Feasibility of day surgery for breast cancer in Glasgow

Over the years, the surgical management of breast cancer has become less invasive due to various factors. Breast conserving surgery and lesser axillary surgery are performed whenever possible. Early stage at diagnosis made possible by breast screening and earlier presentation of symptomatic cancers due to increased awareness has meant that more patients are undergoing breast conserving surgery. Sentinel node biopsy and axillary sampling have helped reduce arm morbidity. These changes have made breast cancer surgery more amenable to day surgery. At the same time, the benefits of early discharge and day surgery have been increasingly recognised in all surgical specialities. In 2007, when this research was undertaken, majority of breast cancer patients in Glasgow underwent operations as inpatients. The aims of this thesis were to establish the evidence base for day surgery in breast cancer and analyse the feasibility, acceptability and safety of performing day surgery in breast cancer patients in Glasgow. In Chapter 2, a systematic review of literature for studies comparing day surgery with inpatient surgery in breast cancer is presented. This was undertaken to establish the present evidence. A randomised controlled trial is the gold standard when comparing one intervention with another. However, this systematic review revealed lack of any randomised controlled trials in literature comparing day surgery with inpatient surgery for breast cancer. Only observational studies were found and these showed day surgery for breast cancer to be safe with high patient satisfaction. In Chapter 3, the feasibility of day surgery for breast cancer in Glasgow was examined. The postoperative length of hospital stay of patients undergoing surgery for breast cancer was studied across five centres in Glasgow. It was noted that 50 percent of patients were discharged within a day of their operation. An analysis of socio-demographic and clinico-pathologic factors influencing postoperative length of stay for all breast cancer surgical patients revealed that the most important factor influencing postoperative stay was the axillary procedure performed. It was seen that symptomatic cancer patients undergo more extensive surgery and are more likely to stay longer in hospital. Patients undergoing re-operations contributed 20 percent to the hospital bed utilisation. Fifty percent of the patients who were discharged within a day of their operation, were potentially thought to be suitable for day surgery. In Chapter 4, the acceptability and safety of day surgery for breast cancer, evaluated in a pilot randomised controlled trial is presented. In this trial, day surgery was compared with inpatient surgery for patients undergoing breast conserving surgery with axillary sampling or sentinel node biopsy. Physical and psychosocial outcomes were examined using validated questionnaires. In a patient satisfaction survey, day surgery was found to be highly acceptable to patients. No difference was found in the physical outcomes between the two groups. Day surgery patients were noted to have a significantly better quality of life one week after their operation. Therefore, this trial found day surgery to be a safe option. In conclusion, the results of the present thesis show that day surgery for breast cancer is a feasible option that was rated by the patients as highly acceptable and had better quality of life outcomes. Moreover, equivalent physical outcomes were noted in both the groups

Vacuum ultraviolet photoabsorption spectra of nitrile ices for their identification on Pluto

Icy bodies, such as Pluto, are known to harbor simple and complex molecules. The recent New Horizons flyby of Pluto has revealed a complex surface composed of bright and dark ice surfaces, indicating a rich chemistry based on nitrogen (N2), methane (CH4), and carbon monoxide (CO). Nitrile (CN) containing molecules such as acetonitrile (CH3CN), propionitrile (CH3CH2CN), butyronitrile (CH3CH2CH2CN), and isobutyronitrile ((CH3)2CHCN) are some of the nitrile molecules that are known to be synthesized by radiative processing of such simple ices. Through the provision of a spectral atlas for such compounds we propose that such nitriles may be identified from the ALICE payload on board New Horizons</i

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

A Simple Technique Using Peri-Prosthetic Irrigation Improves Implant Salvage Rates in Immediate Implant-Based Breast Reconstruction

Background and objectives: Implant-related complications leading to implant loss contribute to major morbidity in immediate breast reconstruction (IBR). Various techniques have been advocated to improve rates of reconstruction salvage. The objective of our study was to assess if a peri-prosthetic irrigation system was an effective adjunct to the conventional wash-out technique in improving reconstruction salvage rates. Methods: The study included patients who had immediate implant-based breast reconstruction from January 2015 to November 2020. The conventional technique of reconstruction salvage, using debridement, wash-out, and implant/expander exchange with systemic use of antibiotics, was performed for patients undergoing exploration for infection until May 2019. A simple technique using a continuous peri-prosthetic irrigation system with vancomycin (1 g/L normal saline over 24 h) for 2 days was added as an adjunct to the conventional technique. Treatment details and clinical outcomes were compared between the groups. The study was approved by the Clinical Governance department. Results: During the study period, 335 patients underwent IBR. A total of 65 patients (19.4%) returned to the theatre due to post-operative complications, of which 45 (13.4%) were due to infection. A conventional technique was used in 38 (84.4%) patients, and peri-prosthetic irrigation was used as an adjunct in 7 patients (15.6%). A total of 16 (42.1%) in the conventional group and all 7 (100%) in the irrigation group had successful reconstruction salvage. No patients had complications due to antibiotic irrigation. Conclusions: The peri-prosthetic irrigation system is a simple, safe, and effective adjunct to conventional techniques in improving reconstruction salvage in IBR

Current Practice of Therapeutic Mammaplasty: A Survey of Oncoplastic Breast Surgeons in England

Introduction. Therapeutic mammaplasty (TM) is a useful technique in the armamentarium of the oncoplastic breast surgeon (OBS). There is limited guidance on patient selection, technique, coding, and management of involved margins. The practices of OBS in England remain unknown. Methods. Questionnaires were sent to all OBS involved with the Training Interface Group. We assessed the number of TM cases performed per surgeon, criteria for patient selection, pedicle preference, contralateral symmetrisation, use of routine preoperative MRI, management of involved margins, and clinical coding. Results. We had an overall response rate of 43%. The most common skin resection technique utilised was wise pattern followed by vertical scar. Superior-medial pedicle was preferred by the majority of surgeons (62%) followed by inferior pedicle (34%). Twenty percent of surgeons would always proceed to a mastectomy following an involved margin, whereas the majority would offer reexcision based on several parameters. The main absolute contraindication to TM was tumour to breast ratio >50%. One in five surgeons would not perform TM in smokers and patients with multifocal disease. Discussion. There is a wide variation in the practice of TM amongst OBS. Further research and guidance would be useful to standardise practice, particularly management of involved margins and coding for optimal reimbursement