- Email: [email protected]
15. VTE prophylaxis in breast surgery – What are we doing?
604
ABSTRACTS
effect size ¼ 2.39), social functioning (p¼0.027, effect size ¼ 2.21), pain (p¼0.035, effect size ¼ 2.11) and physical wellbeing (p¼0.035, effect size ¼ 2.11). Younger age adversely affected psychosocial functioning with decreased role functioning (p¼0.055, effect size¼ 1.92) and social functioning (p¼0.025, effect size¼ 2.24). Conclusion: Evaluation of HRQL effects particularly in functional domains (role and social) are important beyond 12 months up to 3 years, particularly following early surgical complications and in younger women. The effects of PMRT may be considered a surrogate for more aggressive tumours affecting social functioning and arm symptoms in the context of improvements in most HRQL domains, notably global QL. Disease-specific PROMS have a complimentary role alongside surgery-specific PROMS and require future analyses in cohort studies. 1. Winters ZE, et al. Annals of Surgery 2010; 252(6): 929-42. 2. Winters ZE, et al. BJS 2013; 100(2): 240-51. http://dx.doi.org/10.1016/j.ejso.2014.02.202 13. The ongoing requirement of operative procedures following latissimus dorsi reconstruction e are we looking at the tip of an iceberg? Isabella Dash, Marcus Galea Great Western Hospital, Swindon, UK Introduction: Survivorship following breast cancer treatments means that the woman’s ‘reconstruction journey’ often continues long after her cancer treatment has finished. Revision surgery together with increasing numbers of reconstructions means an increased surgical workload long after the primary cancer surgery. Aim: The aim of this study was to look at the type, frequency and timing of additional surgery in a cohort of breast cancer women having Latissimus Dorsi reconstructions after mastectomy, managed in a single centre and with long follow up. Methods: The data was from a prospectively maintained database of Latissimus Dorsi (LD) breast reconstructions following mastectomies from 1995 onwards. Results: Three hundred and seventy women with a median follow up of 8 years (range:1-16yrs) are included. 186 (50%) women underwent a total of 351 further operative procedures. Of these 186 women, 101 (54%) had radiotherapy to their reconstruction and 85 had no radiotherapy; 124 (66%) had an implant assisted reconstruction against 62 (33%) with an autologous LD.
Procedure
No. of Women
Partial Skin Necrosis Soft Tissue Flap Revision Implant Removal Capsulotomy & Implant Exchange Skin Revision Nipple Reconstruction
13 14 22 28 30 105
Timing of Further Procedures
Radiotherapy
No Radiotherapy
0-5 years 5-10 years 10 + years
25% 3% 1%
18% 3% 1%
Conclusion: Fifty percent of women having LD reconstruction for breast cancer undergo further operative procedures, usually for cosmesis and frequently related to the ‘subflap’ prosthesis. Women continue to have revision surgery many years after their initial breast cancer ‘treatment’. This workload will continue to increase with more women having reconstructions
and improved survivorship. With heightened expectation of good outcomes and early discharge from routine follow up, will this extended cosmetic journey remain funded within the current NHS framework. http://dx.doi.org/10.1016/j.ejso.2014.02.203
14. Improving team working within a breast MDT: An observational approach Tasha Gandamihardja1, Susan McInerney1, Tayana Soukup2, Nick Sevdalis2 1 Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK 2 Department of Surgery and Centre for Patient Safety, Imperial College, London, UK Introduction: Multidisciplinary team (MDT) driven cancer care is a mandatory national healthcare policy in the UK. However, there are very few studies that have looked into how individual team-members work together within a cancer MDT setting. We report a study, which investigated team working within our institution’s breast MDT. Method: A prospective observational study was undertaken between June-November 2013 of the Breast MDT. A clinical observer scored quality of information, presentation and contribution by core members in real time, using a validated tool; MDT-MODe (Metric for the Observation of Decision Making)1. Each patient was scored separately (1-5 scales) and aggregated data across all discussed patients were produced. Data was analysed using descriptive and Kruskal-Wallis statistical analysis. Results: Ten MDT meetings were observed (n¼346 patients); 3 meetings were double rated revealing very good reliability of observations (reliability coefficients 0.73-0.93). An average of n¼42 cases were discussed per MDT (range 29-51), with 3mins 20secs (range 31secs-9mins) dedicated to each patient. An outcome decision was made in 99% of cases. Breast care nurses scored significantly lower (mean¼1.79, SD¼0.12) compared to all other team-members in their contribution to discussions. Information on psychosocial aspects (mean¼1.69, SD¼0.68), co-morbidities (mean¼1.36, SD¼0.39) and patient’s views (mean¼1.47, SD¼0.34) were also significantly less well represented compared to biomedical information. Moreover, overall quality of information (p¼0.002) and discussion (p¼0.000) significantly deteriorated over time within meetings, indicating possible meeting fatigue. Conclusion: The study shows that evaluating an MDT via direct observation is feasible and reliable. There was a consistent level of quality of information coverage and contribution within the MDT, but these could be improved. Data were fed back to the team and interventions for improvement were decided, including having a dedicated chair-person, reducing the length of the MDT, and changing the room layout to increase individual contribution. References 1. Lamb BW, Wong HW, Vincent C, Green JS, Sevdalis N. Teamwork and team performance in multidisciplinary cancer teams: Development and evaluation of an observational assessment tool. BMJ Quality & Safety 2011;20:849-56. http://dx.doi.org/10.1016/j.ejso.2014.02.204
15. VTE prophylaxis in breast surgery e What are we doing? Sophie Helme, Jake Sloane, Jasdeep Gahir, Syeda Gilani, Serena Ledwidge, Andrew Baildam, Jennifer Hu St Bartholomew’s Hospital, London, UK Introduction: In breast surgery there is a balance of risk between venous thromboembolism (VTE) and post-operative haematoma.
ABSTRACTS The NICE guidelines (2010) state that all cancer surgery patients should be given mechanical and pharmacological prophylaxis unless contraindicated. More recently published International Clinical Practice guidelines (2012) recommend pharmacological prophylaxis for cancer surgery patients to be given 2-12 hours preoperatively and continued for 7-10 days. In the absence of national guidelines specific to breast surgery we sought to ascertain what current practice is within the UK. Methods: A web based survey was sent to surgeons within the 199 Breast Units in the UK. Results: Responses were received from 67 surgeons. 33% give LMWH to day-case patients and 72% to patients staying overnight. 27% use it for high risk patients only. Pre-operative LMWH is given routinely in 11%, and in high risk patients in 33%. Only 3% give LMWH post discharge. The type of surgery influences whether patients receive LMWH e over 90% for complex reconstructive cases and 50% for wide local excisions. 67% of units use Local Trust Policy Guidelines for general or breast surgery and 33% are guided by individual surgeon preference. Conclusion: There is a wide variation in practice for use of VTE prophylaxis within UK Breast Units. In over 1/3 of units, there are no local or national protocols followed. We suggest a need for national guidelines specific to breast surgery to help guide best practice. http://dx.doi.org/10.1016/j.ejso.2014.02.205
605 16. Is open diagnostic excision biopsy for B3 lesions redundant? Caroline Strachan, Abeer Shaaban, Nisha Sharma, Kieran Horgan St James University Hospital, Leeds, UK Introduction: B3 lesions are defined by their indeterminate nature. Uncertain radiological appearance prompts core biopsy and subsequent B3 pathology traditionally prompts surgical excision due to malignant potential. Vacuum assisted biopsy (VAB) represents a directional change for diagnosis and management of B3 lesions. Offering larger volume sampling allows more representative pathology and diagnostic confidence. Methodology: Our Unit implemented a pathway of second line VAB, following an initial B3 core biopsy for a screened population. We present the 5 year results from analysis of our database. Results: 366 patients with B3 core pathology were identified, of which 294 had 2nd line VAB. VAB allowed 219 to be discharged to mammographic follow up: either routine screening or 5 year annual mammography. No cancers were subsequently detected in this group. Following VAB, 73 patients had surgery. 42 patients had therapeutic surgery, as VAB showed malignancy. In 33 cases, diagnosis remained indeterminate and diagnostic excision was required. 5 of these were malignant. 6 Patients with a VAB diagnosis of in-situ, showed invasive carcinoma on final excisional histology. No patients had downgrading of their pathology following surgery. Conclusion: VAB has revolutionised B3 management, with 88.7% avoiding unnecessary diagnostic surgery. The role of surgery in B3 lesions has evolved, from a ‘gold standard’ diagnostic procedure to definitive therapeutic intervention, following accurate pathological staging through VAB for the majority. http://dx.doi.org/10.1016/j.ejso.2014.02.206
Session 11 e Nursing Submitted Papers, Monday 19th May 2014, 16:30 to 18:00 17. “Moving On” an education programme for people who have completed breast cancer treatment Ruth O’Connor, Jane Watts, Pauline Boardman Frimley Park Hospital, Surrey, UK In 2009 the breast unit committed to Breakthrough Breast Cancers Service Pledge, which emphasises the need for support on completion of breast cancer treatment. After looking into education programmes already available for people after cancer, we could see there was nothing nearby for those who’d had breast cancer. These people often have specific queries about their health post treatment. We responded by designing a Moving on programme and in Autumn 2011 we began three pilot programmes; one each in the morning, afternoon and evening, to cater for people who were working or had childcare commitments. We found a church hall venue and hoped that holding the sessions away from the hospital, where there was easy and free parking, would increase attendance. We invited people who had completed treatment for primary breast cancer, excluding Herceptin. We asked them to commit to attend all six sessions. For the three pilot courses, 100 invitations were sent out, 52 people responded and 40 attended. Only one person dropped out. The courses were run by the breast care nurses and the hospital’s clinical psychologist. We recruited speakers from the hospital and our local cancer centre at no cost, to cover diet, exercise, finance, health and wellbeing, surgery, oncology and lingerie. To monitor the course’s effectiveness we asked the participants to complete two questionnaires before and after: the Quality of life Scale (QoLS) and the General Health Questionnaire (GHQ). The GHQ scores
showed significant improvement and the QoLS remained stable. When we evaluated the course, all attendees said they’d recommend it to a friend. We are now running the course three times a year, alternating between day and evening sessions. The course maintains a core of topics and speakers, but is adapted to suit the attendees each time. Each course is evaluated to ensure content is up to date. We have come to the end of our sixth group and have three more booked for 2014. So far 84 people have completed the programme and the most recent course had a waiting list. From the programme a choir for breast cancer patients has started and a secondary breast care support group has been formed. The programme benefits patients, but it also educates healthcare professionals. We too easily assume that once people complete treatment they’re on the road to recovery. But it can take a long time to recover enough to return to work and family life. http://dx.doi.org/10.1016/j.ejso.2014.02.207
18. The breast care nurse role in the management of breast cancer in a young woman with diminished mental capacity e An example of collaborative working Claire Moody, Jan Harley, Alice Townend North Tees NHS Foundation Trust, Teesside, UK Introduction: This is the case of L, a 45 year old female with learning difficulties who presented to the one stop breast clinic with suspected breast cancer and refused to have mammography or biopsy. The dilemma here was
ABSTRACTS
effect size ¼ 2.39), social functioning (p¼0.027, effect size ¼ 2.21), pain (p¼0.035, effect size ¼ 2.11) and physical wellbeing (p¼0.035, effect size ¼ 2.11). Younger age adversely affected psychosocial functioning with decreased role functioning (p¼0.055, effect size¼ 1.92) and social functioning (p¼0.025, effect size¼ 2.24). Conclusion: Evaluation of HRQL effects particularly in functional domains (role and social) are important beyond 12 months up to 3 years, particularly following early surgical complications and in younger women. The effects of PMRT may be considered a surrogate for more aggressive tumours affecting social functioning and arm symptoms in the context of improvements in most HRQL domains, notably global QL. Disease-specific PROMS have a complimentary role alongside surgery-specific PROMS and require future analyses in cohort studies. 1. Winters ZE, et al. Annals of Surgery 2010; 252(6): 929-42. 2. Winters ZE, et al. BJS 2013; 100(2): 240-51. http://dx.doi.org/10.1016/j.ejso.2014.02.202 13. The ongoing requirement of operative procedures following latissimus dorsi reconstruction e are we looking at the tip of an iceberg? Isabella Dash, Marcus Galea Great Western Hospital, Swindon, UK Introduction: Survivorship following breast cancer treatments means that the woman’s ‘reconstruction journey’ often continues long after her cancer treatment has finished. Revision surgery together with increasing numbers of reconstructions means an increased surgical workload long after the primary cancer surgery. Aim: The aim of this study was to look at the type, frequency and timing of additional surgery in a cohort of breast cancer women having Latissimus Dorsi reconstructions after mastectomy, managed in a single centre and with long follow up. Methods: The data was from a prospectively maintained database of Latissimus Dorsi (LD) breast reconstructions following mastectomies from 1995 onwards. Results: Three hundred and seventy women with a median follow up of 8 years (range:1-16yrs) are included. 186 (50%) women underwent a total of 351 further operative procedures. Of these 186 women, 101 (54%) had radiotherapy to their reconstruction and 85 had no radiotherapy; 124 (66%) had an implant assisted reconstruction against 62 (33%) with an autologous LD.
Procedure
No. of Women
Partial Skin Necrosis Soft Tissue Flap Revision Implant Removal Capsulotomy & Implant Exchange Skin Revision Nipple Reconstruction
13 14 22 28 30 105
Timing of Further Procedures
Radiotherapy
No Radiotherapy
0-5 years 5-10 years 10 + years
25% 3% 1%
18% 3% 1%
Conclusion: Fifty percent of women having LD reconstruction for breast cancer undergo further operative procedures, usually for cosmesis and frequently related to the ‘subflap’ prosthesis. Women continue to have revision surgery many years after their initial breast cancer ‘treatment’. This workload will continue to increase with more women having reconstructions
and improved survivorship. With heightened expectation of good outcomes and early discharge from routine follow up, will this extended cosmetic journey remain funded within the current NHS framework. http://dx.doi.org/10.1016/j.ejso.2014.02.203
14. Improving team working within a breast MDT: An observational approach Tasha Gandamihardja1, Susan McInerney1, Tayana Soukup2, Nick Sevdalis2 1 Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK 2 Department of Surgery and Centre for Patient Safety, Imperial College, London, UK Introduction: Multidisciplinary team (MDT) driven cancer care is a mandatory national healthcare policy in the UK. However, there are very few studies that have looked into how individual team-members work together within a cancer MDT setting. We report a study, which investigated team working within our institution’s breast MDT. Method: A prospective observational study was undertaken between June-November 2013 of the Breast MDT. A clinical observer scored quality of information, presentation and contribution by core members in real time, using a validated tool; MDT-MODe (Metric for the Observation of Decision Making)1. Each patient was scored separately (1-5 scales) and aggregated data across all discussed patients were produced. Data was analysed using descriptive and Kruskal-Wallis statistical analysis. Results: Ten MDT meetings were observed (n¼346 patients); 3 meetings were double rated revealing very good reliability of observations (reliability coefficients 0.73-0.93). An average of n¼42 cases were discussed per MDT (range 29-51), with 3mins 20secs (range 31secs-9mins) dedicated to each patient. An outcome decision was made in 99% of cases. Breast care nurses scored significantly lower (mean¼1.79, SD¼0.12) compared to all other team-members in their contribution to discussions. Information on psychosocial aspects (mean¼1.69, SD¼0.68), co-morbidities (mean¼1.36, SD¼0.39) and patient’s views (mean¼1.47, SD¼0.34) were also significantly less well represented compared to biomedical information. Moreover, overall quality of information (p¼0.002) and discussion (p¼0.000) significantly deteriorated over time within meetings, indicating possible meeting fatigue. Conclusion: The study shows that evaluating an MDT via direct observation is feasible and reliable. There was a consistent level of quality of information coverage and contribution within the MDT, but these could be improved. Data were fed back to the team and interventions for improvement were decided, including having a dedicated chair-person, reducing the length of the MDT, and changing the room layout to increase individual contribution. References 1. Lamb BW, Wong HW, Vincent C, Green JS, Sevdalis N. Teamwork and team performance in multidisciplinary cancer teams: Development and evaluation of an observational assessment tool. BMJ Quality & Safety 2011;20:849-56. http://dx.doi.org/10.1016/j.ejso.2014.02.204
15. VTE prophylaxis in breast surgery e What are we doing? Sophie Helme, Jake Sloane, Jasdeep Gahir, Syeda Gilani, Serena Ledwidge, Andrew Baildam, Jennifer Hu St Bartholomew’s Hospital, London, UK Introduction: In breast surgery there is a balance of risk between venous thromboembolism (VTE) and post-operative haematoma.
ABSTRACTS The NICE guidelines (2010) state that all cancer surgery patients should be given mechanical and pharmacological prophylaxis unless contraindicated. More recently published International Clinical Practice guidelines (2012) recommend pharmacological prophylaxis for cancer surgery patients to be given 2-12 hours preoperatively and continued for 7-10 days. In the absence of national guidelines specific to breast surgery we sought to ascertain what current practice is within the UK. Methods: A web based survey was sent to surgeons within the 199 Breast Units in the UK. Results: Responses were received from 67 surgeons. 33% give LMWH to day-case patients and 72% to patients staying overnight. 27% use it for high risk patients only. Pre-operative LMWH is given routinely in 11%, and in high risk patients in 33%. Only 3% give LMWH post discharge. The type of surgery influences whether patients receive LMWH e over 90% for complex reconstructive cases and 50% for wide local excisions. 67% of units use Local Trust Policy Guidelines for general or breast surgery and 33% are guided by individual surgeon preference. Conclusion: There is a wide variation in practice for use of VTE prophylaxis within UK Breast Units. In over 1/3 of units, there are no local or national protocols followed. We suggest a need for national guidelines specific to breast surgery to help guide best practice. http://dx.doi.org/10.1016/j.ejso.2014.02.205
605 16. Is open diagnostic excision biopsy for B3 lesions redundant? Caroline Strachan, Abeer Shaaban, Nisha Sharma, Kieran Horgan St James University Hospital, Leeds, UK Introduction: B3 lesions are defined by their indeterminate nature. Uncertain radiological appearance prompts core biopsy and subsequent B3 pathology traditionally prompts surgical excision due to malignant potential. Vacuum assisted biopsy (VAB) represents a directional change for diagnosis and management of B3 lesions. Offering larger volume sampling allows more representative pathology and diagnostic confidence. Methodology: Our Unit implemented a pathway of second line VAB, following an initial B3 core biopsy for a screened population. We present the 5 year results from analysis of our database. Results: 366 patients with B3 core pathology were identified, of which 294 had 2nd line VAB. VAB allowed 219 to be discharged to mammographic follow up: either routine screening or 5 year annual mammography. No cancers were subsequently detected in this group. Following VAB, 73 patients had surgery. 42 patients had therapeutic surgery, as VAB showed malignancy. In 33 cases, diagnosis remained indeterminate and diagnostic excision was required. 5 of these were malignant. 6 Patients with a VAB diagnosis of in-situ, showed invasive carcinoma on final excisional histology. No patients had downgrading of their pathology following surgery. Conclusion: VAB has revolutionised B3 management, with 88.7% avoiding unnecessary diagnostic surgery. The role of surgery in B3 lesions has evolved, from a ‘gold standard’ diagnostic procedure to definitive therapeutic intervention, following accurate pathological staging through VAB for the majority. http://dx.doi.org/10.1016/j.ejso.2014.02.206
Session 11 e Nursing Submitted Papers, Monday 19th May 2014, 16:30 to 18:00 17. “Moving On” an education programme for people who have completed breast cancer treatment Ruth O’Connor, Jane Watts, Pauline Boardman Frimley Park Hospital, Surrey, UK In 2009 the breast unit committed to Breakthrough Breast Cancers Service Pledge, which emphasises the need for support on completion of breast cancer treatment. After looking into education programmes already available for people after cancer, we could see there was nothing nearby for those who’d had breast cancer. These people often have specific queries about their health post treatment. We responded by designing a Moving on programme and in Autumn 2011 we began three pilot programmes; one each in the morning, afternoon and evening, to cater for people who were working or had childcare commitments. We found a church hall venue and hoped that holding the sessions away from the hospital, where there was easy and free parking, would increase attendance. We invited people who had completed treatment for primary breast cancer, excluding Herceptin. We asked them to commit to attend all six sessions. For the three pilot courses, 100 invitations were sent out, 52 people responded and 40 attended. Only one person dropped out. The courses were run by the breast care nurses and the hospital’s clinical psychologist. We recruited speakers from the hospital and our local cancer centre at no cost, to cover diet, exercise, finance, health and wellbeing, surgery, oncology and lingerie. To monitor the course’s effectiveness we asked the participants to complete two questionnaires before and after: the Quality of life Scale (QoLS) and the General Health Questionnaire (GHQ). The GHQ scores
showed significant improvement and the QoLS remained stable. When we evaluated the course, all attendees said they’d recommend it to a friend. We are now running the course three times a year, alternating between day and evening sessions. The course maintains a core of topics and speakers, but is adapted to suit the attendees each time. Each course is evaluated to ensure content is up to date. We have come to the end of our sixth group and have three more booked for 2014. So far 84 people have completed the programme and the most recent course had a waiting list. From the programme a choir for breast cancer patients has started and a secondary breast care support group has been formed. The programme benefits patients, but it also educates healthcare professionals. We too easily assume that once people complete treatment they’re on the road to recovery. But it can take a long time to recover enough to return to work and family life. http://dx.doi.org/10.1016/j.ejso.2014.02.207
18. The breast care nurse role in the management of breast cancer in a young woman with diminished mental capacity e An example of collaborative working Claire Moody, Jan Harley, Alice Townend North Tees NHS Foundation Trust, Teesside, UK Introduction: This is the case of L, a 45 year old female with learning difficulties who presented to the one stop breast clinic with suspected breast cancer and refused to have mammography or biopsy. The dilemma here was