Can specific preoperative counseling increase the likelihood a woman will choose postmastectomy breast reconstruction?

BACKGROUND: Low reconstruction rates after mastectomy for breast cancer raise questions about the impact of preoperative education. This study determines whether counseling about reconstruction influences the decision about reconstruction. METHODS: The study was based on a prospectively collected database of breast cancer surgery. RESULTS: A total of 299 operations for breast cancer were performed. Of 127 mastectomies, 21 (16%) were not candidates. In all, 106 women were specifically educated about reconstruction; 40 (37%) women consulted with a plastic surgeon; and 22 (21%) women ultimately chose reconstruction. Forty women had the option of mastectomy or breast conservation. Twelve (30%) women accepted a consultation with a plastic surgeon. Six of these women (15%) ultimately chose reconstruction. Mastectomy was required in 66 women; 28 (42%) accepted a consultation with a plastic surgeon; 16 (24%) underwent reconstruction; 3 additional women are planning delayed reconstruction (28%). CONCLUSIONS: Reconstruction is more likely when mastectomy is required than when it is chosen. Low reconstruction rates reflect patient desire rather than access or education.

Hemorrhage after the preoperative use of complementary and alternative medicines.

The preoperative use of certain complementary and alternative medicines may predispose surgical patients to an acquired coagulation disorder resulting in excessive bleeding. Many herbs and dietary supplements inhibit platelet adhesion and aggregation or contain coumarins. We report the case of a patient undergoing breast surgery at the University of Colorado Health Sciences Center Denver, Colo, who had extensive postoperative bleeding requiring surgical re-exploration. Preoperatively the patient consumed vitamin E and several herbs with potential to alter the hemostatic process combined with the drugs quinine sulfate and sertraline hydrochloride. These combinations of alternative and conventional drugs may have contributed to inhibition of coagulation.

Ultrasound can estimate the pathologic size of infiltrating ductal carcinoma.

HYPOTHESIS: Ultrasound (US) of the breast will accurately measure breast tumor size when compared with size as determined by pathologic examination. DESIGN: Retrospective case series. SETTING: University hospital-based breast center. PATIENTS: Thirty-five women with a diagnosis of breast cancer who had US as a component of their evaluation. MAIN OUTCOME MEASURE: Tumor size as measured by US compared with size measured by pathologic examination. RESULTS: Size measured by US ranged from 0.45 to 3.81 cm. Size measured by pathologic examination ranged from 0.5 to 5 cm. The mean difference of size measured by US vs pathologic size was 0.4 cm (P = .01). When only tumors with invasive ductal histology are evaluated, the mean difference in size is 0.33 cm (P = .008). The range of difference was -1.6 cm to +0.42 cm. Seventeen percent of invasive ductal tumors were underestimated by more than 1 cm; none were underestimated by more than 2 cm. CONCLUSIONS: This study demonstrates that, although US tends to underestimate the pathologic tumor size, 83% of invasive ductal tumors fall within a 1-cm and 100% fall within a 2-cm extension of the US-measured tumor size. Therefore, it is possible to use US to monitor the extent of treatment size when developing very localized therapeutic tools.

Breast conservation therapy in affiliated county, university, and private hospitals.

BACKGROUND: Breast conservation therapy (BCT) offers equivalent survival to modified radical mastectomy in patients with early-stage (I and IIa) breast cancer, but is utilized in less than 50% of eligible patients. While patient demographics have been linked to BCT rates, we suspected that physician influence was a major factor. The purpose of this study was to compare BCT at three affiliated centers staffed by similarly trained surgeons yet serving widely disparate populations, in order to assess the importance of physician influence on the utilization of BCT. METHODS: Tumor registry data were reviewed from 1993 through 1997 at affiliated city/county (CH), university (UH), and private hospitals (PH). Data were analyzed for clinical stage, treatment, and age of patient. RESULTS: The utilization of BCT for stage I and IIa breast cancer is similar at the three hospitals: 45% of patients at CH, 55% of patient at UH, and 57% of patients at PH (P>0.05). Rates of BCT were similar across all patient age groups at all sites. CONCLUSIONS: Similar BCT utilization rates can be achieved despite widely disparate patient populations. The three affiliated hospitals are staffed by surgeons with similar training, and all offer a multidisciplinary approach to breast cancer care. This suggests that physician influence may override patients' socioeconomic issues in providing optimal breast cancer therapy.

Cost-effective management of gynecomastia.

BACKGROUND: Routine endocrine screening of idiopathic gynecomastia has been advocated, but may not be cost effective. We carried out a cost-benefit analysis of this approach. METHODS: A retrospective study (1992 to 1997) of 87 adult males with symptomatic gynecomastia was performed. RESULTS: Thirty-four (39%) patients had extrinsic causes; 53 (61%) were considered idiopathic. Forty-five idiopathic cases underwent endocrine testing: beta human chorionic gonadotropin alone, 16; and beta human chorionic gonadotropin, LH, estradiol, testosterone+/-testicular ultrasound, 29. One (2%) occult Leydig cell testicular tumor was detected. Forty-four patients had normal studies and remain well after local excision. CONCLUSION: Routine endocrine evaluation of idiopathic gynecomastia is rarely productive; such testing is best done selectively.

Palliative pelvic exenteration: patient selection and results.

Total pelvic exenteration is a radical abdominoperineal operation designed to treat locally extensive pelvic malignancy. In the past, the morbidity and mortality has been such that this procedure was considered justified only in the curative setting. As experience has increased and operative survival has improved, the indications for radical pelvic surgery have expanded to include palliation of the symptoms of pelvic tumors, including pain, obstruction, fistulas, and bleeding. The careful selection of suitable candidates for palliative pelvic exenteration requires an extensive preoperative evaluation of the patient's underlying physical and emotional health, as well as an assessment of the local and distant extent of the tumor. In appropriately selected patients, significant palliation of the symptoms associated with an uncontrolled pelvic malignancy can be accomplished with substantial improvement in quality of life.