Breast cancer management pathways during the COVID-19 pandemic: outcomes from the UK ‘Alert Level 4’ phase of the B-MaP-C study

Abstract: Background: The B-MaP-C study aimed to determine alterations to breast cancer (BC) management during the peak transmission period of the UK COVID-19 pandemic and the potential impact of these treatment decisions. Methods: This was a national cohort study of patients with early BC undergoing multidisciplinary team (MDT)-guided treatment recommendations during the pandemic, designated ‘standard’ or ‘COVID-altered’, in the preoperative, operative and post-operative setting. Findings: Of 3776 patients (from 64 UK units) in the study, 2246 (59%) had ‘COVID-altered’ management. ‘Bridging’ endocrine therapy was used (n = 951) where theatre capacity was reduced. There was increasing access to COVID-19 low-risk theatres during the study period (59%). In line with national guidance, immediate breast reconstruction was avoided (n = 299). Where adjuvant chemotherapy was omitted (n = 81), the median benefit was only 3% (IQR 2–9%) using ‘NHS Predict’. There was the rapid adoption of new evidence-based hypofractionated radiotherapy (n = 781, from 46 units). Only 14 patients (1%) tested positive for SARS-CoV-2 during their treatment journey. Conclusions: The majority of ‘COVID-altered’ management decisions were largely in line with pre-COVID evidence-based guidelines, implying that breast cancer survival outcomes are unlikely to be negatively impacted by the pandemic. However, in this study, the potential impact of delays to BC presentation or diagnosis remains unknown

Data from: The importance of a medical chaperone: a quality improvement study exploring the use of a note stamp in a tertiary breast surgery unit

Objectives :The project aim was to determine current use and documentation of medical chaperones within a major breast service unit. It explored ways of improving adherence to professional guidelines concerning chaperones. Setting: The single centre quality improvement project was completed in a tertiary breast service unit in North West London. It was a three-stage project with initial audit in October 2013, 1st postintervention cycle in November 2013 and 2nd postintervention cycle in October 2014. Participants: In each study cycle, data were collected from entries in clinic notes until at least 155 encounters with documented clinical examination were analysed. All notes were of female patients. Interventions: (1) Intervention 1st cycle: presentation and discussion of chaperone guidelines alongside reminder posters and introduction of note stamp. (2) Intervention 2nd cycle: note stamp alone. Primary and secondary outcome measures: Documentation of chaperone offer, documentation of patient preference regarding chaperone, identifier (name or signature) of chaperone present and gender of examining clinician. Results: In the 1st postintervention cycle, 69.95% documentation of chaperone offer was recorded, p<0.001, CI (59.04% to 80.76%). This result was replicated in the 2nd postintervention cycle a year later with 74.86% documentation of chaperone offer recorded, p<0.001, CI (66.41% to 83.31%). The 4.91% difference was insignificant; p=0.294, CI (14.03% to 4.21%). Conclusions: The authors suggest that a proforma approach to medical chaperones is an effective means of ensuring adherence to best practice guidelines. A stamp, or similar, that can be embedded into documentation structure is an effective example of such an approach. Improved documentation allows any problems with adherence to guidelines to be more easily identified, helping to ensure the safeguarding of patients and staff involved in intimate examinations

Raw data for three parts of a QIP study

Data was collected in paper format by researchers at the end of an outpatient clinic and inputted each day into a cumulative excel spreadsheet. The raw data is included in these files. Statistical calculations for this data were calculated using an open access software. Results of a two tailed z-calculation have also been included. Confidence intervals where relevant were included in the paper and calculated by hand

Patient-level costs of staged unilateral versus immediate bilateral symmetrization mammoplasty in breast-conserving surgery

BACKGROUND: Following therapeutic mammoplasty (TM), the contralateral breast may require a later balancing procedure to optimize shape and symmetry. The alternative is to offer patients simultaneous TM with immediate contralateral symmetrization via a dual-surgeon approach, with the goal of reducing costs and minimizing the number of subsequent hospital appointments in an era of COVID-19 surges. The aim of this cost-consequence analysis is to characterize the cost-benefit of immediate bilateral symmetrization dual-operator mammoplasty versus staged unilateral single operator for breast cancer surgery. METHOD: A prospective single-centre observational study was conducted at an academic teaching centre for breast cancer surgery in the UK. Pseudonymized data for clinicopathological variables and procedural care information, including the type of initial breast-conserving surgery and subsequent reoperation(s), were extracted from the electronic patient record. Financial data were retrieved using the Patient-Level Information and Costing Systems. RESULTS: Between April 2014 and March 2020, 232 women received either immediate bilateral (n = 44), staged unilateral (n = 57) for breast cancer, or unilateral mammoplasty alone (n = 131). The median (interquartile range (i.q.r.)) additional cost of unilateral mammoplasty with staged versus immediate bilateral mammoplasty was €5500 (€4330 to €6570) per patient (P < 0.001), which represents a total supplementary financial burden of €313 462 to the study institution. There was no significant difference between groups in age, Charlson comorbidity index, operating minutes, time to adjuvant radiotherapy in months, or duration of hospital stay. CONCLUSION: Synchronous dual-surgeon immediate bilateral TM can deliver safe immediate symmetrization and is financially beneficial, without delay to receipt of adjuvant therapy, or additional postoperative morbidity

A measure of case complexity for cancer multidisciplinary teams: Development and early validation of the MeDiC tool

Background and Objective. There is increasing emphasis in cancer care globally for care to be reviewed and managed by multidisciplinary teams (i.e., in tumor boards). Evidence and recommendations suggest that the complexity of each patient case needs to be considered as care is planned, however no tool currently exists for cancer teams to do so. We report the development and early validation of such a tool. Methods. We used a mixed-methods approach involving psychometric evaluation and expert review to develop the Measure of case-Discussion Complexity (MeDiC) between May 2014 and November 2016. The study ran in 6 phases and included ethnographic interviews, observations, surveys, feasibility and reliability testing, expert consensus, and multiple expert-team reviews. Results. Phase-1: case complexity factors identified through literature review and expert interviews; Phase-2: 51 factors subjected to iterative review and content validation by 9 cancer teams across 4 England Trusts with 9 further items identified; Phase 3: 60-items subjected to expert review distilled to the most relevant; Phase 4: item weighing and further content validation through a national UK survey. Phases 5 and 6: excellent inter-assessor reliability between clinical and non-clinical observers, and adequate validity on 903 video case-discussions achieved. A final set of 27 factors, measuring clinical and logistical complexities were integrated into MeDiC. Conclusions. MeDiC is an evidence-based and expert-driven tool that gauges the complexity of cancer cases. MeDiC may be used as a clinical quality assurance and screening tool for tumor board consideration through case selection and prioritization