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Values-based practice in breast surgery – An innovative approach to clinical decision-making
ABSTRACTS
613
US guided biopsy identified 30 women who can have a primary FAD without the requirement for SLNB. Our US only and US + biopsy sensitivity and specificity results are similar to data reported in the literature (USS only: 48-87% and 55-97%)1 and (USS guided biopsy: 25-97% and 88-100%)2. References 1. Cools-Lartigue J et al, Accuracy of Axillary Ultrasound in the Diagnosis of Nodal Metastasis in Invasive Breast Cancer: A Review. World J Surg 2012 36:46-54 2. Houssami N et al, Preoperative Ultrasound-Guided Needle Biopsy of Axillary Nodes in Invasive Breast Cancer Meta-Analysis of Its Accuracy and Utility in Staging the Axilla, Annals of Surgery 2011; 254:2: 243-251
Table 1 Ultrasound only. B ¼ benign, M ¼ malignant Tissue B Tissue M
US B 143 23 166
US M 19 33 52
162 56 218
Table 2 Ultrasound + ultrasound guided biopsy Tissue B Tissue M
US +/ bio B* 162 26 188
US + bio M 0 30 30
162 56 218
(*166 had US B and no biopsy, 22 had US M but benign on biopsy and therefore are included in US +/ bio B). http://dx.doi.org/10.1016/j.ejso.2014.02.012
P012. Values-based practice in breast surgery e An innovative approach to clinical decision-making Zoe Barber1, Thomas Dobbs2, Ashok Handa2, Bill Fulford3 1 Gloucestershire Royal Hospital, Gloucester, UK 2 John Radcliffe Hospital, Oxford, UK 3 University of Warwick, Warwick, UK Introduction: Clinical decision-making in breast surgery may be influenced by the values of many different people: the patient, friends and family, clinicians, society or the Trust. Evidence-based practice enables us to make a clinical decision based on the best available evidence but evidence may be equivocal, not applicable to an individual situation or simply not exist. Values-based practice (VBP) is a novel means of clinical decisionmaking that we have introduced to surgery for the first time through a series of seminars and workshops. Methods: Consultants, trainees, multidisciplinary staff, patients and relatives were invited to the seminar on breast surgery. A series of exercises asked attendees to identify their values in certain situations. The VBP framework was applied to case studies to highlight how we can explore values in our own practice to aid decision-making. Results: The values identified in the workshop varied significantly, even amongst subgroups (e.g. surgeons), which surprised attendees. Feedback from attendees was universally positive. Discussion: We often assume we know what is important to our patients: survival; morbidity; aesthetics. However, our seminars have
demonstrated that, even within a group of similar individuals, values vary significantly and lead us towards different clinical decisions. We would like to expand the VBP message from its current regional status to a national one. The ABS 2014 Conference would offer us the opportunity to invite the next generation of breast teams to ask their patients, and each other, ’What is important to you?’ - and perhaps to be surprised by the answer. http://dx.doi.org/10.1016/j.ejso.2014.02.013
P013. Patient satisfaction with cosmetic outcome after wide local excision and excision cavity reconstruction using tissue displacement Abdelnasser Salem Royal Victoria Infirmary, Newcastle upon Tyne, UK Background: Wide Local Excision (WLE) of small breast cancers offers excellent treatment with breast conservation. However, it could result in unacceptable deformities if no Excision Cavity Reconstruction (ECR) was performed. Methods: We audited patient satisfaction with WLE and ECR using local tissue displacement performed by one surgeon (Associate Specialist). We asked the patients to mark their satisfaction in a 10-marks score. The ‘Mean’ of Satisfaction Scores (MSS) was used in our calculations then converted to a ‘Percentage’ (PMSS) for ease of interpretation. Photographs of patients who accepted photography were included. Results: A total of 38 patients were enrolled, mean follow up was 15months. 18 patients (47.5%) scored 10/10 satisfaction, 14 (37%): 9/10, 5 (13%): 8/10 and one patient (2.5%) scored 7/10. PMSS was: overall: 93%, right-sided cancers: 93%, left-sided: 92%, UOQ: 94%, UIQ: 93%, LOQ: 90%, LIQ: 96% and central: 85%. PMSS was 93% with no complications (infection/haematoma) and 87% with complications, 94% with no further surgery and 86% with further surgery, 94% with no skin excision and 80% with skin excision, 91% for patient followed up to 12 months, 94% for 13-24 months and 96% above 24 months. Mean tumour size was 17.4mm for 10/10 satisfaction score, 22.5mm for 9/10 and 24mm for 8/10. Mean follow up was 20 months for 10/10 score, 15 months for 9/10, and 9 months for 8/10. Conclusion: ECR is easy to do, results in high satisfaction rates and improves cosmetic outcome of WLE. Satisfaction tends to be higher with smaller cancers and increases overtime after surgery. http://dx.doi.org/10.1016/j.ejso.2014.02.014
P014. Invasive lobular carcinoma of the breast: A retrospective analysis of consecutive cases reviewing preoperative imaging assessment with sonography, digital breast tomosynthesis and MR Alexander Haragan, Anita Maria Huws, Saira Khawaja, Sarada Gurung, Natasha Muniweera, Khaldoun Nadi, Yousef Sharaiha, Simon D.H. Holt Breast Unit Prince Philip Hospital, Llanelli, UK Background: Invasive lobular carcinoma (ILC) of the breast in comparison to invasive ductal carcinoma (IDC) is more likely to be multifocal, and in addition can be more difficult to detect on mammography, often appearing as an architectural distortion. Digital Breast Tomosynthesis (DBT) was introduced into the symptomatic sector of the breast unit in August 2010. The primary aim of the study was to determine whether this modality had improved the preoperative size assessment of ILC. Secondary aims included reviewing all the imaging modalities, and analysing pathological features in this cohort of patients. Methods: All patients diagnosed with pure ILC between August 2010 and January 2013 were identified. Patients with a past history of breast surgery were excluded. Imaging findings were reviewed retrospectively. Size on sonography, DBT and MRI were compared with final histology. Patient demographics, clinical findings and pathological features were recorded.
613
US guided biopsy identified 30 women who can have a primary FAD without the requirement for SLNB. Our US only and US + biopsy sensitivity and specificity results are similar to data reported in the literature (USS only: 48-87% and 55-97%)1 and (USS guided biopsy: 25-97% and 88-100%)2. References 1. Cools-Lartigue J et al, Accuracy of Axillary Ultrasound in the Diagnosis of Nodal Metastasis in Invasive Breast Cancer: A Review. World J Surg 2012 36:46-54 2. Houssami N et al, Preoperative Ultrasound-Guided Needle Biopsy of Axillary Nodes in Invasive Breast Cancer Meta-Analysis of Its Accuracy and Utility in Staging the Axilla, Annals of Surgery 2011; 254:2: 243-251
Table 1 Ultrasound only. B ¼ benign, M ¼ malignant Tissue B Tissue M
US B 143 23 166
US M 19 33 52
162 56 218
Table 2 Ultrasound + ultrasound guided biopsy Tissue B Tissue M
US +/ bio B* 162 26 188
US + bio M 0 30 30
162 56 218
(*166 had US B and no biopsy, 22 had US M but benign on biopsy and therefore are included in US +/ bio B). http://dx.doi.org/10.1016/j.ejso.2014.02.012
P012. Values-based practice in breast surgery e An innovative approach to clinical decision-making Zoe Barber1, Thomas Dobbs2, Ashok Handa2, Bill Fulford3 1 Gloucestershire Royal Hospital, Gloucester, UK 2 John Radcliffe Hospital, Oxford, UK 3 University of Warwick, Warwick, UK Introduction: Clinical decision-making in breast surgery may be influenced by the values of many different people: the patient, friends and family, clinicians, society or the Trust. Evidence-based practice enables us to make a clinical decision based on the best available evidence but evidence may be equivocal, not applicable to an individual situation or simply not exist. Values-based practice (VBP) is a novel means of clinical decisionmaking that we have introduced to surgery for the first time through a series of seminars and workshops. Methods: Consultants, trainees, multidisciplinary staff, patients and relatives were invited to the seminar on breast surgery. A series of exercises asked attendees to identify their values in certain situations. The VBP framework was applied to case studies to highlight how we can explore values in our own practice to aid decision-making. Results: The values identified in the workshop varied significantly, even amongst subgroups (e.g. surgeons), which surprised attendees. Feedback from attendees was universally positive. Discussion: We often assume we know what is important to our patients: survival; morbidity; aesthetics. However, our seminars have
demonstrated that, even within a group of similar individuals, values vary significantly and lead us towards different clinical decisions. We would like to expand the VBP message from its current regional status to a national one. The ABS 2014 Conference would offer us the opportunity to invite the next generation of breast teams to ask their patients, and each other, ’What is important to you?’ - and perhaps to be surprised by the answer. http://dx.doi.org/10.1016/j.ejso.2014.02.013
P013. Patient satisfaction with cosmetic outcome after wide local excision and excision cavity reconstruction using tissue displacement Abdelnasser Salem Royal Victoria Infirmary, Newcastle upon Tyne, UK Background: Wide Local Excision (WLE) of small breast cancers offers excellent treatment with breast conservation. However, it could result in unacceptable deformities if no Excision Cavity Reconstruction (ECR) was performed. Methods: We audited patient satisfaction with WLE and ECR using local tissue displacement performed by one surgeon (Associate Specialist). We asked the patients to mark their satisfaction in a 10-marks score. The ‘Mean’ of Satisfaction Scores (MSS) was used in our calculations then converted to a ‘Percentage’ (PMSS) for ease of interpretation. Photographs of patients who accepted photography were included. Results: A total of 38 patients were enrolled, mean follow up was 15months. 18 patients (47.5%) scored 10/10 satisfaction, 14 (37%): 9/10, 5 (13%): 8/10 and one patient (2.5%) scored 7/10. PMSS was: overall: 93%, right-sided cancers: 93%, left-sided: 92%, UOQ: 94%, UIQ: 93%, LOQ: 90%, LIQ: 96% and central: 85%. PMSS was 93% with no complications (infection/haematoma) and 87% with complications, 94% with no further surgery and 86% with further surgery, 94% with no skin excision and 80% with skin excision, 91% for patient followed up to 12 months, 94% for 13-24 months and 96% above 24 months. Mean tumour size was 17.4mm for 10/10 satisfaction score, 22.5mm for 9/10 and 24mm for 8/10. Mean follow up was 20 months for 10/10 score, 15 months for 9/10, and 9 months for 8/10. Conclusion: ECR is easy to do, results in high satisfaction rates and improves cosmetic outcome of WLE. Satisfaction tends to be higher with smaller cancers and increases overtime after surgery. http://dx.doi.org/10.1016/j.ejso.2014.02.014
P014. Invasive lobular carcinoma of the breast: A retrospective analysis of consecutive cases reviewing preoperative imaging assessment with sonography, digital breast tomosynthesis and MR Alexander Haragan, Anita Maria Huws, Saira Khawaja, Sarada Gurung, Natasha Muniweera, Khaldoun Nadi, Yousef Sharaiha, Simon D.H. Holt Breast Unit Prince Philip Hospital, Llanelli, UK Background: Invasive lobular carcinoma (ILC) of the breast in comparison to invasive ductal carcinoma (IDC) is more likely to be multifocal, and in addition can be more difficult to detect on mammography, often appearing as an architectural distortion. Digital Breast Tomosynthesis (DBT) was introduced into the symptomatic sector of the breast unit in August 2010. The primary aim of the study was to determine whether this modality had improved the preoperative size assessment of ILC. Secondary aims included reviewing all the imaging modalities, and analysing pathological features in this cohort of patients. Methods: All patients diagnosed with pure ILC between August 2010 and January 2013 were identified. Patients with a past history of breast surgery were excluded. Imaging findings were reviewed retrospectively. Size on sonography, DBT and MRI were compared with final histology. Patient demographics, clinical findings and pathological features were recorded.