Dedicated Breast Surgeons Research Articles

Novel single-centre experience - evaluation of outcomes post-implementation of a coordinated combined breast reconstruction service.

Autologous breast reconstruction services are logistically complex and challenging to implement but have better outcomes than implants. This study aimed to evaluate the effect of implementing a coordinated, low-cost combined breast reconstruction service (0.8 FTE nurse liaison, 0.25 FTE plastic surgeon, two dedicated breast surgeons 0.05 FTE each and protected weekly all-day oncoplastic theatre) on unit productivity and efficiency in reducing wait times for immediate autologous breast reconstruction. A retrospective cohort study was conducted on all patients who underwent immediate autologous breast reconstruction at Fiona Stanley Hospital between two study periods, pre-intervention - February 2016 to June 2019 and post-intervention - November 2022. Data were analysed using SPSS v.27. One hundred twenty-seven participants were included, with 49% (n = 62) in the post-intervention group. Most procedures performed were therapeutic (n = 108, 85%). DIEP was the most common flap (84%), and the mean BMI was 26.9 (SD ± 4.2). There was a statistically significant increase in the number of high-risk gene carriers' prophylactic cases and bilateral cases performed post-intervention (5% to 26%, P = 0.001) and (29% to 55%, P = 0.003), respectively. Time to surgery on the waitlist did not significantly change after the intervention (therapeutic group: 3.1 to 3.5 weeks, P = 0.821; prophylactic group: 55.0 to 61.1 weeks, P = 1.000). Overall, there was a marked increase in the overall productivity of the breast service unit in terms of mastectomies, total reconstructions, and autologous reconstructions performed. This single-centre experience showed that implementing a coordinated service significantly increased the unit's productivity. This low-cost intervention can be applied to other healthcare settings.

Evaluation of the Surgical Outcomes of Breast Oncoplastic Techniques Carried Out by a General Surgical Oncologist.

Background With recent advances in different breast cancer treatment modalities, breast conservation surgery (BCS) has gained popularity and has become the mainstay for the treatment of early breast cancer. The model of dedicated breast surgeons working in breast units is standard in some but not all countries. We have aimed to define surgical outcomes of oncoplastic breast surgery carried out by one general surgical oncologist.Patients and methodsWe have conducted a prospective non-randomised case series analysis to assess the oncologic and aesthetic outcome of tissue displacement oncoplastic breast techniques in managing unifocal early-stage breast cancer from January 2019 to January 2020.One surgical oncologist with 23 years of surgical oncology experience carried out all operations.ResultsWe have included 50 female patients treated with variant oncoplastic volume displacement techniques. We have used the round block technique in 20%, the batwing technique in 18%, lateral mammoplasty in 20%, and medial mammoplasty in 2%. We have also carried out wise pattern therapeutic mammoplasty with inferior pedicle in 20% (10 patients), and vertical mammoplasty with superior pedicle in 20% (10 patients).While 8% of our patients had Clavien-Dindo system grade I Immediate complications, including the surgical site infection and postoperative seroma and haematoma, 2% of patients had grade II complications in the form of partial areola and nipple complex necrosis leading to delayed wound healing requiring secondary suturing. No delayed complications or mortalities were recorded.Eight per cent of patients required re-excision to clear margins, 74% had excellent results, 24% had good results, and 2% had fair results. In addition, 64% were very satisfied with their results, 32% were satisfied, while 4% were not satisfied with aesthetic results.ConclusionBased on our limited number of patients, we have found that tissue displacement oncoplastic techniques carried out by a general surgical oncologist are safe and reliable in providing satisfactory oncological outcomes with a low risk of delaying adjuvant therapy and acceptable aesthetic outcomes.

Imaging Evaluation of the Axilla-A National Survey of Clinical Practice Among Radiologists.

To assess awareness and implementation of the American College of Surgeons Oncology Group Z0011 trial findings, approaches to axillary nodal imaging, and to identify differences in practice based on respondent characteristics. An online survey was distributed to members of the Society of Breast Imaging. Questions regarded demographics, evaluation approaches, and impact of the Z0011 trial. Poisson regression with robust standard errors to regression was used to generate multivariable-adjusted relative risks and 95% confidence intervals (CIs) for associations. The response rate was 21.7% (430/2007). The majority (295/430, 68.6%) reported always performing axillary US in patients with a BI-RADS 4B, 4C, or 5 breast mass. Most respondents (299/430, 69.5%) were familiar with the findings of the Z0011 trial. Radiologists in academic practice were 0.67 (95% CI: 0.54-0.83) times less likely than private practice radiologists to perform axillary US in all masses and 1.31 (95% CI: 1.13-1.52) times more likely to be very familiar with the trial. Frequency of axillary US showed no association with time spent in breast imaging, years in practice, or presence of dedicated breast surgeons. Increased time in breast imaging and presence of dedicated breast surgeons was strongly associated with familiarity with the trial. No association was observed with years in practice. Most respondents (291/430, 67.7%) made little or no change to their practice based on trial findings. There is wide variability in approaches to axillary nodal evaluation, demonstrating a need for improved education and guidelines for axillary imaging in breast cancer patients.

Cutting Instruments to Cut Costs: A Simple Initiative with Breast Surgical Operating Room Trays that Resulted in Substantial Savings.

A substantial expense in surgical care is incurred in the operating room (OR). We evaluated the financial impact of a systematic reduction in instrument tray contents on charges for breast surgery procedures. A catalog of OR trays historically used for breast procedures (excisional biopsy, segmental and total mastectomy with or without axillary staging) was reviewed by four dedicated breast surgeons and downsized to a single tray accommodating all surgeon preferences. A matched-case comparison was performed pre- and post-downsizing. Cost analysis for salary and benefits (S&B) and unit supply cost (USC) pre- and post-downsizing were carried out. Instrument number, OR tray weights, set-up, and breakdown times were also compared. Post-downsizing, OR tray counts were reduced from 132 to 67 instruments (49%) and tray weight decreased from 30 to 20pounds (33%). Scrub technician set-up and breakdown times were shorter by 22% and 25%, respectively. Comparing 449 matched cases (239 pre- and 210 post-downsizing), S&B and USC post-downsizing were decreased collectively for all procedures (p<0.0001). With an average variance of S&B and USC (pre- to post-intervention) of $354, and an annualized case load of 813 operations, this could translate into S&B and USC savings of $287,802 per year. Simply downsizing OR breast trays resulted in decreased combined S&B and USC per procedure, leading to a substantial cost savings for the healthcare system. This measure aligns with a value and quality-based approach to patient care and could be easily replicated across institutions and specialties.

Nipple-sparing Mastectomy and Ptosis: Using a Free Nipple Graft with Tissue Expander Reconstruction.

Background:Nipple-sparing mastectomies are increasingly offered to women with breast cancer given the evidence for oncologic safety and improved cosmetic outcomes. Women with significant ptosis are often excluded due to potential nipple malposition and increased risk of nipple ischemia. The use of a harvested free nipple graft may allow women with ptosis to conserve their nipple -areolar complex.Methods:This is an IRB approved retrospective study of breast cancer patients at an academic center with ptosis who underwent free-nipple graft mastectomies with a single plastic surgeon and 5 dedicated breast surgeons from 2014-2017. The primary outcomes were free nipple graft viability and the need for revision. Secondary outcomes included post-operative complications.Results:Fourteen women with ptosis underwent skin and nipple-sparing mastectomy with breast reconstruction involving use of harvested free-nipple graft. More than half of the women were diagnosed with early-stage invasive breast cancer (42% stage 1, 14% stage 2). Four women underwent mastectomy for prophylaxis or other benign reasons. All of the women had significant ptosis during the pre-operative evaluation (57% grade 2 ptosis, 36% grade 3 ptosis, and 7% uncategorized), with an average BMI of 30. None were active smokers. In the postoperative period, one had partial nipple necrosis in combination with skin flap necrosis and positive margin (7%). Other complications included infection (14%) and hypopigmentation (14%). All nipples lost sensation and full projection.Conclusions:This is a novel approach using a free nipple graft with a skin envelope reducing mastectomy and immediate expander-based reconstruction. This successful approach allows women with ptosis to undergo nipple-sparing mastectomy with preservation of the nipple -areolar complex.

Preoperative Breast MRI: Surgeons' Patient Selection Patterns and Potential Bias in Outcomes Analyses.

The purpose of this study is to determine which patient- and tumor-related and clinical variables influence dedicated breast surgeons' and general surgeons' referrals for preoperative breast MRI for patients with newly diagnosed breast cancer. Surgeons who perform breast surgery responded to a survey from June 16, 2014, through August 11, 2014. Participants self-identified as breast or general surgeons and provided professional practice details. They used Likert scores (range, 1-7 with increasing likelihood to order MRI) to weigh numerous patient- and tumor-related and clinical variables. Mean likelihood scores were calculated and compared using a linear mixed model. A p ≤ 0.05 was considered statistically significant. Two hundred eighty-nine surveys from 154 (53%) breast surgeons and 135 (47%) general surgeons showed an overall likelihood to refer for patients with a BRCA mutation (mean Likert score, 6.17), familial (mean Likert score, 5.33) or personal (mean Likert score, 5.10) breast cancer history, extremely dense breasts (mean Likert score, 5.30), age younger than 40 years (mean Likert score, 5.24), axillary nodal involvement (mean Likert score, 6.22), tumor that is mammographically occult (mean Likert score, 5.62) or fixed to the pectoralis (mean Likert score, 5.49), tumor that is a candidate for neoadjuvant treatment (mean Likert score, 5.38), multifocal or multicentric disease (mean Likert score, 5.22), invasive lobular carcinoma (mean Likert score, 5.20), T3 (mean Likert score, 4.48) or T2 (mean Likert score, 4.41) tumor, triple-negative breast cancer (mean Likert score, 4.66), a patient who is a candidate for mastectomy requesting breast conservation therapy (mean Likert score, 5.27), and radiologists' recommendations (mean Likert score, 5.19). Across all patient ages, breast surgeons referred more often than did general surgeons (mean Likert score, 4.32 vs 3.92; p = 0.03), especially for patients with BRCA mutation (mean Likert score, 6.39 vs 5.93; p = 0.01) and tumors smaller than 1 cm (mean Likert score, 3.84 vs 3.40; p = 0.002). Breast surgeons referred less often than did general surgeons for multifocal or multicentric disease (mean Likert score, 5.02 vs 5.44; p = 0.001). Breast surgeons and general surgeons similarly weighed other variables. Preoperative breast MRI referral trended with certain higher risk patient- and tumor-related and clinical variables and were nonuniform between the breast surgeons and general surgeon cohorts. Selection bias could affect outcomes analyses for preoperative breast MRI.

The effect of dedicated breast surgeons on outcomes in breast cancer: do numbers matter?

Improved clinical outcomes as a function of larger case volume likely reflects both the technical competence of the surgeon and his/her participation in a multidisciplinary care team. Increased case numbers are associated with larger percentages of margin-free excisions, smaller volumes of resection and decreased surgical complications for patients undergoing skin-sparing mastectomy with preservation of the nipple-areolar complex. Increased case numbers are also associated with the patient’s receipt of radiotherapy and systemic therapy.

Patterns of reconstruction after unilateral and bilateral mastectomies.

143 Background: A trend for the increased usage of mastectomy to treat breast cancer and for prophylaxis has been reported. Postmastectomy reconstruction (PMR) may improve body image and quality of life for breast cancer survivors. This prompted an investigation of the current pattern of PMR in our breast surgery practice. Methods: An IRB-approved retrospective chart review of women who had mastectomies performed by dedicated breast surgeons from 2006 through 2009 was completed. Data collected included age, unilateral (ULM) or bilateral mastectomy (BLM), type and timing of reconstruction, BRCA status, presence of an in-breast tumor recurrence (IBTR). Two-sided Fisher exact test and t-test were used in comparing groups. Results: From 2006 to 2009, 231 patients ranging in age from 27 to 91 years had ULM (n=155) or BLM (n=76). 38% of the patients had PMR. Patients &lt;50 years old were more likely to undergo PMR than those &gt;50 (67.5% versus 22.7%, p&lt; 0.0001). 4 patients &gt;70 years old had PMR. PMR followed ULM 27.7% of the time and BM 57.9% (p &lt; 0.0001). Only 6 patients underwent delayed PMR. 30 patients had mastectomies after IBTR with 36.7% having PMR and 36.7% opting for BLM. These rates were not significantly different from women with a unilateral de novo breast cancer (33.1% and 21.3%, respectively). In 15 patients with a BRCA mutation, one had ULM. The 14 having BLM were more likely to have BMR than BLM patients without a mutation (92.9% versus 50.0%, respectively, p=0.0029) and were younger (44.6 versus 52.3 years, respectively, p=0.0166). Types of reconstructions were divided between tissue expander/implant (TE/I)(70%) and autologous tissue flaps (AT) techniques. After BLM, TE/I was employed more frequently than after UM (84% versus 56%, respectively, p=0.005). From 2006 to 2009, there was no significant change in type or frequency of PMR. Conclusions: From this data it appears that a majority of women do not have PMR and few women return for a delayed PMR. Fewer women seek PMR after ULM. Rates and types of PMR have not changed over this time period. Further investigation to determine if women feel informed about PRM and to identify factors influencing their choices may be helpful in improving a PMR program.

Sentinel lymph node biopsy in breast cancer surgery

Axillary lymph node status is one of the most reliable prognostic factors of long-term survival in breast cancer surgery. Metastatic involvement of the axillary lymph nodes is also crucial in the decision making of potentially useful adjuvant treatment. Until the last decade, Axillary Lymph Nodes Dissection (ALND) was performed in order to obtain the regional lymphatic system staging. In case of non-metastatic spread, that kind of surgery was limited only to this purpose; no further oncological benefits were obtained and the patients were exposed to several comorbidities affecting this type of surgery. Complications after ALND are reported in 15-30% of cases. They are well known and range from early bleeding, infection, symptomatic nerve damage, and longstanding limb lymph-edema with an incredible impairment of the quality of life.The Sentinel Lymph Node (SLN) theory holds that the SLNs are the first nodes draining lymph from an anatomic region (i.e. the breast) where metastatic disease will most likely to be found. If that node is found to be cancer free, the entire lymphatic system is likely to be cancer free; if it is metastatic, there is an elevated chance of finding more metastatic nodes. Thanks to the application of this hypothesis, several patients over the last 10-15 years have avoided unnecessary major demolitive surgery. To obtain accurate evaluation of the SLN a multidisciplinary dedicated team is necessary. This procedure has been internationally validated and the false negative rate is nowadays less than 5% when performed by expert hands. Dedicated breast surgeons working in a high-volume centres are necessary to reach satisfactory confidence in performing this very specialised procedure in order to obtain an accurate staging. The number of women presenting to the breast oncology units is continuously increasing and the implementation of screening programs has been crucial in detecting numerous patients (more than 75%) with early disease and non-metastatic axillary lymph nodes. The practice of the SLN is clearly able to offer those patients an accurate staging with low comorbidities, preserving their quality of life.

Must Breast Care Delivery Models from Resource Rich Environments Be Applied to Resource Limited Environment: Reply

In response to our invited editorial ‘‘Balancing resource constraints against quality of care’’ [1], Drs. Mouton, Apffelstaedt, and Baatjes ask whether breast care delivery models from resource-rich environments should necessarily be applied to resource-limited environments. We fully agree with our South African colleagues that health care delivery strategies must be adapted to existing resources within a given environment. Our multinational coalition, the Breast Health Global Initiative (BHGI), has published evidencebased, economically feasible, and culturally appropriate guidelines for breast care in lowand middle-income countries (LMCs), the purpose of which is to provide guidance to in-country health care leadership for strategic programmatic development [2]. A core principle developed through the collaborative efforts of breast cancer experts from more than 40 countries convened in four BHGI Global Summits between 2002 and 2010 is that novel breast care delivery models must be developed and applied in LMCs to improve outcomes on a global scale. So, regarding the challenge of health care resource allocation in LMCs, we are in alignment with our South African colleagues. We respectfully suggest that the authors have not understood our primary critique of their now published article [3]. Drs. Mouton, Apffelstaedt and Baatjes have interpreted their data to suggest that ‘‘dedicated breast surgeons are equally proficient at mammography interpretation as radiologists.’’ We reaffirm that this bold conclusion cannot be validated on the basis of their South African data because the surgical investigators have applied a previously abandoned scheme to mammographic interpretation and biopsy that blunts their ability to make a legitimate comparison between their experience and that of radiologists who follow well established and tested approaches for mammographic interpretation. We disagree with the authors’ assertion that their threepoint scale for classifying mammographic lesions as ‘‘negative/indeterminant/positive’’ allows them to make assertions about the reliability of the surgical interpretation in comparison to experienced, trained mammographic readers. Unlike BI-RADS, this three-point scale cannot directly measure individual reader reliability in a graded way. The five-point BI-RADS scale, now universally accepted as the standard method for interpreting mammograms, not only forces the reader to determine whether a biopsy should be performed (the three-point scale), it also provides a qualitative assessment of the likelihood of the lesion to proving to be malignant or benign on biopsy (the five-point scale). Because the BI-RADS categories 4 (suspicious) and 5 (malignant) were collapsed into a single group in the South African study, the relative accuracy of the surgical interpretations cannot be weighed with the level of granularity that permits a legitimate comparison of diagnostic accuracy between surgeons and radiologists. It is certainly encouraging that the cancer diagnosis rates based on clinical follow-up from this South African clinic seem similar to other reported experiences in the literature, but this analysis does not meet evidence-based criteria for establishing the surgeons’ mammographic interpreting skills in comparison to trained radiologists. At a minimum, the authors should acknowledge that they have overstated the findings of their study. B. O. Anderson (&) Department of Surgery, University of Washington, Box 356410, 1959 NE Pacific Street, Seattle, WA 98195, USA e-mail: banderso@u.washington.edu

Surgical Mammography Reporting in a Limited Resource Environment

Lack of resources and dedicated breast radiology has forced professionals other than radiologists to read mammography. We report a series of surgeon-read mammography in a developing country. Data were collected prospectively form January 2003 to June 2008 for all mammography performed at a tertiary hospital. The data acquired were demographics, previous treatment for breast pathology, and indication for and outcome of mammography, including diagnostic procedures and their results. The results were benchmarked against standard performance indicators. Of 8,743 mammograms performed, 1,468 were for palpable lumps; the cancer diagnosis rate was 640 per 1,000 investigations (for 885 of these reported as compatible with malignancy, the cancer diagnosis rate was 95%; for 183 reported as indeterminate 60%, for 400 reported as benign/no abnormality 4%). Of 4,998 cancer follow-up mammograms, the cancer diagnosis rate was 15 per 1,000. For 76 of these reported as compatible with malignancy, the cancer diagnosis rate was 67%, for 161 reported as indeterminate, the biopsy rate was 36%, and cancer diagnosis rates of biopsy was 41%. Of 75 cancers diagnosed, 26 were locally recurrent after breast conservation and 49 new contralateral primaries, 84% of these were stage 0-I. Of 2,001 mammograms performed for screening, the biopsy rate was 4.5% and the cancer diagnosis rate of biopsy was 27%; the overall cancer diagnosis rate was 11 per 1,000 examinations; 96% of these were stage 0-1. Dedicated breast surgeons are equally proficient at mammography interpretation as radiologists. In resource-restricted environments, nonavailability of dedicated breast radiologists should not preclude development of breast units.

Income, productivity, and satisfaction of breast surgeons

Background The purpose of this study was to assess how the practice patterns of breast surgeons affect their income and job satisfaction. Methods A 19-question survey regarding practice patterns and income and job satisfaction was mailed to all active US members of the American Society of Breast Surgeons. Results There were 772 responses. An increasing percentage of breast care was associated with lower incomes ( P = .0001) and similar income satisfaction ( P = .4517) but higher job satisfaction ( P = .0001). The increasing proportion of breast care was also associated with fewer hours worked per week ( P = .0001). Although incomes were lower in surgeons with a higher proportion of their practice in breast care, income satisfaction was not affected. Conclusions Although cause and effect relationships between income and breast surgery are difficult to establish, several trends do emerge. Most significantly, we found that dedicated breast surgeons have higher job satisfaction ratings and similar income satisfaction despite lower incomes.

Accuracy of Office-Based Ultrasound Guided Needle Biopsies Performed by Dedicated Breast Surgeons.

Abstract BACKGROUND: Ultrasound guided core biopsies (USCB) are highly accurate, cost effective, and efficient at diagnosing breast disease when compared to the standard excisional biopsy. However, given the national shortage of breast imagers there may be delay in the diagnosis of benign and malignant breast disease. The American Society of Breast Surgeons (ASBS) provides training and certification in USCB for breast surgeons to perform office based procedures. However, few studies have specifically evaluated the accuracy and efficiency of USCB performed by dedicated breast surgeons. We sought to evaluate this question further by looking at the experience of breast surgeons who perform USCB at the Breast Health Center of an academic women's oncology program. We propose that USCB performed by dedicated breast surgeons in the office setting is highly accurate, and offers the patient the highest quality of care.METHODS: Following IRB approval, we identified 100 patients who underwent an USCB in the office of our Breast Health Center by dedicated breast surgeons as part of a diagnostic work-up from 1/2003 to 8/2008. Data collected included patient age, date of presentation, reason for initial consultation, clinical and ultrasound findings, diagnostic imaging, date of biopsy and subsequent surgery, type of biopsy technique used, laterality, number of biopsies performed, and pathology from both core biopsy and final excision.RESULTS: Of the 100 patients in our study, the reason for evaluation was a palpable mass in 85 (85%), and an abnormal mammogram in 13 (13%). The mean age was 44.3 years (range, 16-84). Of these lesions, 89% had a formal radiologic US(RUS) and 56% underwent definitive excision. Eighty patients underwent USCB at the time of initial consultation (80%).Demographics Total populationBiopsy + ExcisionBiopsy Only n=100n=56n=44Presentation † Mass85 (85%)44 (79%)41 (93%)Abnl MMG13 (13%)11 (20%)2 (5%)Other2 (2%)1 (2%)1 (2%)Surgeons impression* Benign41 (52%)9 (20%)32 (94%)Suspicious38 (48%)36 (80%)2 (6%)Radiologists impression* Benign33 (54%)4 (13%)29 (100%)Suspicious28 (46%)28 (87%)0 (0%)*P&amp;lt;0.001, †P&amp;lt;0.05Comparing clinical impression of benign vs. malignant disease derived from office based US (OUS) to RUS, there was 98% agreement (Kappa statistic: 0.96 (SE: 0.14), p&amp;lt;0.0001). There was good agreement on maximal dimensions between OUS and RUS (Spearman correlation of 0.75, p&amp;lt;0.0001). There was 100% agreement (95%CI: 93.6-100%) between pathology from USCB and final pathology at excision (n=56) when classified as benign versus malignant. Excluding 5 patients who underwent neoadjuvant therapy, the median time from USCB to surgery was 24.5 days(range: 3-419 days), for malignant disease it was 23 days (range: 3-76 days) and for benign it was 41 days (range: 14-419 days).CONCLUSION: USCB of breast nodules performed in the office by dedicated breast surgeons is highly accurate at diagnosing both benign and malignant lesions. The majority of patients evaluated underwent an USCB at the time of initial consultation, expediting their diagnosis and definitive treatment and thereby reducing wait time and diagnosis-related anxiety. Our study supports the ASBS process for breast ultrasound and image guided core biopsy education and certification. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6022.

Management of male breast cancer - comparison of general and dedicated breast surgeons

Aim: Male breast cancer (MBC) is uncommon, and most surgeons have an infrequent exposure to this disease. We have compared the investigation and management of MBC by general surgeons with that of dedicated breast surgeons to see if they differ.

The Effect of Dedicated Breast Surgeons on the Short-Term Outcomes in Breast Cancer

The impact of breast surgeons on short-term outcomes in breast cancer care was compared at a single institution. Many studies have demonstrated a correlation between high procedural volume and lower mortality in technically challenging procedures. Breast cancer treatment has significant impact on patient behavior, psychology, and appearance. Therefore, evaluation of outcomes cannot be limited to only operative mortality and morbidity. We sought to determine the effect of dedicated breast cancer surgeons on short-term outcomes at a single institution. Wishard Memorial Hospital is the county hospital affiliated with the Indiana University School of Medicine. A retrospective review was performed of all patients from January 1, 1997, to February 28, 2006. On July 1, 2003, coverage for the Breast Clinic was changed from general surgeons (G) to breast surgeons (B). There were 596 patients included in the study period. There were no significant differences in patient demographics or disease characteristics between the 2 time periods. For early stage (stage I and II) breast cancer, a higher percentage of patients underwent breast conservation in the breast surgeon period than in the general surgeon period (P = 0.04). Lumpectomy margins in breast conserving operations during the G period were more often positive (P = 0.025) or close (<1 mm) (P = 0.01). Similarly, the rates of re-excision lumpectomy were also significantly lower during the B period (21% vs. 39%, respectively, P = 0.01). Breast surgeons were more likely to perform the sentinel node procedure (P = 0.001). There were no differences in the use of adjuvant chemotherapy and radiation therapy. The use of hormonal manipulation, however, was significantly higher in the B group than in the G group (P < 0.0002). Surgeons specialized in diseases of the breast demonstrate significant improvement in short-term outcomes associated with breast cancer treatment at a single institution. The differences identified cannot be attributed to differences in institutional function, patient population, surgeon case volume, or on the influence of nonsurgeon physicians.

Who Wants a Blind Breast Surgeon?

Mammary ductoscopy was introduced by Japanese surgeons in the early 1990s for the direct visualization of the source of bloody nipple discharge. As techniques and equipment have evolved in the last 15 years, we now have several relatively simple submillimeter endoscopes that can be used to look within saline-distended larger ductal segments within the breast. Valdes et al. demonstrate in their early experience with ductoscopy the ability to find and visualize intraductal lesions for excision. As with prior studies, they were impressed with the ability to identify histologically significant lesions that were relatively distant from the nipple, such as an 8-cmdeep ductal carcinoma-in-situ. They clearly have increased the number of breast cancers identified before traditional radiographical imaging or clinical examination alone. From their study and others, it is not a giant leap to conclude that intraluminal abnormalities in the ductal system have just as much need to undergo biopsy as the average palpable lump or radiographical (mammographic, ultrasound, or magnetic resonance imaging) lesion. But this relatively narrow view misses the greatest power of this new technology. We do not have mammogram and magnetic resonance imaging machines in our operating rooms to direct our surgical procedures. The best we can do is preoperative needle localization and postexcision specimen imaging. Despite this, most breast surgery operations today are performed with the same intraoperative imaging tool that Halsted used: the surgeon’s palpation alone. The last decade has seen a rapid increase in intraoperative ultrasonography use by dedicated breast surgeons to assist in better and more accurate excisions of small invasive cancers. Improving our intraoperative mapping of the suspicious lesions—especially if these are potentially ductal carcinoma-in-situ—can only further enhance our success at getting truly clear margins. We understand that many cancers are years in evolution. We should not be waiting to treat them until they are invasive and have the potential to spread from the breast. Finding cancers earlier and intervening sooner has been the mantra that has led to the dramatic decreases in breast cancer death rates in the last several years. Over the last decade, we have learned the importance of ellictable fluid from the nipple, especially in high-risk individuals. If we know someone is high risk and she is having breast surgery, should we not be certain that any intraductal lesions, related or unrelated to the target of the surgical procedure, are also adequately sampled? Can we perform a more accurate lumpectomy by actually mapping out the extent of the involved ductal system and either excising it all or excising the lesion and all associated intraluminal defects? When vascular surgeons are sewing on small blood vessels, is there any argument about putting on loops to make a better and smoother suture line closure? Although there are many unanswered questions about when and how best to use our new ability to see submillimeter disease with the new ductoscopes, there is no reason for surgeons to continue to blindly operate on the breast if their vision of the extent of intraluminal ductal lesions can be improved. My personal series of using ductoscopy to direct lumpectomy margins has consistently shown a marked decrease in positive margins at first excision. Although we are still following these patients up for Received January 26, 2006; accepted February 1, 2006; published online July 8, 2008. Address correspondence and reprint requests to: William C. Dooley, MD; E-mail: william-dooley@ouhsc.edu.

Breast interventional devices: how they evolve and define new subspecialities

From 1930 to 1990 annual age-adjusted breast cancer death rates for women in the United States remained remarkably constant, oscillating around 32 deaths per 100,000 over 60 years. During this long time-frame, the surgical treatment of breast cancer evolved from radical mastectomy with mandatory lymph node dissection to lumpectomy coupled with radiation therapy. With this new paradigm, lymph node dissection was reserved for women with tumor-invaded axillary lymph nodes. Beginning in the 1970s, chemotherapy after surgery (adjuvant) and before surgery (neoadjuvant) was added to surgical treatment. The radical diminution in the scope of breast surgery did not alter the national breast cancer death rate. Doing less surgery was neither harmful nor beneficial to long-term survival from breast cancer. In the 1980s two events changed this static picture: the addition of tamoxifen to adjuvant and neoadjuvant chemotherapy, and the introduction of mammography. Beginning in 1990 annual breast cancer death rates in the United States began to fall, and have continued to fall each year since then. In 2001, the last year of published statistics, the breast cancer death rate was 26 deaths per 100,000. Best estimates for where to credit this dramatic drop in death rate place approximately 50% of the credit with improved adjuvant chemotherapy and 50% with mammography. Abnormal mammograms demand a breast biopsy since only one in five abnormal mammograms is actually a breast cancer. Consequently, widespread adoption of mammography has produced an image-guided breast biopsy industry in the United States. Open, surgical breast biopsy has been replaced with image-guided breast biopsy because improved breast biopsy tools have made image-guided breast biopsy equivalent in accuracy to open, surgical breast biopsy. These tools, in turn, have changed the professional lives of surgeons, pathologists, and mammographers, leading to the development of dedicated breast surgeons, breast pathologists, and interventional breast radiologists.