Racial Disparity in Immediate Breast Reconstruction; a Gap That is not Closing

2021 ◽  
pp. 229255032110555
Author(s):  
Mahdi Malekpour ◽  
Sean Devitt ◽  
Joseph DeSantis ◽  
Christian Kauffman
Keyword(s):  
Propensity Score ◽  
Breast Reconstruction ◽  
Racial Disparity ◽  
Standard Of Care ◽  
Immediate Breast Reconstruction ◽  
P Value ◽  
National Cancer Database ◽  
Black Females ◽  
Black And White ◽  
Significant Difference

Background: Immediate breast reconstruction (IBR) is offered as part of the standard-of-care to females undergoing mastectomy. Racial disparity in IBR has been previously reported with a longstanding call for its elimination, though unknown if this goal is achieved. The aim of this study was to examine the current association between race and IBR and to investigate whether racial disparity is diminishing. Methods: Data was extracted from the National Cancer Database (NCDB) from 2004 to 2016. All variables in the database were controlled so that the comparison would be made solely between Black and White females. We also analyzed the trend in racial disparity to see if there has been a change from 2004 to 2016 after several calls for healthcare equality. Results: After propensity score matching, 69,084 White females were compared to 69,084 Black females. There was a statistically significant difference between the rate of IBR and race (23,386 [33.9%] in White females vs 20,850 [30.2%] in Black females, P-value  < .001). Despite a twofold increase in the rate of IBR in both White and Black females, a persistent gap of about 4% was observed over the study period, which translates to more than 2,500 Black females not receiving IBR. Conclusions: Using the NCDB database, a racial disparity was identified for IBR between White and Black females from 2004 and 2016. Unfortunately, the gap between the groups remained constant over this 13-year period.

Treatments for metastatic hormone-sensitive prostate cancer: A systematic review.

2018 ◽  
Vol 36 (6_suppl) ◽  
pp. 346-346
Author(s):  
Belal Firwana ◽  
Mohamad Bassam Sonbol ◽  
Fade A. Mahmoud ◽  
Konstantinos Arnaoutakis
Keyword(s):  
Prostate Cancer ◽  
Progression Free Survival ◽  
Standard Of Care ◽  
P Value ◽  
Free Survival ◽  
Appropriate Treatment ◽  
Individual Trial ◽  
Efficacy Outcome ◽  
Significant Difference ◽  
Hormone Sensitive

346 Background: Over the past few years, the treatment of metastatic hormone sensitive prostate cancer (mHSPC) was revolutionized with the addition of docetaxel (DOC) or abiraterone (ABI) to the previous standard of care androgen deprivation treatment (ADT). Here, we sought to compare the effectiveness of docetaxel and abiraterone directly against ADT and indirectly to each other. Methods: We included randomized controlled trials (RCT) evaluating the efficacy of treatments in adults with newly diagnosed mHSPC. First-line treatments with DOC and ABI were considered. Efficacy outcome measures are overall survival (OS) and failure-free survival as (FFS) as defined by individual trial. If FFS was not reported, biochemical progression-free survival was considered FFS due to its specificity. The overall effect was pooled using the DerSimonian random effects model. Testing for subgroup difference was conducted using meta-regression method. Results: A total of five RCTs were included; three RCTs compared DOC+ADT versus ADT involving 2,992 participants, and two RCT compared ABI+ADT versus ADT involving 2,201 participants. The addition of DOC to ADT showed a significant improvement in OS compared to ADT monotherapy (HR 0.77, 95% CI 0.66 to 0.89) as well did the addition of ABI to ADT (HR 0.62, 95% CI 0.53 to 0.71). p-value for subgroup interaction was <0.05, suggesting a significant difference between pooled DOC and ABI effects, favoring the addition of ABI vs. DOC to ADT. Similar effects were found in significantly improving FFS when adding DOC (HR 0.64, 95% CI 0.58 to 0.70) or ABI (HR 0.30, 95% CI 0.27 to 0.34) to ADT compared to ADT monotherapy. p-value for interaction subgroup interaction was again significant <0.05 favoring the addition of ABI vs. DOC to ADT. Conclusions: The addition of either DOC or ABI to ADT showed significant improvement in OS and FFS when compared to ADT monotherapy in patients with mHSPC. Test for interaction suggests better outcome of ABI in comparison against DOC. Discussion with patients is encouraged to choose the appropriate treatment considering the adverse event profile for each. Further head-to-head comparison is needed to determine the effect.

Influencers of Immediate Post-Mastectomy Reconstruction: A National Cancer Database Analysis

2021 ◽  
Author(s):  
Dora Danko ◽  
Yuan Liu ◽  
Feifei Geng ◽  
Theresa W Gillespie
Keyword(s):  
Breast Cancer ◽  
Decision Making ◽  
Breast Reconstruction ◽  
Urban Areas ◽  
Private Insurance ◽  
Immediate Breast Reconstruction ◽  
Third Party ◽  
National Cancer Database ◽  
Immediate Reconstruction ◽  
The Impact

Abstract Background The literature examining decision-making related to treatment and reconstruction for women with breast cancer has established that patient, clinical, and facility factors all play a role. Objectives Using the National Cancer Database (NCDB), determine how patient, clinical, and facility factors influence: 1) the receipt of immediate breast reconstruction; and 2) the type of immediate breast reconstruction received (implant-based, autologous, or a combination). Methods A total of 638,772 female patients with TIS-T3, N0-N1, M0 breast cancers were identified in the NCDB from 2004-2017 who received immediate reconstruction following mastectomy. Univariate and multivariable logistic regression models were conducted to identify characteristics associated with immediate breast reconstruction and type of reconstruction. Results Immediate breast reconstruction was more frequently associated with patients of white race, younger age, with private insurance, with lesser comorbidities, who resided in zip-codes with higher median incomes or higher rate of high-school graduation, in urban areas, with Tis-T2 disease, or with &lt;4 lymph node involvement (all odds ratios (OR) &gt; 1.1). Negative predictors of immediate breast reconstruction were insurance status with Medicaid, Medicare, other government insurance, and none or unknown insurance (all ORs &lt;0.79). Implant-based reconstruction was associated with non-black race, uninsured status, completion of higher education, undifferentiated disease, and stage T0 disease (all ORs &gt;1.10). Conclusions These findings confirm some previous studies on what patient, clinical, and facility factors affect decision making, but also raise new questions that relate to the impact of third-party payor on receipt and type of reconstruction post-mastectomy for breast cancer.

Ready for the Frontline: Is Early Thoracoscopic Decortication the New Standard of Care for Advanced Pneumonia with Empyema?

2006 ◽  
Vol 72 (8) ◽  
pp. 688-693 ◽  
Author(s):  
Adam M. Suchar ◽  
Amer H. Zureikat ◽  
Loretto Glynn ◽  
Mindy B. Statter ◽  
Jongin Lee ◽  
...  
Keyword(s):  
Pleural Fluid ◽  
Surgical Outcome ◽  
Standard Of Care ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
P Value ◽  
X Rays ◽  
Necrotizing Pneumonia ◽  
Significant Difference ◽  
Student’S T

Video-assisted thoracoscopic decortication (VATD) has been established as an effective and potentially less morbid alternative to open thoracotomy for the management of empyema. However, the timing and role of VATD for advanced pneumonia with empyema is still controversial. In assessing surgical outcome, the authors reviewed their VATD experience in children with empyema or empyema with necrotizing pneumonia. The charts of 42 children who underwent VATD at our institution between July 2001 and July 2005 were retrospectively reviewed for surgical outcome. For purposes of analysis, patients were cohorted into four classes with increasing severity of pneumonia: 1 (-) intraoperative pleural fluid cultures, (-) necrotizing pneumonia, 18 (43%); 2 (+) pleural fluid cultures, (-) necrotizing pneumonia, 10 (24%); 3 (-) pleural fluid cultures, (+) necrotizing pneumonia, 6 (14%); 4 (+) pleural fluid cultures, (+) necrotizing pneumonia, 8 (19%). A P value of <0.05 via Student's t test or Fischer's exact analysis was considered an indicator of significant difference in the comparison of group outcomes. VATD was successfully completed in all 42 patients with no mortality and without significant morbidity (82% had less than 20 cc blood loss). There was found to be no significant difference (p = NS) in time to surgical discharge (removal of chest tube) among all groups. Hospital length of stay postsurgery was found to be significantly increased between 1 and 4 (6 days vs 9 days; P = 0.038). 14/14 (100%) of children with necrotizing pneumonia were found to have evidence of lung parenchymal preservation with improved aeration on follow-up CT scan and/or chest x-rays. The authors conclude that early VATD in children with advanced pneumonia with empyema is indicated to avoid unnecessarily lengthy hospitalization and prolonged intravenous antibiotic therapy. Furthermore, early VATD can be safely performed in various stages of advanced pneumonia with empyema, promoting lung salvage, and accelerating clinical recovery.

scholarly journals 1443 Comparison of Outcomes Between Immediate Direct-to-Implant Breast Reconstruction versus Two-Stage Implant Breast Reconstruction; a Systematic Review and Meta-analysis

2021 ◽  
Vol 108 (Supplement_6) ◽  
Author(s):  
O Kelly ◽  
I Balasubramanian ◽  
C Cullinane ◽  
R Prichard
Keyword(s):  
Systematic Review ◽  
Breast Reconstruction ◽  
Meta Analysis ◽  
Capsular Contracture ◽  
Tissue Expander ◽  
Immediate Breast Reconstruction ◽  
Two Stage ◽  
Significant Difference ◽  
Implant Reconstruction ◽  
Implant Breast Reconstruction

Abstract Background Direct-to-implant (DTI) breast reconstruction is increasingly performed as the preferred method of immediate breast reconstruction following mastectomy. The proposed advantages of DTI over two-stage tissue expander (TE)/implant reconstruction relate to fewer surgical procedures. This systematic review and meta-analysis aims to evaluate the safety and efficacy of DTI versus conventional TE/implant breast reconstruction. Method A systematic review was performed (PubMed, Embase, Scopus) to identify relevant studies that compared outcomes between DTI and TE/Implant reconstructions. Publications up to October 2020 were included. The primary outcome was overall complication rate. Secondary outcomes included infection rate and implant loss. Results Nineteen studies, including 32,971 implant-based breast reconstructions, were analysed. Median age was 48 years. Mean BMI was 25.9. There was no statistically significant difference between the two groups. Duration of follow up ranged from 1-60 months. Overall complications were significantly more likely to occur in the DTI group (OR 1.81 [1.17-2.79]). Overall complications refers to all reported complications including seroma, haematoma, would dehiscence, infection, skin necrosis and capsular contracture. Implant loss was also significantly higher in the DTI cohort (OR 1.31 [1.12-1.78]). There was no significant difference in infection rates between the two groups. Subgroup analyses, focusing on high-powered multicentre studies showed that the risks of overall complications were significantly higher in the DTI group (OR 1.51 [1.06-2.14]). Conclusions This meta-analysis demonstrates significantly greater risk of complications and implant loss in the DTI breast reconstruction group. These findings serve to aid both patients and clinicians in the decision-making process regarding implant reconstruction following mastectomy

Economic Impact of Refinements in ERAS Pathways in DIEP Flap Breast Reconstruction

2021 ◽  
Author(s):  
Pope Rodnoi ◽  
Sumeet S. Teotia ◽  
Nicholas T. Haddock
Keyword(s):  
Breast Reconstruction ◽  
Hospital Length Of Stay ◽  
P Value ◽  
Diep Flap ◽  
Total Cost ◽  
Contribution Margin ◽  
Significant Difference ◽  
Post Hoc ◽  
The Impact ◽  
Operating Suite

Abstract Introduction Enhanced recovery after surgery (ERAS) protocols at our institution have led to an expected decrease in hospital length of stay and opioid consumption for patients treated with deep inferior epigastric perforator (DIEP) flaps for breast reconstruction. We look to examine the economic patterns across these years to see the impact of costs for the patient and institution. Methods This study retrospectively evaluated consecutive patients treated with bilateral DIEP flaps for breast reconstruction between October 2015 and August 2020. We categorized the cases into three categories: pre-ERAS, ERAS, ERAS + bupivacaine. Primary outcomes observed included the contribution margin per operating suite case minute and total cost to the patient. An analysis of variance determined whether there was a difference between the three groups and a Tukey post-hoc analysis made pairwise comparisons. A p-value < 0.05 was significant. Results A total of 268 cases of bilateral DIEPs performed by the two senior authors were analyzed in this study. Seventy-four cases were pre-ERAS, 72 were ERAS, and 122 were ERAS + bupivacaine. There was a statistical difference between the contribution margin per operating minute. A Tukey post hoc test revealed that the average contribution margin per operating suite case minute was significantly higher for the ERAS and ERAS + bupivacaine compared with the pre-ERAS groups.There was a statistically significant difference between the total cost to the patients. A Tukey post hoc test revealed that the average total cost to the patient was statistically significantly lower for the ERAS and ERAS + bupivacaine compared with the pre-ERAS group. Conclusion Implementation of ERAS and continued improvements in ERAS resulted in significantly decreased costs for the patient and increased profitability for the hospital. Investing in improvements to ERAS protocols can improve profitability for the institution while simultaneously improving costs and access to care for patients in need of breast reconstruction.

Skin-Sparing Mastectomy: A Survey Based Approach to Defining Standard of Care

2008 ◽  
Vol 74 (10) ◽  
pp. 902-905 ◽  
Author(s):  
Jeannie Shen ◽  
Joshua Ellenhorn ◽  
Dajun Qian ◽  
David Kulber ◽  
Joel Aronowitz
Keyword(s):  
Breast Reconstruction ◽  
Early Stage ◽  
Standard Of Care ◽  
Postal Questionnaire ◽  
Immediate Breast Reconstruction ◽  
Breast Cancer Surgery ◽  
Effective Treatment Option ◽  
Immediate Reconstruction ◽  
Skin Envelope ◽  
General Surgeons

Skin-sparing mastectomy (SSM) followed by immediate reconstruction has been advocated as an effective treatment option for patients with early-stage breast carcinoma. It markedly improves the quality of breast reconstruction through preservation of the natural skin envelope and a smaller incision. The purpose of this study was to investigate general surgeons’ attitudes towards SSM. A postal questionnaire survey of California general surgeons was conducted regarding SSM. Of 370 respondents who stated they performed breast cancer surgery, 331 perform mastectomy for cancer with planned immediate reconstruction. Ninety per cent of respondents did not feel that SSM resulted in higher rates of local recurrence. In addition, 70 per cent felt that the cosmetic results of immediate breast reconstruction after SSM were better than those after a standard mastectomy. Despite this, only 61 per cent perform SSM in most cases when immediate breast reconstruction is planned. The majority of general surgeons perform SSM and therefore it should be considered standard of care. Despite a growing body of literature demonstrating high rates of patient satisfaction and long-term oncologic safety with SSM, there remains significant variation in practice patterns among general surgeons. Additional effort in general surgery education regarding the feasibility and safety of SSM is needed.

scholarly journals Enough with the madness: a systematic review and meta-analysis of hydroxychloroquine for COVID-19

2021 ◽  
Vol 13 (2) ◽  
pp. 186-220
Author(s):  
André Santos ◽  
◽  
Érica Gonçalves ◽  
Ananda Oliveira ◽  
Douglas Lima ◽  
...  
Keyword(s):  
Systematic Review ◽  
Adverse Events ◽  
Meta Analysis ◽  
Standard Of Care ◽  
P Value ◽  
Serious Adverse Events ◽  
Risk Of Death ◽  
Increased Risk ◽  
Significant Difference

Objective: Because of preliminary results from in vitro studies, hydroxychloroquine (HCQ) and chloroquine (CQ) have been proposed as possible treatments for COVID-19, but the clinical evidence is discordant. This study aims to evaluate the safety and efficacy of CQ and HCQ for the treatment of COVID-19. Methods: A systematic review with meta-analysis was performed. An electronic search was conducted in four databases for randomized controlled trials that compared HCQ or CQ with standard-of-care. A complementary search was performed. A quantitative synthesis of clinical outcomes was performed using the inverse variance method adjusting for a random-effects model. Results: In total, 16 studies were included. The meta-analysis found no significant difference between intervention and control groups in terms of mortality at the most extended follow-up (RR = 1.09, CI95% = 0.99-1.19, p-value = 0.08), patients with negative PCR results (RR = 0.99, CI95% = 0.89-1.10, p-value = 0.86), or serious adverse events (RR = 2.21, CI95% = 0.89-5.47, p-value = 0.09). HCQ was associated with an increased risk of adverse events (RR = 2.28, CI95% = 1.36-2.83, p-value < 0.01). The quality of evidence varied from very low to high. Conclusion: There is no evidence that HCQ reduces the risk of death or improves cure rates in patients with COVID-19, but it might be associated with an increased risk of adverse events

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