TP8.1.8 Blue flag clinics. A way to achieve a 2 week wait service in the age of plentiful referrals, radiological pressures and pension threat

Introduction In early 2019 increased referrals to the Breast 2WW Service, limited radiologist capacity and the pension crisis combined to cause the 2 week wait target to fail. A multidisciplinary solution was sought. Using the Nottingham Breast Institute triage criteria and decoupling clinical and radiological assessments, patients were referred along 2 pathways; red and blue flag. Methods Patients were clinically assessed by a trained breast surgeon within 2 weeks. Red flag patients underwent standard triple assessment. The aim for blue flag patients was to undergo any necessary imaging within 10 days. In both cohorts selected patients were given a patient satisfaction questionnaire. Data from red flag clinics were obtained from cancer services. Notes were reviewed for blue flag patients. Results Data on 858 blue flag patients seen were analysed. There was no difference between satisfaction scores. Conclusions The 2WW target was regained within a month of implementing change. As long as the standard operating procedure is maintained, the triage criteria adopted were successful and reduced pressure on radiology services. Patient safety and satisfaction were maintained.

Oncoplastic Reconstructive Breast Surgeon (ORBS) Performance and Impact on Breast Reconstructions: Clinical Outcome, Learning Curve, and Patient Reported Aesthetic Results- An analysis of 451 Procedures

Oncoplastic and reconstructive breast surgeon (ORBS) aimed to incorporate aesthetics and plastic technique into breast cancer operations to balance the oncologic safety and cosmetic outcome, and also to promote breast reconstructions. The outcome of breast reconstruction performed by an ORBS was reported from a single institute. Among the 451 breast reconstructions performed by an ORBS, 75.8% were gel implant reconstructions, 3.3% were tissue expander, 16.9% were transverse rectus abdominal myocutaneous (TRAM) flap, 3.1% latissimus dorsi (LD) flap, and 0.9% LD flap + implant. The patients reported aesthetic evaluation showed that 53.9% responded excellent, 41.1% good, 4.4% fair, and 0.6% poor. In cumulative sum plot learning curve analysis, it took around 58 procedures for an ORBS to be familial with mastectomy followed by immediate gel implant reconstruction and to significantly decrease the operation time. In multivariate analysis, younger age, MRI, nipple sparing mastectomy, ORBS, and high-volume surgeon were factors related to breast reconstructions. Current study demonstrated that a breast surgeon after adequate training could become an ORBS and perform breast reconstructions with adequacy. Complimentary to traditional breast surgeon-to-plastic surgeon breast reconstruction pathways, ORBS could increase breast reconstructions rate, which remained low worldwide.

Optimizing the Mastectomy Flap to Improve Aesthetic Outcomes

The aesthetics of breast reconstruction inherently rely on both the ablative and reconstructive procedures. Mastectomy flap quality remains one of the most critical factors in determining the success of a reconstruction and its aesthetic outcome. Maintaining the segmental perfusion to the nipple and skin envelope during mastectomy requires preserving the subcutaneous tissue superficial to the breast capsule. Because this layer of tissue varies in thickness among different patients and within each breast, anatomic dissection along the appropriate planes is required rather than a “one-size-fits-all” mentality. A team-based approach between the breast surgeon and plastic surgeon will optimize both the ablative and reconstructive procedures while engaging in a process of shared decision-making with the patient. Preoperative clinical analysis and utilization of imaging to assess individual breast anatomy will help guide mastectomies as well as decisions on reconstructive modalities. Critical assessment of mastectomy flaps is paramount and requires flexibility to adapt reconstructive paradigms intraoperatively to minimize the risk of complications and provide the best aesthetic result.

Health System Barriers to the Discussion of Breast Reconstruction Options in Australia: Improving Access Through Appropriate Referral

Background: This study aimed to document referral-based barriers impeding Australian women's informed decision-making about breast reconstruction (BR) and to propose a designated BR referral pathway to help overcome these barriers.Methods: Semi-structured, in-depth interviews were conducted with ten women previously treated for breast cancer, 9 breast and reconstructive surgeons and 6 health professionals [n=25] who had identified problems with referrals for BR. Results: Referral-based barriers to BR discussion were identified at three different levels: from a public or private screening center to a General Practitioner (GP) or breast surgeon; from a GP to a breast surgeon; and from one breast surgeon (without BR skills) to another breast or plastic reconstructive surgeon (with BR skills). A lack of designated referral pathways has meant that clinically eligible women who are interested in considering immediate BR have been denied this opportunity.Conclusions: Streamlining referral processes, along with patient and clinician education, would help to ensure that women are at least seen by the most appropriate clinicians to discuss BR options and to maximise their opportunity for BR should they choose that option. Designated referral pathways could also be useful in ensuring that preference-sensitive treatment decisions are facilitated in settings with varying degrees of resources and in a range of clinical conditions.