Which Factors Are Important to Women When Choosing a Breast Reconstruction Surgeon?

BACKGROUND: Women undergoing breast reconstruction often research their health care provider options. The authors studied which factors may influence how a woman selects a plastic surgeon for breast reconstruction surgery. METHODS: An online survey was distributed by means of Amazon Mechanical Turk (MTurk; Amazon Web Services, Inc., Seattle, Wash.) to 1025 adult women. Participants were asked to imagine a scenario in which they had breast cancer, needed to undergo mastectomy, and were choosing a reconstructive surgeon. They were then asked to rank factors influencing this decision on a 1 to 7 Likert scale. Two-sample t tests were used to compare Likert scores between dichotomized categories based on participant characteristics. RESULTS: Women assigned the highest scores [mean (standard deviation)] to online reviews on Vitals or WebMD [6.1 (1.2)], years of experience [5.7 (1.4)], recommendations from another surgeon [5.7 (1.3)] or family/friend [4.9 (1.7)], and attending a top medical school [4.7 (1.7)]. Lowest ranked factors were online advertising and surgeon demographics, including having a sex concordant (female) surgeon. After amalgamation into attribute subsections, mean (standard deviation) rated relative importance of surgeon reputation [0.72 (0.13)] was higher than that of appearance [0.46 (0.19)] and demographics [0.31 (0.13)]. Patient demographics influenced relative importance of certain attributes; older, educated, and higher-income patients placed higher value on surgeon appearance (all p < 0.05). CONCLUSIONS: When selecting a breast reconstruction surgeon, women place the highest value on surgeons' online, educational, and personal reputations. Though most show no strong preferences for surgeon demographics or physical attributes, specific features may be important for some patients. Cognizance of these preferences may enable providers to more effectively understand patient expectations.

A Comparison of Complications in Therapeutic versus Contralateral Prophylactic Mastectomy Reconstruction: A Paired Analysis.

BACKGROUND: Although breast reconstruction after bilateral mastectomies including a contralateral prophylactic mastectomy is known to have a higher overall complication profile, whether reconstructive complication rates differ between the therapeutic mastectomy and contralateral prophylactic mastectomy sides remains unclear. METHODS: Women undergoing bilateral mastectomies with autologous or implant-based breast reconstruction for a unilateral breast cancer at a single institution were identified (2009 to 2019). Postoperative complications were stratified by laterality (therapeutic mastectomy versus contralateral prophylactic mastectomy). Paired data were analyzed to compare the risks of complications between prophylactic and therapeutic reconstruction sides in the same patient. RESULTS: A total of 130 patients (260 reconstructions) underwent bilateral autologous or implant-based reconstruction. Although most women underwent a simple mastectomy, a higher proportion of therapeutic mastectomies were modified radical mastectomies including axillary lymph node dissections compared to contralateral prophylactic mastectomies (15.4 percent versus 0 percent). Forty-four percent of women completed postmastectomy radiation therapy of the therapeutic side before definitive reconstruction. Overall, both therapeutic and prophylactic reconstructions had a similar incidence of reconstructive failure (p = 0.57), return to the operating room (p = 0.44), mastectomy skin flap necrosis (p = 0.32), seroma (p = 0.82), fat necrosis (p = 0.16), wound infection (p = 0.56), and cellulitis (p = 0.56). Nearly one-fifth of patients experienced complications limited to the prophylactic side [contralateral prophylactic mastectomy reconstruction complications, n = 26 (20.0 percent); therapeutic mastectomy reconstruction complications, n = 15 (11.5 percent)]. CONCLUSION: Despite a history of local radiation therapy and more extensive oncologic surgery on the therapeutic side, there are no significant differences in the incidence of postsurgical complications on the therapeutic mastectomy and contralateral prophylactic mastectomy sides after bilateral reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Breast Implant-Associated Bilateral B-Cell Lymphoma.

Lymphomas associated with implants are predominantly of T-cell type-with anaplastic large cell lymphoma (ALCL) being most reported. That said, to date, 6 cases of B-cell lymphoma associated with breast implants have been reported. All cases exhibited unilateral breast involvement. Here, the authors report a case of low-grade B-cell lymphoma occurring bilaterally in a 34-year-old woman with a history of Poly Implant Prosthese silicone implants at age 20, T-cell angioimmunoblastic lymphoma, and subsequent myeloablative double cord blood transplantation. Lymphoma cells were positive for CD20, CD5, BCL-2, CD21, CD23, IgD, IgM, with very low Ki-67 of 1%. Nevertheless, cases of ALCL associated with breast implants are rare but much more documented in the literature than B-cell lymphomas associated with breast implants, as in this patient. Identification of a relationship between breast cancer and silicone is still ongoing in the literature, with long-term clinical follow up required. More research will be necessary to fully characterize the occurrence, course, and association of this disease with breast implants in order to properly guide diagnosis and management.

Surgical Management of the Radiated Chest Wall and Its Complications.

Radiation to the chest wall is common before resection of tumors. Osteoradionecrosis can occur after radiation treatment. Radical resection and reconstruction can be lifesaving. Soft tissue coverage using myocutaneous or omental flaps is determined by the quality of soft tissue available and the status of the vascular pedicle supplying available myocutaneous flaps. Radiation-induced sarcomas of the chest wall occur most commonly after radiation therapy for breast cancer. Although angiosarcomas are the most common radiation-induced sarcomas, osteosarcoma, myosarcomas, rhabdomyosarcoma, and undifferentiated sarcomas also occur. The most effective treatment is surgical resection. Inoperable tumors are treated with chemotherapy, with low response rates.

Community health workers recruitment from within: an inner-city neighborhood-driven framework.

BACKGROUND: Community health workers (CHWs) are frontline public health workers who are trusted members of and/or have an unusually close understanding of the community served (APHA 2009). Among other roles, they are effective in closing critical communication gap between healthcare providers and patients as they possess key abilities to overcome cultural barriers, minimize disparities, and maximize adherence to clinical directions. In previous descriptions of the selection of CHWs, the role of community is clearly emphasized, but residence in the community is not indicated. OBJECTIVE: We present an effective model of CHW selection by the community of members that reside in the community to be served. METHODS: We outlined and implemented necessary steps for recruiting CHWs from within their target neighborhood between years 2011 and 2013. The identified community was an "isolated" part of Newark, New Jersey comprised of approximately 3000 people residing in three publicly-funded housing developments. We utilized a community empowerment model and established a structure of self-governance in the community of interest. In all phases of identification and selection of CHWs, the Community Advisory Board (CAB) played a leading role. RESULTS: The process for the successful development of a CHW initiative in an urban setting begins with community/resident engagement and ends with employment of trained CHWs. The steps needed are: (1) community site identification; (2) resident engagement; (3) health needs assessment; (4) CHW identification and recruitment; and (5) training and employment of CHWs. Using an empowered community model, we successfully initiated CHW selection, training, and recruitment. Thirteen CHW candidates were selected and approved by the community. They entered a 10-week training program and ten CHWs completed the training. We employed these ten CHWs. CONCLUSIONS: These five steps emerged from a retrospective review of our CHW initiative. Residing in the community served has significant advantages and disadvantages. Community empowerment is critical in changing the health indices of marginalized communities.

Radiation therapy for breast cancer patients who undergo oncoplastic surgery: localization of the tumor bed for the local boost.

INTRODUCTION: Oncoplastic reconstructive surgery is performed in select patients with breast cancer to allow conservation treatment when the lumpectomy would be expected to have a poor cosmetic outcome. These techniques not only rearrange the breast tissue but may also shift the position of the tumor bed. The oncoplastic incision may have no relationship to the tumor bed. Although use of whole-breast radiation therapy (RT) is straightforward, difficulties in localization of the tumor bed for the local RT boost have not been investigated. MATERIALS AND METHODS: A retrospective review was performed of 25 patients with 26 cancers who received RT after breast conservation surgery with oncoplastic reconstruction. RESULTS: Among 11 patients with a minimum of 4 surgical clips placed at tumor resection, 8 (73%) had the final tumor bed extend beyond the original breast quadrant or be completely relocated into a different region. In 3 (27%) cases, the clinical treatment volume was 2 to 3 separated regions within the breast. DISCUSSION: For breast cancer patients who have had oncoplastic surgery, the tumor bed is frequently more extensive and possibly relocated compared with original presentation. Placement of surgical clips after tumor resection and before oncoplastic reconstruction may be the most accurate method to localize the RT local boost field.

Annual pediatric pedestrian education does not improve pedestrian behavior.

BACKGROUND: Pediatric pedestrian injuries are a major health care concern, specifically in urban centers. An educational program (WalkSafe), given one time during the school year, has been shown to improve childhood pedestrian safety. We examined whether this program could create similar long-term cognitive and behavioral changes in our school-aged children. METHODS: An established pediatric pedestrian curriculum was modified slightly for use in our area. Students K-fourth grade were exposed to the program once annually for 2 years. The program was carried out weekly for 3 consecutive weeks. The first and third sessions consisted of an educational module given by the classroom teacher. The second week consisted of an interactive assembly that allowed the children to demonstrate good pedestrian safety using a simulated street. Short- and intermediate-term cognitive knowledge was evaluated using standardized pre-, post- and 3-month follow-up tests. Long-term knowledge was assessed by comparing scores as students advanced in grade from year 1 to 2 of the program (K to first, first to second, etc.). At six schools during year 2, pedestrian behavior was measured through direct observation of children on city streets before and after administering the program. The project was approved by university and school board institutional review boards. RESULTS: During the 2 years, 1,564 students from nine schools were educated. In both years of the program, students in all grades had a significant gain in test scores immediately after and at 3 months compared with baseline knowledge. In contrast, only students moving from grade 3 to 4 demonstrated long-term retention (K→1: 7.7 vs. 6.7; grade 1→2: 7.8 vs. 6.7; grade 2→3: 7.3 vs. 6.8; grade 3→4: 7.1 vs. 8.0; all p < 0.05 year 2 pretest vs. year 1 3-month posttest; analysis of variance and generalized linear model). Only 30% of children walk with an adult. Direct observation showed 64% of children stopped at the curb but only 8% looked left-right-left. Children walking alone were more likely to cross mid-block compared with those walking with an adult (12% vs. 3%; p < 0.001) and also tend to look left-right-left significantly more than those walking with an adult (67% vs. 20%; p < 0.0001). CONCLUSIONS: A one-time annual educational program resulted in long-term knowledge retention between grades 3 and 4 only. In contrast, scores in younger grades reverted to baseline pretest values seen in year 1. Short- and intermediate-term knowledge gains were seen in all grades for both years. Because older children more often walk alone, we postulate that the improved retention may be the result of repeated exposure and practice as a pedestrian. Cognitive knowledge did not appear to translate into improved pedestrian behavior. Walking with an adult also had a negative impact on observed pedestrian safety behavior. The efficacy and impact of a one-time educational program may be insufficient to change long-term behavior and must be reevaluated.

Anaplastic large cell lymphoma associated with a breast implant capsule: a case report and review of the literature.

Primary lymphomas of the breast are rare and predominately of B-cell phenotype. Anaplastic large cell lymphoma is a T-cell lymphoma that accounts for only 3% of all non-Hodgkin lymphomas. We present a rare case of primary anaplastic large cell lymphoma of the breast in association with a silicone breast implant capsule in a healthy 40-year-old woman. The patient had bilateral breast implants placed at 21 years of age and presented with painful bilateral breast contractures and associated breast asymmetry. Histology, immunohistochemistry, and T-cell gene rearrangement studies were supportive of a CD 30-positive ALK-1 negative anaplastic large cell lymphoma. This case represents the 14th reported case of primary breast lymphoma in association with breast prosthesis. Of interest is that 11 of these cases were T-cell lymphomas with 8 specifically of the CD30-positive anaplastic large cell lymphoma type. This rare case highlights the importance of histologic examination of breast capsule specimens.