be disadvantaged by SMS-R interventions for breast screening. FundingNational Institute for Health Research Imperial Patient Safety Translational Research Centre and the Association of Breast Surgeons and Prevent Breast Cancer.

Post-traumatic Neuroma Following Breast Surgery

specimen. The patient received psychologic counseling and support in adjusting to the results of the mastectomy. To date, she has not elected to pursue reconstruction, but requested that her unique experience be shared and change policy. False-positive core needle biopsies (CNB) are rarely reported in the literature. False positives in most cases are in screening patients (<0.5%) when ductal carcinoma in situ (DCIS) is upstaged in reporting as invasive cancer or when no lesion is subsequently found is explained by very small lesions having been excised completely by the core biopsy. Hidradenoma is a recognized source of diagnostic confusion and on FNA can mimic breast carcinoma and other adenocarcinoma, but has not been reported before as source of a false-positive diagnosis of breast cancer on core biopsy. What makes this case an essential learning point is that as skin lesions can often be confused with breast lesions and they should be reported differently both radiologically and clinically. Subsequent clinical guidance from the Association of Breast Surgeons regarding biopsy of skin lesions is reproduced below:

Size does matter: High volume breast surgeons accept smaller excision margins for wide local excision – A national survey of the surgical management of wide local excision margins in UK breast cancer patients

IntroductionOptimal margins for wide local excision (WLE) have not been clearly established. Larger margins lead to lower recurrence rates but at the expense of cosmetic appearance. NICE guidelines recommend a 2 mm margin for ductal carcinoma in-situ (DCIS), whilst the British Association of Surgical Oncology (BASO) recommend units develop local guidelines. There are presently no specific guidelines for invasive cancer. We surveyed members of the Association of Breast Surgeons (ABS) in order to establish current practice nationally. We hypothesised that larger units may accept narrower excision margins to the benefit of better cosmesis. Materials and methodsA postal questionnaire was sent to all ABS members in October 2010. This consisted of questions about the current practice of the surgeon and their unit. 481 questionnaires were posted in total, all questionnaires returned by April 2011 were analysed. ResultsQuestionnaire response rate was 60% (281). Surgeons operating on over 50 cancers per year accepted smaller margins than those operating on less than 50 (p < 0.02). Acceptable adequate anterior and radial margins ranged from 0 to 10 mm for DCIS and 0 to 5 mm for invasive cancer. A variety of approaches to re-excising anterior margins were reported. ConclusionsThis survey suggests that substantial variations exist in current practice with regard to the approach to WLE. Operator workload appears to influence what is deemed to be an acceptable margin. There is a need for standardised national and international guidelines.

Mastectomy and reconstruction in stage IV breast cancer: A survey of UK breast and plastic surgeons

The number of women with stage IV disease who have breast reconstruction is small. The primary aim of this study was to examine opinions as to the appropriateness of breast reconstruction in this group. The Association of Breast Surgeons (ABS) and the British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS) were invited to take part in an online survey. Of the respondents, 78.7% would operate on the primary tumour. Plastic surgeons showed a propensity for immediate reconstruction compared to their breast surgery colleagues, and 26.3% of breast surgeons would not offer reconstruction at all. Immediate latissimus dorsi (LD) flap and implant were the favoured method in early stage disease with delayed LD and implant the most popular option for stage IV disease. As survival figures continue to improve, the number of patients requesting reconstruction is likely to increase. Further debate will be necessary in anticipation of future service development.

Audit of local recurrence following breast conservation surgery with 5-mm target margin and hypofractionated 40-Gray breast radiotherapy for invasive breast cancer

The risk of ipsilateral breast tumour recurrence (IBTR) following breast conservation surgery (BCS) for invasive breast cancer (IBC) and radiotherapy is dependent on patient-, tumour- and treatment-related variables. In the Cambridge Breast Unit, breast conserving surgery has been performed with a target radial margin of 5 mm for IBC, in combination with 40-Gy hypofractionated (15 fractions) breast radiotherapy, since 1999. An audit was performed of cases treated between 1999 and 2004. A total of 563 patients underwent BCS for invasive breast cancer with 90.4% receiving radiotherapy (RT) and 60.4% of patients receiving boost RT (3 fractions of 3-Gy). After a median follow-up of 58 months, five of the 563 (0.9%) patients developed IBTR. The 5-year actuarial IBTR rate was 1.1%. In terms of distant disease recurrence (DDR), 29 of the 563 (5.2%) had DDR during follow-up, giving a 5-year actuarial DDR rate of 5.4%. The 5-year breast cancer specific survival was 95%, with the poorer NPI groups having worse breast cancer specific survival (Log-rank, P<0.0001). More importantly, patients with IBTR had a shorter breast cancer-specific survival than those who were IBTR-free (Log-rank, P<0.0001). Our treatment regimen, combining BCS with a 5-mm target margin and hypofractionated 40-Gy RT, results in an extremely low rate of IBTR, and compares favourably with the target IBTR rate of <5% defined by the Association of Breast Surgeons (ABS) at BASO guidelines.

Establishing axillary Sentinel Lymph Node Biopsy (SLNB) for early breast cancer in the United Kingdom: A survey of the national training program

Introduction The UK National training programme (NEWSTART) for SLNB in breast cancer was established in 2004, aimed at providing structured, standardised training with a focus on multidisciplinary team (MDT) delivery. Methodology A questionnaire was devised and after approval by the Association of Breast Surgeons (ABS) executive committee they were sent to all full members of the ABS. Results Most (97%) of breast surgeons are convinced by the evidence for SLNB as standard of care for early breast cancer. 64% use SLNB to stage clinically node negative patients, of whom 23% use it as a standalone procedure. 38% of surgeons were dissatisfied with the time it takes to complete the in house training, and 87% with the time it takes to complete the validation phase. Logistical and funding issues were the main problems cited. The majority of surgeons (86%) use the recommended combined technique, with 47% continuing to use the dual localisation method. 14% use either blue dye or isotope alone, without scintiscan. Only 10% offer intra operative diagnosis, of which the majority (6%) use touch imprint cytology. 31% included their results in their most recent surgical appraisal. Conclusions The majority of breast surgeons in the UK are convinced by the evidence for SLNB, and most use SLNB in their practice for staging. Reasons for not conducting SLNB are logistical rather than lack of belief in the procedure. The majority of respondents completed their training within the anticipated time line. The majority of centres do not perform intra-operative assessment.

Establishing Axillary Sentinel Lymph Node Biopsy (SLNB) for Early Breast Cancer in the United Kingdom: A Survey of the National Training Program.

Abstract IntroductionThe UK National training programme (NEWSTART) for SLNB in breast cancer was established in 2004. This unique national educational initiative aimed at providing structured, standardised training with a focus on multidisciplinary team (MDT) delivery. Patient safety was the primary aim and central audit and validation was integral to the program.We conducted a national survey 4 years after its introduction with the aim of obtaining a snap shot of the training program and identifying if there are any common barriers that might limit participation and progression in SLNB training.MethodologyIn collaboration with the Association of Breast Surgeons (ABS) in the UK, paper and electronic questionnaires were sent to 400 registered surgeons. The questionnaire was divided into three sections, exploring the SLNB concept, training and post training experiences.ResultsMost (97%) of breast surgeons are convinced by the evidence for SLNB as standard of care for early breast cancer. 64% of respondents use SLNB to stage clinically node negative breast cancers, of whom 23% use it as a standalone procedure in their practice.The NewStart program begins with a theory day, which has been completed by 86% of respondants. Participants then either follow an apprentiship model of training (completed by 29%) or a proctorship model for which there is initially an in-house training phase (completed by 49%) and then a validation phase (completed by 41%). 38% of surgeons were dissatisfied with the time it takes to complete the in house training, and 87% with the time it takes to complete the validation phase. Logistical and funding issues were the main problems cited.The majority of surgeons (86%) use the recommended SLNB detection technique (combined isotope and blue dye), with 47% continuing to use the dual localisation method. 14% use either blue dye or isotope alone, without scintiscan imaging. Only 10% offer intra operative diagnosis, of which the majority (6%) use touch imprint cytology. These low figures are due to logistical constraints, including lack of on-site pathologists, funding and time. 31% included their results in their most recent surgical appraisal.ConclusionsThe NEW START program introduced and set a standard of care in a systematic method. It was unique in the sense that training was validated across a comprehensive national health service, translating specialist standards to every unit in the country, over a relatively short time frame. The majority of breast surgeons in the UK are convinced by the evidence for SLNB, and so most now use SLNB in their practice for staging clinically node negative breast cancer. Reasons for not conducting SLNB or IOD are logistical rather than lack of belief in the procedure. Barriers to uptake and progress were as expected - logistical and financial rather than attitudinal. The majority of respondents who completed their training did so within the anticipated time line. The majority of centres do not perform intra-operative assessment of the SLN due to lack of resources which means node positive patients have to undergo a second operation. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1020.

Ultrasound of the breast

This course is aimed mainly at medical professionals who regularly work in the field of breast disease, such as general surgical trainees with an interest in the breast; breast clinicians; radiographers; and general practitioners who do breast clinics. We did this course during our final year of surgical training. It is expected that the course will take six months to complete. There has been considerable debate about whether breast training should be separate from general surgical training. A recent statement from the ex-president of the Association of Breast Surgeons, Hugh Bishop, states that “unless trainee breast surgeons learn a lot more about breast imaging, particularly breast ultrasound, then they will rapidly be reduced to the status of a greeter in a new breast patient clinic.”1 We felt as surgeons that we would like to offer our patients a more holistic experience when they come to the breast clinic, rather than …

Titanium clip placement to allow accurate tumour bed localisation following breast conserving surgery – Audit on behalf of the IMPORT Trial Management Group

Introduction Accurate tumour bed (TB) localisation is a key requirement for the UK IMPORT (Intensity Modulated Partial Organ Radiotherapy) trial. We audited the value of titanium clips for TB localisation following breast conserving surgery (BCS) in breast radiotherapy (RT) planning. Patients and methods At surgery, paired clips were positioned around the TB as follows: 1. Medial, lateral, superior and inferior: half-way between skin and fascia; 2. Posterior: at the pectoral fascia; 3. Anterior: close to the suture line. Thirty consecutive patients with clips inserted were audited at the time of RT planning. Audit standards were set as follows: (i) 5/6 pairs of clips identified on RT planning computed tomography (CT) scan – 100%; (ii) possible clip migration: <10%; (iii) TB localisation improved with clips: >50%. Inter- and intra-observer variability in clinician outlining of the TB was studied in a subset of 12 randomly selected patients to see if this impacted on positioning of radiotherapy field borders. Results Five or six pairs of clips were identified in all 30 cases. The TB could be successfully identified using CT seroma alone in only 8/30 (27%) patients. Clips were essential for the TB localisation of the other 22/30 (73%) patients. There was no evidence of clip migration. TB localisation led to modified RT field borders in 18/30 (60%) patients. Five of these patients had highly visible seromas, so the addition of clips modified field borders in 13/30 (43%) patients. Both inter- and intra-observer variability was reasonable and did not impact on positioning of radiotherapy field borders. Conclusion Titanium clips provide an accurate and reliable method of TB localisation following BCS. We anticipate that the audit results will lead to clips being adopted as best practice by the Association of Breast Surgeons (ABS) at BASO (British Association of Surgical Oncology).

Association of Breast Surgeons at the British Association of Surgical Oncology (ABS AT BASO)

This section provides current contact details and a summary of recent or ongoing clinical trials being coordinated by Association of Breast Surgeons at the British Association of Surgical Oncology (ABS at BASO). Clinical trials include: BASO DCIS II TRIAL: Randomised trial testing observation (no radiotherapy) against radiotherapy in women with low-risk completely excised ER positive ductal carcinoma in situ (DCIS) of the breast on adjuvant endocrine therapy.Neoadjuvant trial of preoperative exemestane or letrozole ± celecoxib in the treatment of ER positive postmenopausal early breast cancer.

Advanced Surgical Practice

Advanced Surgical Practice

Book Review: Advanced Surgical Practice

Book Review: Advanced Surgical Practice