UK Breast Units Research Articles

The post Montgomery era: A new model of consent forms fit for purpose

Introduction: The Supreme Court case of Mongomery vs Lanarkshire Health Board (2015) changed informed consent; however, few departments have updated their consent form. This project sought to improve documentation of consent to comply with RCS Consent: Supported Decision–Making guidelines (2016). It involved audit cycles to monitor Quality Improvement and implementing a standardised consent form for Breast Surgery operations in a UK Breast Unit.

Variation in the management of ductal carcinoma in situ in the UK: Results of the Mammary Fold National Practice Survey

IntroductionDuctal carcinoma in situ (DCIS) accounts for approximately 10% of all newly-diagnosed breast cancers in the UK. The latest national guidelines were published in 2009 and may not reflect current best practice. We aimed to explore variation in the current management of DCIS to support the need for updated guidelines. MethodsA national practice questionnaire was developed by the Mammary Fold Academic Committee (MFAC) focussing on the pre, intra and post-operative management of DCIS. Trainees at UK breast units were invited to complete the questionnaire at their multidisciplinary team meeting to provide a comprehensive picture of current national practice. Results76 of 144 UK breast units (52.8%) participated in the survey. Variation was observed in radiological pre-operative assessment with only 33/76 units (43.4%) performing routine ultrasound assessment of the tumour or axilla. There was no clear consensus regarding indications for mastectomy; multifocality (38.2%) and extensive microcalcifications (34.2%) were the most frequent indications. 34/76 units (44.7%) offered nipple sparing mastectomy. 33/76 units (43.3%) perform sentinel node biopsy in the presence of a palpable/mass lesion and 51/76 (67.1%) at the time of mastectomy. The most widely accepted pathological radial margin remained 2 mm (36.8%). The commonest factors in decision-making for radiotherapy were tumour grade (51.3%) and size (35.5%). Only 12 units (15.8%) routinely used the Van Nuys Prognostic Index. Approximately half of all breast units offer clinical long-term follow-up. DiscussionThere is marked variation in the management of DCIS in the UK. Updated evidence-based guidelines may standardise practice and improve outcomes for patients.

Use of sulphur hexafluoride microbubbles injection to identify the sentinel lymph node in breast cancer patients: initial experience in a UK breast unit

In our Trust, all breast cancer patients undergo preoperative axillary staging with ultrasound. Over the past year we have introduced intradermal sulphur hexafluoride microbubbles ultrasound contrast injection to help identify sentinel lymph nodes for a preoperative needle biopsy in each patient. Only patients with malignant node morphology on grey-scale ultrasound undergo biopsy without microbubbles injection.

Current attitudes to breast reconstruction surgery for women at risk of post-mastectomy radiotherapy: A survey of UK breast surgeons

Decision-making for women requiring reconstruction and post-mastectomy radiotherapy (PMRT) includes oncological safety, cosmesis, patient choice, potential delay/interference with adjuvant treatment and surgeon/oncologist preference. This study aimed to quantitatively assess surgeons' attitudes and perceptions about reconstructive options in this setting, and to ascertain if surgical volume influenced advice given. A questionnaire was sent to surgical members of the UK Association of Breast Surgery (ABS) in March–June 2014. The questionnaire elicited information on surgeon volume, reconstructive practice and drivers influencing decision-making. Response rate was 42% (148/355), representing 71% of UK breast units. Delayed breast reconstruction (DBR) was offered more commonly than immediate implant, delayed-immediate or immediate autologous reconstruction (p < 0.05). Cosmesis was thought to be equivalent between IBR and DBR by 15% of surgeons, and 26% believe IBR and DBR offer similar Health-related Quality of Life (HRQoL). Surgeon volume had no effect on reconstruction choice. Common decision-making drivers included negative effects of radiotherapy upon reconstructive and cosmetic outcome. The majority of surgeons (77%) believe the current evidence base is insufficient to guide decision-making. Despite surgeons believing that cosmesis and quality of life are not equivalent between IBR and DBR, DBR remains the commonest approach to this difficult clinical scenario. Surgeons perceive they are using a variety of newer techniques such as Delayed-Immediate Reconstruction and Acellular Dermal Matrices to try to ameliorate the effects of PMRT. This survey demonstrates that there is wide variation in reported surgical practice in this difficult setting. There is widespread acknowledgement of the lack of evidence to guide decision-making.

P167. Patient satisfaction following immediate breast reconstruction using 2 stage implants

S S73 Conclusion: There is a growing body of literature regarding 3D-SI. However, evidence of its superiority over current methods of clinical decision making, surgical planning, communication and evaluation of outcome is required before it can be accepted into mainstream practice. http://dx.doi.org/10.1016/j.ejso.2015.03.204 P167. Patient satisfaction following immediate breast reconstruction using 2 stage implants Claire Quinnell, Eifion Vaughan-Williams 1 Cardiff University, Cardiff, UK Breast Unit, Royal Glamorgan Hospital e Cwm Taf NHS Trust, Llantrisant, UK Introduction: Studies have shown that breast reconstruction is an important determinant of long-term health, and is recommended for all patients without contraindications following mastectomy. The aim of this study was to ascertain the level of patient satisfaction with the cosmetic outcomes following immediate breast reconstruction (IBR). Methods: Data was collected for 127 patients, treated by IBR under a single surgeon between January 2009 and May 2014. Nineteen patients were excluded (10 failed IBRs, 9 expanders not exchanged), the remaining 108 were sent the BREAST-Q questionnaire; 74 were returned, 5 were unanswered. Results: Sixty nine questionnaires were included (64%) with a mean patient age 49 (30e73) years. Forty four (64%) reconstructed breasts matched or superseded the patients’ natural cup size; the largest implant used was 795cc e which gave its recipients at the most, a DD cup. Of the patients whose reconstructions did not match, 68% had at least a D cup naturally. Following IBR, thirty three (48%) women had further elective surgery to the contralateral breast. With regards to shape, size and alignment, 57 (83%), 50 (72%) and 37 (54%) of patients reported that they are at least somewhat happy with each of these elements respectively, and no patients reported very unsatisfactory results with their appearance when clothed. Despite encouraging results only 75% reported their reconstructions matched their expectations Conclusion: This studyhas shown that IBRoffers cosmetically acceptable results, especially if the natural breast was small. However there is clearly an opportunity for progress with regards to meeting patient expectations. http://dx.doi.org/10.1016/j.ejso.2015.03.205 P168. The ability of human observers to discriminate cosmetic outcomes of DIEP breast reconstruction following mastectomy Andrew Clayton Lee, Justin Chatterjee, Andrew Devine 1 Changi General Hospital, Singapore NHS Tayside, Dundee, UK Department of Plastic Surgery, University of British Columbia, British Columbia, Canada Dundee University School of Medicine, Dundee, UK Aim: Most systems for assessing cosmetic outcomes of breast reconstructions use humans as assessors. The validity of such systems was dependent on the ability of individuals to discriminate between good and bad cosmetic outcomes consistently within individuals and between individuals, which had never been studied. The aim of this study was to test the hypothesis that individuals were capable to discriminate cosmetic outcomes with strong intra-assessor and inter-assessor reliabilities. Methods: Clinical photographs of 20 women who underwent free DIEP-flap breast reconstruction were selected from a series of 96 to ensure a full range of aesthetic outcomes. 24 assessors ranked the clinical photographs in order according to the following parameters on 2 separate occasions: (A) Overall appearance, differences in size, shape and position between the reconstructed and natural breasts, and (B) Overall appearance, shape, deformity and scarring of the reconstructed breast. Each photo received a score fromeach ranking activity, whichwas equivalent to the respective rank position. The primary endpoints were (a) median Spearman’s rank correlation coefficients (rs) between the 1st and 2nd rankings of each individual assessor and (b) Kendall’s coefficient of concordance for ranks (W) for inter-observer concordance, for all of the above parameters. For the hypothesis to be accepted, median rs and W had to be greater than 0.70 and 0.50 respectively for each of the cosmetic parameters. Results: Median rs andW for each parameter were recorded in Table 1.

PB.10. Stereotactic 20 mm basket Intact Breast Lesion Excision System biopsy for indeterminate breast microcalcification: pilot study within a UK breast unit

For several years our breast unit has evaluated indeterminate breast microcalcification using stereo-guided vacuum-assisted core biopsy (VACB) - piecemeal acquisition of unorientated tissue. The Intact Breast Lesion Excision System (Intact) removes a single larger piece of tissue, potentially allowing pathologists to calculate margins and visualise lesion architecture more easily. This study evaluates the role of the 20 mm Intact in assessment of subcentimetre clusters of indeterminate breast microcalcification.

204. Breast cancer in women under 40: A 10 year cohort from a large UK teaching hospital

Background: Breast cancer is uncommon in young women but correlates with a less favourable prognosis. There are few studies examining this group of patients from Western European countries. The aim of this study was to explore clinical and pathological findings, management, and outcome of young breast cancer patients under the age of 40 in a large UK breast unit.

The availability of mammotome biopsy in UK breast units: Results of a national questionnaire study

The availability of mammotome biopsy in UK breast units: Results of a national questionnaire study

The ‘information spectrum’: a qualitative study of how breast cancer surgeons give information and of how their patients experience it

Cancer clinicians are routinely criticised for communicating information poorly to patients, but expert guidance is sometimes contradictory or impractical. We wanted to understand how, and how well, breast cancer surgeons in their normal practice balanced the competing tasks of informing patients while keeping them hopeful. In a post-operative surgical outpatient clinic in a UK breast unit, we recruited 9 surgeons and 20 breast cancer patients with whom they consulted. We audio recorded and interviewed both patients and surgeons about their consultations, then analysed data qualitatively within and across cases taking a constant comparative approach. Every consultation contained biomedical factually explicit information, but the information that was most significant for patients was factually less explicit. Progressively less explicit forms, along a 'spectrum' of information, included: judgments about treatment implications; judgments about prognosis; evaluative comments; and clues about what information signified. Surgeons used the less explicit types of information to communicate hope. Where prognosis was poor, communication was confined to more explicit information. Surgeons' practice was closely aligned with what patients sought. Common criticisms of cancer clinicians for giving 'too little' information belie the complexity of their task in simultaneously managing information needs and hope. The 'information spectrum' could help educators and clinicians to understand this task.

The Z11 Completion Axillary Clearance (cANC) Study Arm: Are tumour characteristics and node positivity rates comparable to a UK breast unit?

The Z11 Completion Axillary Clearance (cANC) Study Arm: Are tumour characteristics and node positivity rates comparable to a UK breast unit?

One UK Breast Unit's Experience of GP 2 week wait referrals to breast care clinic - are they appropriate?

Purpose of Audit: Around 80% of patients who go to breast clinics for investigation of possible or suspected breast cancer are referred by GPs. All patients with possible or suspected breast cancer should be referred to a breast clinic without delay. Referral guidelines have been published by the Department of Health in the UK. NICE recommends that GPs should be given feedback on their use of these guidelines, as reflected in the appropriateness of their referrals to breast clinics. This audit compared the initial GP referral letter to the end outcome in one breast care unit to assess the appropriateness of GP referrals.

ACOSOG Z0011: Are the results applicable to patients undergoing sentinel node biopsy in a UK Breast Unit

ACOSOG Z0011: Are the results applicable to patients undergoing sentinel node biopsy in a UK Breast Unit