Assessing outcomes after breast surgery:patient and clinician reported outcomes

Background: Survival has significantly improved in women diagnosed with breast cancer, and as a result, it has become increasingly important to assess the psychological outcomes from the patient’s perspective. Interpreting the outcome based on the opinion of the operating surgeons may not reflect the opinions of the patient. The aim of this study was to assess clinician and patient reported outcomes of breast surgery at routine follow-up.Methods: Consecutive patients previously treated for breast cancer attending routine follow-up breast clinic over a period of 5 weeks were invited to participate. Patients were first seen by a clinician for review (four breast surgeons and one clinical nurse specialist), and cosmetic outcome was assessed using the Harris Harvard scale. Patient reported outcomes were measured using the Hopwood body image scale 10-item questionnaire.Results: Of 105 patients, complete data were available for 84 patients. All patients were female with a median age of 65 years (range 32 - 83 years). Wide local excisions accounted for 54% of all surgeries (n = 45), mastectomies 26% (n = 22) and mastectomy with reconstruction 20% (n = 17). Patients’ scores ranged from 0 to 30 with a median score of 1; 9% of patients had a score of > 10. Clinician rating was “excellent” for 37%, 34% as “very good”, 22% as “good” and 5.9% as “poor”. There was a weak correlation of patient scores to clinician score (Spearman rho: 0.219; 95% CI: 0.005 - 0.414; P = 0.045).Conclusions: With standard breast surgery, the majority of patients seen at follow-up clinics were satisfied with their cosmetic outcome, with the most favorable outcomes in patients who had undergone breast conservation, with mastectomy and reconstruction yielding the poorest results. Patient reported outcomes are not reflected in the clinician assessment of cosmesis

Stiffness at shear-wave elastography and patient presentation predicts upgrade at surgery following an ultrasound-guided core biopsy diagnosis of ductal carcinoma in situ

AIM: The aim of this study is to establish predictors of invasion in lesions yielding an ultrasound-guided biopsy diagnosis of ductal carcinoma in situ (DCIS).MATERIALS AND METHODS: Patients subjected to ultrasound-guided core biopsy yielding DCIS were studied. At shear-wave elastography (SWE) a threshold of 50 kPa was used for mean elasticity (Emean) to dichotomise the elasticity data between invasive and non-invasive masses. Data recorded included the mammographic and ultrasound features, the referral source, and grade of DCIS in the biopsy. The chi-square test was used to detect statistical significance.RESULTS: Of 57 lesions, 24 (42%) had invasion at excision. Symptomatic patients and patients with stiff lesions were more likely to have invasion than patients presenting through screening and with soft lesions (58% [14 of 24] versus 30% [10 of 33], p=0.03) and (51% [20 of 39] versus 22% [4 of 18], p=0.04). No other factors showed a relationship with invasion. Combining the two predictors of invasion improved risk stratification with symptomatic and stiff lesions having a risk of invasion of 67% (12 of 18) and soft lesions presenting at screening having only a 17% (2 of 12) risk of invasion (p=0.02).CONCLUSION: Stiffness on SWE and the referral source of the patient are predictors of occult invasion in women with an ultrasound-guided core biopsy diagnosis of DCIS.</p

Percutaneous sentinel node removal using a vacuum-assisted needle biopsy in women with breast cancer:a feasibility and acceptability study

AIMS: To assess the feasibility and acceptability of large-gauge percutaneous removal of the axillary sentinel lymph node (SLN) using dual gamma probe and ultrasound guidance.MATERIALS AND METHODS: Technetium nanocolloid was administered the day before surgery. On the day of surgery, potential SLNs were identified with gamma probe and ultrasound scanning. A 7 G vacuum-assisted biopsy (VAB) device was inserted percutaneously deep to the target node and the node(s) removed. The gamma probe was used to confirm removal of radiolabelled tissue. At surgery, any residual radiolabelled or blue nodes were removed. Morbidity was assessed via (1) a pain questionnaire immediately after the percutaneous procedure, (2) relevant items from the FACT B+4 questionnaire 7-10 days after surgery, and (3) case note review 1 month after surgery.RESULTS: Twenty-two patients consented and 20 patients underwent the procedure. Radiolabelled nodal tissue was obtained in 18/20 (90%). The mean procedure time was 11 minutes. Four of 18 patients had metastatic disease identified in the VAB excision tissue with 100% sensitivity for axillary metastasis. At axillary surgery, additional intact SLN or fragments were found in 14 patients. No additional metastatic disease was found at surgery. One patient suffered a pneumothorax during instillation of local anaesthetic. The median pain score was 10/100 by visual analogue scale. Immediate post-procedure haematoma was common (14 of 20) and prolonged manual compression frequent.CONCLUSION: VAB removal of sentinel nodes using dual scanning is feasible. Although preliminary sensitivity and specificity levels are encouraging, complications may discourage widespread implementation.</p

Defining forgiveness: Christian clergy and general population perspectives.

The lack of any consensual definition of forgiveness is a serious weakness in the research literature (McCullough, Pargament &amp; Thoresen, 2000). As forgiveness is at the core of Christianity, this study returns to the Christian source of the concept to explore the meaning of forgiveness for practicing Christian clergy. Comparisons are made with a general population sample and social science definitions of forgiveness to ensure that a shared meaning of forgiveness is articulated. Anglican and Roman Catholic clergy (N = 209) and a general population sample (N = 159) completed a postal questionnaire about forgiveness. There is agreement on the existence of individual differences in forgiveness. Clergy and the general population perceive reconciliation as necessary for forgiveness while there is no consensus within psychology. The clergy suggests that forgiveness is limitless and that repentance is unnecessary while the general population suggests that there are limits and that repentance is necessary. Psychological definitions do not conceptualize repentance as necessary for forgiveness and the question of limits has not been addressed although within therapy the implicit assumption is that forgiveness is limitless.</p

Developing autonomous learning in first year university students using perspectives from positive psychology

Autonomous learning is a commonly occurring learning outcome from university study, and it is argued that students require confidence in their own abilities to achieve this. Using approaches from positive psychology, this study aimed to develop confidence in first‐year university students to facilitate autonomous learning. Psychological character strengths were assessed in 214 students on day one at university. Two weeks later their top three strengths were given to them in study skills modules as part of a psycho‐educational intervention designed to increase their self‐efficacy and self‐esteem. The impact of the intervention was assessed against a control group of 40 students who had not received the intervention. The results suggested that students were more confident after the intervention, and that levels of autonomous learning increased significantly compared to the controls. Character strengths were found to be associated with self‐efficacy, self‐esteem and autonomous learning in ways that were theoretically meaningful

Randomised controlled trial to assess the impact of a lifestyle intervention (ActWELL) in women invited to NHS breast screening

Peer reviewedPublisher PD

The influence of synaptic activity on neuronal health

According to the theory of neuronal health, neurons exist in a spectrum of states ranging from highly resilient to vulnerable. An unhealthy neuron may be rendered dysfunctional or non-viable by an insult that would ordinarily be non-toxic to a healthy neuron. Over the years it has become clear that a neuron’s health is subject to dynamic regulation by electrical or synaptic activity. This review highlights recently identified activity dependent signalling events which boost neuronal health through the transcriptional control of pro- and anti-apoptotic genes, the enhancement of antioxidant defences, and the regulation of mitochondrial and neurotrophic factor availability. Furthermore, activity dependent signals have recently been shown to influence a variety of events specific to individual neurodegenerative diseases, which will also be highlighted

The mental health of university students in the United Kingdom

There are increasing concerns globally about the mental health of students (Kadison,& Digeronimo, 2004). In the UK, the actual incidence of mental disturbance is unknown, although university counselling services report increased referrals (Association of University & College Counselling, 2011). This study assesses the levels of mental illness in undergraduate students to examine whether widening participation in education has resulted in increases as hypothesized by the UK Royal College of Psychiatrists (2003, 2011). Patterns of disturbance across years are compared to identify where problems arise. Students (N = 1197) completed the General Health Questionnaire-28 either on day one at university or midway through the academic year for first, second and third year students. Rates of mental illness in students equalled those of the general population but only 5.1% were currently receiving treatment. Second year students reported the most significant increases in psychiatric symptoms. Factors contributing to the problem are discussed

Breast MRI and tumour biology predict axillary lymph node response to neoadjuvant chemotherapy for breast cancer

Background: In patients who have had axillary nodal metastasis diagnosed prior to neoadjuvant chemotherapy for breast cancer, there is little consensus on how to manage the axilla subsequently. The aim of this study was to explore whether a combination of breast magnetic resonance imaging (MRI) assessed response and primary tumour pathology factors could identify a subset of patients that might be spared axillary node clearance.Methods: A retrospective data analysis was performed of patients with core biopsy-proven axillary nodal metastasis prior to commencement of neoadjuvant chemotherapy (NAC) who had subsequent axillary node clearance (ANC) at definitive breast surgery. Breast tumour and axillary response at MRI before, during and on completion of NAC, core biopsy tumour grade, tumour type and immunophenotype were correlated with pathological response in the breast and the number of metastatic nodes in the ANC specimens.Results: Of 87 consecutive patients with MRI at baseline, interim and after neoadjuvant chemotherapy who underwent ANC at time of breast surgery, 33 (38%) had no residual macrometastatic axillary disease, 28 (32%) had 1–2 metastatic nodes and 26 (30%) had more than 2 metastatic nodes. Factors that predicted axillary nodal complete response were MRI complete response in the breast (p &lt; 0.0001), HER2 positivity (p = 0.02) and non-lobular tumour type (p = 0.015).Conclusion: MRI assessment of breast tumour response to NAC and core biopsy factors are predictive of response in axillary nodes, and can be used to guide decision making regarding appropriate axillary surgery