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Surgical registrars' perceptions of surgical training and capacity in Zambia: Results from three COSECSA affiliated training hospitals

Freitas, Derek M; Munthali, James; Musowoya, Joseph; Ismail, Hebah; Herbst, Allyson; Chikoya, Laston; Dhage, Shubhada; Hopkins, Mary Ann
BACKGROUND: Surgery is a vital component of a comprehensive health system, but there are often personnel limitations in resource constrained areas. Zambia provides post graduate surgical training through two systems to help address this shortage. However, no studies have analyzed surgical trainees' perceptions of these programs. METHODS: Surgical registrars at COSECSA affiliated hospitals in Zambia were surveyed about their programs. Responses were analyzed to identify key strengths and challenges across several categories including: operative training, clinical training, educational experiences, and career plans. RESULTS: Registrars report having significant independence and receiving broad and high quality operative training. They note specific challenges including limitations in specialty training, resources, and infrastructure. CONCLUSIONS: Zambian training programs have the potential to increase number of surgeons in Zambia by a significant amount in the coming years. These programs have many strengths but also face challenges in their goal to expand surgical access in the country.
PMID: 28764850
ISSN: 1879-1883
CID: 2655722

What matters most: protocol for a randomized controlled trial of breast cancer surgery encounter decision aids across socioeconomic strata

Durand, Marie-Anne; Yen, Renata West; O'Malley, A James; Politi, Mary C; Dhage, Shubhada; Rosenkranz, Kari; Weichman, Katie; Margenthaler, Julie; Tosteson, Anna N A; Crayton, Eloise; Jackson, Sherrill; Bradley, Ann; Volk, Robert J; Sepucha, Karen; Ozanne, Elissa; Percac-Lima, Sanja; Song, Julia; Acosta, Jocelyn; Mir, Nageen; Elwyn, Glyn
BACKGROUND:Breast cancer is the most commonly diagnosed malignancy in women. Mastectomy and breast-conserving surgery (BCS) have equivalent survival for early stage breast cancer. However, each surgery has different benefits and harms that women may value differently. Women of lower socioeconomic status (SES) diagnosed with early stage breast cancer are more likely to experience poorer doctor-patient communication, lower satisfaction with surgery and decision-making, and higher decision regret compared to women of higher SES. They often play a more passive role in decision-making and are less likely to undergo BCS. Our aim is to understand how best to support women of lower SES in making decisions about early stage breast cancer treatments and to reduce disparities in decision quality across socioeconomic strata. METHODS:We will conduct a three-arm, multi-site randomized controlled superiority trial with stratification by SES and clinician-level randomization. At four large cancer centers in the United States, 1100 patients (half higher SES and half lower SES) will be randomized to: (1) Option Grid, (2) Picture Option Grid, or (3) usual care. Interviews, field-notes, and observations will be used to explore strategies that promote the interventions' sustained use and dissemination. Community-Based Participatory Research will be used throughout. We will include women aged at least 18 years of age with a confirmed diagnosis of early stage breast cancer (I to IIIA) from both higher and lower SES, provided they speak English, Spanish, or Mandarin Chinese. Our primary outcome measure is the 16-item validated Decision Quality Instrument. We will use a regression framework, mediation analyses, and multiple informants analysis. Heterogeneity of treatment effects analyses for SES, age, ethnicity, race, literacy, language, and study site will be performed. DISCUSSION:Currently, women of lower SES are more likely to make treatment decisions based on incomplete or uninformed preferences, potentially leading to poorer decision quality, quality of life, and decision regret. This study hopes to identify solutions that effectively improve patient-centered care across socioeconomic strata and reduce disparities in decision and care quality. TRIAL REGISTRATION:NCT03136367 at ClinicalTrials.gov Protocol version: Manuscript based on study protocol version 2.2, 7 November 2017.
PMCID:5812033
PMID: 29439691
ISSN: 1471-2458
CID: 2957882

Contralateral Prophylactic Mastectomy in Young Breast Cancer Patients: Is there a Difference Between Public and Private Hospitals? [Meeting Abstract]

Warnack, E.; Ma, S.; Schnabel, F.; Joseph, K.; Axelrod, D.; Dhage, S.
ISI:000431188600201
ISSN: 1068-9265
CID: 3113852

A genomic ruler to assess oncogenic transition between breast tumor and stroma

Dhage, Shubhada; Ernlund, Amanda; Ruggles, Kelly; Axelrod, Deborah; Berman, Russell; Roses, Daniel; Schneider, Robert J
BACKGROUND:Cancers induce gene expression alterations in stroma surrounding tumors that supports cancer progression. However, it is actually not at all known the extent of altered stromal gene expression enacted by tumors nor the extent to which altered stromal gene expression penetrates the stromal tissue. Presently, post-surgical "tumor-free" stromal tissue is determined to be cancer-free based on solely on morphological normality-a criteria that has not changed in more than 100 years despite the existence of sophisticated gene expression data to the contrary. We therefore investigated the extent to which breast tumors alter stromal gene expression in three dimensions in women undergoing mastectomy with the intent of providing a genomic determination for development of future risk of recurrence criteria, and to inform the need for adjuvant full-breast irradiation. METHODS AND FINDINGS/RESULTS:Genome-wide gene expression changes were determined in histopathologically normal breast tissue in 33 women undergoing mastectomy for stage II and III primary invasive ductal carcinoma at serial distances in three dimensions from the tumor. Gene expression was determined by genome-wide mRNA analysis and subjected to metagene mRNA characterization. Tumor-like gene expression signatures in stroma were identified that surprisingly transitioned to a plastic, normalizing homeostatic signature with distance from tumor. Stroma closest to tumor displayed a pronounced tumor-like signature enriched in cancer-promoting pathways involved in disruption of basement membrane, cell migration and invasion, WNT signaling and angiogenesis. By 2 cm from tumor in all dimensions, stromal tissues were in transition, displaying homeostatic and tumor suppressing gene activity, while also expressing cancer supporting pathways. CONCLUSIONS:The dynamics of gene expression in the post-tumor breast stroma likely co-determines disease outcome: reversion to normality or transition to transformation in morphologically normal tissue. Our stromal genomic signature may be important for personalizing surgical and adjuvant therapeutic decisions and risk of recurrence.
PMID: 30325954
ISSN: 1932-6203
CID: 3368992

Compliance and adherence to breast cancer treatment in a medically underserved population [Meeting Abstract]

Wu, Q W; Dhage, S; Joseph, K -A
Background/Objective: Compliance and completion of treatment for breast cancer is associated with improved outcomes. It has been reported that patients may not complete treatment for several reasons including cost of treatment and side effects. We examine the rate of compliance and completion of treatment in a population of breast cancer patients treated at a safety net hospital Methods: One hundred ninety-seven patients treated for breast cancer (stage 0-IIIC) were identified from the surgery and pathology records during 2011- 2014. The patients' medical records were retrieved and data analyzed retrospectively. The main outcome variables were compliance and completion of therapy. Additional variables examined included race, age at diagnosis, stage, and income. Results: Median age was 52. Of this group, 36% were Asian, 17% African-American, 10% White, 37% Hispanic. The majority of patients presented early stage; however, blacks and Hispanics were more likely to be diagnosed at later stages (p=0.000). Sixty-four percent of the patients reported an income of <=$15,000. Eighty-seven percent of patients offered chemotherapy accepted, 91% of these patients completed treatment. These patients did not differ significantly by race (p=NS). Ninety-four percent of patients offered radiation therapy accepted, and 99% completed radiation therapy, and these patients did not differ significantly by race (p=NS). Ninety percent of patients offered hormonal therapy accepted, and 95% adhered to therapy (p=NS). Conclusions: There are many factors involved in patient compliance and early discontinuation of therapy particularly in safety net hospitals. We find that in our large safety net hospital, there is a higher acceptance of treatment for chemotherapy, radiation, and hormonal therapy as well as completion of treatment compared to most academic institutions, and this is independent of race. While the reasons for the high rates are unclear, we believe culturally competent care and enhanced patient navigation are instrumental in patient compliance. Further prospective studies will need to be done to determine the main contributor of enhanced compliance and adherence to treatment
EMBASE:616338136
ISSN: 1534-4681
CID: 2583892

Referral patterns from primary care services to a metropolitan safety net hospital [Meeting Abstract]

Keshinro, A; Dhage, S; Joseph, K -A
Background/Objective: Safety net hospitals provide an important role in the care of women diagnosed with breast cancer who may lack insurance or rely on public insurance. While many of these women may present at late stages, more attention has been paid to primary care services and increasingly, the number of women who are referred for breast cancer management come through primary care. We look at our volume to assess our referral pattern and how our patients are referred to our breast clinic. Methods: A retrospective chart review of the EMR for breast cancer patients newly diagnosed from 2012-2013 was performed using the tumor registry at Bellevue Hospital Center. Patients with recurrent breast cancer, stage IV breast cancer, and those that weren't managed surgically at our institution were excluded from the study. Data including patient demographics, established relationship with PCP, and SM and palpable mass at presentation were obtained and analyzed using SPSS Statistics Software. Results: One hundred seventy-three patients were included in the study, of which 5 presented with bilateral breast cancer (n=178). The majority of the patients seen at our institution were from minority groups, primarily Hispanic (34%) and Chinese (23%). One hundred twenty-nine patients (72%) had a PCP at the time of diagnosis versus 49 patients (28%) without a PCP. Patients without a PCP were more likely to have a palpable breast mass at presentation, compared to patients with a PCP (73% vs. 42% respectively, p < 0.05). While fully a third (33%) of our patients were referred from within our institution (internal medicine, gynecology, and geriatrics), another 27% came from our local community ambulatory care center. The remaining patients were referred from outside institutions or self-referred. Twenty percent were referred to our institution due to lack of insurance. Conclusions: PCPs play a valuable role in breast cancer screening and detection. Given that our institution, a tertiary referral center, has double the volume of our ambulatory care center, the primary care doctors at the latter center have more time to engage the patient in health-promoting behaviors. By engaging more of the PCPs and educating them on the changing landscape of breast screening guidelines, there is an opportunity to make gains in patient outcomes
EMBASE:616365297
ISSN: 1534-4681
CID: 2583882

The Impact of Primary Care Providers on Patient Screening Mammography and Initial Presentation in an Underserved Clinical Setting

Keshinro, Ajaratu; Hatzaras, Ioannis; Rifkind, Kenneth; Dhage, Shubhada; Joseph, Kathie-Ann
INTRODUCTION: Cancer screening is a key component of primary care, and access to regular screening mammography (SMG) is highly dependent on recommendation and referral by a primary care provider (PCP). Women with no health insurance or who are underinsured often lack access to a regular PCP and thus access to routine screening. METHODS: We retrospectively reviewed the charts of 173 surgical patients diagnosed between January 2012 and December 2013. The main outcome variables were PCP status, method of cancer detection, and breast cancer stage at diagnosis. Additional variables included race, age at diagnosis, family history of breast and ovarian cancer, and medical comorbidities. RESULTS: Patients with a PCP received more mammograms (SMG) compared with patients without a PCP (61 vs. 37 %; p = 0.003). The majority (73 %) of patients without a PCP presented symptomatically with a palpable mass versus 42 % of patients with a PCP. A significant difference was noted with regard to final pathologic stage of breast cancer between the two groups (p = 0.019), and Caucasian and African American patients were more likely to have locally advanced breast cancer. CONCLUSIONS: Underserved patients with a PCP are more likely to present asymptomatically and at an earlier stage of breast cancer compared with patients without a PCP. Community engagement programs that build relationships with patients may help bring vulnerable patients into the healthcare system for routine screening. Moreover, PCP education regarding the subtleties of breast cancer screening guidelines and referral to a breast specialist is also critical in improving outcomes of underserved patients.
PMID: 27766557
ISSN: 1534-4681
CID: 2280142

Determining the breast tumor margin through genomics of the cancer-stromal interaction [Meeting Abstract]

Dhage, S; Ernlund, A; Wang, J; Axelrod, D; Berman, R; Roses, D; Schneider, R
ISI:000397999001213
ISSN: 1538-7445
CID: 2529392

A Comparison of the Pathologic Response Rate After Neoadjuvant Chemoradiation in Patients with Locally Advanced Breast Cancer in an Underserved Population [Meeting Abstract]

Keshinro, A; Huppert, N; Dhage, S; Formenti, S; Joseph, K
ISI:000368185000174
ISSN: 1534-4681
CID: 1930992

Primary large cell neuroendocrine carcinoma of the breast, a case report with an unusual clinical course

Janosky, Maxwell; Bian, Jessica; Dhage, Shubhada; Levine, Jamie; Silverman, Joshua; Jors, Kathryn; Moy, Linda; Cangiarella, Joan; Muggia, Franco; Adams, Sylvia
Large cell neuroendocrine carcinoma of the breast (NECB) is an extremely rare type of breast cancer; little is known about effective chemotherapies, and data on pathologic response to treatment are unavailable. We report the case of a 34-years-old woman with large cell NECB with initial clinical and pathologic evidence of treatment response to anthracycline-containing neo-adjuvant therapy. Histologic reassessment early during anthracycline chemotherapy revealed cell death with necrosis of 50% of the tumor cells seen in the biopsy specimen. After completing neo-adjuvant chemotherapy, the patient underwent breast-conserving surgery. Pathologic evaluation of the surgical specimen showed a partial response but margins were positive for residual carcinoma. Despite repeated neo-adjuvant chemotherapy, radiotherapy, and surgical resection, the tumor grew rapidly between surgeries and recurred systemically. Therefore, we review the literature on large cell NECB and its treatment options.
PMID: 25823996
ISSN: 1524-4741
CID: 1544112