Faculty Bibliography

INTRODUCTION/UNASSIGNED:The OncotypeDX test for patients with breast cancer with early-stage, hormone-receptor-positive, HER2-negative disease can predict the benefit of adjuvant chemotherapy in addition to hormone therapy. Delivering OncotypeDX results in a timely manner is important to inform treatment decisions. We implemented a strategy to reduce the turnaround time (TAT) from breast surgery to OncotypeDX report at a large urban public safety-net hospital in New York City. METHODS/UNASSIGNED:The Plan-Do-Study-Act model was used to implement quality improvement changes. The goal was to improve efficiency to get treatment information for treatment decisions for patients with breast cancer and encourage teamwork with existing resources in the large public hospital. The primary measure was TAT from surgery to receiving OncotypeDX results in the electronic medical record (EMR). We compared TAT before and after the implementation of our strategy. The historical control included patients from May 2021 through March 2022, whereas the timeline after strategy implementation was from June 2023 to February 2024. The strategy involved the creation of a smartphrase in the EMR for breast surgery to identify and order OncotypeDX in eligible patients, and collaboration between breast surgery, pathology, vendor, and medical oncology. RESULTS/UNASSIGNED:= 0.65). Our strategy reduced the average TAT from 42 to 30 days. CONCLUSION/UNASSIGNED:We developed a strategy to optimize the OncotypeDX workflow in a large safety net health system despite an increase in patients from MUAs and MUPs. Initiating ordering of OncotypeDX by breast surgery, along with communication with pathology, vendor, and medical oncology, significantly reduced TAT.

BACKGROUND/UNASSIGNED:There is compelling evidence that the incidence of melanoma in cigarette smokers is substantially lower than in non-smokers. However, the risks of both recurrence and death appear to be higher in smokers if melanoma does develop. The magnitude of these increased risks is poorly documented. This systematic review aimed to analyse melanoma survival outcomes among smokers compared to never-smokers using published studies, and report the magnitude of any survival differences. METHODS/UNASSIGNED:Searches of Medline, Embase and Cochrane CENTRAL (to 11/03/2024) using terms for melanoma and smoking were conducted. Included studies were those reporting outcomes including disease severity at presentation, risk of death or adverse effects from treatment in smokers and never-smokers with melanoma. No study design or language restrictions were imposed. Risk of bias was assessed using the Newcastle-Ottawa tool. The review protocol was registered with PROSPERO (ID CRD42024518505). FINDINGS/UNASSIGNED:63%). From univariable analyses, current-smokers had a higher risk of sentinel node-positivity compared to never-smokers (HR 1.35 95% CI 1.13, 1.62, p = 0.001, 5163 patients). Ever-smokers had a greater risk of complications from sentinel node biopsy (Odds Ratio (OR) 2.0 95% CI 1.41-2.85, p = 0.0001, 3745 patients) and lymph node dissection (OR 1.7, 95% CI 1.23-2.20, p = 0.0007, 4596 patients) than never-smokers based on risks from multivariable analyses. INTERPRETATION/UNASSIGNED:Current smokers are more likely to die from their melanoma than never-smokers, while former-smokers appear to have similar risks to never-smokers. Smokers have higher risks of sentinel node-positivity and of complications from node surgery. Study limitations included reliance on self-reporting of smoking status. In only seven studies did patients receive modern systemic therapies, limiting the ability to assess their relative efficacy in smokers and non-smokers. FUNDING/UNASSIGNED:None.

BACKGROUND:There is a strong correlation between cigarette smoking and the development of many cancer types. It is therefore paradoxical that multiple reports have suggested a reduced incidence of melanoma in smokers. This study aimed to analyze all existing studies of melanoma incidence in smokers relative to non-smokers. METHODS:Searches of MEDLINE and Embase were conducted for studies reporting data on melanoma in smokers and never-smokers. No study design limitations or language restrictions were applied. The outcome examined was the association between smoking status and melanoma. Analyses focussed on risk of melanoma in smokers and never-smokers generated from multivariable analyses and these were pooled using a fixed effects model. Risk of bias was assessed using the Newcastle-Ottawa tool. FINDINGS/RESULTS:Forty-nine studies that included 59,429 melanoma patients were identified. Pooled analyses showed that current-smokers had a significantly-reduced risk of melanoma both in males (risk ratio (RR) 0.60, 95%CI_0.56 to0.65, p < .001) and females (RR 0.79- 95%-CI-0.73-to-0.86, p < .001). Male former-smokers had a 16% reduction in melanoma risk compared to never-smokers (RR-0.84,-95%CI-0.77-to-0.93, p < .001), but no risk reduction was observed in female former-smokers (RR-1.0-95%CI-0.92-to-1.08). INTERPRETATION/CONCLUSIONS:Current-smokers have a significantly-reduced risk of developing melanoma compared to never-smokers, with a reduction in melanoma risk of 40% in men and 21% in women.

BACKGROUND:Shared decision making (SDM) in breast cancer care improves outcomes, but it is not routinely implemented. Results from the What Matters Most trial demonstrated that early-stage breast cancer surgery conversation aids, when used by surgeons after brief training, improved SDM and patient-reported outcomes. Trial surgeons and patients both encouraged using the conversation aids in routine care. We will develop and evaluate an online learning collaborative, called the SHared decision making Adoption Implementation Resource (SHAIR) Collaborative, to promote early-stage breast cancer surgery SDM by implementing the conversation aids into routine preoperative care. Learning collaboratives are known to be effective for quality improvement in clinical care, but no breast cancer learning collaborative currently exists. Our specific aims are to (1) provide the SHAIR Collaborative resources to clinical sites to use with eligible patients, (2) examine the relationship between the use of the SHAIR Collaborative resources and patient reach, and (3) promote the emergence of a sustained learning collaborative in this clinical field, building on a partnership with the American Society of Breast Surgeons (ASBrS). METHODS:We will conduct a two-phased implementation project: phase 1 pilot at five sites and phase 2 scale up at up to an additional 32 clinical sites across North America. The SHAIR Collaborative online platform will offer free access to conversation aids, training videos, electronic health record and patient portal integration guidance, a feedback dashboard, webinars, support center, and forum. We will use RE-AIM for data collection and evaluation. Our primary outcome is patient reach. Secondary data will include (1) patient-reported data from an optional, anonymous online survey, (2) number of active sites and interviews with site champions, (3) Normalization MeAsure Development questionnaire data from phase 1 sites, adaptations data utilizing the Framework for Reporting Adaptations and Modifications-Extended/-Implementation Strategies, and tracking implementation facilitating factors, and (4) progress on sustainability strategy and plans with ASBrS. DISCUSSION/CONCLUSIONS:The SHAIR Collaborative will reach early-stage breast cancer patients across North America, evaluate patient-reported outcomes, engage up to 37 active sites, and potentially inform engagement factors affecting implementation success and may be sustained by ASBrS.

Preoperative localization of nonpalpable breast lesions using a radar reflector surgical guidance system has become commonplace, but the clinical utility of this emerging technology in the musculoskeletal system has not yet been well established. The system components include a console, a handpiece, an implanted radiofrequency reflector that works as a lesion marker, and an infrared light-emitting probe to guide the surgeon. The reflector can be deployed to localize small nonpalpable nodules within the subcutaneous fat as well as lesions within the deeper soft tissues. It can also be used for lymph nodes and foreign bodies. Localization can be performed both before and after treatment. The objective of this article is to describe the potential applications and our technique and initial experience for radar-reflector localization within the musculoskeletal system.

BACKGROUND:Acral lentiginous melanoma is associated with worse survival than other subtypes of melanoma. Understanding prognostic factors for survival and recurrence can help better inform follow-up care. OBJECTIVES/OBJECTIVE:To analyze the clinicopathologic features, melanoma-specific survival, and recurrence-free survival by substage in a large, multi-institutional cohort of primary acral lentiginous melanoma patients. METHODS:Retrospective review of the United States Melanoma Consortium database, a multi-center prospectively collected database of acral lentiginous melanoma patients treated between January 2000 and December 2017. RESULTS:= .001) were also prognostic factors for recurrence-free survival. CONCLUSION/CONCLUSIONS:In this cohort of patients, acral lentiginous melanoma was associated with poor outcomes even in early stage disease, consistent with prior reports. Stage IIB and IIC disease were associated with particularly low melanoma-specific and recurrence-free survival. This suggests that studies investigating adjuvant therapies in stage II patients may be especially valuable in acral lentiginous melanoma patients.

Most international clinical guidelines recommend 5-10 mm clinical margins for excision of melanoma in situ (MIS). While the evidence supporting this is weak, these guidelines are generally consistent. However, as a result of the high incidence of subclinical extension of MIS, especially of the lentigo maligna (LM) subtype, wider margins will often be needed to achieve complete histologic clearance. In this review, we assessed all available contemporary evidence on clearance margins for MIS. No randomized trials were identified and the 31 non-randomized studies were largely retrospective reviews of single-surgeon or single-institution experiences using Mohs micrographic surgery (MMS) for LM or staged excision (SE) for treatment of MIS on the head/neck and/or LM specifically. The available data challenge the adequacy of current international guidelines as they consistently demonstrate the need for clinical margins > 5 mm and often > 10 mm. For LM, any MIS on the head/neck, and/or ≥ 3 cm in diameter, all may require wider clinical margins because of the higher likelihood of subclinical spread. Histologic clearance should be confirmed prior to undertaking complex reconstruction. However, it is not clear whether wider margins are necessary for all MIS subtypes. Indeed, it seems that this is unlikely to be the case. Until optimal surgical margins can be better defined in a randomized trial setting, ideally controlling for MIS subtype and including correlation with histologic excision margins, techniques such as preliminary border mapping of large, ill-defined lesions and, most importantly, sound clinical judgement will be needed when planning surgical clearance margins for the treatment of MIS.

Introduction:Hispanics are the largest minority group in the US at 18% of the population, of which Puerto Ricans are the second largest subgroup. Puerto Ricans have poorer health status than other US Hispanic and non-Hispanic populations. Thus, health care providers need to know about and distinguish the health care problems of Puerto Ricans to improve their health. Although there are some published curricula addressing how to provide health care to Hispanic populations, none address the specific needs of Puerto Ricans. Methods:We developed a 60-minute interactive workshop consisting of a PowerPoint presentation and case discussion aimed at increasing health care providers' knowledge and understanding of the historical perspective that led to Puerto Rican identity, health issues and disparities, and the health care access problems of mainland and islander Puerto Ricans. Evaluation consisted of pre- and postworkshop questionnaires. Results:There were a total of 64 participants with diverse ethnoracial identities including medical students, residents, faculty, physicians, researchers, administrators, and students/faculty from nursing, occupational therapy, genetic counseling, biomedical sciences, and social work programs. A comparison of pre- and postworkshop data showed a statistically significant increase in participants' confidence in meeting all learning objectives. Participants positively commented on the interactive nature of the workshop, the case discussion, and the historical perspective provided. Discussion:With the increasing migration of Puerto Ricans to the US mainland this module can uniquely improve the preparation of current and future health care providers to provide competent care to Puerto Rican patients.