Breast Cancer Surgery In Women Research Articles

TH1.8 Changes In the Operative Management of Breast Cancer During The COVID Pandemic -- Single Institution Experience

Abstract Aims COVID has had a wide ranging impact on surgical practice; including staffing issues, procedural prioritisation and changes to perioperative practice. We aim to compare the operative management of breast cancer before and during year 1 of the pandemic. Methods A retrospective review of primary breast cancer surgery in women between 23/3/2020–23/3/2021 with sub-analysis looking at wave 1 of COVID (23/3/2020–23/7/2020), compared to pre-COVID (1/1/2018–31/12/2018). Data collected include type and complexity of surgery, re-operations and complications. Results Pre-COVID, 606 cancers were included, with 217 (35.8%) simple BCS, 241(39.8%) oncoplastic BCS, 88 (14.5%) simple mastectomies and 60 (9.9%) mastectomies with immediate reconstruction. During COVID study period, a total of 398 cancers were included, with operative number (percentages) being 104(26.1%), 176(44.2%), 83(20.9%) and 35(8.8%) respectively. During wave 1, 47 cancers were diagnosed and operated on. The operative numbers (percentages) during initial wave COVID pandemic were 9 (19.1%), 25(53.2%), 12(25.5%) and 1(2.1%) respectively. Conclusions In our unit COVID led to a shift of breast cancer operative management to more BCS and simple mastectomies. As a unit, we were able to maintain good oncoplastic BCS service, however, reconstruction options were limited.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Impact of Physiotherapy on Quality of Life and Arm Function after Breast Cancer Surgery in Women of Different Age

Breast cancer is the most common oncological disease among women. After breast cancer surgery women face various physical and psychosocial problems. They often suffer from arm lymphedema, poor posture, and pain. Side effects of breast cancer surgery can greatly affect general physical health and quality of life. To manage the problems it is necessary to apply rehabilitation. The most important part of rehabilitation is physiotherapy with the main aim of helping patients to recover and to achieve their maximum functional level (Hsieh et al., 2008). The aim of this study was to determine the impact of physiotherapy on differently aged women’s arm function after breast cancer surgery. The sample size of the survey was 40 women who were referred for post operative outpatient rehabilitation. The participants were divided into two age groups: I group – women aged 35–49 years (n = 20, average age 42 ± 4.30 yrs.); II group – women aged 50–64 years (n = 20, average age 56 ± 5.39 yrs.). Shoulder range of motion, arm circumference and pain were measured before and after 14 physiotherapy procedures, their general health state and quality of life were assessed as well. Shoulder range of motion increased, arm swelling and pain on the operated side decreased significantly in women of different age. General health status and quality of life after physiotherapy improved significantly both in younger and older women, but there were no significant differences between groups. After breast cancer surgery more than half of the women had psychological problems and were worried about their health in future, and less than half experienced body image problems and faced various social problems. Physical therapy was equally effective for both younger and older women.Keywords: physiotherapy, breast cancer, lymphedema, quality of life.

Bridging the Age Gap in Breast Cancer - Analysis of the Complication Rates of Surgery in Older Women

Background: The Bridging the Age Gap in Breast Cancer study is a multicentre retrospective cohort study examining the management of older patients with breast cancer. This study aimed to examine the selection criteria for breast cancer surgery in patients over 70 and the adverse events risk in this population. We present the adverse event risks for breast cancer surgery in women over age 70 in the UK according to surgical type. Materials and Methods: Baseline information on patient characteristics, surgery type and adverse events was collected across 56 UK breast units. Surgery was classified as major (mastectomy or axillary node clearance) or minor surgery (breast conserving surgery +/- sentinel node biopsy). Adverse events were recorded for 2 years following surgery and classified using the Common Terminology for Classification of Adverse Events system and designated as systemic or local/wound complications. Rates of adverse events were calculated and compared between surgical categories using Chi Squared. Results: Between 2013-2018, 3460 women with operable breast cancer were recruited; 2792 (80.7%) were treated surgically. There were 62 bilateral tumours, giving a total of 2854 surgical events (1321 major, 1533 minor). There were no surgical related deaths (30-day mortality). The overall rate of systemic complications was 59/2854 (2.1%) and local complications was 1072/2854 (37.6%) although 547 had only a seroma and these have been excluded from further analysis. Major surgery was associated with higher rates of local complications (22.7%) vs minor (14.7%; P<0.01). Systemic complications (cardiorespiratory, CVA, embolic) were rare (major 2.9% vs minor 1.4%; p<0.01). Conclusions: Breast cancer surgery has a zero mortality rate in this large prospective UK series with acceptable rates of morbidity suggesting that it is safe in the 80% of older women selected as fit for surgery.

Interrater Reliability of Dynamic Muscle Testing After Breast Cancer Surgery in Women at High Risk of Lymphedema: To Improve Quality in Clinical Practice.

Background: The purpose of this study is to determine the interrater reliability of dynamic muscle tests in the early rehabilitation phase in women after breast cancer surgery with axillary lymph node dissection (ALND) based on the “preventive intervention against lymphedema after breast cancer” (LYCA) randomised controlled trial. Methods: Fifteen women treated with breast cancer surgery including ALND were recruited from participants in the LYCA trial. In this interrater reliability study, women were tested in 4 dynamic muscle tests by 2 physiotherapists at a Capital Hospital in Denmark. Intraclass correlation coefficients (ICCs) with 95% confidence intervals (CIs) was used to assess the relative reliability between raters. A Bland-Altman plot and limits of agreement were calculated to describe the absolute reliability. Results: All 6 subtests displayed high interrater reliability. ICC values were: leg press 0.96 (95% CI = 0.87-0.99), elbow flexion (contralateral) 0.94 (0.83-0.98), elbow flexion (affected arm) 0.93 (0.80-0.98), elbow extension 0.80 (0.41-0.93), shoulder abduction (contralateral) 0.89 (0.68-0.96), and shoulder abduction (affected arm) 0.91 (0.74-0.97). Cumulated interrater reliability for the test battery was very high (ICC = 0.99, 95% CI = 0.990-1.0). The absolute reliability of this study was considered high, and the absence of large shifts between mean and the line of 0 difference suggest no systematic bias that could influence clinical interpretation. Conclusions: The dynamic muscle tests evaluated in this study had high interrater reliability and can be used reliably in women in the postoperative phase after breast cancer surgery with ALND.

Effectiveness of myofascial release after breast cancer surgery in women undergoing conservative surgery and radiotherapy: a randomized controlled trial.

The scars derived from the treatment of breast cancer lead to adverse effects such as fibrosis or retractions of the connective tissue. Myofascial release (MR) seeks to reduce restrictions of the fascial system. Therefore, the aim of this study was to analyze the clinical impact of MR treatment on women survivors of breast cancer. We enrolled 24 women with breast cancer, 13 received myofascial release treatment (MR) and 11, a placebo manual lymphatic drainage treatment (PMLD). Both interventions were administered over a period of 4weeks. The outcomes studied were pain, shoulder range of motion (ROM), functionality, quality of life (QoL), and depression, immediately after treatment and 1month later. After 4weeks of treatment, only the participants who received MR experienced a significant decrease in pain intensity in the short and midterm (p < 0.05). This therapy also achieved a general improvement in ROM (p < 0.05), except for internal rotation, that persisted 1month after treatment. Regarding functionality, both therapies achieved the level of significance (p < 0.05), but only MRG sustained the improvement in the midterm. General QoL, assessed with FACT-B, and its physical well-being dimension were significantly improved after MR implementation (p < 0.05), while the emotional dimension and the breast cancer subscale improved only with PMLD (p < 0.05). In conclusion, an MR-based treatment shows physical benefits (i.e., overall shoulder movement, functionality, and perceived pain) in women after breast cancer surgery. This study is registered on ClinicalTrials.gov NCT03182881.

The Effect of Intraoperative Systemic Lidocaine on Postoperative Persistent Pain Using Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials Criteria Assessment Following Breast Cancer Surgery: A Randomized, Double-Blind, Placebo-Controlled Trial.

To compare the incidence in postsurgical persistent pain following breast cancer surgery in women receiving intravenous lidocaine compared to saline using validated pain instruments in accordance with the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) recommendations. The study was a randomized, double-blinded, placebo-controlled, clinical trial. Subjects were randomized into Group 1 (1.5mg/kg bolus of intravenous lidocaine followed by a 2mg/kg/hour infusion) or Group 2 (normal saline at the same bolus and infusion rate). Patients were evaluated at 3 and 6months for the presence of chronic persistent postsurgical pain. One hundred forty-eight patients were included in the study analysis. There were no differences in quality of recovery, pain burden, or opioid consumption between groups at 24hours. Pain (yes/no) at 6months attributed to surgery was reported in 29% of Group 2 vs. 13% of Group 1 patients (P=0.04); however, only 3 subjects (5%) in Group 1 and 2 subjects (3%) in Group 2 met IMMPACT criteria for persistent postoperative pain (P=0.99). Perioperative infusion of lidocaine has been reported to decrease the incidence of postsurgical pain at 3 and 6months following mastectomy using dichotomous (yes/no) scoring. Although intravenous lidocaine reduced the reported incidence of pain at rest at 6months, pain with activity, pain qualities, and the physical or emotional impact of the pain were unaffected. Future studies evaluating postsurgical persistent pain should adhere to the IMMPACT recommendations in order to more accurately describe the effect of an intervention on persistent pain.

Associations Between Single-Nucleotide Polymorphisms and Epidural Ropivacaine Consumption in Patients Undergoing Breast Cancer Surgery

Up to date, few published studies indicated the associations between genetic polymorphisms and epidural local anesthetics consumption. In this study, we investigated the associations between seven single-nucleotide polymorphisms (SNPs) and epidural ropivacaine consumption during breast cancer surgery in women from northeastern China. These seven SNPs (rs3803662 and rs12443621 in TNCR9, rs889312 in MAP3K1, rs3817198 in LSP1, rs13387042 at 2q35, rs13281615 at 8q24, and rs2046210 at 6q25.1) were identified by recent genome-wide association studies associated with tumor susceptibility. A total of 418 breast cancer women received thoracic epidural anesthesia with ropivacaine for elective mastectomy with axillary clearance. Their blood samples were genotyped for the seven SNPs using the SNaPshot method. For SNP rs13281615, the subjects with genotype AG and GG consumed a greater amount of the total epidural ropivacaine and the mean ropivacaine dose than the subjects with genotype AA (p=0.047 and p=0.003, respectively). Furthermore, no statistical differences were found in the total dose of ropivacaine, the mean consumption of ropivacaine, the onset of ropivacaine, or the initial dose of lidocaine among the three genotypic groups for the other six SNPs studied. Our study indicated that SNP rs13281615 at 8q24 was associated with the consumption of epidural ropivacaine during breast cancer surgery in northeastern Chinese women. It might provide new insights into the mechanisms of ropivacaine action and metabolism and facilitate the development of personalized medicine.

Perioperative Complications of Breast Cancer Surgery in Elderly Women (≥80 Years)

There has been much controversy regarding the optimal management of breast cancer in very elderly women. Some clinicians are reluctant to offer surgical treatment for women older than aged 80years because of the assumed higher operative risk associated with advanced age. This study was designed to investigate the perioperative complications of breast cancer surgery in women of this age group. Data were reviewed of all women ≥80years of age who underwent breast cancer surgery at a university clinic during the period 1990-2005. Symptoms, comorbidities, preoperative risk assessment, type of operation, postoperative histological diagnosis, hospital stay, morbidity, and mortality were documented and analyzed. During this 16-year period, 140 operations for breast cancer were performed in 129 women. The majority of the patients (37.9%) underwent a modified radical mastectomy, 32.1% underwent a simple mastectomy, 24.3% underwent breast-conserving therapy, and 5.7% underwent an axillary lymph node dissection. Complications occurred in 37.1% of the cohort: 31.4% were minor complications and only 5.7% were major. Intraoperative morbidity was 18.6% and postoperative morbidity was 20%. Late complications occurred in 5% of patients. The most common complications were associated with the wound region (50%). The perioperative mortality in this group of elderly women was zero. Breast cancer surgery has acceptable perioperative morbidity and mortality in women aged ≥80years. Surgery is the cornerstone of breast cancer treatment and should be offered as first-line treatment for all patients regardless of their age.

Morbidity and Mortality Following Breast Cancer Surgery in Women

Most reports on postoperative (OP) morbidity and mortality following breast cancer surgery (BCS) are limited by relatively small sample size resulting in a lack of national benchmarks for quality of care. This paper reports the 30-day morbidity and mortality following BCS in women using a large prospective multi-institutional database. The National Surgical Quality Improvement Program Patient Safety in Surgery, prospectively collected inpatient and outpatient 30 day postoperative morbidity and mortality data on patients undergoing surgery at 14 university and 4 community centers. Using the procedure CPT code, the database was queried for all women undergoing mastectomy (MT) or lumpectomy with an axillary procedure (L-ANP). Morbidity and mortality were categorized as mortality, wound, cardiac, renal, pulmonary, and central nervous system. Logistic regression models for the prediction of wound complications were developed. Preoperative variables having bivariate relationships with postoperative wound complications with P < or = 0.20 were submitted for consideration. We identified 1660 and 1447 women who underwent MT and l-ANP, respectively. The mean age was 55.9 years. The majority of procedures were under general anesthesia. The 30-day postoperative mortality for MT and l-ALNP were 0.24% and 0%, respectively. The most frequent morbid complication was wound infection, more commonly occurring in the mastectomy (4.34%) group versus the lumpectomy group (1.97%). Cardiac and pulmonary complications occurred infrequently in the mastectomy group (cardiac: MT, 0.12%; and pulmonary: MT, 0.66%). There were no cardiac or pulmonary complications in the lumpectomy group. CNS morbidities were rare in both surgical groups (MT, 0.12%; and l-ALNP, 0.07%). Development of a UTI was more common in women who underwent a mastectomy (0.66%) when compared with women that had a lumpectomy (0.14%). The only significant predictors of a wound complication were morbid obesity (BMI >30), having had a MT, low preoperative albumin and hematocrit greater than 45%. Morbidity and mortality rates following BCS in women are low, limiting their value in assessing quality of care. Mastectomy carries higher complication rate than l-ANP with wound infection being the most common.