Preparing for the Renaissance: Treating Breast Cancer during the COVID-19 Pandemic and Planning for a Safe Re-Emergence to Routine Surgical Care within a Universal Health Care System

The evolving covid-19 pandemic is placing tremendous pressure on health systems. [...

Cost-Effectiveness Analysis of Whole-Mount Pathology Processing for Patients with Early Breast Cancer Undergoing Breast Conservation

Background: Obtaining accurate histopathologic detail for breast lumpectomy specimens is challenging because of sampling and loss of three-dimensional conformational features with conventional processing. The whole-mount (WM) technique is a novel method of serial pathologic sectioning designed to optimize cross-sectional visualization of resected specimens and determination of margin status. Methods: Using a Markov chain cohort simulation cost-effectiveness model, we compared conventional processing with WM technique for breast lumpectomies. Cost-effectiveness was evaluated from the perspective of the Canadian health care system and compared using incremental cost-effectiveness ratios (ICERs) for cost per quality-adjusted life–year (QALY) over a 10-year time horizon. Deterministic and probabilistic sensitivity analyses were performed to test the robustness of the model with willingness-to-pay (WTP) thresholds of $0–$100,000. Costs are reported in adjusted 2014 Canadian dollars, discounted at a rate of 3%. Results: Compared with conventional processing, WM processing is more costly ($19,989 vs.$18,427) but generates 0.03 more QALYs over 10 years. The ICER is $45,414, indicating that this additional amount is required for each additional QALY obtained. The model was robust to all variance in parameters, with the prevalence of positive margins accounting for most of the model’s variability. Conclusions: After a WTP threshold of$45,414, WM processing becomes cost-effective and ultimately generates fewer recurrences and marginally more QALYs over time. Excellent baseline outcomes for the current treatment of breast cancer mean that incremental differences in survival are small. However, the overall benefit of the WM technique should be considered in the context of achieving improved accuracy and not just enhancements in clinical effectiveness

Locoregional Management of in-Transit Metastasis in Melanoma: An Ontario Health (Cancer Care Ontario) Clinical Practice Guideline

Objective: The purpose of this guideline is to provide guidance on appropriate management of satellite and in-transit metastasis (itm) from melanoma. Methods: The guideline was developed by the Program in Evidence-Based Care (pebc) of Ontario Health (Cancer Care Ontario) and the Melanoma Disease Site Group. Recommendations were drafted by a Working Group based on a systematic review of publications in the medline and embase databases. The document underwent patient- and caregiver-specific consultation and was circulated to the Melanoma Disease Site Group and the pebc Report Approval Panel for internal review; the revised document underwent external review. Recommendations: “Minimal itm” is defined as lesions in a location with limited spread (generally 1–4 lesions); the lesions are generally superficial, often clustered together, and surgically resectable. “Moderate itm” is defined as more than 5 lesions covering a wider area, or the rapid development (within weeks) of new in-transit lesions. “Maximal itm” is defined as large-volume disease with multiple (>15–20) 2–3 cm nodules or subcutaneous or deeper lesions over a wide area. (1) In patients presenting with minimal itm, complete surgical excision with negative pathologic margins is recommended. In addition to complete surgical resection, adjuvant treatment may be considered. (2) In patients presenting with moderate unresectable itm, consider using this approach for localized treatment: intralesional interleukin 2 or talimogene laherparepvec as 1st choice, topical diphenylcyclopropenone as 2nd choice, or radiation therapy as 3rd choice. Evidence is insufficient to recommend intralesional bacille Calmette– Guérin or CO2 laser ablation outside of a research setting. (3) In patients presenting with maximal itm confined to an extremity, isolated limb perfusion, isolated limb infusion, or systemic therapy may be considered. In extremely select cases, amputation could be considered as a final option in patients without systemic disease after discussion at a multidisciplinary case conference. (4) In cases in which local, regional, or surgical treatments for itm might be ineffective or unable to be performed, or if a patient has systemic metastases at the same time, systemic therapy may be considered

Primary Excision Margins, Sentinel Lymph Node Biopsy, and Completion Lymph Node Dissection in Cutaneous MelanomA: A Clinical Practice Guideline

Background: For patients who are diagnosed with early-stage cutaneous melanoma, the principal therapy is wide surgical excision of the primary tumour and assessment of lymph nodes. The purpose of the present guideline was to update the 2010 Cancer Care Ontario guideline on wide local excision margins and sentinel lymph node biopsy (slnb), including treatment of the positive sentinel node, for melanomas of the trunk, extremities, and head and neck. Methods: Using Ovid, the medline and embase electronic databases were systematically searched for systematic reviews and primary literature evaluating narrow compared with wide excision margins and the use of slnb for melanoma of the truck and extremities and of the head and neck. Search timelines ran from 2010 through week 25 of 2017. Results: Four systematic reviews were chosen for inclusion in the evidence base. Where systematic reviews were available, the search of the primary literature was conducted starting from the end date of the search in the reviews. Where systematic reviews were absent, the search for primary literature ran from 2010 forward. Of 1213 primary studies identified, 8 met the inclusion criteria. Two randomized controlled trials were used to inform the recommendation on completion lymph node dissection. Key updated recommendations include: (1) Wide local excision margins should be 2 cm for melanomas of the trunk, extremities, and head and neck that exceed 2 mm in depth. (2) SLNB should be offered to patients with melanomas of the trunk, extremities, and head and neck that exceed 0.8 mm in depth. (3) Patients with sentinel node metastasis should be considered for nodal observation with ultrasonography rather than for completion lymph node dissection. Conclusions: Recommendations for primary excision margins, sentinel lymph node biopsy, and completion lymph node dissection in patients with cutaneous melanoma have been updated based on the current literature