RESUMEN
BACKGROUND: Repeat operations after breast-conserving surgery (BCS) for cancer have been termed "epidemic." To aid improvement activities, we sought to identify those National Cancer Data Base (NCDB) characteristics that were associated with reoperations. METHODS: A retrospective cohort of patients with invasive breast cancer undergoing initial BCS in the NCDB from 2004 to 2015 were identified. Univariate, multivariate, ranking (effect size and R2), and time-trend methods were used to assess associations between patient, facility, tumor, treatment, and calendar-year characteristics with reoperation. RESULTS: In 1226 facilities, 84,462 (16.1%) of 524,594 patients underwent reoperations after BCS [range 0-75%; 10th/90th performance percentilesâ¯=â¯6.6%/25%]. Of 18 factors associated with reoperations, facility ID was the highest-ranked. Its estimated impact on the odds of reoperation was more than 10 times greater than any other factor considered, followed by tumor size, neo-adjuvant chemotherapy receipt, patient age, cancer histology, and nodal status. Reoperations after the year of the SSO-ASTRO margin guideline declined significantly compared with prior years. Significant inter-facility reoperation variability persisted after risk adjustment for more than a dozen distinct patient, facility, tumor, and treatment characteristics. CONCLUSION: In the NCDB, significant inter-facility variability exists regardless of case volume, case mix, and risk adjustment. There were fewer reoperations after the SSO-ASTRO guideline. An endorsed target rate of 10% was achieved by only 1 in 4 facilities. The most impactful determinant of reoperation was the facility itself. Thus, all stakeholders should consider participation in improvement activities. Such activities will benefit from risk-adjusted profiling; the relevant adjustors were identified.
Asunto(s)
Neoplasias de la Mama/cirugía , Carcinoma Ductal de Mama/cirugía , Carcinoma Lobular/cirugía , Hospitales/estadística & datos numéricos , Mastectomía Segmentaria , Reoperación/estadística & datos numéricos , Centros Médicos Académicos , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Antineoplásicos/uso terapéutico , Antineoplásicos Hormonales/uso terapéutico , Neoplasias de la Mama/metabolismo , Neoplasias de la Mama/patología , Instituciones Oncológicas , Carcinoma Ductal de Mama/metabolismo , Carcinoma Ductal de Mama/patología , Carcinoma Lobular/metabolismo , Carcinoma Lobular/patología , Femenino , Hospitales Comunitarios , Hospitales de Alto Volumen , Hospitales de Bajo Volumen , Humanos , Ganglios Linfáticos/patología , Persona de Mediana Edad , Terapia Neoadyuvante/estadística & datos numéricos , Estadificación de Neoplasias , Guías de Práctica Clínica como Asunto , Receptor ErbB-2/metabolismo , Receptores de Estrógenos/metabolismo , Receptores de Progesterona/metabolismo , Estudios Retrospectivos , Factores de Riesgo , Carga TumoralRESUMEN
BACKGROUND: Recent observational studies are concerning because they document rising mastectomy rates coinciding with more than a dozen reports that lumpectomy has better overall survival (OS) than mastectomy. Our aim was to determine if there were differences in OS of matched breast cancer patients undergoing lumpectomy versus mastectomy in the National Cancer Database (NCDB). PATIENTS AND METHODS: A retrospective cohort of patients with stage I-III breast cancer in the NCDB (2004-2013) was identified. Propensity score matching (PSM), Kaplan-Meier, and multivariate Cox proportional hazards models were used to examine OS by type of surgery. RESULTS: Of 845,136 patients, 464,052 (54.9%) underwent lumpectomy and 381,084 (45.1%) underwent mastectomy. After PSM, the hazard ratio (HR) and confidence interval (CI) for OS in all patients comparing lumpectomy with mastectomy was 1.02 (CI, 1.00-1.04; P = .002). In patients with stage I, II, and III, they were HR 1.27 (CI, 1.23-1.36; P < .001), HR 0.98 (CI, 0.95-1.01; P = .21), and HR 0.83 (CI, 0.80-0.86; P < .001), respectively. In subgroup analyses of all patients by estrogen receptor (ER) status, they were HR 1.05 (CI, 1.03-1.07; P < .001) and HR 1.00 (CI, 0.96-1.03; P = .65) in ER+ and ER- patients. CONCLUSION: In our primary model of all stage I-III matched patients, using the most recent NCDB data and the largest observational sample size to date, the OS after mastectomy was not inferior to lumpectomy. This finding can be reassuring to patients and providers. In subgroup analyses, the association between type of surgery and OS differed by cancer stage and hormone receptor status.
Asunto(s)
Neoplasias de la Mama/mortalidad , Bases de Datos Factuales , Mastectomía Segmentaria/mortalidad , Mastectomía/mortalidad , Adulto , Anciano , Anciano de 80 o más Años , Neoplasias de la Mama/patología , Neoplasias de la Mama/cirugía , Femenino , Estudios de Seguimiento , Humanos , Persona de Mediana Edad , Pronóstico , Puntaje de Propensión , Estudios Retrospectivos , Tasa de SupervivenciaRESUMEN
BACKGROUND: Surgical site infections (SSIs) are the most common nosocomial infection among surgical patients. We hypothesized that mupirocin ointment would decrease SSI rates compared to standard surgical dressings in patients undergoing colorectal surgery. METHODS: A prospective randomized controlled trial was performed, including patients undergoing elective open and minimally invasive colorectal surgery. Patients were randomized 1:1 to receive standard gauze dressings or mupirocin ointment (2%) dressings. The primary outcome was incisional SSI at 30 days postoperative. RESULTS: A total of 192 patients were enrolled; 150 underwent randomization: 75 to the mupirocin arm, and 75 to the standard gauze dressing arm. Three SSIs occurred; one (1%) in the mupirocin group, and two (3%) in the standard gauze group (Pâ¯=â¯0.560). There was no significant difference between standard gauze dressings and mupirocin dressings. CONCLUSION: Mupirocin (2%) ointment failed to show a benefit compared to standard dressings for postoperative SSI.
Asunto(s)
Antibacterianos/administración & dosificación , Vendajes , Colectomía , Mupirocina/administración & dosificación , Proctectomía , Infección de la Herida Quirúrgica/prevención & control , Adulto , Anciano , Antibacterianos/uso terapéutico , Femenino , Estudios de Seguimiento , Humanos , Análisis de Intención de Tratar , Masculino , Persona de Mediana Edad , Mupirocina/uso terapéutico , Estudios Prospectivos , Método Simple Ciego , Infección de la Herida Quirúrgica/epidemiología , Resultado del TratamientoRESUMEN
OBJECTIVES: The Accreditation Council for Graduate Medical Education requires scholarly activity within general surgery residency programs. The association between in-training research presentations and postgraduation publications is unknown. We hypothesized that surgical trainee presentations at an American College of Surgeons (ACS) state chapter meeting resulted in peer-reviewed publications and future scholarly activity. DESIGN: The ACS Wisconsin state chapter meeting agendas from 2000 to 2014 were reviewed to identify all trainees who delivered podium presentations. A literature search was completed for subsequent publications. Program coordinators were queried and an electronic search was performed to determine practice location and type for each residency graduate. SETTING: Wisconsin state chapter ACS meeting. PARTICIPANTS: General surgery residents, fellows, and medical students in Wisconsin. RESULTS: There were 288 podium presentations by trainees (76% residents, 20% medical students, and 4% fellows). Presentations were clinical (79.5%) and basic science (20.5%). There were 204 unique presenters; 25% presented at subsequent meetings. Of these unique presenters, 46% published their research and 31% published additional research after residency. Among presenters who completed residency or fellowship (N = 119), 34% practiced in a university setting, and 61% practiced in a community setting; 31% practiced in Wisconsin. When comparing clinical vs basic science presenters, there was no difference in fellowship completion (37% vs 44%; p = 0.190) or practice type (38% vs 46% in a university setting; p = 0.397). Repeat presenters were more likely to pursue a fellowship vs those presenting once (76% vs 37%; p = 0.001). CONCLUSIONS: Research presentations by surgical trainees at an ACS state chapter meeting frequently led to peer-reviewed publications. Presenters were likely to pursue research opportunities after residency. Repeat presenters were more likely to pursue a fellowship. ACS Wisconsin chapter meetings provide an excellent opportunity for scholarly activity. These outcomes should encourage ACS chapters and ACS members to support trainee research.