BACKGROUND:Breast conserving surgery (BCS) with partial breast reconstruction (PBR) results in less morbidity, better cosmetic outcomes, and improved patient satisfaction compared to mastectomy. Perforator flap reconstruction can attenuate defects prone to breast deformity after BCS. Usually, postoperative drains and inpatient admission are part of this treatment. The main objective of this study is to report on postoperative complications and patient satisfaction after drainless perforator flap reconstruction by a dedicated breast surgeon. METHODS:In a retrospective case series, 42 patients were included. All patients underwent BCS with drainless perforator flap reconstruction, planned and performed by a single breast surgeon. Outcomes were complication incidence and patient satisfaction reported in the Breast-Q Breast Conserving Therapy (BCT) module. RESULTS:In the study cohort, the median age was 59.5 (49.8-71.3) years. Tumour types were ductal carcinoma in situ (DCIS, four patients, 9.5%), invasive no special type (NST, 22 patients, 52.4%), invasive lobular (12 patients, 28.6%), and other invasive cancers (4 patients, 9.5%). Complication incidence was seven of 42 patients (16.7%), including hematoma, seroma, wound dehiscence, fat necrosis, and lymphedema, all Clavien Dindo grade 0-1, without readmission or reoperation. Reported Breast-Q scores (median of 17 months after surgery) were 87/100 for psychosocial well-being, 82/100 for breast satisfaction, and 71/100 for physical well-being. Outpatient treatment was successful in 38 patients (90.5%), and 13 patients (31.0%) had an unplanned visit to the outpatient clinic. CONCLUSION:Drainless perforator flap reconstruction performed by the breast surgeon results in high patient satisfaction and limited complications, both in number and severity. The use of drains and hospital stays after perforator flap reconstruction must be discouraged.

BACKGROUND:Integrating outcome information into the process of shared decision-making (SDM) about post-treatment surveillance can enhance its effectiveness. The Breast Cancer Surveillance Decision Aid (BCS-PtDA) integrates risk estimations of patients' risks for recurrences as well as outcome information on fear of cancer recurrence (FCR). The SHOUT-BC study aimed to evaluate the effectiveness of the implementation of the BCS-PtDA. Patients' satisfaction with the BCS-PtDA was also evaluated. METHODS:As described in a previously published protocol paper, the study employed a Prospective multiple interrupted time series (ITS) design in which the BCS-PtDA was implemented stepwise into the care pathways of eight Dutch hospitals. RESULTS:A total of 507 participants completed a questionnaire after their first surveillance consultation which usually takes place approximately one year after surgery. ITS analysis per hospital and subsequent meta-analysis over hospital effects indicated a significant increase in patient-reported SDM from pre- to post-implementation (overall estimated effect: 27.14, 95 % CI: 22.71 to 31.87, p < .0001). Moreover, post-implementation participants (n = 225) reported a more active role in decision-making, decreased decisional conflict, and increased knowledge on the aim and methods of surveillance. Furthermore, a decrease in FCR was seen post-implementation. The self-reported intensity of surveillance schedules decreased slightly and the BCS-PtDA received highly positive evaluations. DISCUSSION:The implementation of the BCS-PtDA, which integrates outcome information, led to increased patient-reported SDM and an improved quality of decision-making. The BCS-PtDA was evaluated highly positively by participants. Further research should address optimisation of the implementation.

Background and purpose: In the BOOG 2013-08 trial (NCT02271828), cT1-2N0 breast cancer patients were randomized between breast conserving surgery with or without sentinel lymph node biopsy (SLNB) followed by whole breast radiotherapy (WBRT). While awaiting primary endpoint results (axillary recurrence rate), this study aims to perform a quality assurance analysis on protocol adherence and (incidental) axillary radiation therapy (RT) dose. Materials and methods: Patients were enrolled between 2015 and 2022. Data on prescribed RT and (in 25% of included patients) planning target volumes (PTV) parameters were recorded for axillary levels I -IV and compared between treatment arms. Multivariable linear regression analysis was performed to determine prognostic variables for incidental axillary RT dose. Results: 1,439/1,461 included patients (98.5%) were treated according to protocol and 87 patients (5.9%) received regional RT (SLNB 10.9%, no-SLNB 1.5 %). In 326 patients included in the subgroup analysis, the mean incidental PTV dose at axilla level I was 59.5% of the prescribed breast RT dose. In 5 patients (1.5%) the mean PTV dose at level I was >= 95% of the prescribed breast dose. No statistically or clinically significant differences regarding incidental axillary RT dose were found between treatment arms. Tumour bed boost (yes/no) was associated with a higher incidental mean dose in level I (R2 = 0.035, F(6, 263) = 1.532, p 0.168). Conclusion: The results indicate that RT-protocol adherence was high, and that incidental axillary RT dose was low in the BOOG 2013-08 trial. Potential differences between treatmentarms regarding the primary endpoint can thus not be attributed to different axillary radiation doses.

Background Frailty in newly-diagnosed multiple myeloma (NDMM) patients is associated with treatment-related toxicity, which negatively affects health-related quality of life (HRQoL). Currently, data on changes in HRQoL of frail and intermediate-fit MM patients during active treatment and post-treatment follow-up are absent. Methods The HOVON123 study (NTR4244) was a phase II trial in which NDMM patients ≥75 years were treated with nine dose-adjusted cycles of Melphalan-Prednisone-Bortezomib (MPV). Two HRQoL instruments (EORTC QLQ-C30 and -MY20) were obtained before start of treatment, after 3 and 9 months of treatment and 6 and 12 months after treatment for patients who did not yet start second-line treatment. HRQoL changes and/or differences in frail and intermediate-fit patients (IMWG frailty score) were reported only when both statistically significant (p<0.005) and clinically relevant (>MID). Results 137 frail and 71 intermediate-fit patients were included in the analysis. Compliance was high and comparable in both groups. At baseline, frail patients reported lower global health status, lower physical functioning scores and more fatigue and pain compared to intermediate-fit patients. Both groups improved in global health status and future perspective; polyneuropathy complaints worsened over time. Frail patients improved over time in physical functioning, fatigue and pain. Improvement in global health status occurred earlier than in intermediate-fit patients. Conclusion HRQoL improved during anti-myeloma treatment in both intermediate-fit and frail MM patients. In frail patients, improvement occurred faster and, in more domains, which was retained during follow-up. This implies that physicians should not withhold safe and effective therapies from frail patients in fear of HRQoL deterioration.

AIMS:This nationwide study provides an overview of trends and variations in radiotherapy use as part of multimodal treatment of invasive non-metastatic breast cancer in the Netherlands in 2008-2019. MATERIALS AND METHODS:Women with invasive non-metastatic breast cancer were selected from the population-based Netherlands Cancer Registry. Treatments trends were presented over time. Factors associated with (1) boost irradiation in breast-conserving therapy and (2) regional radiotherapy instead of axillary lymph node dissection (ALND) in N+ disease were identified using multilevel logistic regression analyses. RESULTS:Radiotherapy use increased from 61% (2008) to 70% (2016), caused by breast-conserving therapy instead of mastectomy, increased post-mastectomy radiotherapy, and increased regional radiotherapy (32% in 2011 to 61% in 2019) instead of ALND in N+ disease. Omission of radiotherapy after breast-conserving surgery (BCS) in 2016-2019 (4-9%, respectively), mainly in elderly, decreased overall radiotherapy use to 67%. Radiotherapy treatment was further de-escalated by decreased boost irradiation in breast-conserving therapy (66% in 2011 to 37% in 2019) and partial (1% in 2011 to 6% in 2019) instead of whole breast irradiation following BCS. Boost irradiation was associated with high-risk features: younger age (OR>75 vs <50:0.04, 95%CI:0.03-0.05), higher grade (OR grade III vs I:11.46, 95%CI:9.90-13.26) and residual disease (OR focal residual vs R0-resection:28.08, 95%CI:23.07-34.17). Variation across the country was found for both boost irradiation use (OR South vs North:0.58, 95%CI:0.49-0.68), and regional radiotherapy instead of ALND (OR Southwest vs North:0.55, 95%CI:0.37-0.80). CONCLUSION:Overall radiotherapy use increased in 2008-2016, while a decreasing trend was observed after 2016, caused by post-BCS radiotherapy omission. Boost irradiation in breast-conserving therapy became omitted in low-risk patients, and regional radiotherapy use increased as an alternative for ALND in N+ disease.

Background: The results presented originate from the BOOG 2013-08 study which investigates the oncological safety of sentinel lymph node biopsy (SLNB) omission in cN0 T1-2 breast cancer patients treated with breast conserving therapy (BCT). The aim of current study was to assess the impact of personality traits 'trait anxiety' (TA) and neuroticism (N) on HRQoL up to three years after study inclusion.

This study aimed to: (1) determine the accuracy of Dutch breast cancer survivors’ estimations of the locoregional recurrence risk (LRR); (2) examine which variables influence (the accuracy of) risk estimations, and risk appraisals; and (3) investigate the influence of the objective LRR risk (estimated using the INFLUENCE-nomogram), risk estimations and risk appraisals on fear of cancer recurrence (FCR). Findings of this study will inform clinicians on risk communication and can improve communication about FCR. In a cross-sectional survey among 258 breast cancer survivors, women’s recurrence risk estimations (in odds) and risk appraisals (in high/low), FCR, demographics and illness perceptions, about one year after surgery were measured and compared to the objective risk for LRRs estimated using the INFLUENCE-nomogram. Half of the women (54%) accurately estimated their LRR risk, 34% underestimated and 13% overestimated their risk. Risk estimations and risk appraisals were only moderately positively correlated (r = 0.58). Higher risk appraisals were associated with radiotherapy (r = 0.18) and having weaker cure beliefs (r = − 0.19). Younger age was associated with overestimation of risk (r = − 0.23). Recurrence risk estimations and risk appraisals were associated with more FCR (r = 0.29, r = 0.39). In regression, only risk appraisal contributed significantly to FCR. Although women were fairly accurate in recurrence risk estimations, it remains difficult to predict over- or underestimation. Recurrence risk estimations and risk appraisal are two different concepts which are both associated with FCR and should therefore be addressed in patient-provider communication.

BackgroundSeroma is the most common complication following breast cancer surgery, with reported incidence up to 90%. Seroma causes patient discomfort, is associated with surgical site infections (SSI), often requires treatment and increases healthcare consumption. The quilting suture technique, in which the skin flaps are sutured to the pectoralis muscle, leads to a significant reduction of seroma with a decrease in the number of aspirations and surgical site infections. However, implementation is lagging due to unknown side effects, increase in operation time and cost effectiveness. Main objective of this study is to assess the impact of large scale implementation of the quilting suture technique in patients undergoing mastectomy and/or axillary lymph node dissection (ALND).MethodsThe QUILT study is a stepped wedge design study performed among nine teaching hospitals in the Netherlands. The study consists of nine steps, with each step one hospital will implement the quilting suture technique. Allocation of the order of implementation will be randomization-based. Primary outcome is 'textbook outcome', i.e.no wound complications, no re-admission, re-operation or unscheduled visit to the outpatient clinic and no increased use of postoperative analgesics. A total of 113 patients is required based on a sample size calculation. Secondary outcomes are shoulder function, cosmetic outcome, satisfaction with thoracic wall and health care consumption. Follow-up lasts for 6 months.DiscussionThis will be one of the first multicentre prospective studies in which quilting without postoperative wound drain is compared with conventional wound closure. We hypothesize that quilting is a simple technique to increase textbook outcome, enhance patient comfort and reduce health care consumption.

Purpose Omitting sentinel lymph node biopsy (SLNB) in breast cancer treatment results in patients with unknown positive nodal status and potential risk for systemic undertreatment. This study aimed to investigate whether gene expression profiles (GEPs) can lower this risk in cT1-2N0 ER+ HER2– breast cancer patients treated with BCT. Methods Patients were included if diagnosed between 2011 and 2017 with cT1-2N0 ER+ HER2– breast cancer, treated with BCT and SLNB, and in whom GEP was applied. Adjuvant chemotherapy recommendations based on clinical risk status (Dutch breast cancer guideline of 2020 versus PREDICT v2.1) with and without knowledge on SLNB outcome were compared to GEP outcome. We examined missing adjuvant chemotherapy indications, and the number of GEPs needed to identify one patient at risk for systemic undertreatment. Results Of 3585 patients, 2863 (79.9%) had pN0 and 722 (20.1%) pN + disease. Chemotherapy was recommended in 1354 (37.8% guideline-2020) and 1888 patients (52.7% PREDICT). Eliminating SLNB outcome ( n = 722) resulted in omission of chemotherapy recommendation in 475 (35.1% guideline-2020) and 412 patients (21.8% PREDICT). GEP revealed genomic high risk in 126 (26.5% guideline-2020) and 82 patients (19.9% PREDICT) in case of omitted chemotherapy recommendation in the absence of SLNB. Extrapolated to the whole group, this concerns 3.5% and 2.3%, respectively, resulting in the need for 28–44 GEPs to identify one patient at risk for systemic undertreatment. Conclusion If no SLNB is performed, clinical risk status according to the guideline of 2020 and PREDICT predicts a very low risk for systemic undertreatment. The number of GEPs needed to identify one patient at risk for undertreatment does not justify its standard use.

•ICWC can be used to determine receptor status in malignant breast lesions with comparable accuracy to CNB.•Needle thickness and number of obtained cores do not affect the accuracy of Immunostained Core Wash Cytology.•Processing time of Immunostained Core Wash Cytology was under 5 h, allowing for same day diagnosis and treatment planning.

Background: The BOOG 2013-08 study examined non-inferiority of omission of the sentinel lymph node biopsy (SLNB) in clinically node negative cT1-2 breast cancer patients treated with breast conserving therapy (NCT02271828).1 This study explores whether omission of the SLNB results in a significant decrease in axillary morbidity rate and improved health-related QoL (HRQoL) at 6- 12- and 24 months post-surgery.

Background The rate of inpatient mastectomies remains high despite multiple studies reporting favourably on outpatient mastectomies. Outpatient mastectomies do not compromise quality of patient care and are more efficient than inpatient care. The objective of this study was to evaluate the feasibility of outpatient mastectomy. Materials and Methods Implementation of an outpatient mastectomy program was evaluated in a retrospective study. All patients who underwent mastectomy between January 2019 and September 2021 were included. Results 213 patients were enrolled in the study: 62.4% (n = 133) outpatient mastectomies versus 37.6% (n = 80) inpatient mastectomies. A steady rise in outpatient mastectomies was observed over time. The second quarter of 2020, coinciding with the first COVID-19 wave, showed a peak in outpatient mastectomies. The only significant barrier to outpatient mastectomy proved to be bilateral mastectomy. Unplanned return to care was observed in 27.8% of the outpatient versus 36.3% of the inpatient mastectomies (P=0.198); the reason for unplanned return of care was similar in both groups. Conclusions Outpatient mastectomy is shown to be feasible and safe with a steady increase during the study period. A barrier to outpatient mastectomy was bilateral mastectomy. Incidence of unplanned return to care or complications did not differ significantly between the outpatient and inpatient cohorts.

To investigate the prevalence of adjustment disorder (AD) among cancer patients and the acceptance of psychological treatment, in relation to sociodemographic, clinical, and psychological factors. Breast, prostate, and head and neck cancer patients of all stages and treatment modalities (N = 200) participated in this observational study. Patients completed the Hospital Anxiety and Depression Scale, Checklist Individual Strength, Distress Thermometer and problem list. Patients with increased risk on AD based on these questionnaires were scheduled for a diagnostic interview. Patients diagnosed with AD were invited to participate in a randomized controlled trial on the cost-effectiveness of psychological treatment. Participation in this trial was used as a proxy of acceptance of psychological treatment. Logistic regression analyses were used to investigate associated factors. The overall prevalence of AD was estimated at 13.1%. Sensitivity analyses showed prevalence rates of AD of 11.5%, 15.0%, and 23.5%. Acceptance of psychological treatment was estimated at 65%. AD was associated both with being employed (OR = 3.3, CI = 1.3–8.4) and having a shorter time since diagnosis (OR = 0.3, CI = 0.1–0.8). Taking sensitivity analysis into account, the prevalence of AD among cancer patients is estimated at 13 to 15%, and is related to being employed and having a shorter time since diagnosis. The majority of cancer patients with AD accept psychological treatment.

Objectives: To determine the extent and characteristics of delay in breast cancer diagnosis in women recalled at screening mammography. Methods: We included a consecutive series of 817,656 screens of women who received biennial screening mammography in a Dutch breast cancer screening region between 1997 and 2016. During at least 3.5 years follow-up, radiological reports and biopsy reports were collected of all recalled women. The inclusion period was divided into four cohorts of four years each. We determined the number of screen-detected cancers and their characteristics, and assessed the proportion of recalled women who experienced a diagnostic delay of at least 4 months in breast cancer confirmation. Results: The proportion of recalled women who experienced diagnostic delay decreased from 7.5 % in 1997 2001 (47/623) to 3.0 % in 2012 2016 (67/2223, P < 0.001). The proportion of women with a delay of at least two years increased from 27.7 % (13/47) in 1997 2001 to 75.7 % (53/70) in 2012 2016 (P < 0.001). Cancers with a diagnostic delay > 2 years were more frequently invasive (P = 0.009) than cancers with a diagnostic delay of 4 24 months. The most frequent cause of diagnostic delays was incorrect radiological classifications by clinical radiologists (55.2 % overall) after recall. Conclusions: The proportion of recalled women with a delayed breast cancer diagnosis has more than halved during two decades of screening mammography. Delays in breast cancer diagnosis are characterized by longer delay intervals, although the proportion of these delays among all screen-detected cancers has not increased. Preventing longer delays in breast cancer confirmation may help improve breast cancer survival.