Combined breast conservation therapy versus mastectomy for BRCA mutation carriers - A systematic review and meta-analysis.

BACKGROUND: The non-inferiority of combined breast conservation surgery (BCS) and radiotherapy (breast conservation therapy or BCT) compared to mastectomy in sporadic breast cancer cases is well recognised. Uncertainty remains regarding optimal surgical practice in BRCA mutation carriers. AIMS: To evaluate the oncological safety of combined BCT versus mastectomy in BRCA mutation carriers following breast cancer diagnosis. METHODS: A systematic review was performed as per PRISMA and MOOSE guidelines. Observational studies comparing BCS and mastectomy in BRCA carriers were identified. Dichotomous variables were pooled as odds ratios (OR) using the Mantel-Haenszel method. Log hazard ratios (lnHR) for locoregional recurrence (LRR), contralateral breast cancer, disease-free and overall survival and their standard errors were calculated from Kaplan-Meier or cox-regression analyses and pooled using the inverse variance method. RESULTS: Twenty three studies of 3807 patients met inclusion criteria; 2200 (57.7%) were BRCA1 and 1212 (31.8%) were BRCA2 carriers. Median age at diagnosis was 41 years with 96 months follow up. BCS was performed on 2157 (56.7%) while 1408 (41.5%) underwent mastectomy. An increased risk of LRR was observed in patients treated with BCS (HR:4.54, 95% Confidence Interval: 2.77-7.42, P < 0.001, heterogeneity (I2) = 0%). However, the risks of contralateral breast cancer (HR:1.51, 95%CI: 0.44-5.11, P = 0.510, I2 = 80%), disease recurrence (HR:1.16, 95%CI: 0.78-1.72, P = 0.470, I2 = 44%), disease-specific recurrence (HR:1.58, 95%CI: 0.79-3.15, P = 0.200, I2 = 38%) and death (HR:1.10, 95%CI: 0.72-1.69, P = 0.660, I2 = 38%) were equivalent for combined BCT and mastectomy. CONCLUSIONS: Survival outcomes following combined BCT is comparable to mastectomy in BRCA carriers. However, the risk of LRR is increased. Patient counselling should be tailored to incorporate these findings.

A survey of experience of parenteral analgesia at Role 1.

OBJECTIVES: To assess the confidence of deploying Role 1 Medical Officers (MOs) in the use of parenteral analgesia, to collate opinion as to whether analgesia training for Role 1 MOs is fit for purpose and to explore options for future analgesic approaches at Role 1. METHODS: A survey distributed to Role 1 doctors prior to deployment to Afghanistan. RESULTS: Areas of expressed concern included the use of ketamine and a lack of experience of intraosseous drug administration. Qualitative data collected included anecdotal experiences with analgesia administration which provides evidence to support a change in training. CONCLUSIONS: Doctors have the capability to provide good analgesic care but lack the confidence and experience to do it effectively. Improved analgesia training is required for deploying Role 1 MOs.

A proposed model for improving battlefield analgesia training: post-graduate medical officer pain management day.

In response to increasing awareness of the need to improve Post Graduate Medical Officers training in the use of analgesics when on Operations and exercises, a new "Pain Day" format has been realised and included in the Post Graduate Medical Officers Course. This article discusses the format of the Pain Day; gives evidence of the feedback received; explores areas where further training may be required and suggests mechanisms through which improved training could be provided throughout the armed forces medical community.