Community and Research Perspectives on Cancer Disparities in Wisconsin.

INTRODUCTION: Significant disparities are apparent in geographic areas and among racial/ethnic minority groups in Wisconsin. Cancer disparities are complex and multifactorial and require collaborative, multilevel efforts to reduce their impact. Our objective was to understand cancer disparities and identify opportunities to collaborate across community and research sectors to address them. METHODS: From May 2017 through October 2018, we assembled groups of community members and researchers and conducted 10 listening sessions and 29 interviews with a total of 205 participants from diverse backgrounds. Listening sessions and interviews were scheduled on the basis of participant preference and consisted of a brief review of maps illustrating the breast and lung cancer burden across Wisconsin, and a semistructured set of questions regarding causes, solutions, and opportunities. Interviews followed the same structure as listening sessions, but were conducted between a facilitator and 1 or 2 individuals. Major themes were summarized from all sessions and coded. We used the Model for Analysis of Population Health and Health Disparities to identify areas for collaboration and to highlight differences in emphasis between community participants and researchers. RESULTS: Participants identified the need to address individual behavioral risks and medical mistrust and to build equitable multilevel partnerships. Communities provided insights on the impact of environment and location on cancer disparities. Researchers shared thoughts about societal poverty and policy issues, biologic responses, genetic predisposition, and the mechanistic influence of lifestyle factors on cancer incidence and mortality. CONCLUSION: Listening sessions and interviews provided insight into contributors to cancer disparities, barriers to improving outcomes, and opportunities to improve health. The unique perspectives of each group underscored the need for multisector teams to tackle the complex issue of cancer disparities.

Engaging young African American women breast cancer survivors: A novel storytelling approach to identify patient-centred research priorities.

BACKGROUND: Patient-centredness is considered an essential aspiration of a high-quality health-care system, and patient engagement is a critical precursor to patient-centred care. OBJECTIVES: To engage patients, health-care providers and stakeholders in identifying recommendations to address research and practice gaps that impact young African American breast cancer survivors. METHODS: This paper reported an approach for research priority setting. This approach applies an engagement process (January-September 2018) of using patient and stakeholder groups, patient storytelling workshops and a culminating storytelling conference in Wisconsin to generate relevant research topics and recommendations. Topics were prioritized using an iterative engagement process. Research priorities and recommendation were ranked over the conference by counting participants' anonymous votes. RESULTS: One hundred attendees (43 patients/family members, 20 providers/researchers and 37 community members) participated in the conference. Five topics were identified as priorities. The results showed that three priority areas received the most votes, specifically community outreach and education, providing affordable health care and engaging in complementary care practice. Stakeholders also agreed it is critical to 'include youth in the conversation' when planning for cancer support and educational programmes for caregivers, friends and family members. CONCLUSION: Storytelling as a patient engagement approach can build trust in the patient-research partnership, ensure that patients are meaningfully engaged throughout the process and capture the diversity of patient experiences and perspectives.

Culture, identity, strength and spirituality: A qualitative study to understand experiences of African American women breast cancer survivors and recommendations for intervention development.

OBJECTIVE: Despite advancements in cancer treatment, racial disparities in breast cancer survival persist, with African American women experiencing lower survival rates and poorer quality of life than non-Hispanic White women. Using a social cognitive model of restorative well-being as a framework, this qualitative study sought: (a) to examine strength- and culture-related factors associated with African American female breast cancer survivors' cancer coping and post-treatment experiences and (b) to make recommendations for culturally sensitive intervention. METHODS: Eight focus groups occurred with a total of 40 local African American breast cancer survivors. Focus groups were audiotaped and transcribed verbatim. Framework analyses were used to identify themes. NVivo qualitative analysis software-managed data. RESULTS: Two major themes emerged from the focus group discussions: (a) God enables breast cancer survivorship and works every day in our lives and (b) the healthiest thing about us is that we are strong African American women. Recommendations for intervention planning and implementation were made towards intervention structure, content development and language framing in a local context. CONCLUSION: Findings suggest a need for community-based participatory survivorship interventions that are culturally and spiritually consonant and peer-based. Such interventions may respond to the cancer-related and personal needs of the target population.

Use of the dialectical behavior therapy skills and management of psychosocial stress with newly diagnosed breast cancer patients.

Stress-related health concerns have the potential to impact quality of life for patients with breast cancer. National cancer organizations such as the National Cancer Institute, the Institute of Medicine, and the National Comprehensive Cancer Network have acknowledged that all patients with cancer experience some level of distress during the course of illness and treatment. Literature on cancer suggests a range of expected distress from 20% to 50% among all patients diagnosed with cancer. Acknowledging and managing this distress with patients with cancer and providing them behavioral-based Interventions are important parts of cancer research. Dialectical Behavioral Therapy skill is are an empirically proven treatment modality across numerous patient populations. The main objective of this study was to evaluate the utilization and effectiveness of Dialectical Behavior Therapy skills modified for use with patients with breast cancer.

A phase I/II study piloting accelerated partial breast irradiation using CT-guided intensity modulated radiation therapy in the prone position.

BACKGROUND AND PURPOSE: External beam accelerated partial breast irradiation (EB-aPBI) is noninvasive with broader potential applicability than aPBI using brachytherapy. However, it has inherent challenges in daily reproducibility. Image-guide radiotherapy (IGRT) can improve daily reproducibility, allowing smaller treatment margins. Our institution proposed IG-IMRT in the prone position to evaluate dose homogeneity, conformality, normal tissue avoidance, and reliable targeting for EB-aPBI. We report preliminary results and toxicity from a phase I/II study evaluating the feasibility of EB-aPBI in the prone position using IG-IMRT. MATERIALS AND METHODS: Twenty post-menopausal women with node-negative breast cancer, excised tumors <3.0 cm, negative sentinel lymph node biopsy, and surgical clips demarcating the lumpectomy cavity underwent prone EB-aPBI using IG-IMRT on an IRB-approved phase I/II study. All patients underwent CT planning in the prone position. The lumpectomy cavity PTV represented a 2.0 cm expansion. 38.5 Gy was delivered in 10 fractions over 5 days, such that 95% of the prescribed dose covered >99% of the PTV. Dose constraints for the whole breast, lungs and heart were met. RESULTS: The median patient age was 61.5. Mean tumor size was 1.0 cm. 35% of patients had DCIS. Median PTV was 243 cc (108-530) and median breast reference volume was 1698 cc (647-3627). Average daily shifts for IGRT were (0.6, -4.6, 1.7 mm) with standard deviations of (6.3, 6.5, 6.4mm). Acute toxicity was G1 erythema in 80%, and G2 erythema, G2 fatigue, and G2 breast pain each occurred in 1 patient. With a median follow-up of 18.9 months (12-35), 40% of patients have G1 fibrosis and 30% have G1 hyperpigmentation. 95% of patients have good to excellent cosmesis. There have been no recurrences. CONCLUSIONS: These data demonstrate that EB-aPBI in the prone position using IG-IMRT is well tolerated, yields good dosimetric conformality, and results in promising early toxicity profiles.

Communication between breast cancer patients and their physicians about breast-related body image issues.

Breast cancer patients encounter body image changes throughout their diagnosis, treatment, and recovery from breast cancer. No prospective studies were identified investigating communication between physicians and breast cancer patients related to body image. This qualitative pilot study determines (1) how breast cancer patients prefer their physicians communicate regarding body image changes and (2) how comfortable physicians are in discussing body image issues with their patients. Data were collected from patients over 12 weeks through the breast evaluation questionnaire (BEQ), a valid and reliable instrument, and a qualitative questionnaire. Ten physicians completed a qualitative questionnaire. The data were analyzed using frequency analysis. Nearly 70% of the patients reported there was more the physician could do to improve patient comfort in discussing breast-related body image concerns. Honesty, openness, and directness were important to the patients. Thirty-three percent of the patients answered that their physicians should be honest, open, and direct while discussing these issues. On a five-point Likert scale (1 = very uncomfortable and 5 = very comfortable), the physicians most frequently answered a 4 when asked how comfortable they are speaking about breast-related body image issues; however, only four out of 10 always address the topic themselves during the patient's visit. These data suggest that patients want honesty, openness, and directness from their physicians during the discussion of breast-related body image issues. The physicians report they are comfortable speaking about breast-related body image issues; yet, they do not directly initiate the topic.

Prone whole-breast irradiation using three-dimensional conformal radiotherapy in women undergoing breast conservation for early disease yields high rates of excellent to good cosmetic outcomes in patients with large and/or pendulous breasts.

PURPOSE: To report our institution's experience using prone positioning for three-dimensional conformal radiotherapy (3D-CRT) to deliver post-lumpectomy whole breast irradiation (WBI) in a cohort of women with large and/or pendulous breasts, to determine the rate of acute and late toxicities and, more specifically, cosmetic outcomes. We hypothesized that using 3D-CRT for WBI in the prone position would reduce or eliminate patient and breast size as negative prognostic indicators for toxicities associated with WBI. METHODS AND MATERIALS: From 1998 to 2006, 110 cases were treated with prone WBI using 3D-CRT. The lumpectomy, breast target volumes, heart, and lung were contoured on all computed tomography scans. A dose of 45-50 Gy was prescribed to the breast volume using standard fractionation schemes. The planning goals were ≥95% of prescription to 95% of the breast volume, and 100% of boost dose to 95% of lumpectomy planning target volume. Toxicities and cosmesis were prospectively scored using the Common Terminology Criteria for Adverse Effects Version 3.0 and the Harvard Scale. The median follow-up was 40 months. RESULTS: The median body mass index (BMI) was 33.6 kg/m(2), and median breast volume was 1396 cm(3). The worst toxicity encountered during radiation was Grade 3 dermatitis in 5% of our patient population. Moist desquamation occurred in 16% of patients, with only 2% of patients with moist desquamation outside the inframammary/axillary folds. Eleven percent of patients had Grade ≥2 late toxicities, including Grade 3 induration/fibrosis in 2%. Excellent to good cosmesis was achieved in 89%. Higher BMI was associated with moist desquamation and breast pain, but BMI and breast volume did not impact fibrosis or excellent to good cosmesis. CONCLUSION: In patients with higher BMI and/or large-pendulous breasts, delivering prone WBI using 3D-CRT results in favorable toxicity profiles and high excellent to good cosmesis rates. Higher BMI was associated with moist desquamation, but prone positioning removed BMI and breast size as factors for poorer cosmetic outcomes. This series adds to the growing literature demonstrating that prone WBI may be advantageous in select patients.

A contemporary, population-based study of lymphedema risk factors in older women with breast cancer.

BACKGROUND: We studied potential risk factors for lymphedema in a contemporary population of older breast cancer patients. METHODS: Telephone surveys were conducted among women (65-89 years) identified from Medicare claims as having initial breast cancer surgery in 2003. Lymphedema was classified by self-report. Surgery and pathology information was obtained from Medicare claims and the state cancer registries. RESULTS: Of 1,338 patients treated by 707 surgeons, 24% underwent sentinel lymph node biopsy (SLNB) and 57% axillary lymph node dissection (ALND). At a median of 48 months postoperatively, 193 (14.4%) had lymphedema. Lymphedema developed in 7% of the 319 patients who underwent SLNB and in 21% of the 759 patients who underwent ALND. When controlling for patient age, tumor size, type of breast cancer, type of breast and axillary surgery, receipt of radiation, chemotherapy, and hormonal therapy, and surgeon case volume, the independent predictors of lymphedema were removal of more than five lymph nodes [odds ratio (OR) 4.68-5.61, 95% confidence interval (CI) 1.36-19.74 for 6-15 nodes; OR 10.50, 95% CI 2.88-38.32 for >15 nodes] and presence of lymph node metastases (OR 1.98, 95% CI 1.21-3.24). CONCLUSIONS: Four years postoperatively, 14% of a contemporary, population-based cohort of elderly breast cancer survivors had self-reported lymphedema. In this group of predominantly community-based surgeons, the number of lymph nodes removed is more predictive of lymphedema rather than whether SLNB or ALND was performed. As more women with breast cancer undergo only SLNB, it is essential that they still be counseled on their risk for lymphedema.

Five-year results: the initial clinical trial of MammoSite balloon brachytherapy for partial breast irradiation in early-stage breast cancer.

OBJECTIVE: Patients with early-stage invasive ductal breast cancer were prospectively evaluated using MammoSite RTS balloon brachytherapy (RTS Cytyc Corp, Marlborough, MA) as the sole modality for delivering accelerated partial breast irradiation to the lumpectomy bed with breast-conserving surgery. This report presents the 5-year results of the treated patients. METHODS: From May 2000 to October 2001, 70 patients were enrolled in this prospective study. Forty-three patients completed accelerated partial breast irradiation with MammoSite brachytherapy following lumpectomy and axillary staging. Thirty-six patients have been followed for a median of 5.5 years (mean 65.2 months). Criteria for entry into the study were unifocal invasive ductal carcinoma, tumor size < or = 2 cm, age > or = 45 years, absence of extensive intraductal component, cavity size > or = 3 cm in 1 dimension, node-negative, and final margins negative per National Surgical Adjuvant Breast and Bowel Project definition. A minimum balloon-to-skin surface distance of 5 mm was required. A dose of 34 Gy was delivered in 10 fractions over 5 days prescribed to 1 cm from the applicator surface using iridium-192 high-dose-rate brachytherapy. Data on infection, seromas, cosmetic outcome, and toxicities were collected at 3 and 6 months and at yearly intervals. Local recurrences, both true recurrences in the lumpectomy bed and failures outside the initially treated target volume (elsewhere failures), were recorded. Contralateral breast failure rates were noted. RESULTS: The catheter was not implanted in 16 of the 70 enrolled patients due to cavity size not amenable to balloon placement (n = 10), ineligible by criteria (n = 4), and skin spacing (n = 2). Fifty-four patients were implanted and 43 were successfully treated with MammoSite balloon brachytherapy. Reasons for catheter explantation in 11 patients were poor cavity conformance in 7, inadequate skin spacing in 2, positive node in 1 and age less than 45 years in 1. Of the 43 patients who completed treatment, the infection rate was 9.3%. Seroma formation occurred in 32.6% of patients, of which 12% were symptomatic requiring aspiration. Asymptomatic fat necrosis was identified in 4 of the 43 patients, noted from time of catheter removal at 11, 14, 42, and 63 months. Good-excellent cosmetic outcomes were achieved in 83.3% of the 36 patients with more than 5 years of follow-up. Cosmetic outcomes were improved, with increased skin spacing having statistical significance at skin spacing > or = 7 mm. The only serious adverse events were 2 infections: mastitis and abscess. Seven of the 43 treated patients have been discontinued from follow-up. None had a local recurrence recorded at last visit. Reasons for exit from the study were death from metastatic disease (n = 3), lost to follow-up (n = 2), and placed in hospice for other medical conditions (n = 2). No local recurrences (either at the tumor bed or elsewhere in the breast) or regional recurrences have occurred in the 36 patients who have been followed for a median of 5.5 years. No contralateral cancers have developed. CONCLUSIONS: MammoSite balloon brachytherapy as a sole modality for delivering radiation to the tumor bed has been successful in achieving excellent local control in this initial clinical study of patients with early-stage invasive ductal breast cancer. This has been achieved with minimal toxicities and good-excellent cosmetic outcomes in 83.3%. Accelerated partial breast irradiation using the MammoSite balloon in a carefully selected group of patients has demonstrated 5-year local recurrence results comparable to those achieved with conventional whole breast radiation therapy and interstitial catheter brachytherapy as reported at 5-year data points in studies of these treatment modalities. Poor cavity conformance and inadequate skin distance were the main factors limiting use of the MammoSite device. Extended follow-up will be required to determine the long-term efficacy of this treatment modality.

Prevention of an additional surgery for regional lymphadenectomy in melanoma: rapid intraoperative immunostaining of sentinel lymph node imprint smears.

BACKGROUND: Sentinel lymph node (SLN) biopsy is performed at many institutions and is considered a standard of care in the management of cutaneous melanoma. The discriminatory immunostaining pattern with the 'MCW Melanoma Cocktail' (a mixture of MART-1 {1:500}, Melan- A {1:100}, and Tyrosinase {1:50} monoclonal antibodies) allows intraoperative immunocytochemical evaluation of imprint smears of SLNs for melanoma metastases. Cohesive cells of benign capsular melanocytic nevi that were also immunoreactive with the cocktail do not exfoliate easily for imprint smear detection. METHODS: We prospectively evaluated 73 lymph nodes (70 SLN & 3 non-SLN) from 41 cases (mean 1.8, 1 to 4 SLNs/case) of cutaneous melanoma using a rapid 17-minute immunostaining previously published protocol. The results were compared with permanent sections also immunostained with 'the cocktail'. RESULTS: 19.5%, 8/41 cases (12%, 9/73 lymph nodes) were positive for melanoma metastases on permanent sections immunostained with the 'MCW melanoma cocktail'. Melanoma metastases in 87.5% (7/8) of these cases were also detected in rapidly immunostained imprint smears, with 100% specificity and 90% sensitivity. None of the 7 SLNs from 7 cases with capsular nevi showed false positive results. CONCLUSION: Melanoma metastases could be detected in imprint smears immunostained with 'MCW Melanoma Cocktail' utilizing a rapid intraoperative protocol. The cohesive cells of the capsular nevi do not readily exfoliate and do not lead to false positive interpretation. In a majority of positive cases, a regional lymphadenectomy could have been completed during the same surgery for SLN biopsy and wide excision of primary melanoma site, potentially eliminating the need for an additional surgery.

Sentinel node biopsy after neoadjuvant chemotherapy in breast cancer: results from National Surgical Adjuvant Breast and Bowel Project Protocol B-27.

PURPOSE: Experience with sentinel node biopsy (SNB) after neoadjuvant chemotherapy is limited. We examined the feasibility and accuracy of this procedure within a randomized trial in patients treated with neoadjuvant chemotherapy. PATIENTS AND METHODS: During the conduct of National Surgical Adjuvant Breast and Bowel Project trial B-27, several participating surgeons attempted SNB before the required axillary dissection in 428 patients. All underwent lymphatic mapping and an attempt to identify and remove a sentinel node. Lymphatic mapping was performed with radioactive colloid (14.7%), with lymphazurin blue dye alone (29.9%), or with both (54.7%). RESULTS: Success rate for the identification and removal of a sentinel node was 84.8%. Success rate increased significantly with the use of radioisotope (87.6% to 88.9%) versus with the use of lymphazurin alone (78.1%, P = .03). There were no significant differences in success rate according to clinical tumor size, clinical nodal status, age, or calendar year of random assignment. Of 343 patients who had SNB and axillary dissection, the sentinel nodes were positive in 125 patients and were the only positive nodes in 70 patients (56.0%). Of the 218 patients with negative sentinel nodes, nonsentinel nodes were positive in 15 (false-negative rate, 10.7%; 15 of 140 patients). There were no significant differences in false-negative rate according to clinical patient and tumor characteristics, method of lymphatic mapping, or breast tumor response to chemotherapy. CONCLUSION: These results are comparable to those obtained from multicenter studies evaluating SNB before systemic therapy and suggest that the sentinel node concept is applicable following neoadjuvant chemotherapy.

Feasibility of breast duct lavage performed by a physician extender.

BACKGROUND: The safety and feasibility of ductal lavage (DL), a risk-assessment tool utilizing a minimally invasive technique that permits sampling of breast duct epithelium, performed primarily by a nurse practitioner (NP), was studied prospectively. METHODS: Women at high risk for breast cancer with a normal clinical breast exam and mammogram were enrolled. Nipple aspirate fluid (NAF)-yielding ducts were identified, cannulated, and lavaged primarily by an NP in collaboration with a breast surgeon. Samples with sufficient cellularity were categorized as benign, mild atypia, marked atypia, or malignant. Pain and adverse events were recorded. RESULTS: Thirty-seven women, with a mean age of 51.7 years, were enrolled. Thirty-one (83.8%) women yielded NAF and, of those, 28 (90.3%) had one or more ducts successfully cannulated. Of 65 lavaged ducts in these 28 women, cellularity was adequate for diagnosis in 44 (67.7%) samples. Cytologic findings were as follows: 24 benign, 15 mild atypia, 4 marked atypia, and 1 malignant. The procedure was well tolerated with a mean pain score of 3.2 (SD +/- 1.81). The most frequent adverse event was breast fullness, reported by 44.8% of the women. Two women with marked atypia were evaluated further and found to have intraductal papillomata. The woman with malignant cytology had ductal carcinoma in situ. CONCLUSION: DL is a safe, generally well-tolerated procedure that can be performed successfully by a trained NP.

Sequelae of cryotherapy in breast tissue.

Cryotherapy is a novel treatment for benign and malignant breast lesions that is under evaluation. We assessed the acute and subacute outcomes of breast cryotherapy in normal goat teats using physical, microscopic, and imaging modalities. Eight goats were subjected to two freeze-thaw cycles of breast tissue producing a 2cm iceball and sacrificed either 2 or 7 weeks later. Acute skin changes were minimal unless obvious tissue injury occurred during cryotherapy; however, depigmentation developed over several weeks in dark-skinned goats despite the presence of melanocytes. By histology, breast epithelial elements could not be identified at cryotherapy sites. There was no cystic degeneration, which is common at surgical excision sites. Neither calcifications nor prominent scarring could be attributed to cryotherapy on imaging studies after 2 or 7 weeks. When compared to standard breast surgery, the sequelae of cryotherapy using histologic, radiographic, and sonographic criteria were decreased. Our study suggests that cryotherapy, with technical modifications, is feasible within breast tissue and warrants further study.

Does breast tumor location influence success of sentinel lymph node biopsy?

BACKGROUND: Controversy exists regarding the influence of sentinel lymph node (SLN) mapping technique or patient variables on the success rate of SLN mapping. We undertook a prospective study in a single institution series to evaluate multiple variables that could adversely affect SLN identification rates. STUDY DESIGN: Data were collected on 174 patients who underwent 177 SLN mapping procedures followed by axillary dissection from October 1996 through January 2000. Patient demographics, body mass index (BMI), biopsy method, tumor size, palpability, and location were recorded. SLNs were identified by blue dye only (n = 31), Tc-99m sulfur colloid only (n = 34), or combined techniques (n = 112). Data were analyzed by logistic regression analysis and expressed as the probability of failure to map the SLN. RESULTS: SLNs were identified successfully in 150 of 177 procedures (85%) with a false negative rate of 3.7%. Mapping success reached 93% using combination blue dye and isotope. Variables found to adversely affect SLN mapping success and the odds ratio of failure (OR) included lower inner quadrant (LIQ) location (OR 35.6), blue dye only (OR 42.4), BMI >30 and upper outer quadrant (UOQ) location (OR 14.6), and nonpalpable UIQ location (OR 25). LIQ location adversely affects mapping success independent of technique, tumor size, or obesity. Obesity and nonpalpability were adverse factors when tumors were located in the UOQ and UIQ, respectively. Age, biopsy technique, and tumor diameter did not affect SLN mapping success. CONCLUSIONS: SLN mapping success is influenced by technique and tumor location, with best results achieved using combined techniques and for lesions located in quadrants other than the LIQ. Obesity and tumor palpability influence success in the context of tumor location.

Biometrial - associated infections in surgery: part I clinical application, etiology and pathogenesis

Nas ultimas decadas presenciamos um aumento consideravel em relacao ao numero e a variedade de biometrias disponiveis para o uso medico, sem que, no entanto, um correspondente aumento na seguridade de seu uso fosse observada. Considerada uma complicacao de rara ocorrencia, a infeccao esta geralmente associada a uma alta morbidade e suas consequencias podem ser catastroficas para o paciente. Sua incidencia esta diretamente relacionada a reacao tecidual, fatores relacionados ao microorganismo e as caracteristicas do biomaterial. Atualmente, as opcoes terapeuticas estao limitadas as medidas profilaticas, antibioticoterapia e a remocao da protese...