A series of the first 13 combined Magseed and Magtrace cases in a single centre in regional Victoria.

BACKGROUND: The standard journey for a patient with impalpable breast cancer wishing to undergo breast-conserving surgery involves placement of a guidewire and lymphoscintigraphy pre-operatively. Access to these procedures is limited in the regional centres, this scheduling can require overnight stays away from home and can delay theatre which can increase patient distress. The Sentimag technology uses magnetism for localisation of preoperatively inserted Magseeds (for impalpable breast lesions) and Magtrace (for sentinel node biopsy), avoiding guidewire placement and nuclear medicine. This study evaluates the first 13 cases using this combined technique by a single specialist breast surgeon in a regional centre. METHODS: Thirteen consecutive patients were enrolled with ethics approval. Magseeds were placed under ultrasound guidance preoperatively, and Magtrace was injected at the time of pre-operative consultation. RESULTS: The median age of patients was 60 (range 27-78). The average distance from hospital was 81.63 km (2.8-238 km). The average operating time was 1h54m (range 1 h 17 m-2 h 39 m) and the mean total journey time was 8h54m (range 6-23 h). The earliest time-out was 8:40 am. Re-excision rate was 23% (n = 3), however, in each re-excision case the lesions were in the axilla, were small (<15 mm) and were in patients with dense breasts on mammography. There were no significant adverse outcomes. CONCLUSION: In this preliminary study Sentimag localisation appears to be safe and reliable when used in combination. Re-excision rates were only slightly higher than reported in the literature and predicted to downtrend with ongoing learning curve.

Comparing Pathways to Diagnosis and Treatment for Rural and Urban Patients With Colorectal or Breast Cancer: A Qualitative Study.

PURPOSE: Colorectal cancer patients living in rural areas have poorer outcomes than urban counterparts, but such disparities are not found for breast cancer. Although time to care may contribute to rural-urban disparities, few studies examine patient experiences to understand how and why delays may occur. We compared rural and urban patient experiences of pathways to colorectal or breast cancer diagnosis and treatment in Victoria, Australia. METHODS: Semistructured telephone interviews were conducted with 43 patients (49% colorectal; 60% rural, median 7 months postdiagnosis). A framework analysis was applied using the Model of Pathways to Treatment. FINDINGS: Rural and urban patients expressed similar attitudes and reasons for prolonged symptom appraisal and help-seeking triggers. However, some rural patients reported long waiting times to see a Primary Care Practitioner (PCP) and perceived greater gatekeeping to diagnostic services. Patient perceptions of the urgency of PCP referral could impact behavior, such as waiting longer to book appointments. Colorectal cancer patients reported more variable types of symptoms, interpretation, and coping strategies, as well as diverse presentation routes and reduced sense of urgency, compared to breast cancer patients. Waiting time for colonoscopy could be long, particularly in the public health system, but mammograms were quickly arranged. CONCLUSIONS: Pathway variation was more evident by cancer type than residential location. However, access to primary care and diagnostic services for rural patients with colorectal cancer may be important policy targets. Future research should investigate the impact of diagnostic service accessibility on PCP referral behavior to further understand rural-urban disparities.

Research evidence supports cancer policymaking but is insufficient for change: Findings of key informant interviews from five countries.

Evidence-based policymaking values the use of research in the process of developing, implementing and evaluating policy. However, there is limited research attempting to understand how cancer policymaking occurs and the role of evidence in this process. Our study aimed to provide a deeper understanding of levers and challenges to the development and implementation of large-scale, health service policies or programs in cancer care. Within a realist framework, we conducted a thematic analysis of interviews with 13 key informants from five countries: Australia, Canada, Scotland, Denmark and New Zealand. Results identified a complex array of program mechanisms and contextual factors influencing cancer health-service policymaking. Research evidence was important and could form a rationale for change, such as by identifying unwarranted variation in cancer outcomes across or within countries. However, other factors were equally important in driving policy change, including advocacy, leadership, stakeholder collaboration, program adaptability, clinician and consumer involvement, and the influential role of context. These findings resonate with political science theories and health service reform literature, while offering novel insight into specific factors that influence policymaking in cancer care, namely clinical engagement, consumer input and policy context. Although research evidence supports policymaking, the complex ways in which cancer policies are developed and implemented requires recognition and should be considered when designing new programs and promoting the use of evidence in policymaking.

Rural-Urban Disparities in Time to Diagnosis and Treatment for Colorectal and Breast Cancer.

Background: Longer cancer pathways may contribute to rural-urban survival disparities, but research in this area is lacking. We investigated time to diagnosis and treatment for rural and urban patients with colorectal or breast cancer in Victoria, Australia.Methods: Population-based surveys (2013-2014) of patients (aged ≥40, approached within 6 months of diagnosis), primary care physicians (PCPs), and specialists were collected as part of the International Cancer Benchmarking Partnership, Module 4. Six intervals were examined: patient (symptom to presentation), primary care (presentation to referral), diagnostic (presentation/screening to diagnosis), treatment (diagnosis to treatment), health system (presentation to treatment), and total interval (symptom/screening to treatment). Rural and urban intervals were compared using quantile regression including age, sex, insurance, and socioeconomic status.Results: 433 colorectal (48% rural) and 489 breast (42% rural) patients, 621 PCPs, and 370 specialists participated. Compared with urban patients, patients with symptomatic colorectal cancer from rural areas had significantly longer total intervals at the 50th [18 days longer, 95% confidence interval (CI): 9-27], 75th (53, 95% CI: 47-59), and 90th percentiles (44, 95% CI: 40-48). These patients also had longer diagnostic and health system intervals (6-85 days longer). Breast cancer intervals were similar by area of residence, except the patient interval, which was shorter for rural patients with either cancer in the higher percentiles.Conclusions: Rural residence was associated with longer total intervals for colorectal but not breast cancer; with most disparities postpresentation.Impact: Interventions targeting time from presentation to diagnosis may help reduce colorectal cancer rural-urban disparities. Cancer Epidemiol Biomarkers Prev; 27(9); 1036-46. ©2018 AACR.

Harmonic dissection versus electrocautery in breast surgery in regional Victoria.

BACKGROUND: Harmonic instruments are an alternative tool for surgical dissection. The aim of this study is to evaluate differences in clinical outcomes relating to harmonic dissection when compared with electrocautery in patients undergoing major breast surgery in a regional centre over a 3-year period. METHODS: Retrospective chart analysis was conducted of 52 patients undergoing major breast surgery for carcinoma or ductal carcinoma in situ by a single surgeon in a regional centre from May 2008 to January 2011. Analysis involved the extraction of qualitative data relating to patient demographics, surgery type and specimen histopathology. Quantitative data were extracted relating to duration of surgery, duration of patient-controlled analgesia (PCA) use, length of hospital admission, drainage output and presence of infection, haematoma or seroma. RESULTS: Fifty-two patients underwent major breast surgery; harmonic dissection n = 32 and electrocautery n = 20. The two groups were comparable. There was no significant difference identified relating the outcome measures. The median operative duration was shorter in the harmonic dissection group, however, was not of statistical significance. No significant difference was identified between groups relating to length of inpatient stay, duration of PCA use and total volume wound drainage and total days of drainage. Incidence of seroma and infection in the groups was not significantly different. CONCLUSION: The harmonic dissection is safe and effective in major breast surgery. The study did not demonstrate any clinical advantage from the use of harmonic dissection in major breast surgery compared with electrocautery, nor was there any difference in the complication rates measured.

Anal sphincter injury, fecal and urinary incontinence: a 34-year follow-up after forceps delivery.

PURPOSE: This study was designed to determine the long-term outcome of forceps delivery in terms of evidence of anal sphincter injury and the incidence of fecal and urinary incontinence. METHODS: Women who delivered in 1964 were evaluated by using endoanal ultrasound, manometry, and a continence questionnaire. Women delivered by forceps were matched with the next normal delivery and elective cesarean delivery in the birth register. RESULTS: The women's overall obstetric history was evaluated. Women who had ever had a forceps delivery (n = 42) had a significantly higher incidence of sphincter rupture compared with women who had only unassisted vaginal deliveries (n = 41) and elective cesarean sections (n = 6) (44 vs. 22 vs. 0 percent; chi-squared 7.09; P = 0.03). There was no significant difference in the incidence of significant fecal incontinence between the three groups (14 vs. 10 vs. 0 percent) or significant urinary incontinence (7 vs. 19 vs. 0 percent). CONCLUSION: Anal sphincter injury was associated with forceps delivery in the past; however, significant fecal and urinary incontinence was not.