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1.  Tabbed Tissue Expanders Improve Breast Symmetry Scores in Breast Reconstruction 
Archives of Plastic Surgery  2014;41(1):57-62.
Achieving symmetry is a key goal in breast reconstruction. Anatomically shaped tabbed expanders are a new tool in the armamentarium of the breast reconstruction surgeon. Suture tabs allow for full control over the expander position and thus inframammary fold position, and, in theory, tabbed expanders mitigate many factors responsible for poor symmetry. The impact of a tabbed expander on breast symmetry, however, has not been formally reported. This study aims to evaluate breast symmetry following expander-implant reconstruction using tabbed and non-tabbed tissue expanders.
A chart review was performed of 188 consecutive expander-implant reconstructions that met the inclusion criteria of adequate follow-up data and postoperative photographs. Demographic, oncologic, postoperative complication, and photographic data was obtained for each patient. The photographic data was scored using a 4-point scale assessing breast symmetry by three blinded, independent reviewers.
Of the 188 patients, 74 underwent reconstruction with tabbed expanders and 114 with non-tabbed expanders. The tabbed cohort had significantly higher symmetry scores than the non-tabbed cohort (2.82/4±0.86 vs. 2.55/4±0.92, P=0.034).
The use of tabbed tissue expanders improves breast symmetry in tissue expander-implant-based breast reconstruction. Fixation of the expander to the chest wall allows for more precise control over its location and counteracts the day-to-day translational forces that may influence the shape and location of the expander pocket, mitigating many factors responsible for breast asymmetry.
PMCID: PMC3915158  PMID: 24511496
Breast; Mammaplasty; Tissue expansion devices; Outcome assessment (health care)
2.  What determines satisfaction with surgeon treatment in low income women with breast cancer? 
To examine the relationship of overall patient satisfaction with the treatment provided by the surgeon and the consultation process and skills, in low income women undergoing surgical treatment for breast cancer.
Cross sectional survey. Logistic regression was used to assess the relationship between satisfaction with surgeon treatment and four consultation skills and processes (time spent, listens carefully, explains things in a way you could understand, and shows respect for what you had to say), controlling for a range of patient, surgeon, and treatment characteristics.
Setting & Patients
A statewide sample of 789 low income women in California receiving treatment for breast cancer under the state’s Breast and Cervical Cancer Treatment Program (BCCTP).
Main outcome measures
Satisfaction with surgeon treatment.
Three out of every four women reported being extremely satisfied with the treatment they received from their surgeon. African-American women and those with arm swelling were less likely to be satisfied, while those reporting that the surgeon always spent enough time and explained things in a way they could understand were more likely to report greater satisfaction.
Our findings highlight the importance of two relatively simple behaviors that surgeons can easily implement to increase patient satisfaction, which can be of potential benefit in today’s litigious world.
PMCID: PMC3228842  PMID: 19917945
3.  Contribution of breast density to the volume of the augmented breast: A preliminary study 
Breast augmentation is one of the most common procedures performed, and obtaining symmetry and the correct postoperative volume is of the utmost importance. Currently, three-dimensional analysis is used to calculate breast volume, shape, size, etc, which aids the surgeon in deciding on the correct implant size. This study used three-dimensional analysis on 38 breasts (21 women) to measure breast volume and compare it with the implant size, in addition to comparing the results with breast density on mammogram.
Prediction of soft tissue contribution to the shape, volume and texture of the augmented breast proves to be an ever-challenging, uncontrollable variable. Similarly, the understanding of the contribution of breast density in breast augmentation has been elusive and, generally, not well studied.
With the aid of three-dimensional photographic analysis, the present preliminary study examined the contribution of differing breast densities to the overall volume of the augmented breast.
All patients undergoing primary augmentation over a six-month period were included in the study. To standardize technique and implant type, all patients received saline-filled moderate-profile implants, which were placed partially underneath the pectoralis muscle through a lower pole approach. Photographic analysis of the breast volume was completed preoperatively and, subsequently, at a minimum of six months postoperatively. Preoperatively, each breast was also assigned to one of four classes of increasing mammographic density, as judged by the mammographic radiologist (fatty, moderately dense, heterogeneously dense and extremely dense). Postoperative breast volumes were, subsequently, correlated to mammographic densities.
Thirty-eight augmented breasts in 21 patients were examined. The average volume gain based on the implant size used was 92.7%. Heterogeneously dense breasts comprised 68% of the total breasts and showed an average volume gain of 100.67%, extremely dense breasts comprised 26% of the total breasts and showed an average volume gain of 97.3%, and moderately dense breasts comprised 5% of the total breasts with an average gain of 100.04%. There was no significant difference between the augmented breast volumes and the respective expected volumes (combined preaugmented breast volumes and implant volumes; P=0.3483). Additionally, no statistical difference was found between the density classes and the expected augmented volumes.
No statistical difference was found between expected and actual augmented breast volumes among or between four different breast density classes. Thus, one would expect that the soft tissue compression or the response of the impression of the implant on the parenchyma, would not be statistically different among classes. Additionally, compressive atrophy, as seen with atrophy of the breasts over time, would be expected to be multifactorial and not uniquely independent to breast density. However, longitudinal analysis is needed to study the durability of breast shape relative to breast density.
PMCID: PMC3269329  PMID: 22942658
Breast; Breast augmentation; Breast density; Breast implant; Breast implant size; Mammographic density
4.  Analysis of Breast Contour using Rotated Catenary 
Surgical reconstruction of natural-appearing breasts is a challenging task. Currently, surgical planning is limited to the surgeon’s subjective assessment of breast morphology. Therefore, it is useful to develop objective measurements of breast contour. In this paper, a novel quantitative measure of the breast contour based on catenary theory is introduced. A catenary curve is fitted on the breast contour (lateral and inferior) and the key parameter determining the shape of the curve is extracted. The new catenary analysis was applied to pre- and post-operative clinical photographs of women who underwent tissue expander/implant (TE/Implant) reconstruction. A logistic regression model was developed to predict the probability that the observed contour is that of a TE/Implant reconstruction from the catenary parameter, patient age, and patient body mass index. It was demonstrated that the parameters contain useful information for distinguishing TE/Implant reconstructed breasts from pre-operative breasts.
PMCID: PMC3041438  PMID: 21347015
5.  Breast reconstruction and radiation therapy: A Canadian perspective 
Immediate reconstruction following mastectomy is a favourable option because breast shape and the skin envelope are maintained, resulting in a better aesthetic result. Postreconstruction radiation, however, increases the rate of complications such as contracture and/or necrosis, and these risks are particularly high when implants are chosen over native tissue. Clearly, the increase in the use of radiation therapy for breast cancer has presented plastic surgeons with challenges in timing reconstructive procedures, especially in patients whose need for radiation is unknown at the time of mastectomy. This survey-based study investigated the approaches taken by Canadian plastic surgeons to this area of reconstruction.
When and how best to perform breast reconstruction in the setting of radiation therapy is a much debated topic.
To investigate the approaches that Canadian plastic surgeons are taking to breast reconstruction in patients who require or may require radiation therapy.
In April 2009, a survey invitation was sent to Canadian plastic surgeons via e-mail. Survey responses were collected over a two-month period.
Of the 307 invitees, 90 surgeons responded, of whom 76 met the inclusion criteria. Most surgeons (66%) do not perform immediate reconstruction in patients who require postmastectomy radiation. Most respondents (64%) perform immediate reconstructions for patients whose need for radiation is uncertain at the time of mastectomy. Expander and implants is their preferred option, followed by free transverse rectus abdominis myocutaneous (TRAM) flap. Thirty-five per cent use the delayed immediate technique in these cases. Twenty-one per cent are unfamiliar with the delayed-immediate technique. For delayed reconstruction of the irradiated patient, the pedicled TRAM is the most common choice.
The reconstructive options are increasing for patients who may need postmastectomy radiation. The use of the delayed immediate technique could increase as physicians gain more knowledge of the technique.
PMCID: PMC3307681  PMID: 23598766
Breast reconstruction; Clinical practice survey; Radiation therapy
6.  Usefulness of a Lateral Thoracodorsal Flap after Breast Conserving Surgery in Laterally Located Breast Cancer 
Archives of Plastic Surgery  2013;40(4):367-373.
Breast-conserving surgery is widely accepted as an appropriate method in breast cancer, and the lateral thoracodorsal flap provides a simple, reliable technique, especially when a mass is located in the lateral breast. This study describes the usefulness of a lateral thoracodorsal flap after breast conserving surgery in laterally located breast cancer.
From September 2008 to February 2013, a lateral thoracodorsal flap was used in 20 patients with laterally located breast cancer treated at our institution. The technique involves a local medially based, wedge shaped, fasciocutaneous transposition flap from the lateral region of the thoracic area. Overall satisfaction and aesthetic satisfaction surveys were conducted with the patients during a 6-month postoperative follow-up period. Aesthetic results in terms of breast shape and symmetry were evaluated by plastic surgeons.
The average specimen weight was 76.8 g. The locations of the masses were the upper lateral quadrant (n=15), the lower lateral quadrant (n=2), and the central lateral area (n=3). Complications developed in four of the cases, partial flap necrosis in one, wound dehiscence in one, and fat necrosis in two. The majority of the patients were satisfied with their cosmetic outcomes.
Partial breast reconstruction using a lateral thoracodorsal flap is well matched with breast color and texture, and the surgery is less aggressive than other techniques with few complications. Therefore, the lateral thoracodorsal flap can be a useful, reliable technique in correcting breast deformity after breast conserving surgery, especially in laterally located breast cancer.
PMCID: PMC3723997  PMID: 23898433
Mammaplasty; Surgical flaps; Mastectomy
7.  Oncoplastic Breast Surgery 
The Indian Journal of Surgery  2012;74(3):255-263.
Breast Surgery is now a recognized subspecialty of General Surgery abroad with structured training for designated ‘Oncoplastic Breast Surgeons’. Oncoplastic Breast surgery is probably one of the most interesting and challenging new developments over the past 20 years. The aims of Oncoplastic surgery are wide local excision of the cancer coupled with partial reconstruction of the defect to achieve a cosmetically acceptable result. Avoidance of mastectomy and consequent reduction of psychological morbidity are the principal goals in the development of various oncoplastic techniques. The use of plastic surgical techniques not only ensures good cosmetic outcome, but also allows the cancer surgeon to remove the tumour with greater volume of surrounding tissue, thus extending the boundaries of breast conserving surgery. Proper patient selection and careful planning after proper radiological and clinical assessment are the two essential prerequisites before undertaking oncoplastic breast surgery. Oncoplastic surgery involves both volume displacement and volume replacement techniques. Some commonly used volume displacement procedures are described in the article. The need for adjustment of contralateral breast should also be anticipated at the time of planning breast conserving surgery, which can be done either at the same time as breast cancer surgery or as a delayed setting.
PMCID: PMC3397185  PMID: 23730053
8.  Pre-consultation educational group intervention to improve shared decision-making in postmastectomy breast reconstruction: study protocol for a pilot randomized controlled trial 
Trials  2013;14:199.
The Pre-Consultation Educational Group Intervention pilot study seeks to assess the feasibility and inform the optimal design for a definitive randomized controlled trial that aims to improve the quality of decision-making in postmastectomy breast reconstruction patients.
This is a mixed-methods pilot feasibility randomized controlled trial that will follow a single-center, 1:1 allocation, two-arm parallel group superiority design.
Setting: The University Health Network, a tertiary care cancer center in Toronto, Canada.
Participants: Adult women referred to one of three plastic and reconstructive surgeons for delayed breast reconstruction or prophylactic mastectomy with immediate breast reconstruction.
Intervention: We designed a multi-disciplinary educational group workshop that incorporates the key components of shared decision-making, decision-support, and psychosocial support for cancer survivors prior to the initial surgical consult. The intervention consists of didactic lectures by a plastic surgeon and nurse specialist on breast reconstruction choices, pre- and postoperative care; a value-clarification exercise led by a social worker; and discussions with a breast reconstruction patient.
Control: Usual care includes access to an informational booklet, website, and patient volunteer if desired.
Outcomes: Expected pilot outcomes include feasibility, recruitment, and retention targets. Acceptability of intervention and full trial outcomes will be established through qualitative interviews. Trial outcomes will include decision-quality measures, patient-reported outcomes, and service outcomes, and the treatment effect estimate and variability will be used to inform the sample size calculation for a full trial.
Our pilot study seeks to identify the (1) feasibility, acceptability, and design of a definitive RCT and (2) the optimal content and delivery of our proposed educational group intervention. Thirty patients have been recruited to date (8 April 2013), of whom 15 have been randomized to one of three decision support workshops. The trial will close as planned in May 2013.
Trial registration
PMCID: PMC3708760  PMID: 23829442
9.  Where Do Neurologists Look When Viewing Brain CT Images? An Eye-Tracking Study Involving Stroke Cases 
PLoS ONE  2011;6(12):e28928.
The aim of this study was to investigate where neurologists look when they view brain computed tomography (CT) images and to evaluate how they deploy their visual attention by comparing their gaze distribution with saliency maps. Brain CT images showing cerebrovascular accidents were presented to 12 neurologists and 12 control subjects. The subjects' ocular fixation positions were recorded using an eye-tracking device (Eyelink 1000). Heat maps were created based on the eye-fixation patterns of each group and compared between the two groups. The heat maps revealed that the areas on which control subjects frequently fixated often coincided with areas identified as outstanding in saliency maps, while the areas on which neurologists frequently fixated often did not. Dwell time in regions of interest (ROI) was likewise compared between the two groups, revealing that, although dwell time on large lesions was not different between the two groups, dwell time in clinically important areas with low salience was longer in neurologists than in controls. Therefore it appears that neurologists intentionally scan clinically important areas when reading brain CT images showing cerebrovascular accidents. Both neurologists and control subjects used the “bottom-up salience” form of visual attention, although the neurologists more effectively used the “top-down instruction” form.
PMCID: PMC3236228  PMID: 22174928
10.  Psychological outcomes of different treatment policies in women with early breast cancer outside a clinical trial. 
BMJ : British Medical Journal  1990;301(6752):575-580.
OBJECTIVES--To assess outside a clinical trial the psychological outcome of different treatment policies in women with early breast cancer who underwent either mastectomy or breast conservation surgery depending on the surgeon's opinion or the patient's choice. To determine whether the extent of psychiatric morbidity reported in women who underwent breast conservation surgery was associated with their participation in a randomised clinical trial. DESIGN--Prospective, multicentre study capitalising on individual and motivational differences among patients and the different management policies among surgeons for treating patients with early breast cancer. SETTING--12 District general hospitals, three London teaching hospitals, and four private hospitals. PATIENTS--269 Women under 75 with a probable diagnosis of stage I or II breast cancer who were referred to 22 different surgeons. INTERVENTIONS--Surgery and radiotherapy or adjuvant chemotherapy, or both, depending on the individual surgeon's stated preferences for managing early breast cancer. MAIN OUTCOME MEASURES--Anxiety and depression as assessed by standard methods two weeks, three months, and 12 months after surgery. RESULTS--Of the 269 women, 31 were treated by surgeons who favoured mastectomy, 120 by surgeons who favoured breast conservation, and 118 by surgeons who offered a choice of treatment. Sixty two of the women treated by surgeons who offered a choice were eligible to choose their surgery, and 43 of these chose breast conserving surgery. The incidences of anxiety, depression, and sexual dysfunction were high in all treatment groups. There were no significant differences in the incidences of anxiety and depression between women who underwent mastectomy and those who underwent lumpectomy. A significant effect of surgeon type on the incidence of depression was observed, with patients treated by surgeons who offered a choice showing less depression than those treated by other surgeons (p = 0.06). There was no significant difference in psychiatric morbidity between women treated by surgeons who offered a choice who were eligible to choose their treatment and those in the same group who were not able to choose. Most of the women (159/244) gave fear of cancer as their primary fear rather than fear of losing a breast. The overall incidences of psychiatric morbidity in women who underwent mastectomy and those who underwent lumpectomy were similar to those found in the Cancer Research Campaign breast conservation study. At 12 months 28% of women who underwent mastectomy in the present study were anxious compared with 26% in the earlier study, and 27% of women in the present study who underwent lumpectomy were anxious compared with 31% in the earlier study. In both the present and earlier study 21% of women who underwent mastectomy were depressed, and 19% of women who underwent lumpectomy in the present study were depressed compared with 27% in the earlier study.) CONCLUSIONS--There is still no evidence that women with early breast cancer who undergo breast conservation surgery have less psychiatric morbidity after treatment than those who undergo mastectomy. Women who surrender autonomy for decision making by agreeing to participate in randomised clinical trials do not experience any different psychological, sexual, or social problems from those women who are treated for breast cancer outside a clinical trial.
PMCID: PMC1663731  PMID: 2242455
11.  Breast reconstruction at a district general hospital. 
Breast reconstruction is normally carried out by plastic surgeons, but the advent of permanent tissue expanders places post-mastectomy reconstruction within easy reach of the general surgeon. Nineteen patients underwent breast reconstruction between 1989 and 1991 using a subpectoral silicone-based, double lumen tissue expander. Assessment of results was by: (a) patient completed questionnaire; and (b) third party evaluation of standardized photographs. The mean operating time was 58 min (40-80 min) and mean hospital stay 3 days (2-7 days). Complications included one flap necrosis and one leaking injection port. Outpatient tissue expansion required an average of seven visits (4-11) and was completed in an average of 12 months (7-19). The injection port was subsequently removed under local anaesthetic as a day case. The fully dressed appearance following reconstruction was graded good or excellent by 100% of patients and in over 80% of third-party assessments. Equivalent figures for the appearance when wearing a bra were 93% and 60% and undressed 57% and 47%, respectively. All patients recommended the procedure but 25% found inflation uncomfortable. Subpectoral tissue expansion is a safe, cosmetically acceptable method of breast reconstruction which is associated with a high level of patient satisfaction.
PMCID: PMC1294218  PMID: 8258795
12.  A Non-Verbal Turing Test: Differentiating Mind from Machine in Gaze-Based Social Interaction 
PLoS ONE  2011;6(11):e27591.
In social interaction, gaze behavior provides important signals that have a significant impact on our perception of others. Previous investigations, however, have relied on paradigms in which participants are passive observers of other persons’ gazes and do not adjust their gaze behavior as is the case in real-life social encounters. We used an interactive eye-tracking paradigm that allows participants to interact with an anthropomorphic virtual character whose gaze behavior is responsive to where the participant looks on the stimulus screen in real time. The character’s gaze reactions were systematically varied along a continuum from a maximal probability of gaze aversion to a maximal probability of gaze-following during brief interactions, thereby varying contingency and congruency of the reactions. We investigated how these variations influenced whether participants believed that the character was controlled by another person (i.e., a confederate) or a computer program. In a series of experiments, the human confederate was either introduced as naïve to the task, cooperative, or competitive. Results demonstrate that the ascription of humanness increases with higher congruency of gaze reactions when participants are interacting with a naïve partner. In contrast, humanness ascription is driven by the degree of contingency irrespective of congruency when the confederate was introduced as cooperative. Conversely, during interaction with a competitive confederate, judgments were neither based on congruency nor on contingency. These results offer important insights into what renders the experience of an interaction truly social: Humans appear to have a default expectation of reciprocation that can be influenced drastically by the presumed disposition of the interactor to either cooperate or compete.
PMCID: PMC3212571  PMID: 22096599
13.  Breast Reduction Surgery in the UK and Ireland–Current Trends 
This paper reviews the current status of bilateral breast reduction surgery in the UK and Ireland. It examines the pre-operative, operative and postoperative management of women.
A questionnaire established information about surgeons' experience, bilateral breast reduction work-load, pre-operative assessment, selection criteria, issues of operative technique and postoperative management. This was sent to 230 consultant plastic surgeons working in the NHS in the UK and Ireland.
There was a 61% response rate. Of respondent surgeons, 82% always perform pre-operative photography, 71% never do a mammogram even in patients above the age of 50 years. Body mass index (BMI) is the most commonly used criteria for patient selection (60%). Two-thirds of the surgeons use an inferior pedicle technique and 75% of surgeons work in health authorities that restrict breast reduction surgery.
There was significant variation in practice among surgeons performing bilateral breast reduction. This may reflect a lack of evidence base for practise. Published literature focuses almost exclusively on the description of different techniques. Further work is required to evaluate the role of pre-operative mammography, specimen mammography, antibiotics and selection criteria for surgery.
PMCID: PMC1963764  PMID: 17059724
Bilateral breast reduction; Audit; Pre-operative assessment; Selection criteria; Operative technique; Postoperative management
14.  Breast conserving surgery versus mastectomy: cancer practice by general surgeons in Iran 
BMC Cancer  2005;5:35.
There appear to be geographical differences in decisions to perform mastectomy or breast conserving surgery for early-stage breast cancer. This study was carried out to evaluate general surgeons' preferences in breast cancer surgery and to assess the factors predicting cancer practice in Iran.
A structured questionnaire was mailed to 235 general surgeons chosen from the address list of the Iranian Medical Council. The questionnaire elicited information about the general surgeons' characteristics and about their work experience, posts they have held, number of breast cancer operations performed per year, preferences for mastectomy or breast conserving surgery, and the reasons for these preferences.
In all, 83 surgeons returned the completed questionnaire. The results indicated that only 19% of the surgeons routinely performed breast conserving surgery (BCS) and this was significantly associated with their breast cancer case load (P < 0.01). There were no associations between BCS practice and the other variables studied. The most frequent reasons for not performing BCS were uncertainty about conservative therapy results (46%), uncertainty about the quality of available radiotherapy services (32%), and the probability of patients' non-compliance in radiotherapy (32%).
The findings indicate that Iranian surgeons do not routinely perform BCS as the first and the best treatment modality. Further research is recommended to evaluate patients' outcomes after BCS treatment in Iran, with regard to available radiotherapy facilities and cultural factors (patients' compliance).
PMCID: PMC1087478  PMID: 15811187
15.  Self-Detection Remains a Key Method of Breast Cancer Detection for U.S. Women 
Journal of Women's Health  2011;20(8):1135-1139.
The method by which breast cancer is detected becomes a factor for long-term survival and should be considered in treatment plans. This report describes patient characteristics and time trends for various methods of breast cancer detection in the United States.
The 2003 National Health Interview Survey (NHIS), a nationally representative self-report health survey, included 361 women survivors diagnosed with breast cancer between 1980 and 2003. Responses to the question, How was your breast cancer found? were categorized as accident, self-examination, physician during routine breast examination, mammogram, and other. We examined responses by income, race, age, and year of diagnosis.
Most women survivors (57%) reported a detection method other than mammographic examination. Women often detected breast cancers themselves, either by self-examination (25%) or by accident (18%).
Despite increased use of screening mammography, a large percentage of breast cancers are detected by the patients themselves. Patient-noted breast abnormalities should be carefully evaluated.
PMCID: PMC3153870  PMID: 21675875
16.  Living in the context of poverty and trajectories of breast cancer worry, knowledge and perceived risk after a breast cancer risk education session 
The purpose of this paper was to demonstrate how living in neighborhoods with high levels of poverty (while controlling for personal income) impacts personal characteristics which in turn impacts retention of breast cancer risk knowledge and changes in worry and perceived risk.
The data from this project come from a larger NCI funded study that included a pre-test, a breast cancer risk education session, a post-test, the option of an individualized risk assessment via the Gail Model and three follow-up phone calls over the next nine months.
The percent of individuals living below poverty in the community in which the participant resided was predictive of the personal characteristics assessed, and these characteristics were predictive of changes in breast cancer worry, and knowledge across time.
Differentiation of self and monitoring, two of the individual characteristics that appear to allow people to process and use information to make “rational” decisions about health care, appear to be impacted by the necessity for adaptation to a culture of poverty. Thus, as a health care community, we need to tailor our messages and our recommendations with an understanding of the complex intersection of poverty and health care decision making.
PMCID: PMC2974806  PMID: 20688528
17.  A Research Agenda for Appearance Changes Due to Breast Cancer Treatment 
Breast cancer is one of the most prevalent forms of cancer in the US. It is estimated that more than 180,000 American women will be diagnosed with invasive breast cancer in 2008. Fortunately, the survival rate is relatively high and continually increasing due to improved detection techniques and treatment methods. However, maintaining quality of life is a factor often under emphasized for breast cancer survivors. Breast cancer treatments are invasive and can lead to deformation of the breast. Breast reconstruction is important for restoring the survivor’s appearance. However, more work is needed to develop technologies for quantifying surgical outcomes and understanding women’s perceptions of changes in their appearance. A method for objectively measuring breast anatomy is needed in order to help both the breast cancer survivors and their surgeons take expected changes to the survivor’s appearance into account when considering various treatment options. In the future, augmented reality tools could help surgeons reconstruct a survivor’s breasts to match her preferences as much as possible.
PMCID: PMC3085417  PMID: 21655363
breast cancer; 3D imaging of breast; computer-assisted image analysis; quality of life
18.  Risk, Characteristics, and Prognosis of Breast Cancer after Hodgkin's Lymphoma 
The Oncologist  2012;17(6):783-791.
Patients with breast cancer after Hodgkin's lymphoma were compared with patients with other breast cancers using the Surveillance, Epidemiology and End Results dataset. Hodgkin's lymphoma survivors had a higher risk for breast cancer, more aggressive breast cancers, a higher risk for a second breast cancer, and a poorer prognosis.
Learning Objectives:
After completing this course, the reader will be able to: Explain the differences in risk and aggression of breast cancer for Hodgkin's lymphoma survivors.Describe the difference in breast tumor sites for Hodgkin's lymphoma survivors.Use adapted guidelines for surveillance and treatment of these high-risk patients.
This article is available for continuing medical education credit at
To assess breast cancer (BC) risk after Hodgkin's lymphoma (HL) and compare characteristics, risk of second BC, and prognosis of patients with these BCs with patients with first primary BC.
Patients and Methods.
We considered all 9,620 women with HL recorded in the Surveillance, Epidemiology and End Results dataset in 1973–2007. We calculated age-period standardized incidence ratios of BC. We compared patient, tumor, and treatment characteristics, risk of second BC, and prognosis between patients with BC after HL (n = 316) and patients with other BCs occurring during the same period (n = 450,413) using logistic regression and Cox models adjusted for confounders.
HL patients had a 2.4-fold higher risk for developing BC (95% confidence interval [CI], 2.2–2.7) than the general population. Age at HL diagnosis and radiation therapy influenced this risk. Compared with first primary BCs, BCs after HL were diagnosed at a younger age, at an earlier stage, were less frequently hormone receptor positive, were located more frequently in external quadrants, and were less frequently treated using radiotherapy. These patients had a higher risk (adjusted hazard ratio [HR], 2.85; 95% CI, 1.79–4.53) for developing a second BC and had a higher BC mortality risk (adjusted HR, 1.36; 95% CI, 1.05–1.76). The higher mortality risk was only partly explained by the higher occurrence rate of a second BC.
HL survivors have a higher risk for developing BC, their BCs are more aggressive, they have a higher risk for a second BC occurrence, and they have a poorer prognosis. Guidelines of care should be adapted to decrease the impact of BC in these high-risk patients.
PMCID: PMC3380877  PMID: 22588325
Breast cancer; Hodgkin's lymphoma; Radiation therapy; Prognosis
19.  One-Stage Nipple and Breast Reconstruction Following Areola-Sparing Mastectomy 
Archives of Plastic Surgery  2013;40(5):553-558.
Skin-sparing mastectomy with immediate breast reconstruction is increasingly becoming a proven surgical option for early-stage breast cancer patients. Areola-sparing mastectomy (ASM) has also recently become a popular procedure. The purpose of this article is to investigate the reconstructive and aesthetic issues experienced with one-stage nipple and breast reconstruction using ASM.
Among the patients who underwent mastectomy between March 2008 and March 2010, 5 women with a low probability of nipple-areolar complex malignant involvement underwent ASM and immediate breast reconstruction with simultaneous nipple reconstruction using the modified C-V flap. The cosmetic outcomes of this series were reviewed by plastic surgeons and patient self-assessment and satisfaction were assessed via telephone interview.
During the average 11-month follow-up period, there were no cases of cancer recurrence, the aesthetic outcomes were graded as excellent to very good, and all of the patients were satisfied. Two patients developed a gutter-like depression around the reconstructed nipple, and one patient developed skin erosion in a small area of the areola, which healed with conservative dressing. The other complications, such as necrosis of the skin flap or areola, seroma, hematoma, or fat necrosis did not occur.
Since one-stage nipple and breast reconstruction following ASM is an oncologically safe, cost-effective, and aesthetically satisfactory procedure, it is a good surgical option for early breast cancer patients.
PMCID: PMC3785589  PMID: 24086809
Breast; Mammaplasty; Nipples; Mastectomy
20.  Automated calculation of symmetry measure on clinical photographs 
Breast cancer is one of the most prevalent forms of cancer in the world. More than 250,000 American women are diagnosed with breast cancer annually. Fortunately, the survival rate is relatively high and continually increasing due to improved detection techniques and treatment methods. The quality of life of breast cancer survivors is ameliorated by minimizing adverse effects on their physical appearance. Breast reconstruction is important for restoring the survivor’s appearance. In breast reconstructive surgery, there is a need to develop technologies for quantifying surgical outcomes and understanding women’s perceptions of changes in their appearance. Methods for objectively measuring breast anatomy are needed in order to help breast cancer survivors, radiation oncologists, and surgeons quantify changes in appearance that occur with different breast reconstructive surgical options. In this study, we present an automated method for computing a variant of the normalized Breast Retraction Assessment (pBRA), a common measure of symmetry, from routine clinical photographs taken to document breast cancer treatment procedures.
PMCID: PMC2958233  PMID: 20630015
BRA; pBRA; Automated Detection; Digital Photographs; Umbilicus; Nipple Complex; Breast Cancer
21.  Mammographers’ Perception of Women’s Breast Cancer Risk 
To understand mammographers’ perception of individual women’s breast cancer risk.
Materials and Methods
Radiologists interpreting screening mammography examinations completed a mailed survey consisting of questions pertaining to demographic and clinical practice characteristics, as well as 2 vignettes describing different risk profiles of women. Respondents were asked to estimate the probability of a breast cancer diagnosis in the next 5 years for each vignette. Vignette responses were plotted against mean recall rates in actual clinical practice.
The survey was returned by 77% of eligible radiologists. Ninety-three percent of radiologists overestimated risk in the vignette involving a 70-year-old woman; 96% overestimated risk in the vignette involving a 41-year-old woman. Radiologists who more accurately estimated breast cancer risk were younger, worked full-time, were affiliated with an academic medical center, had fellowship training, had fewer than 10 years experience interpreting mammograms, and worked more than 40% of the time in breast imaging. However, only age was statistically significant. No association was found between radiologists’ risk estimate and their recall rate.
U.S. radiologists have a heightened perception of breast cancer risk.
PMCID: PMC3131742  PMID: 15951455
perception; risk; pretest probability
22.  Concordance in communication between surgeon and patient 
Canadian Journal of Surgery  1998;41(6):439-445.
To examine (1) the capability of using interactive voice response (IVR) system technology for clinical research studies involving assessment of clinician–patient interactions and (2) the concordance of surgeons and their breast cancer patients about the content of a postbiopsy pre-treatment decision meeting.
A descriptive comparison of the perceptions of 2 volunteer groups — surgeons and their patients — using interactive voice technology.
Surgeons’ offices.
Twenty-six dyads of surgeons and their patients with newly diagnosed breast cancer.
Outcome measures
Concordance as determined through a 15-item patient questionnaire and a parallel 11-item surgeon questionnaire addressing surgical and psychosocial aspects of breast cancer treatment.
Fifty-four percent to 100% of the 26 dyads indicated concordance about treatment preference, treatment choice, how treatment was chosen, preference for how treatment was chosen, time for discussion about treatment, and discussion about lymph-node removal. Only 27% to 50% of dyads agreed about patient understanding of lymph-node removal, the thoroughness of discussions about adjuvant treatment, the thoroughness of discussion about emotional coping, and the sufficiency of time for the discussion of patient’s concerns. In these areas of disagreement surgeons often underestimated the patient’s ability to understand and underestimated the patient’s perception of the thoroughness of discussions about the psychosocial aspects of the illness (concerns and coping).
Surgeons and patients demonstrated concordance on their perceptions of the type of treatment desired and needed but were discordant on their perceptions of the degree of patients’ understanding about post-treatment and psychosocial issues.
PMCID: PMC3949800  PMID: 9854533
23.  Attribution of functional limitation to cancer decreases in the year following breast cancer diagnosis in older patients 
To examine the prevalence of self-reported functional limitations in a breast cancer population, identify whether these reported limitations are attributed to breast cancer versus other coexisting illnesses, and examine how this attribution changes over time from early in treatment to 9-months later.
Longitudinal, observational study.
Community dwelling adults in Detroit metropolitan area.
2033 participants (1011 breast cancer patients, 1022 controls), aged 40–84 years.
Participants were asked about each of 23 possible coexisting illnesses in addition to breast cancer and whether or not each illness, including breast cancer, caused any activity limitation.
Of the 933 cancer patients who completed both baseline and follow up evaluations, 45% were aged 65 years and older. At baseline, 56% of patients 65 years and older reported functional limitation compared with 50% of patients younger than 65 years (p =0.005). Of those patients who reported limitation at baseline, 59% of older patients and 78% of younger patients attributed their limitation to breast cancer (p<0.001). At follow up, 53% of older and 37% of younger patients reported functional limitation (p<0.001), with 27% of older patients compared with 57% of younger patients (p<0.001) attributing limitation to breast cancer.
Self-reported functional limitations are common 3 months after breast cancer diagnosis, being attributed primarily to breast cancer. By 1 year after diagnosis, much of the limitation due to breast cancer resolves. Older women are less likely to have resolution of their limitations, which are most commonly due to other coexisting illnesses.
PMCID: PMC2753256  PMID: 19081266
breast cancer; functional limitation; comorbidity
24.  Scan path entropy and arrow plots: capturing scanning behavior of multiple observers 
Designers of visual communication material want their material to attract and retain attention. In marketing research, heat maps, dwell time, and time to AOI first hit are often used as evaluation parameters. Here we present two additional measures (1) “scan path entropy” to quantify gaze guidance and (2) the “arrow plot” to visualize the average scan path. Both are based on string representations of scan paths. The latter also incorporates transition matrices and time required for 50% of the observers to first hit AOIs (T50). The new measures were tested in an eye tracking study (48 observers, 39 advertisements). Scan path entropy is a sensible measure for gaze guidance and the new visualization method reveals aspects of the average scan path and gives a better indication in what order global scanning takes place.
PMCID: PMC3872074  PMID: 24399993
scan-path; entropy; eye-tracking; gaze-guidance; data visualization
25.  Effects of specialisation on treatment and outcomes in screen-detected breast cancers in Wales: cohort study 
British Journal of Cancer  2006;94(1):36-42.
Volume–outcome relationships have been found for management of symptomatic but not for screen-detected, breast cancers. The study included 2705 patients with breast cancer detected by the Welsh breast cancer-screening programme from its inception in 1989 to 1997. Survival was tracked until 1999. Data validity was assessed for 10% of subjects. Hospitals' and surgeons' annual patient volumes were calculated as indices of specialisation. Effects of hospital and surgeon volumes on survival were estimated using Cox regression. Surgeons' and hospitals' volumes ranged from 1 to 90, and 1 to 86 patients, respectively. Patients managed by higher volume surgeons survived significantly longer (adjusted hazards ratio for a volume difference of 10 patients per year=0.90 (95% confidence intervals 0.84–0.97)). The adjusted hazard ratio for breast cancer survival was similar (0.91 (95% confidence intervals 0.82–1.00)). This association decreased over time. Patients of higher volume surgeons were significantly more likely to have axillary surgery and impalpable excision biopsies and were less likely to have mastectomy or radiotherapy. Surgeons' specialisation in management of screen-detected breast cancers was associated with longer survival, but this effect appeared to decrease over time.
PMCID: PMC2361068  PMID: 16333307
specialisation; outcomes; survival; breast cancer

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