Faculty Bibliography

BackgroundBreast conserving surgery represents the preferred surgical treatment option for patients with early-stage breast cancer. Reexcision rates are generally higher for patients undergoing lumpectomies for ductal carcinoma in situ (DCIS) compared to invasive breast cancer, as the microscopic extent of disease is difficult to assess during excision. This study investigated the clinicopathological characteristics of patients undergoing BCS for pure DCIS and reexcision rates over time, including the effect of the MarginProbe™ device.MethodsWe queried our prospectively maintained Institutional Breast Cancer Database for patients diagnosed with DCIS and treated with BCS as their primary procedure from 2010-2021. The primary endpoint was the rate of reexcision. Variables of interest included age at diagnosis, race/ethnicity, mode of diagnostic imaging, mammographic breast density, method of core biopsy, nuclear grade, size of DCIS, multifocality, DCIS subtype, and MarginProbe™ use.ResultsPapillary DCIS (P < 0.004) and larger size (P < 0.001) was associated with an increased reexcision rate. There were also differences in the method of core biopsy (P < 0.001), with stereotactic core biopsy predominating among patients who did not require reexcision (71.3% vs 49.5%). In an unadjusted estimate for the odds ratio for association, patients who had MarginProbe™ used were 81% less likely to require reexcision (OR = 0.19, 95% CI = 0.12, 0.31, P < 0.0001).ConclusionYounger age, papillary DCIS, larger DCIS size, and non-stereotactic core biopsy method were found to be associated with higher reexcision rates. Additionally, patients whose primary procedures included intraoperative margin assessment with the MarginProbe™ were significantly less likely to require reexcision.

OBJECTIVE/UNASSIGNED:To investigate the number of safety net hospitals (SNHs) that have American College of Surgeons (ACS) accreditation for surgical programs. BACKGROUND/UNASSIGNED:SNHs provide healthcare to a substantial proportion of uninsured and underserved patient populations and rely heavily on public funding to sustain their operations. ACS accreditation emphasizes evidence-based care and standardization to improve patient outcomes. However, SNHs face financial and administrative barriers to ACS accreditation. METHODS/UNASSIGNED:We investigated the number of SNHs with ACS accreditation for specific programs by utilizing the publicly available listing of ACS-accredited programs and the listing of SNHs from the America's Essential Hospitals membership. We then performed a descriptive analysis of the number and geographic distribution of SNHs within the United States and the number of SNHs with ACS-accredited programs. RESULTS/UNASSIGNED:SNHs vary by regional disparities and demographic characteristics of respective states. Almost 20% of states are without access to SNHs. Most SNHs do not pursue ACS accreditation. Of 322 SNHs, 36% were accredited for cancer care (Commission on Cancer), 31% for trauma (Trauma Quality Improvement Program), 21% for bariatrics (Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program), 13% for breast care (National Accreditation Program for Breast Centers), and 5% for rectal cancer (National Accreditation Program for Rectal Cancer). CONCLUSIONS/UNASSIGNED:ACS accreditation can benefit SNHs in improving guideline-concordant care for medically underserved patients and SNHs should be encouraged to attain ACS accreditation to improve access to and quality of care for vulnerable patient populations.

BACKGROUND:Nodal surveillance (NS) has overtaken completion lymphadenectomy as the preferred management for sentinel node-positive (SLN+) melanoma, but requires frequent exams and nodal ultrasound (US). Social determinants of health (SDoH) may affect US adherence in real-world populations, and evaluation of these potential impacts is needed. METHODS:Adults with SLN+ melanoma diagnosed from July 2017 to December 2019 who received NS at nine cancer centers were identified retrospectively. Exposures included insurance status, travel distance, and Centers for Disease Control and Prevention (CDC) Social Vulnerability Index (SVI), a validated measure of area-level SDoH, indicated as 0 (low) to 1 (high) vulnerability. The primary outcome was US adherence (≥ 1 study per 6-month follow-up interval). The secondary outcomes were combined-modality adherence [US, computed tomography (CT), or positron emission tomography (PET)] and loss to follow-up (LTFU). Bivariate analyses and mixed-effects multivariable logistic regression were performed. RESULTS:Most of the 519 patients were male (57%), non-Hispanic white (94.4%), and insured privately (45.3%) or by Medicare (43.5%). The median travel distance was 63.3 miles (interquartile range [IQR], 31.2-111.0 miles), and the median SVI was 0.426 (IQR, 0.253-0.610). The surveillance adherence rates were 41.6% for US and 75.1% for combined modalities. No significant differences in US adherence were observed based on sociodemographic covariates in regression analysis. Medicaid (odds ratio [OR], 3.12; p = 0.02) and uninsured (OR 4.48; p = 0.01) patients had increased likelihood of LTFU. CONCLUSIONS:Less than half of the patients in this multicenter cohort achieved US adherence, although the rates improved with combined modalities. Medicaid or non-insurance were social risk factors for LTFU. Optimizing surveillance practices for socially vulnerable groups will be crucial for the ongoing real-world implementation of NS.

BACKGROUND:Patients with disabilities face widespread barriers to accessing surgical care given inaccessible health systems, resulting in poor clinical outcomes and perpetuation of health inequities. One barrier is the lack of education, and therefore awareness, among trainees/providers, of the need for reasonable accommodations for surgical patients with disabilities. METHODS:We conducted a scoping review of the literature on the current state of disabilities curricula in medical education and graduate residency curriculum. RESULTS:While the literature does demonstrate a causal link between reasonable accommodation training and positive patient-provider relationships and improved clinical outcomes, in practice, disability-focused curricula are rare and often limited in time and to awareness-based didactic courses in medical education and surgical training. CONCLUSIONS:The absence of structured curricula to educate on anti-ableism and care for patients with disabilities promotes a system of structural "ableism." Expanding disability curricula for medical students and trainees may be an opportunity to intervene and promote better surgical care for all patients.

BACKGROUND:Health and healthcare disparities for surgical patients with blindness and low vision (pBLV) stem from inaccessible healthcare systems that lack universal design principles or, at a minimum, reasonable accommodations (RA). OBJECTIVES/OBJECTIVE:We aimed to identify barriers to developing and implementing RAs in the surgical setting and provide a review of best practices for providing RAs. METHODS:We conducted a search of PubMed for evidence of reasonable accommodations, or lack thereof, in the surgical setting. Articles related to gaps and barriers to providing RAs for pBLV or best practices for supporting RAs were reviewed for the study. RESULTS:Barriers to the implementation of reasonable accommodations, and, accordingly, best practices for achieving equity for pBLV, relate to policies and systems, staff knowledge and attitudes, and materials and technology. CONCLUSIONS:These inequities for pBLV require comprehensive frameworks that offer, maintain, and support education about disability disparities and RAs in the surgical field. Providing RAs for surgical pBLV, and all patients with disabilities is an important and impactful step towards creating a more equitable and anti-ableist health system.

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/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:Conventional advice to reduce the risk of breast cancer-related lymphedema (BCLE) suggests avoidance of daily-living risks, and limited research has investigated these risks. OBJECTIVE:This study aimed to examine the occurrence, patterns, and effects of daily-living risks on BCLE. METHODS:A cross-sectional design was used to collect data from 567 patients at a metropolitan cancer center in the United States. The Lymphedema Risk-Reduction Behavior Checklist was used to assess the occurrence of 11 daily-living risks. Descriptive, regression, and factor analyses were performed. RESULTS:Significant odds of BCLE were associated with infection (odds ratio [OR] 2.58, 95% confidence interval [CI] 1.95-3.42), cuts/scratches (OR 2.65, 95% CI 1.97-3.56), sunburn (OR 1.89, 95% CI 1.39-3.56), oil splash or steam burns (OR 2.08, 95% CI 1.53-3.83), and insect bites (OR 1.59, 95% CI 1.18-2.13). The daily-living risks were clustered into factors related to skin trauma and carrying objects. Skin trauma risk was significantly associated with BCLE (B = 0.539, z = 3.926, OR 1.714, 95% CI 1.312-2.250; p < 0.001). Having three, four, or five skin trauma risks significantly increased the odds of BCLE to 4.31, 5.14, and 6.94 times, respectively. The risk of carrying objects had no significant or incremental effects on BCLE. CONCLUSION/CONCLUSIONS:Complete avoidance of daily-living risks is challenging given 52.73% of patients incurred more than five daily-living risks. Our study findings underscore the importance of 'what to do' strategies to minimize infection and skin trauma.