RESUMEN
We sought to evaluate the impact of needle core size and number of core samples on diagnostic accuracy and upgrade rates for image-guided core needle biopsies of the breast. A total of 234 patients underwent image-guided percutaneous needle biopsies and subsequent surgical excision. Large-core needles (9 gauge or less) were used in 14.5 per cent of cases and the remainder were performed with smaller core needles. More than four core samples were taken in 78.9 per cent of patients. In 71.8 per cent of cases, needle biopsy pathology matched surgical excision pathology. After surgical excision, upgraded pathology was revealed in 10.7 per cent of cases. Of 11 patients (52.4%) with benign needle core pathology who had upgraded final pathology on surgical excision, 10 had a Breast Imaging Recording and Data System score 4 or 5 imaging study. Lesions smaller than 10 mm were more likely to be misdiagnosed (P = 0.01) or have upgraded pathology (P = 0.009). Other predictors of upgraded pathology were patient age 50 years or older (P = 0.03) and taking four or fewer core samples (P = 0.003). Needle core size did not impact accuracy or upgrade rates. Surgeons should exercise caution when interpreting needle biopsy results with older patients, smaller lesions, and limited sampling. Discordant pathology and imaging still mandate surgical confirmation.
Asunto(s)
Neoplasias de la Mama/patología , Biopsia con Aguja/métodos , Neoplasias de la Mama/cirugía , Carcinoma Intraductal no Infiltrante/patología , Carcinoma Intraductal no Infiltrante/cirugía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Cirugía Asistida por ComputadorRESUMEN
National Institutes of Health (NIH) guidelines recommend the use of pelvic radiation in T3N0 rectal cancer. We sought to determine the rate of compliance with NIH radiation guidelines for patients with T3N0 rectal cancer. We performed a retrospective cohort study of T3NO rectal cancer diagnosed between January 1, 1994, and December 31, 2003, in Region 5 of the California Cancer Registry (R5 CCR). Three hundred twenty-nine patients with T3N0 rectal cancer were identified. The mean age of the study population was 68 years (range, 28 to 93 years). Only 54.1 per cent of patients with T3N0 cancer received pelvic radiation. There was no difference in gender (P = 0.13) or the number of nodes examined (P = 0.19) between patients who had treatment with pelvic radiation and those who did not. However, patients receiving radiation were significantly younger (mean 64 years with radiation therapy [XRT] vs. 72 years without XRT, P < 0.001) and significantly more likely to be treated with systemic chemotherapy (75% with XRT vs. 8.6% without XRT, P < 0.001). Significant numbers of patients with T3N0 rectal cancer are not receiving pelvic radiation in R5 CRR. NIH guidelines are not being translated into clinical practice. The reasons for this warrant continued investigation.
Asunto(s)
Adhesión a Directriz/estadística & datos numéricos , Guías de Práctica Clínica como Asunto , Neoplasias del Recto/radioterapia , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Neoplasias del Recto/patología , Estudios RetrospectivosRESUMEN
No clear guidelines exist defining the appropriate time frame from diagnosis to definitive surgical treatment of breast cancer. Studies have suggested that treatment delays greater than 90 days may be associated with stage migration. We sought to evaluate demographic factors that influence 30-day and 90-day benchmarks for time from diagnosis to definitive surgical treatment of breast cancer. Between 2004 and 2007, 19,896 women with stage I to III invasive breast cancer were treated with primary surgical therapy and did not receive preoperative systemic therapy in the California Cancer Registry. Overall, 75.7 per cent of patients were treated within 30 days of diagnosis, and 95.5 per cent of patients were treated within 90 days of diagnosis. Multivariate analyses revealed that treatment delays were associated with smaller tumor size, use of total mastectomy, lower socioeconomic status, and Hispanic and nonHispanic black race/ethnicity. Furthermore, disparities in those that did not meet 30-day benchmark timeframes were exaggerated with 90-day treatment delays. These benchmarks can be used to measure disparities in health care delivery.
Asunto(s)
Neoplasias de la Mama/diagnóstico , Neoplasias de la Mama/cirugía , Adulto , Negro o Afroamericano , Anciano , Neoplasias de la Mama/etnología , Femenino , Hispánicos o Latinos , Humanos , Persona de Mediana Edad , Análisis Multivariante , Clase SocialRESUMEN
Multidisciplinary therapy (MDT) of node-positive rectal cancer is considered optimal. We performed a retrospective cohort study of node positive rectal cancer patients diagnosed between January 1, 1994 and December 31, 2003 in Region 5 of the California Cancer Registry to determine the impact of MDT on disease specific survival (DSS). During the study period, 398 patients with stage III rectal cancer were identified. Only 251 patients (63.1%) received radiation (XRT). Patients receiving XRT had significantly improved survival when compared with those who did not (5 year DSS 55% with XRT vs. 36% without XRT, median follow-up 43 months, P < 0.001). There was no statistically significant difference in Tstage (P = 0.41), the number of N1 patients (P = 0.45), or the number of positive nodes harvested (mean 11.5 w/o XRT vs. 12.8 w/XRT, P = 0.37) between patients receiving XRT and those who did not. Patients receiving XRT were far more likely to receive systemic chemotherapy (83% vs. 27%, P < 0.0001). Multidisciplinary therapy of node-positive rectal cancer is associated with improved DSS. However, substantial numbers of node positive rectal cancer patients are not receiving MDT. Greater efforts are needed to implement consistent multidisciplinary algorithms into rectal cancer management.
Asunto(s)
Neoplasias del Recto/terapia , Adulto , Anciano , Anciano de 80 o más Años , Algoritmos , Terapia Combinada , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Neoplasias del Recto/tratamiento farmacológico , Neoplasias del Recto/mortalidad , Neoplasias del Recto/radioterapia , Neoplasias del Recto/cirugía , Resultado del TratamientoRESUMEN
BACKGROUND: Utilization of percutaneous needle biopsy (PNB) has been proposed as a quality measure of breast cancer care. We evaluated rates and reasons for failure of patients undergoing PNB as the initial diagnostic procedure for evaluation of breast pathology. METHODS: We performed a retrospective review of sequential patients undergoing image-guided PNB and open surgical excisional breast biopsies from January 2006 to July 2009 at our institution. Factors associated with failure to undergo a percutaneous approach were analyzed. RESULTS: During the study period, 1196 breast biopsies were performed; 87 (7.3%) were open surgical biopsies, and 1109 (92.7%) were PNB. Imaging used for percutaneous guidance or needle localization was ultrasound in 58.9%, mammogram in 40.0%, and magnetic resonance imaging (MRI) in 0.9%. Open surgical excisional biopsy was associated with mammographic guidance (P < .001), location in the central or lower inner quadrant of the breast (P = .002), BIRADS score of 1 or 6 (P < .001), or calcifications as target (P < .001). There were no differences in rates of PNB by age, size of lesion, or breast density. Reasons for failure of PNB were technical (calcifications not visualized, proximity to implant, etc.) in 86.2% of cases. No reason was documented in 10.3%, and 3.4% of patients refused a percutaneous approach. CONCLUSIONS: The majority of patients in this series underwent PNB as an initial diagnostic approach. Most percutaneous failures are due to technical reasons. PNB rates are a reasonable quality measure in breast cancer care. Documentation of failure to meet this benchmark should be stringently monitored.
Asunto(s)
Biopsia con Aguja/normas , Neoplasias de la Mama/patología , Neoplasias de la Mama/cirugía , Mama/patología , Indicadores de Calidad de la Atención de Salud , Femenino , Humanos , Persona de Mediana Edad , Estadificación de Neoplasias , Pronóstico , Estudios RetrospectivosRESUMEN
BACKGROUND: Guidelines recommend sentinel lymph node dissection (SLND) for patients with clinical stage I/IIA/IIB breast cancer; however, a significant fraction of patients do not undergo this procedure. We sought to identify factors associated with noncompliance with the SLND benchmark in early-stage breast cancer. MATERIALS AND METHODS: All patients with an initial diagnosis of Stage I/IIA/IIB invasive breast carcinoma who were treated between 2004 and 2007 with records in the California Cancer Registry were evaluated. Odds ratios evaluating receipt of SLND were compared for sex, age, stage, socioeconomic status (SES), race/ethnicity, surgery type, year of diagnosis, and hospital cancer program approval from the American College of Surgery (ACOS). RESULTS: Of 55,207 patients identified, 66% underwent SLND. On multivariable analyses, patients were significantly less likely to undergo SLND if they were >65 years of age, stage IIA or IIB, of lower socioeconomic status, of nonwhite race/ethnicity, treated with total mastectomy, treated during 2004-2005, or at a non-ACOS approved institution. CONCLUSIONS: SLND use in California has increased over time; however, only two-thirds of eligible patients undergo this recommended procedure. Using SLND as a quality measure demonstrates significant disparities that have implications not only for patient and provider education, but also for health care policy and reform.
Asunto(s)
Neoplasias de la Mama/patología , Neoplasias de la Mama/cirugía , Cooperación del Paciente , Indicadores de Calidad de la Atención de Salud , Biopsia del Ganglio Linfático Centinela/estadística & datos numéricos , Adulto , Anciano , Anciano de 80 o más Años , Neoplasias de la Mama/etnología , California , Femenino , Adhesión a Directriz , Humanos , Escisión del Ganglio Linfático , Persona de Mediana Edad , Invasividad Neoplásica , Estadificación de Neoplasias , Guías de Práctica Clínica como Asunto , Pronóstico , Adulto JovenRESUMEN
We sought to evaluate factors influencing the choice of surgery for women with early-stage breast cancer. Between 1996 and 2005, 47,837 women who were diagnosed with Stage I breast cancer underwent partial (PM) or total mastectomy (TM) in the California Cancer Registry. A total of 72.8 per cent of women underwent PM. Those treated in the most recent 5-year period were more likely to undergo PM than in the prior 5 years (76.5 vs 69.5%, P < 0.0001). PM rates increased with increasing socioeconomic status (SES): 65.1 per cent of patients in the lowest SES quintile underwent PM versus 77.2 per cent in the highest SES quintile (P < 0.0001). Forty- to 64-year-old women were more likely to receive PM compared with their older and younger counterparts (74.5 vs 71.2 and 67.0%, respectively; P < 0.0001). Asian/Pacific Islander women were least likely to undergo PM (64.0%), whereas non-Hispanic black women were most likely to undergo PM (75.0%) (P < 0.0001). On multivariate analysis, these demographic factors remained independent predictors of surgical treatment. PM rates have increased over time; however, significant differences in surgical management exist among women of different race/ethnic groups, ages, and SES. Further research is required to elucidate modifiable factors that impact the choice of surgery for women with early-stage breast cancer.
Asunto(s)
Neoplasias de la Mama/cirugía , Disparidades en Atención de Salud , Mastectomía/estadística & datos numéricos , Adulto , Anciano , Neoplasias de la Mama/epidemiología , Neoplasias de la Mama/patología , California , Estudios de Cohortes , Etnicidad/estadística & datos numéricos , Femenino , Humanos , Persona de Mediana Edad , Estadificación de Neoplasias , Estudios Retrospectivos , Programa de VERF , Factores Socioeconómicos , Población Blanca/estadística & datos numéricosRESUMEN
We sought to examine the significance of the number of nodes examined in node-positive colorectal cancer. Between January 1, 1994, and December 31, 2003, 7192 patients with colorectal cancer underwent potentially curative resection in Region 5 of the California Cancer Registry. Of these patients, 2636 patients were node-positive: 65.1 per cent were N1 and 34.9 per cent were N2. The median follow up was 39.5 months. The mean number of nodes examined was 10.4 (range, 1-89) for N0, 11.0 (range, 1-72) for N1, and 14.6 (range, 4-79) for N2 (P < 0.0001). N1 and N2 patients were stratified according to the percentage of positive nodes into quintiles (0.19 or less, 0.20 to 0.39, 0.40 to 0.59, 0.60 to 0.79, and 0.80 to 1.0). In both N1 and N2 disease, a lower percentage of lymph nodes involved with metastatic disease was associated with improved survival (P < 0.0001). The increasing ratio of positive to total nodes was the result of a decrease in the total number of nodes examined in N1 disease and a steeper decline in total nodes examined in relation to the increase in the number of positive nodes in N2 disease. The ratio of positive to total nodes has prognostic significance in node-positive colorectal cancer.
Asunto(s)
Neoplasias Colorrectales/mortalidad , Neoplasias Colorrectales/patología , Ganglios Linfáticos/patología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , California , Estudios de Cohortes , Neoplasias Colorrectales/cirugía , Femenino , Humanos , Escisión del Ganglio Linfático , Metástasis Linfática , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Estudios Retrospectivos , Programa de VERF , Tasa de Supervivencia , Adulto JovenRESUMEN
BACKGROUND: Disparities in the quality of health care delivered among different socioeconomic strata (SES), race/ethnic groups, and health care systems are well documented; however, relevant quality measures in breast cancer have been debated. The identification of isolated tumor cells (ITCs) in axillary lymph nodes of patients with breast cancer requires diagnosis of early stage disease, appropriate implementation of sentinel lymph node (SLN) dissection, and pathologic analysis of the SLN with serial sectioning and immunohistochemical staining. We hypothesized that ITCs could be interpreted as a quality indicator and sought to determine factors that are associated with the identification and treatment of ITCs. METHODS: We performed a retrospective cohort review of women with N0(i+) breast cancer diagnosed between 2004 and 2006 in the California Cancer Registry. The proportions of patients in SES quintiles (1 = lowest, 5 = highest), race/ethnicity groups, and hospital surgical volume tertiles (low, 1-241 cases/y; medium, 242-491 cases/y; high, >or=492 cases/y) were compared for use of SLN dissection, identification of ITCs, and treatment of ITCs with additional axillary surgery or chemotherapy. RESULTS: SLN dissections were performed less frequently in women of lower SES, of nonwhite race/ethnicity, and in hospitals with lower surgical volumes (P <.0001). A total of 369 patients had ITCs (.6%). With increasing SES, the proportion of patients with ITCs increased: 7.1% of patients with ITCs were from SES 1; 15.7% were from SES 2; 20.3% were from SES 3; 23.9% were from SES 4; and 33.1% were from SES 5. A total of 69.4% of patients with ITCs were non-Hispanic white, 12.8% were Asian, 11.9% were Hispanic, and 5.2% were non-Hispanic black. A total of 46.9% of ITCs were identified in high-volume hospitals, although high-volume hospitals represented only one third of all surgical cases. There were no differences in the use of additional axillary surgery among different groups with ITCs, but chemotherapy was given more frequently to Hispanic women (P = .002) and those in higher-volume hospitals (P = .01). CONCLUSIONS: Although the identification and chemotherapy treatment of ITCs vary among SES categories, race/ethnic groups, and hospitals, the infrequent occurrence of ITCs precludes its use as a valid quality indicator. Because significant disparities exist in the use of SLN dissection, further research will be required to validate the use of SLN dissection as a quality measure.
Asunto(s)
Neoplasias de la Mama/patología , Disparidades en Atención de Salud , Indicadores de Calidad de la Atención de Salud , Biopsia del Ganglio Linfático Centinela/normas , Axila , Neoplasias de la Mama/cirugía , Estudios de Cohortes , Femenino , Humanos , Metástasis Linfática , Estadificación de Neoplasias , Estudios RetrospectivosRESUMEN
BACKGROUND: Strategies to reduce the risk of developing breast and ovarian cancer in carriers of deleterious BRCA 1 and 2 mutations are readily available. However, many people who are at high risk of having these genetic mutations are reluctant to obtain the test. We sought to identify factors associated with choice of testing. METHODS: We performed a retrospective cohort review of high-risk patients referred to a multidisciplinary breast health center for BRCA testing between January 2001 and March 2008. Demographic variables were compared by using logistic regression between those who completed genetic testing and those who did not. RESULTS: A total of 213 patients were referred for BRCA testing. The mean age was 49.2 years (range, 16-84 y). Five patients were male. The majority of individuals (63.4%) were white, 15% were Hispanic, 6.6% were black, and 4.7% were Asian. Insurance coverage for testing was available in 91.1% of patients, of whom 49.2% had private insurance, 26.7% had managed care insurance, and 24.1% had government-sponsored insurance. A total of 111 patients (52.1%) underwent testing. On multivariate analysis, patients were significantly more likely to complete testing if they had a personal history of breast cancer (73.0% of tested patients) (P = .005) and had at least some college education (61.3%) (P = .03). There were no statistically significant differences in tested versus untested groups by age, race, language, family history, parity, marital status, religion, socioeconomic status, or insurance status. Of patients whose insurance plans offered coverage for genetic testing, 51.4% underwent testing and 48.6% did not (P = not significant [NS]). Of those who had no insurance coverage for testing, 41.2% underwent testing and 58.9% did not (P = NS). CONCLUSIONS: Our data show that half of those patients at risk for carrying a BRCA mutation do not undergo testing. Insurance coverage for genetic testing does not influence the decision to test. Developing counseling instruments that explain the benefits of testing to unaffected high-risk individuals or targeted to those with a high school level education may be a strategy to improve testing rates.
Asunto(s)
Neoplasias de la Mama/genética , Genes BRCA1 , Genes BRCA2 , Disparidades en Atención de Salud , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Neoplasias de la Mama Masculina/genética , Estudios de Cohortes , Toma de Decisiones , Femenino , Pruebas Genéticas , Accesibilidad a los Servicios de Salud , Humanos , Cobertura del Seguro , Masculino , Persona de Mediana Edad , Aceptación de la Atención de Salud , Estudios Retrospectivos , Adulto JovenRESUMEN
We sought to examine the impact of hospital surgical volume on the number of nodes harvested and survival in colorectal cancer (CRC). Between January 1994 and December 2004, a total of 8567 patients with T1, 2, 3, and 4 primary tumors and N0, N1, or N2 disease were studied. Hospitals were stratified into very low volume (VLV) (<33 cases/year), low volume (LV) (33-56 cases/year), and medium volume (MV) (57-84 cases/year). Surgery for CRC was performed most commonly at VLV hospitals: 3488 (40.7%) VLV centers versus 2359 (27.5%) LV centers versus 2720 (31.7%) MV centers. The mean number of nodes retrieved for VLV centers was 8.6, for LV centers 9.4, and MV centers 10.2 (P < 0.0002). Actuarial 5-year survival for VLV centers was 71.4 per cent, for LV centers 75.6 per cent, and for MV 77.0 per cent (P < 0.00001). By Cox proportional hazards analysis, hospital volumes (P < 0.0011) and the number of lymph nodes harvested (P < 0.0034) remain significant predictors of disease specific survival. The number of nodes retrieved is impacted by hospital volumes. Hospital volumes impact survival in CRC. These findings cannot be attributed solely to improved staging due to increased node retrieval in VLV, LV, and MV hospitals.
Asunto(s)
Neoplasias Colorrectales/secundario , Hospitales/estadística & datos numéricos , Escisión del Ganglio Linfático/estadística & datos numéricos , Anciano , California/epidemiología , Neoplasias Colorrectales/mortalidad , Neoplasias Colorrectales/cirugía , Femenino , Estudios de Seguimiento , Mortalidad Hospitalaria/tendencias , Humanos , Metástasis Linfática , Masculino , Estadificación de Neoplasias , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Tasa de Supervivencia/tendencias , Factores de TiempoRESUMEN
BACKGROUND: The number of nodes retrieved is a powerful predictor of survival in node-negative colorectal cancer (CRC). Whether this is because of improved staging or improved surgery, or both, is unclear. We sought to quantitate the impact of stage migration in node-negative colorectal cancer. STUDY DESIGN: Between January 1994 and December 2003, 7,192 patients in Region 5 of the California Cancer Registry, diagnosed with node-negative or node-positive colorectal cancer, were reviewed. The number of nodes examined, node-positive rate, and disease-specific survival (DSS) were analyzed. RESULTS: The mean number of nodes examined was 9.3 (range 0 to 89 nodes). The 5-year DSS was 84.5% for N0, 65.2% for N1, and 46.8% for N2 disease. The 5-year DSS difference for those who had more than 12 nodes retrieved was 87.3% (95% CI, 85.2% to 89.3%) and for those with 0 to 3 nodes retrieved, 83.7% (95% CI, 80.6% to 86.82%; p = 0.0009). As the number of retrieved nodes increased, the risk of understaging patients decreased. For 0 to 3 nodes, 78.3% of patients were N0; for 4 to 7 nodes, 67.6%; 8 to 9 nodes, 62.1%; 10 to 12 nodes, 59.5%; and only 57.2% for more than 12 nodes examined. Using more than 12 nodes as the definition of an adequate lymphadenectomy and staging, for apparently N0 patients with 0 to 3 nodes retrieved, DSS survival would be affected by approximately 5%. CONCLUSIONS: Differences in outcomes between CRC patients with limited numbers of nodes harvested and those with more than 12 nodes harvested are substantial. Stage migration alone can explain the entire DSS difference between patients with more than 12 nodes retrieved and those with smaller numbers of nodes retrieved.