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Is intra-operative touch imprint cytology of sentinel lymph nodes for breast cancer cost-effective in a district general hospital setting?
496
ABSTRACTS
Aim: To explore the reasons behind declining an immediate reconstruction. Methods: Between January 2010 and January 2012, all patients with mastectomy were identified. We excluded all patients when either an immediate reconstruction was done or not offered to them at the time of diagnosis. 34 patients were identified in which an immediate reconstruction was discussed but the patient chose not to have it. The patients filled in a questionnaire about the possible reasons behind their choice. Some patients selected more than one answer. Results: The reasons behind their choice are listed in this table:
Answer
Number of times selected
My aim to get the cancer sorted out first. Not interested because of my age. The time was too short for me to consider anything more than mastectomy. I was not concerned about my appearance. I was afraid of the complications and the long recovery time. There was too much information to take in at that time. Not be safe to have it done with the cancer.
21 18 17 9 8 6 4
Discussion: Patient’s anxiety because of the diagnosis of cancer, age and too short time to consider and decide are the main factors behind not having immediate reconstruction. Considering all these reasons and allowing more time with more information and support may help patients to consider this option in a better and positive way. http://dx.doi.org/10.1016/j.ejso.2013.01.159
P124. Routine follow-up of benign phylloides tumours is not indicated Senthurun Mylvaganama, Lucinda Frankb, Clare Toroa, Sarah Vesteyb, Steven Thrusha a Worcestershire Acute NHS Trust, Worcester, Worcestershire, UK b Gloucestershire Hospital NHS Trust, Gloucester, Gloucestershire, UK
Introduction: Phylloides tumours are rare fibroepithelial breast tumours accounting for 1% of breast cancers. They occur more commonly with increasing age and are usually cured with local excision. No clear national guidance exists on the assessment, treatment and follow-up of these patients. Aims: To determine the current follow-up practice and assess the recurrence rate of phylloides tumours across 2 trusts (10 breast surgeons). Methods: Multicentre retrospective analysis of all cases of phylloides tumours on core and/or excision biopsy from March 2006 to July 2012 at Worcestershire Acute NHS Trust and Gloucestershire Hospitals NHS Trust. Results: N ¼ 94. Mean age 48. Mean clinical size 31.7mm, mean radiological size 35.4mm. Excision margin of >1mm achieved in 62%. All 4 malignant phylloides reported as B3 Benign on core biopsy. 23 different follow-up regimes were observed. Follow-up length ranged from postoperative discharge to 4yr follow-up. 6 recurrent phylloides tumours were seen, 4 benign and 2 malignant. All benign recurrences were local and found independently of follow-up. The earliest recurrence was at 6 yrs and the latest at 10yrs. The 2 malignant recurrences were seen at 1 and 3 years post-operatively. Discussion: There is no standard for the follow-up of benign or malignant phylloides tumours, which is demonstrated by the varying number of
regimes demonstrated. This study suggests that in the benign group, the risk of recurrence is small and when it occurs is identified by the patient. We advocate no routine follow-up of this group. Malignant (or indeterminate) Phylloides tumours do require follow-up surveillance. http://dx.doi.org/10.1016/j.ejso.2013.01.160
P125. Selective tissue adhesion reducing seroma formation in extensive breast surgery: the application of TissuGluÒ - only problematic case solver or possible standard procedure? Stefan Paepke, Marion Kiechle Klinikum Rechts der Isar, TU M€unchen, Frauenklinik and Poliklinik, Munich, Germany
Background: Seroma development remains a common postoperative complication after breast surgery.In up to 8-12% seroma formation leads to severe problems during postoperative care such as repeated fluid puncture and aspiration, wound healing disorders, surgical revision and therefore delayed start of adjuvant treatment. Postoperative seroma formation is a multifactorial process with an integral self-sustaining component as the fluid accumulation leads to spreading of the tissue surfaces averting local mechanisms promoting surface adherence and wound healing processes. The cavity and shearing forces between the tissue layers supports further seroma production. The surgical adhesive TissuGluÒ is a lysine-derived urethane curing moisture behavior. The adhesive is resorbable and biocompatible and forms a bond between tissue layers. Operation principle lies in the reduction of the resection area through selective tissue adhesion and therefore reduction of the exudative surface. Methods: Initially in our collective TissuGluÒ was used in cases with excessive postoperative seroma formation needing surgical revision (n¼3). After experimental verification of post interventional good response and smooth wound healing the indication was extended to primary usage in patients receiving mastectomy at high risk for wound healing disorders (n¼4). Results: In our patient collective a reduced seroma rate and a lower wound healing deficit could be surveyed. Accordingly the average length of time for drain removal could be shortened. Conclusions: Our experience on few patients showed a benefit in problematic cases and may also indicate a reduction of seroma formation in subgroups of patients with extensive breast surgery with an expectedly high incidence of wound exsudate. Protectively collected date will clarify future use and economic profitability. http://dx.doi.org/10.1016/j.ejso.2013.01.161
P126. Is intra-operative touch imprint cytology of sentinel lymph nodes for breast cancer cost-effective in a district general hospital setting? Andrea Pisesky, Wahidun Nabi, Victor Chow, Bavithra Vijayakumar, Andrzej Karmolinski, Peter Frecker, Md Zaker Ullah Whipps Cross University Hospital, London, UK
Introduction: Touch imprint cytology (TIC) of sentinel lymph nodes intra-operatively is an established method of analyzing lymph node status for breast cancer patients. Due to a lack of resources and cytological expertise, this test is not universally available within the NHS. We have calculated the cost-effectiveness of intra-operative TIC of sentinel lymph nodes (SLN) since its introduction in our DGH. Method: Data was collected between April 2010 and April 2012. 102 consecutive patients with invasive breast carcinoma were studied. Using a double-dye technique, SLN biopsies were sent intra-operatively for
ABSTRACTS
497
TIC. Patients with positive nodes had axillary node clearance during the same operation. All samples were sent for final histopathological analysis. Cost-effective analysis was performed based on the number of re-do axillary operations avoided. Results: 102 consecutive cases were studied. The majority (83 patients) had negative SLN involvement and 13 had positive SLNs, resulting in axillary clearance during the same operation. 11 false negative results (7 micrometastases) were identified along with 1 false positive result. The sensitivity of TIC was 76.5% and the specificity 98.8%. Micro-metastases defined as <2mm were treated as negative results as recent studies from ACOSOG Z0011 have shown no survival benefit of further axillary surgery. Conclusion: TIC is a cost-effective method of analyzing lymph node status intra-operatively in a DGH. Within the first 2 years of TIC we have managed to save 13 redo axillary clearance surgical procedures. Furthermore, it serves to reduce patient anxiety, time and morbidity associated with a second surgical procedure. http://dx.doi.org/10.1016/j.ejso.2013.01.162
P128. Breast cancer surgery for the elderly e are we meeting a growing need? Sisse Olsen, Mary Davies, Julie Dunn Royal Devon & Exeter Hospital, Devon, UK
Introduction: NICE guidelines issued in February 2009 recommend surgery for breast cancer where possible over endocrine treatment. We aim to review management and proportion of patients presenting with breast cancer aged over 80 during a 12 year period and audit patients presenting after 2009 against NICE guideline and explore reasons for noncompliance. Method: Retrospective audit of all patients presenting with breast cancer to a single high-volume centre from 2000-2012. One-tailed Fisher’s Exact Test used throughout. Results: 5446 patients were treated at our unit from 2000-2012 with the over 80s comprising 6.0-8.7% p.a. This age group increased over time by 29% from 6.5% in 2000-2003 to 8.4% (p¼ 0.0001) in 20092012. The population aged 90 or over increased by 50% from 1.7% to 2.6% (p¼ 0.06) in the same period. See Table 1.
Table 1 Patients undergoing breast cancer surgery Patients aged 80-89 2000-2008 267/396 (67%)
Patients aged 90 and over 2009-2012 172/230 (75%)
p-value 0.03
P127. Clinician-led financial review of breast cancer surgery e making the service sustainable Sisse Olsen, Douglas Ferguson Royal Devon and Exeter Hospital, Devon, UK
Background: NHS trusts must reduce costs to meet available income from national tariffs. We describe the result of clinician led financial review of wide local excision (WLE). Methods: Data from financial databases and theatre database covering all cases over a 12 month period and record review for selected cases in a teaching NHS Foundation Trust was performed by a senior surgical trainee with consultants, management, finance and information services. Results: Mean WLE cost per inpatient was £2024 but income only £1645, resulting in a £378 loss. For day-case WLE loss was slightly lower£323. The total loss on all WLE procedure groups was £97013/year. Costs per case were: Theatre related 50%, pathology 20% and ward 19%. 66% of Day-cases had falsely high ward costs due to a systematic error in cost allocation. In 30% cases the charged tariff was too low as 28% wire-guided excisions were coded incorrectly leading to undercharging of £338-486/case and sentinel nodes were not charged for. In addition the coding system did not take account of co-morbidities in 77% patients. Patients with comorbidities attract higher tariffs of £200-300/case. Discussion: This departmental service line reporting pilot informed clinicians and managers of possible improvements of pathways of care and efficiency savings with respect to Trust cost improvement programmes. Routine co-morbidity recording in clinic letters, maximising same day discharges, addressing erroneous low tariff allocation, accurate ward charges and controlling theatre costs (consumables and theatre time) will all improve financial management. With these changes a small profit would be achievable. http://dx.doi.org/10.1016/j.ejso.2013.01.163
2000-2008 18/64 (28%)
2009-2012 21/47 (44%)
p-value 0.05
The proportion of patients undergoing surgery increased following the 2009 NICE guidelines. Following introduction of regional anaesthesia without GA in 2011, the proportion having surgery aged over 90 increased to 16/25 (64% p-0.0031). Of patients not having surgery after 2009, 48 were deemed unfit and 36 declined surgery. Conclusion: The elderly are a growing part of our population of breast cancer patients. We have increased the proportion of elderly patients having surgery in line with NICE guidance, partly due to regional anaesthesia for breast surgery and modification of care pathways. http://dx.doi.org/10.1016/j.ejso.2013.01.164
P129. Managing the axilla after neoadjuvant chemotherapy e An alorithm approach Mandana Pennick St Helens & Knowsley NHS Trust, Merseyside, UK
Background: Data suggest neoadjuvant chemotherapy (NAC) can downstage the axilla in up to 40% of breast cancers, yet there is no consensus regarding timing and extent of axillary surgery post NAC. Sentinel lymph node biopsy (SLNB) after NAC is also debated. We performed a literature review and suggest an algorithm for the management of the axilla post NAC. Methods: Available literature & trial data relating to the topic were reviewed. We then designed a suggested treatment algorithm for these patients, based on the available evidence. Results: Level one evidence supports of SLNB post chemotherapy. No consensus exists regarding the management of the ‘downstaged’ axilla. National Trial data show low chest wall and regional node failure rates in these patients, especially when complete pathological response in the breast is achieved. Conclusions: SLNB post NAC is possible, false negative rates are comparable to SLNB pre systemic treatment. We suggest an NAC-Axillary algorithm: Any patient with clinically involved nodes pre-NAC undergoes ALND post-NAC. All patients have pre-NAC axillary ultrasound (USS). If node negative pre-NAC, perform SLNB post-NAC. If SLNB positive, for
ABSTRACTS
Aim: To explore the reasons behind declining an immediate reconstruction. Methods: Between January 2010 and January 2012, all patients with mastectomy were identified. We excluded all patients when either an immediate reconstruction was done or not offered to them at the time of diagnosis. 34 patients were identified in which an immediate reconstruction was discussed but the patient chose not to have it. The patients filled in a questionnaire about the possible reasons behind their choice. Some patients selected more than one answer. Results: The reasons behind their choice are listed in this table:
Answer
Number of times selected
My aim to get the cancer sorted out first. Not interested because of my age. The time was too short for me to consider anything more than mastectomy. I was not concerned about my appearance. I was afraid of the complications and the long recovery time. There was too much information to take in at that time. Not be safe to have it done with the cancer.
21 18 17 9 8 6 4
Discussion: Patient’s anxiety because of the diagnosis of cancer, age and too short time to consider and decide are the main factors behind not having immediate reconstruction. Considering all these reasons and allowing more time with more information and support may help patients to consider this option in a better and positive way. http://dx.doi.org/10.1016/j.ejso.2013.01.159
P124. Routine follow-up of benign phylloides tumours is not indicated Senthurun Mylvaganama, Lucinda Frankb, Clare Toroa, Sarah Vesteyb, Steven Thrusha a Worcestershire Acute NHS Trust, Worcester, Worcestershire, UK b Gloucestershire Hospital NHS Trust, Gloucester, Gloucestershire, UK
Introduction: Phylloides tumours are rare fibroepithelial breast tumours accounting for 1% of breast cancers. They occur more commonly with increasing age and are usually cured with local excision. No clear national guidance exists on the assessment, treatment and follow-up of these patients. Aims: To determine the current follow-up practice and assess the recurrence rate of phylloides tumours across 2 trusts (10 breast surgeons). Methods: Multicentre retrospective analysis of all cases of phylloides tumours on core and/or excision biopsy from March 2006 to July 2012 at Worcestershire Acute NHS Trust and Gloucestershire Hospitals NHS Trust. Results: N ¼ 94. Mean age 48. Mean clinical size 31.7mm, mean radiological size 35.4mm. Excision margin of >1mm achieved in 62%. All 4 malignant phylloides reported as B3 Benign on core biopsy. 23 different follow-up regimes were observed. Follow-up length ranged from postoperative discharge to 4yr follow-up. 6 recurrent phylloides tumours were seen, 4 benign and 2 malignant. All benign recurrences were local and found independently of follow-up. The earliest recurrence was at 6 yrs and the latest at 10yrs. The 2 malignant recurrences were seen at 1 and 3 years post-operatively. Discussion: There is no standard for the follow-up of benign or malignant phylloides tumours, which is demonstrated by the varying number of
regimes demonstrated. This study suggests that in the benign group, the risk of recurrence is small and when it occurs is identified by the patient. We advocate no routine follow-up of this group. Malignant (or indeterminate) Phylloides tumours do require follow-up surveillance. http://dx.doi.org/10.1016/j.ejso.2013.01.160
P125. Selective tissue adhesion reducing seroma formation in extensive breast surgery: the application of TissuGluÒ - only problematic case solver or possible standard procedure? Stefan Paepke, Marion Kiechle Klinikum Rechts der Isar, TU M€unchen, Frauenklinik and Poliklinik, Munich, Germany
Background: Seroma development remains a common postoperative complication after breast surgery.In up to 8-12% seroma formation leads to severe problems during postoperative care such as repeated fluid puncture and aspiration, wound healing disorders, surgical revision and therefore delayed start of adjuvant treatment. Postoperative seroma formation is a multifactorial process with an integral self-sustaining component as the fluid accumulation leads to spreading of the tissue surfaces averting local mechanisms promoting surface adherence and wound healing processes. The cavity and shearing forces between the tissue layers supports further seroma production. The surgical adhesive TissuGluÒ is a lysine-derived urethane curing moisture behavior. The adhesive is resorbable and biocompatible and forms a bond between tissue layers. Operation principle lies in the reduction of the resection area through selective tissue adhesion and therefore reduction of the exudative surface. Methods: Initially in our collective TissuGluÒ was used in cases with excessive postoperative seroma formation needing surgical revision (n¼3). After experimental verification of post interventional good response and smooth wound healing the indication was extended to primary usage in patients receiving mastectomy at high risk for wound healing disorders (n¼4). Results: In our patient collective a reduced seroma rate and a lower wound healing deficit could be surveyed. Accordingly the average length of time for drain removal could be shortened. Conclusions: Our experience on few patients showed a benefit in problematic cases and may also indicate a reduction of seroma formation in subgroups of patients with extensive breast surgery with an expectedly high incidence of wound exsudate. Protectively collected date will clarify future use and economic profitability. http://dx.doi.org/10.1016/j.ejso.2013.01.161
P126. Is intra-operative touch imprint cytology of sentinel lymph nodes for breast cancer cost-effective in a district general hospital setting? Andrea Pisesky, Wahidun Nabi, Victor Chow, Bavithra Vijayakumar, Andrzej Karmolinski, Peter Frecker, Md Zaker Ullah Whipps Cross University Hospital, London, UK
Introduction: Touch imprint cytology (TIC) of sentinel lymph nodes intra-operatively is an established method of analyzing lymph node status for breast cancer patients. Due to a lack of resources and cytological expertise, this test is not universally available within the NHS. We have calculated the cost-effectiveness of intra-operative TIC of sentinel lymph nodes (SLN) since its introduction in our DGH. Method: Data was collected between April 2010 and April 2012. 102 consecutive patients with invasive breast carcinoma were studied. Using a double-dye technique, SLN biopsies were sent intra-operatively for
ABSTRACTS
497
TIC. Patients with positive nodes had axillary node clearance during the same operation. All samples were sent for final histopathological analysis. Cost-effective analysis was performed based on the number of re-do axillary operations avoided. Results: 102 consecutive cases were studied. The majority (83 patients) had negative SLN involvement and 13 had positive SLNs, resulting in axillary clearance during the same operation. 11 false negative results (7 micrometastases) were identified along with 1 false positive result. The sensitivity of TIC was 76.5% and the specificity 98.8%. Micro-metastases defined as <2mm were treated as negative results as recent studies from ACOSOG Z0011 have shown no survival benefit of further axillary surgery. Conclusion: TIC is a cost-effective method of analyzing lymph node status intra-operatively in a DGH. Within the first 2 years of TIC we have managed to save 13 redo axillary clearance surgical procedures. Furthermore, it serves to reduce patient anxiety, time and morbidity associated with a second surgical procedure. http://dx.doi.org/10.1016/j.ejso.2013.01.162
P128. Breast cancer surgery for the elderly e are we meeting a growing need? Sisse Olsen, Mary Davies, Julie Dunn Royal Devon & Exeter Hospital, Devon, UK
Introduction: NICE guidelines issued in February 2009 recommend surgery for breast cancer where possible over endocrine treatment. We aim to review management and proportion of patients presenting with breast cancer aged over 80 during a 12 year period and audit patients presenting after 2009 against NICE guideline and explore reasons for noncompliance. Method: Retrospective audit of all patients presenting with breast cancer to a single high-volume centre from 2000-2012. One-tailed Fisher’s Exact Test used throughout. Results: 5446 patients were treated at our unit from 2000-2012 with the over 80s comprising 6.0-8.7% p.a. This age group increased over time by 29% from 6.5% in 2000-2003 to 8.4% (p¼ 0.0001) in 20092012. The population aged 90 or over increased by 50% from 1.7% to 2.6% (p¼ 0.06) in the same period. See Table 1.
Table 1 Patients undergoing breast cancer surgery Patients aged 80-89 2000-2008 267/396 (67%)
Patients aged 90 and over 2009-2012 172/230 (75%)
p-value 0.03
P127. Clinician-led financial review of breast cancer surgery e making the service sustainable Sisse Olsen, Douglas Ferguson Royal Devon and Exeter Hospital, Devon, UK
Background: NHS trusts must reduce costs to meet available income from national tariffs. We describe the result of clinician led financial review of wide local excision (WLE). Methods: Data from financial databases and theatre database covering all cases over a 12 month period and record review for selected cases in a teaching NHS Foundation Trust was performed by a senior surgical trainee with consultants, management, finance and information services. Results: Mean WLE cost per inpatient was £2024 but income only £1645, resulting in a £378 loss. For day-case WLE loss was slightly lower£323. The total loss on all WLE procedure groups was £97013/year. Costs per case were: Theatre related 50%, pathology 20% and ward 19%. 66% of Day-cases had falsely high ward costs due to a systematic error in cost allocation. In 30% cases the charged tariff was too low as 28% wire-guided excisions were coded incorrectly leading to undercharging of £338-486/case and sentinel nodes were not charged for. In addition the coding system did not take account of co-morbidities in 77% patients. Patients with comorbidities attract higher tariffs of £200-300/case. Discussion: This departmental service line reporting pilot informed clinicians and managers of possible improvements of pathways of care and efficiency savings with respect to Trust cost improvement programmes. Routine co-morbidity recording in clinic letters, maximising same day discharges, addressing erroneous low tariff allocation, accurate ward charges and controlling theatre costs (consumables and theatre time) will all improve financial management. With these changes a small profit would be achievable. http://dx.doi.org/10.1016/j.ejso.2013.01.163
2000-2008 18/64 (28%)
2009-2012 21/47 (44%)
p-value 0.05
The proportion of patients undergoing surgery increased following the 2009 NICE guidelines. Following introduction of regional anaesthesia without GA in 2011, the proportion having surgery aged over 90 increased to 16/25 (64% p-0.0031). Of patients not having surgery after 2009, 48 were deemed unfit and 36 declined surgery. Conclusion: The elderly are a growing part of our population of breast cancer patients. We have increased the proportion of elderly patients having surgery in line with NICE guidance, partly due to regional anaesthesia for breast surgery and modification of care pathways. http://dx.doi.org/10.1016/j.ejso.2013.01.164
P129. Managing the axilla after neoadjuvant chemotherapy e An alorithm approach Mandana Pennick St Helens & Knowsley NHS Trust, Merseyside, UK
Background: Data suggest neoadjuvant chemotherapy (NAC) can downstage the axilla in up to 40% of breast cancers, yet there is no consensus regarding timing and extent of axillary surgery post NAC. Sentinel lymph node biopsy (SLNB) after NAC is also debated. We performed a literature review and suggest an algorithm for the management of the axilla post NAC. Methods: Available literature & trial data relating to the topic were reviewed. We then designed a suggested treatment algorithm for these patients, based on the available evidence. Results: Level one evidence supports of SLNB post chemotherapy. No consensus exists regarding the management of the ‘downstaged’ axilla. National Trial data show low chest wall and regional node failure rates in these patients, especially when complete pathological response in the breast is achieved. Conclusions: SLNB post NAC is possible, false negative rates are comparable to SLNB pre systemic treatment. We suggest an NAC-Axillary algorithm: Any patient with clinically involved nodes pre-NAC undergoes ALND post-NAC. All patients have pre-NAC axillary ultrasound (USS). If node negative pre-NAC, perform SLNB post-NAC. If SLNB positive, for