Enhanced recovery after surgery for oncological breast surgery reduces length of stay in a resource limited setting.

BACKGROUND: Early recovery after surgery (ERAS) protocols in breast surgery optimizes resources and reduces healthcare costs by facilitating early discharges. These protocols are well established in tertiary centres, but not commonly adopted in regional centres. ERAS implementation potentially impacts smaller hospitals significantly, where resources are limited and persistent bed shortages with mounting waitlist pressures exist. Our study evaluates the feasibility of early discharge with the application of our ERAS protocol to mastectomies in a resource-constrained and rural setting. METHODS: Breast cancer patients who underwent mastectomies with or without reconstruction between January 2017 and July 2023 were retrospectively reviewed. From January 2022, we implemented a standardized ERAS protocol for patients undergoing mastectomy. This incorporated a combination of pre-, intra- and post-operative elements to enhance patient readiness for discharge. Our study compared these patients (post-ERAS group) with the outcomes of mastectomies performed prior to January 2022 (pre-ERAS group). RESULTS: 104 patients were identified. In the post-ERAS group, 74.4% were discharged within 24 h compared to 23.1% in the pre-ERAS group. Length of stay was reduced from 2.26 to 1.42 days. There were no differences in unplanned clinician reviews or early representation to the emergency department between the two groups. CONCLUSION: Reducing the length of stay without increased complications can be achieved in a resource-limited environment with our protocolized ERAS principals. Our protocol has been instrumental in allowing safe discharges within 24 h. Other regional centres may benefit in adopting strategies implemented by us for their own ERAS protocols in breast cancer surgery.

Evaluation of apical clips placed during axillary dissection demonstrates potential under-coverage of axillary radiation therapy target volumes during breast cancer regional nodal irradiation.

INTRODUCTION: Evidence-based Australian guidelines (eviQ) recommend adjuvant supraclavicular fossa irradiation after axillary lymph node dissection (ALND) in node-positive breast cancer patients. Disparity between surgically determined versus computed tomography (CT) determined nodal volumes may result in discontiguous nodal volumes and untreated nodal tissue. We examine the extent of untreated nodal tissue in women with breast cancer post-level II or III ALND and adjuvant radiation therapy (RT) using ESTRO contouring guidelines. METHODS: Female breast cancer patients who underwent level II and III ALND with apical clip placement from 2016 to 2020 and CT simulated in supine position were included. CT-defined axillary level II-IV volumes were contoured using ESTRO guidelines. The distance between the apical clip and RT nodal volumes was measured to indicate extent of untreated tissue. RESULTS: Of 34 eligible patients treated by 7 surgeons, 76% had level II ALND and 24% level III ALND. Only 5.9% of clips entirely encompassed the corresponding RT nodal volumes. 55.9% of clips fell within and 44.1% fell inferolaterally outside the corresponding RT nodal volumes. A median 3.6 cm (range 0-7.5 cm) of undissected nodal tissue would not be included within standard RT target volumes following eviQ recommendations. CONCLUSION: There is a disparity between surgically determined versus CT determined axillary nodal volumes, leading to discontiguous nodal volumes and untreated axillary nodal tissue, despite following standard radiation contouring guidelines. Intraoperatively placed apical axillary clips may assist radiation oncologists to accurately delineate undissected nodal tissues at risk.

Survival outcomes for breast cancer patients who decline recommended treatment: a propensity score-matched analysis.

BACKGROUND: For patients with breast cancer who decline recommended treatments, available data examining survival outcomes are sparse. We compared overall survival and relapse-free survival outcomes between patients with breast cancer who declined recommended primary treatments and those who received recommended primary treatments. METHODS: Using data from the BreastSurgANZ Quality Audit database, a retrospective cohort study was performed for patients diagnosed with breast carcinoma (stage 0-IV) between 2001 and 2014 who were treated in our integrated cancer centre. A propensity score-matched analysis was performed to compare overall survival and relapse-free survival between patients who either declined or received the standard recommended treatment. RESULTS: A total of 56/912 (6.1%) patients declined one or more recommended therapies. Five-year overall survival for those who declined or received treatment as recommended was 81.8% versus 88.9% (P = 0.17), respectively. Ten-year survival was 61.3% versus 67.8% (P = 0.22), respectively. For patients who declined treatments, 5-year relapse-free survival was 72.4%, compared to 87.4% for those who received them (P = 0.005). Ten-year relapse-free survival was 61.0% versus 80.6% (P = 0.002), respectively. On adjusted Cox regression analysis, treatment refusal was associated with poorer relapse-free survival (adjusted hazard ratio 2.76 (95% confidence interval 1.52-5.00), P < 0.001). CONCLUSION: In conclusion, patients who declined recommended treatment for breast cancer had poorer relapse-free survival compared to those who received them. These data may help clinicians assist patients with breast cancer in their decision-making.

Assessment of genetic referrals and outcomes for women with triple negative breast cancer in regional cancer centres in Australia.

BACKGROUND: Guidelines for referral to cancer genetics service for women diagnosed with triple negative breast cancer have changed over time. This study was conducted to assess the changing referral patterns and outcomes for women diagnosed with triple negative breast cancer across three regional cancer centres during the years 2014-2018. METHODS: Following ethical approval, a retrospective electronic medical record review was performed to identify those women diagnosed with triple negative breast cancer, and whether they were referred to a genetics service and if so, the outcome of that genetics assessment and/or genetic testing. RESULTS: There were 2441 women with newly diagnosed breast cancer seen at our cancer services during the years 2014-2018, of whom 237 women were diagnosed with triple negative breast cancer. Based on age of diagnosis criteria alone, 13% (31/237) of our cohort fulfilled criteria for genetic testing, with 81% (25/31) being referred to a cancer genetics service. Of this group 68% (21/31) were referred to genetics services within our regions and went on to have genetic testing with 10 pathogenic variants identified; 5x BRCA1, 4x BRCA2 and × 1 ATM:c.7271 T > G. CONCLUSIONS: Referral pathways for women diagnosed with TNBC to cancer genetics services are performing well across our cancer centres. We identified a group of women who did not meet eligibility criteria for referral at their time of diagnosis, but would now be eligible, as guidelines have changed. The use of cross-discipline retrospective data reviews is a useful tool to identify patients who could benefit from being re-contacted over time for an updated cancer genetics assessment.

Development of the 'People-Processes-Paradigm' critical analysis tool for mortality and morbidity reviews: improving understanding of systems factors.

BACKGROUND: The impact of systems problems and human factors on delivering safe, high-quality patient care is well recognized. In the surgical setting, mortality and morbidity reviews (MMRs) are the key forum for reviewing and analysing adverse events in patient care yet there is a paucity of simple tools for undertaking such analyses. The aim of this study was to develop and pilot a new tool for analysing mortality and morbidity cases incorporating human factors and systems analysis. METHODS: The published literature, professional standards, guidelines and existing audit tools for MMRs were reviewed. The 'People-Processes-Paradigm' tool was developed and pilot testing was undertaken and stakeholder feedback was obtained. RESULTS: Models found for undertaking systems-based analysis of adverse surgical events included the 3D model, SEIPS and the Queensland Health human error and patient safety (HEAPS) Incident Management Tool. Guidelines for standards in MMRs are provided by the Royal Australasian College of Surgeons, New South Wales Clinical Excellence Commission and Australia and New Zealand audit of surgical mortality (ANZASM). The People-Processes-Paradigm model incorporates these standards and evidence-based systems analysis tools into a single effective tool. The pilot study evaluating the use of this tool demonstrated it to be practical and easily applicable to regular use by clinicians, with the ability to be tailored to individual health service use. Improvements such as electronic format and clarification of case selection processes were recommended by users. CONCLUSION: The People-Processes-Paradigm tool has been developed for surgeons by surgeons incorporating current professional, legal and regulatory requirements in Australasia, easily transferrable to electronic platforms. This model requires further testing for validation.

What are the appropriate thresholds for High Quality Performance Indicators for breast surgery in Australia and New Zealand?

AIM: To evaluate BreastSurgANZ members' compliance at various threshold rates for 4 evaluable High-Quality Performance Indicators (HQPIs) introduced to improve patient care. To benchmark global best practice to assist in determining the eventual threshold standards. METHOD: BreastSurgANZ Quality Audit data 2012-2016 & 2018 was used to determine rates of attainment through a range of thresholds for 4 HQPI's. Rates were assessed for different volume surgeons and comparison made to international standards. RESULTS: 1.3761 patients needing mastectomy for in situ disease, if the threshold rate for immediate breast reconstruction (IBR) was ≥ 40% then 30% of all members and 78% of very high-volume surgeons achieved that rate, which is comparable to international recommendations. 2.26,007 patients requiring mastectomy, if the threshold rate for IBR was ≥ 20% then 28% of all surgeons and 78% very high-volume surgeons met the standard. This is below most international recommendations. 3. For 31,698 invasive tumours ≤ 2 cm, if the threshold rate for breast conservation was ≥ 70% then 64% of all surgeons met the standard; 70% is comparable internationally. 4.1382 women =<50 years if the threshold rate for neoadjuvant chemotherapy was set at ≥ 15% then 36% of surgeons complied; 15% is below most international recommendations. CONCLUSIONS: Even at these modest thresholds there are low levels of achievement by BreastSurgANZ members with high volume surgeons more likely to comply. These thresholds are either comparable or lower than globally accepted standards. Members should strive to meet, even exceed these important goals as they are a metric of improved patient care.

Increasing access to breast reconstruction for women living in underserved non-metropolitan areas of Australia.

PURPOSE: The potential quality of life benefits of breast reconstruction (BR) for women who have undergone mastectomy for breast cancer have long been recognised. While many women will not want to have BR, international best-practice guidance mandates that all should be given the choice. The aim of this article is to highlight potential policies to support patients' informed discussion of BR options and to improve access to BR for women living in underserved locations. METHODS: Ninety semi-structured interviews were conducted from May 2015 to May 2017 with a convenience sample of 31 breast reconstructive surgeons, 37 breast cancer health professionals and a purposive sample of 22 women who underwent mastectomy as part of their breast cancer treatment. Breast, plastic reconstructive surgeons and health professionals based in major cities also provided information about how they cared for patients from more remote areas. RESULTS: Analysis of interview data revealed a range of barriers that were grouped into four major categories describing issues for women living outside major cities: population characteristics associated with lower socioeconomic status; locational barriers including limited health services resources and distance; administrative barriers such as hospital policies and inadequate support for women who need to travel; and surgical workforce recruitment barriers. CONCLUSIONS: Suggestions for potential solutions included the following: greater geographical centralisation of BR services within major cities; the creation of designated breast centres with minimum caseload requirements similar to the UK's system; and a buddy system, whereby smaller hospitals network with multidisciplinary teams based in larger hospitals.