Preoperative chemotherapy: where do we go from here?
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Breast Neoplasms↗
Biomedical subjects
T J Eberlein
Publications and source records attributed to T J Eberlein.
Prognostic factors predictive of survival for truncal and retroperitoneal soft-tissue sarcoma.
OBJECTIVE: The authors identified prognostic factors relevant to clinical outcomes (especially survival) in truncal and retroperitoneal soft-tissue sarcoma. SUMMARY BACKGROUND DATA: These results can be used to optimize surgical management and select patients most likely to benefit from novel therapeutic strategies in future trials. METHODS: A retrospective analysis was performed of a prospectively compiled database of 183 consecutive patients with truncal and retroperitoneal sarcomas seen at the Brigham and Women's Hospital and the Dana Farber Cancer Institute between 1970 to 1994. RESULTS: For truncal sarcoma, multivariate analysis showed that high-grade histology was associated with an eightfold increased risk of death compared with low-grade histology (p = 0.001). In addition to grade, gross positive margin of resection (p = 0.001), microscopic positive margin (p = 0.023), and tumors greater than 5 cm in size (p = 0.018) were important independent prognostic factors for survival. In this series, postoperative radiation therapy for truncal sarcoma was associated with a 2.4-fold decreased risk of death compared with truncal sarcoma patients receiving no adjuvant radiation therapy, having adjusted for the other prognostic factors (p = 0.030). In contrast, for retroperitoneal sarcoma, multivariate analysis showed that high-grade and intermediate-grade histology were associated with a five- to sixfold increased risk of death compared with low-grade histology (p = 0.009). In addition to grade, gross positive margin of resection (p = 0.001) and microscopic positive margin (p = 0.004) were important independent prognostic factors for survival in retroperitoneal sarcoma. Patients who received either preoperative or postoperative chemotherapy for retroperitoneal sarcoma had a 4.6-fold (p = 0.002) and 3-fold (p = 0.010) increased risk of death, respectively, compared with patients receiving no adjuvant chemotherapy, having adjusted for the other prognostic factors. CONCLUSIONS: The histologic grade and the margin of resection are prognostic for survival in both truncal and retroperitoneal soft-tissue sarcoma. Tumor size was an independent prognostic factor for truncal sarcoma, but not for retroperitoneal sarcoma. Postoperative adjuvant radiation was beneficial to overall survival for truncal sarcoma. In this series of patients receiving a heterogeneous mixture of chemotherapeutic regimens-either as preoperative "neoadjuvant" therapy or as postoperative "adjuvant" therapy, there were no beneficial effects on survival compared with nonrandomized patients not receiving chemotherapy.
Adult↗
Thoracic epidural anesthesia improves outcome after breast surgery.
OBJECTIVE: The authors' objective was to compare the outcomes, including the incidence of nausea and vomiting and the time until discharge to home, of patients undergoing general anesthesia and thoracic epidural anesthesia for oncologic breast procedures. SUMMARY BACKGROUND DATA: General anesthesia is the traditional anesthetic technique used in oncologic breast procedures. In March 1993, the authors initiated the use of high thoracic epidural anesthesia for patients undergoing oncologic breast surgery and reconstructive procedures. METHODS: A retrospective analysis was undertaken of 136 operations performed by one surgeon (T.J.E.) at Brigham and Women's Hospital. A chi square analysis was used to compare the outcomes of patients undergoing general anesthesia and thoracic epidural anesthesia. RESULTS: Compared with general anesthesia, thoracic epidural anesthesia was associated with a statistically significant earlier hospital discharge (p = 0.01). For quadrantectomy/axillary node dissection procedures, 20 of 39 patients (51%) having thoracic epidural anesthesia were discharged on the operative day versus 7 of 32 patients (22%) in the general anesthesia group. Furthermore, 8 of 39 patients (20%) in the thoracic epidural group experienced nausea and/or vomiting during their hospital stay versus 18 of 32 patients (56%) in the general anesthesia group (p = 0.002). CONCLUSION: Thoracic epidural anesthesia is a safe technique not associated with neurologic or respiratory complications. The use of thoracic epidural anesthesia for breast surgery could improve patients recovery and reduce the cost of these procedures.
Adult↗
Adoptive immunotherapy with tumor-infiltrating lymphocytes and interleukin-2 in patients with metastatic malignant melanoma and renal cell carcinoma: a pilot study.
PURPOSE: The objective of this study was to determine the tolerance and effect of moderate-dose recombinant human interleukin-2 (rHu IL-2) and tumor-infiltrating lymphocytes (TIL) in patients with metastatic melanoma (MM) or renal cell carcinoma (RCC) refractory to standard therapy. PATIENTS AND METHODS: Twenty-six patients (18 MM and eight RCC) were entered onto this pilot study. TIL were isolated from fresh biopsy material and activated with anti-CD3 antibody, OKT3, for 48 hours and expanded in 100 IU/mL r-methionyl Hu IL-2 alanine 125 (r-met Hu IL-2 [ala-125]). At least 10(10) TIL were reinfused intravenously in three divided injections on days 2, 4, and 6 of the protocol. A maximum dose of 30,000 U/kg of IL-2 per injection was administered every 8 hours from day 2 through day 11 for a total of 28 doses. RESULTS: Sixteen melanoma patients completed the study. Of these, three (19%) showed a durable complete response (CR), nine (56%) had no response (NR), and four (25%) had progressive disease (PD). One nonresponder demonstrated complete tumor regression within 1 year of treatment. Of four assessable RCC patients, two experienced a minor response (MR) and two showed NR. All TIL cultures showed comparably high cytotoxic activity as determined by antibody-redirected lysis (ARL). More importantly, melanoma TIL from responders possessed significantly higher cytotoxicity against autologous tumor cells than TIL from nonresponders (P < .05). Production of granulocyte-macrophage colony-stimulating factor (GM-CSF), interferon gamma (IFN-gamma), interleukin-6 (IL-6), tumor necrosis factor alpha (TNF-alpha), and IL-4 was similar for TIL from melanoma responders and nonresponders, or TIL from RCC patients. CONCLUSIONS: Immunotherapy with polyclonally activated TIL and moderate-dose IL-2 could be successfully used for the treatment of immunogenic tumors with less toxicity and lower costs as compared with high-dose IL-2 protocols.
Adult↗
Prognosis of patients with advanced melanoma.
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Age Factors↗
Human tumor-infiltrating CD4+ T cells react to B cell lines expressing heat shock protein 70.
Human tumor-infiltrating lymphocytes (TIL) include a minor population of tumor-specific T cells, but the nature of the majority of TIL remains unknown. Recently, it has been suggested that T cells that recognize stressed cells may play an important role in immune surveillance. We have examined the proliferative response of anti-CD3-activated TIL cultures from human tumors against heat-stressed (hs) (42.8 degrees C, 25 min) B cell lines (TK6 (HLA-DR7+, -DRw13+, -DRw52+, and -DRw53+) and JY (HLA-DR4+ and -DRw52+)) and the mutant cell line (T2 (no HLA-DR)) by measuring [3H]thymidine incorporation. TIL lines from three of four ovarian cancers, two of four lung cancers, one of two renal cell cancers, one of two melanomas, and one of one breast cancer showed a positive proliferative response against hs-TK6 and/or hs-JY, but not against hs-T2. These TIL did not respond to autologous tumor cells. The response to hs-B cells was mediated by CD4+ TIL and inhibited by anti-HLA-DR Ab, but not by anti-HLA class I. Protein analysis revealed a significant increase of heat shock protein 70 (hsp70) expression in hs-TK6 and hs-JY. In addition, the CD4+ TIL responded to TK6 that had been pulsed with hsp70. This response could be blocked by anti-HLA-DR Ab. The CD4+ TIL produced IFN-gamma, but not IL-4, in response to hs-TK6. From these results, we conclude that hsp70-reactive CD4+ T cells exist in tumor tissues. Furthermore, these TIL recognize stressed cells and seem to play a Th1-like role that may support antitumor T cell responses at local tumor sites.
Antibodies, Monoclonal↗
The relationship between microscopic margins of resection and the risk of local recurrence in patients with breast cancer treated with breast-conserving surgery and radiation therapy.
BACKGROUND: The relationships among the involvement of tumor at the final margins of resection, the presence of an extensive intraductal component (EIC), and the risk of local recurrence are important considerations in patients treated with conservative surgery and radiation therapy for early stage breast cancer but have not been defined adequately. METHODS: Between 1982 and 1985, 885 patients were treated for clinical Stage I or II invasive breast cancer. The study population was limited to 181 patients with an infiltrating ductal carcinoma who received a radiation dose to the surgical site of 60 Gy or greater, whose final microscopic margins of resection were evaluable, and who had at least 5 years of follow-up. A positive margin was defined as tumor present at the inked margin of resection, a close margin as tumor within 1 mm of the inked margin, and a negative margin as no tumor within 1 mm of the inked margin. A focally positive margin was defined as tumor at the margin in three or fewer low-power fields. In 157 patients (87%), the tumor was evaluable for the presence or absence of an EIC. The median follow-up was 86 months. RESULTS: In 12 of 181 patients (7%), a recurrence developed at or near the primary site (true recurrence/marginal miss [TR/MM]) within 5 years. The 5-year rate of TR/MM (with 95% confidence intervals) among patients with negative, close, focally positive, and more than focally positive margins was 0% (0-4%), 4% (0-20%), 6% (1-17%) and 21% (10-37%), respectively. Patients with positive margins also were more likely to have a distant failure within 5 years (14%, 8%, 25%, and 32% in the four groups, respectively). However, patients with positive margins more often had positive axillary lymph nodes than patients with negative or close margins (59% vs. 38%, P < 0.02). The 5-year rate of TR/MM was 20% for patients with an EIC-positive tumor and 7% for patients with an EIC-negative tumor. However, among the 127 patients with an EIC-negative tumor, the 5-year rate of TR/MM was less than 10% in all margin groups. Among the 30 patients with an EIC-positive tumor, the 5-year rate of TR/MM was 0% when margins were negative or close but 50% when margins were more than focally positive. CONCLUSIONS: These results provide support for the use of breast-conserving surgery and breast irradiation in all patients with uninvolved margins, whether the tumor is EIC-positive or EIC-negative. This study suggests that breast-conserving therapy (including a radiation boost to the primary site) also may be a reasonable option for some patients with an EIC-negative tumor and margin involvement.
Breast↗
Breast reconstruction.
Breast reconstruction after mastectomy is becoming more common despite the general trend toward breast conserving therapy with lumpectomy and radiation. Reconstruction at the time of mastectomy can be done safely and eliminates the disadvantages associated with a second operation under general anesthesia. There are also some psychologic benefits to immediate reconstruction. Autologous reconstruction with flap tissue usually is preferred by the authors. In a woman with small breasts or when autologous tissue is not available, a prosthetic reconstruction is an acceptable choice. The authors prefer the use of textured saline implants in a submuscular position. Nipple and areola reconstruction is performed at least 3 months later as an outpatient procedure under local anesthesia. In 216 consecutive patients with immediate reconstruction, the patients with autologous reconstruction with transverse rectus abdominis or latissimus dorsi flaps ranked their level of symmetry as well as their level of overall satisfaction significantly higher than did the patients with prosthetic reconstruction. Similarly, the surgeons ranked the results from the autologous reconstructions higher. In the patients who underwent autologous reconstruction, 6% had necrosis of a significant portion of the flap. Prosthetic reconstructions were complicated by infections, hematomas, and chest-skin necrosis, resulting in removal of the implant in a total of 8% of the patients in this group. Thirty-four percent of the patients received adjuvant chemotherapy, and the reconstructive surgery did not result in a delay of the onset of this treatment. The authors conclude that breast reconstruction is a safe procedure with an acceptable morbidity when done either as an immediate or a delayed procedure. Patient satisfaction rates are high, particularly with autologous reconstructions.
Adult↗
HER2/neu-derived peptides are shared antigens among human non-small cell lung cancer and ovarian cancer.
Previously, we have reported a correlation between the expression of HER2/neu and sensitivity to HLA-A2-restricted cytotoxic T-cells (CTL) in ovarian cancer. To investigate the role of HER2/neu in human non-small cell lung cancer (NSCLC), we established autologous tumor-specific CTL from tumor-infiltrating lymphocytes of HLA-A2+ HER2/neu+ NSCLC patients. These CTL lines specifically recognized HLA-A2+ HER2/neu+ autologous and allogeneic NSCLC cell lines as well as HLA-A2+ HER2/neu+ heterologous ovarian cancer cell lines. Furthermore, these CTL recognized an overexpressed, HER2/neu-derived peptide. From these results, we conclude that HLA-A2 serves as a restriction element in NSCLC. More importantly, at least one HER2/neu-derived peptide is a tumor-associated antigen in NSCLC and ovarian cancer.
Antigens, Neoplasm↗
TCR V beta 3+ and V beta 6+ CTL recognize tumor-associated antigens related to HER2/neu expression in HLA-A2+ ovarian cancers.
We have recently shown that HLA-A2-restricted, tumor-specific CTL can be isolated from tumor-infiltrating lymphocytes (TIL) in ovarian cancer, and that the sensitivity of ovarian tumors to these CTL is correlated with HER2/neu expression. Furthermore, utilizing PCR, we have documented previously that V beta 2, V beta 3, V beta 6, and V beta 7 are represented in increased proportions in ovarian tumor-specific CTL lines. Therefore, to correlate the interaction of these specific TCR V beta segments with the HLA-A2 molecule and potential tumor-associated Ags (TAA) related to HER2/neu expression, we have utilized available mAbs to V beta 2, V beta 3, and V beta 6. We found that V beta 2+, V beta 3+, and V beta 6+ CTL mediate antitumor activity, and a combination of these mAbs resulted in 83 to 95% inhibition of the cytotoxicity against autologous tumor from three separate patients. These mAbs also were capable of blocking HLA-A2-matched allogeneic cytotoxicity, suggesting that all three V beta families recognize TAA in the context of HLA-A2. An HLA-A2+ melanoma was transfected with the HER2/neu gene and became sensitive to HLA-A2+ ovarian cancer-specific CTL lysis. This cytotoxicity was mediated by V beta 3+ and V beta 6+ CTL, as demonstrated by mAb-blocking studies. FACS-depletion studies confirmed that CTL populations depleted of V beta 3 or V beta 6 no longer could recognize the HER2/neu transfectant. We conclude that V beta 3 and V beta 6 recognize some TAA that are either derived from the HER2/neu protein or induced by the expression of the HER2/neu gene and presented in the context of HLA-A2. Furthermore, V beta 2 seems to recognize an HER2/neu-unrelated Ag system also presented by HLA-A2.
Antigens, Neoplasm↗
T lymphocytes synthesize and export heparin-binding epidermal growth factor-like growth factor and basic fibroblast growth factor, mitogens for vascular cells and fibroblasts: differential production and release by CD4+ and CD8+ T cells.
T lymphocytes infiltrate wounds, tumors, and atherosclerotic plaques, pathophysiological processes characterized by the migration and proliferation of vascular cells and fibroblasts. Although T lymphocytes are known to produce cytokines for inflammatory cells, it has not been demonstrated that they synthesize growth factors that are mitogenic for vascular cells and fibroblasts. We demonstrate that cultured T lymphocytes isolated from normal human peripheral blood synthesize and export two well-characterized growth factors, heparin-binding epidermal growth factor-like growth factor (HB-EGF) and basic fibroblast growth factor (bFGF). This conclusion is based on mRNA expression analysis, heparin-affinity chromatography profiles, target-cell specificity, and functional inhibition by specific neutralizing antibodies. Atypically, a substantial amount of T-cell-derived bFGF-like activity appears to be constitutively released into conditioned medium, almost as much as is associated with T-cell lysates. bFGF is synthesized and exported by purified CD4+ and CD8+ T cells, whereas HB-EGF is synthesized and exported primarily by CD4+ T cells. The T-cell-derived HB-EGF and bFGF activities are potent mitogens for fibroblasts and smooth muscle cells, and the bFGF-like activity is also mitogenic for endothelial cells. These results suggest that T lymphocytes may play key roles in mediating smooth muscle hyperplasia associated with atherosclerosis and in angiogenesis associated with wound healing and tumor growth by acting locally to deliver vascular-cell growth factors to tissues.
CD4-Positive T-Lymphocytes↗
Association of HER2/neu expression with sensitivity to tumor-specific CTL in human ovarian cancer.
To study potential sources of tumor-associated Ags in human ovarian cancer, we have established two ovarian tumor cell lines (OvS1 and OvA2) from two ovarian cancer patients, which express the cellular oncogene HER2/neu. Corresponding tumor infiltrating lymphocyte cultures have also been established and display an autologous tumor-specific pattern of cytotoxicity that is HLA-A2 restricted. To determine the potential relationship between HER2/neu expression and CTL-mediated cytolysis, we first established tumor cell clones from OvS1. These were categorized as high or low expressors of HER2/neu (cOvS1+ or cOvS1-, respectively), and cOvS1+ clones displayed a significantly higher sensitivity to CTL killing as compared with cOvS1- clones. To modulate the expression of HER2/neu, ovarian cancer cells were treated with IFN-gamma. After this exposure, HER2/neu expression was significantly decreased, whereas the expression of HLA Class I was significantly increased. Despite the increase in HLA Class I molecules on the cell surface, CTL-mediated cytolysis of both OvS1 and OvA2 was significantly decreased. IFN-gamma treated cOvS1+ clones displayed a similar decrease in sensitivity to CTL killing, whereas IFN-gamma treated cOvS1- clones displayed an increase or no change in sensitivity to CTL. To confirm this apparent association between HER2/neu expression and CTL recognition, melanoma tumor cell lines that were insensitive to ovarian tumor-specific CTL were transfected with the HER2/neu gene. An HLA-A2+ HER2/neu-transfected melanoma cell line was made sensitive to HLA-A2 restricted ovarian tumor-specific CTL but not to HLA-A2 unrestricted CTL, whereas an HLA-A2- HER2/neu-transfected melanoma remained insensitive to HLA-A2 restricted CTL. These results demonstrate that the sensitivity of ovarian epithelial tumor cells to CTL-mediated lysis is associated with the level of expression of HER2/neu, suggesting that this oncogene product may serve as a source of tumor-associated Ags or as an inducer of such peptides. This is the first time in a human tumor system that oncogene expression has been related to the induction of antigenicity. These results prompt us to approach new strategies for immunotherapy of cancer.
Antibodies, Monoclonal↗
Classification of CD4+ T helper cell clones in human melanoma.
We have previously described the generation of tumor-infiltrating lymphocyte (TIL) clones from renal cell cancer by solid-phase anti-CD3 antibody activation and expansion in 100 IU/ml IL-2 plus irradiated allogeneic B cells. These culture conditions did not select for a particular T cell subset. Using these culture conditions, we report here the generation of 66 CD4+ and 36 CD8+ TIL clones from five patients with melanoma. Eighty-five percent of the CD4+ TIL clones were not cytolytic (< 30% lysis, E:T 20:1) as determined by antibody-redirected lysis (ARL), whereas all CD8+ clones showed strong ARL activity (> 30% lysis). Clones were further tested for production of IL-2, IL-4, and IFN-gamma after activation for 48 hr by solid-phase anti-CD3. CD8+ clones produced significant amounts of IFN-gamma, little IL-2, and no IL-4. CD4+ clones were classified as Th0, Th1, or Th2, analogous to the classification of T helper cells in the mouse. Sixty-six percent existed as Th0, producing IL-2, IL-4, and IFN-gamma. Only 15% existed as Th1, producing IL-2 and IFN-gamma, and 19% as Th2, producing IL-4 but no IL-2 or IFN-gamma. In all cases, unstimulated clones or clones stimulated with the allogeneic B cell line did not produce detectable amounts of cytokines. Solid-phase anti-CD3 activation was compared to activation with autologous melanoma cells. Five of nine CD8+ clones produced low amounts of IL-2 (< 200 pg/ml/10(6) cells) in response to autologous tumor, but none of the CD8 clones produced IFN-gamma or IL-4. Also, 5/7 Th0 clones from one patient produced similar amounts of IL-2 after stimulation with anti-CD3 or autologous tumor. The other two clones produced only 10% or less of the amount produced in response to anti-CD3. No IL-4 or IFN-gamma could be detected in response to autologous tumor. In contrast, none of the 12 T helper clones from two other patients produced any cytokines after stimulation with autologous tumor cells. Together these data suggest that the T cell infiltrate in melanoma consists primarily of IL-2-producing Th0 cells, but few of those are triggered by autologous tumor cells.
CD4-Positive T-Lymphocytes↗
Reactivation of murine tumour-infiltrating lymphocytes with solid-phase anti-CD3 antibody: in vitro cytokine production is associated with in vivo efficacy.
Previously we described the use of solid-phase anti-CD3 monoclonal antibody (mAb) to stimulate murine tumour-infiltrating lymphocytes (TIL) and their subsequent expansion in recombinant interleukin 2 (rIL-2). In a pulmonary metastases model using the methylcholanthrene-induced sarcoma MCA-105 anti-CD3 activated TIL were capable of eradicating disease similar to TIL cultured in rIL-2 only. Here we extend these observations by characterizing the biological effects of sequential solid-phase anti-CD3 activation. TIL from MCA-105 tumour activated with solid-phase anti-CD3 on day 1 were reactivated on day 14, or day 26, or both and compared to TIL grown in rIL-2 only or TIL activated with anti-CD3 once on day 1. Reactivation enhanced in vitro proliferation 1.8- to 4-fold compared to TIL activated once with anti-CD3 (P < 0.05). In addition, the total lytic capacity of the cultures was enhanced after reactivation without changing the phenotype of the TIL cultures. Reactivation resulted in a greater in vivo efficacy when the TIL were administered within 72 h of reactivation. In contrast, TIL activated with anti-CD3 on day 1 and day 14 were least effective of all TIL cultures (P < 0.05). This correlated with in vitro cytokine production. The most effective TIL cultures in vivo produced 4- to 100-fold higher amounts of cytokines, especially interferon gamma (IFN gamma) and granulocyte macrophage colony stimulating factor (GM-CSF), than the other cultures. On the other hand, the least effective in vivo TIL culture, TIL activated with anti-CD3 on day 1 and 14, produced little or no cytokines. These data suggest that in vitro production of cytokines is indicative of in vivo efficacy of anti-CD3 activated TIL.
Animals↗
Postmastectomy complications in breast reconstruction.
In a group of patients where breast reconstruction was performed at the time of mastectomy, the incidence of complications was studied. One hundred one consecutive patients had an autologous reconstruction using the transverse rectus abdominis musculocutaneous flap, and 115 consecutive patients had a prosthetic reconstruction with tissue expanders or with tissue expander and/or implant. One patient in the autologous reconstruction group had a cardiac arrhythmia requiring monitoring, but there were no other serious complications. Infection was more common in the group undergoing prosthetic reconstruction (5% compared with 3% in the autologous reconstruction group). A total of 8% of the patients in the group undergoing prosthetic reconstruction had to have their implants removed because of infection or exposure of the implant. Seven percent of the transverse rectus abdominis musculocutaneous flap patients had significant necrosis of a portion of the flap. Secondary surgical revision of the reconstructed breast was much more common (20%) in the prosthetic reconstruction group compared with 6% in the autologous reconstruction group.
Adult↗
Prognostic factors predictive of survival and local recurrence for extremity soft tissue sarcoma.
OBJECTIVE: The authors sought to identify prognostic factors in the management of extremity soft tissue sarcoma. SUMMARY BACKGROUND DATA: The surgical management of soft tissue sarcoma has evolved because of advances in therapy, resulting in increased limb preservation and quality of life. However, identifying a subset of patients most likely to benefit from adjuvant chemotherapy has been difficult to achieve. METHODS: A retrospective analysis of a prospective data base of 182 patients with extremity sarcomas from 1970 to 1992 was performed. RESULTS: A histologic diagnosis of Ewing's sarcoma, synovial sarcoma, and angiosarcoma was associated with a 13-fold increased risk of death compared with liposarcoma, fibrosarcoma, and malignant peripheral nerve sheath histologic types after having adjusted for the other prognostic factors (p < 0.001). In addition to histologic type, high-grade sarcomas (p = 0.018), sarcomas greater than 10 cm in size (p = 0.006), and age at diagnosis (p = 0.016) were found to be important prognostic factors for survival but not for local recurrence. For the first time to their knowledge, the authors showed that mean mitotic activity has prognostic value after having adjusted for other prognostic factors, such as grade (p = 0.005). The only prognostic factors predictive for local recurrence were whether the patient presented with locally recurrent disease (p = 0.0001) or had microscopically positive margins (p = 0.052). CONCLUSIONS: The use of mitotic activity along with grade, size, histologic type, and age at diagnosis is prognostic for survival in extremity soft tissue sarcoma. The use of an objective pathologic feature, such as mean mitotic activity, is also useful in selecting patients for future systemic neoadjuvant or adjuvant trials and primary therapy.
Adolescent↗
Accelerated surgical stay programs. A mechanism to reduce health care costs.
OBJECTIVE: To increase cost-efficiency while maintaining the standard of medical care, an accelerated surgical stay program for patients having breast surgery was instituted. SUMMARY BACKGROUND DATA: In the past 20 years, annual health care costs have soared and now comprise 12.2% of the United States gross national product. The annual inflation rate of almost 11% has prompted third-party payers to scrutinize hospital costs as hospitals now consume 38% of health care costs. METHODS: A multidisciplinary task force was formed to analyze and reduce lengths of stay for breast surgeries and to standardize clinical protocols to address ensuing issues. RESULTS: After 1 year, this prospective study found a 39% decrease in average length of stay and a 22% increase in patient volume. This was also accompanied by a low incidence of surgical complications. Through information obtained from 373 consecutive patients through telephone surveys and questionnaires, the Center for Cost-Effective Care reported high patient acceptance and satisfaction. CONCLUSIONS: As a management strategy, accelerated surgical stay programs increase operating efficiency and reduce medical care costs without compromising quality of patient care. Success of this program was attributed to support from senior management, expansion of available educational resources for patients, and to a carefully planned transition from the program's developmental to its operational phase.
Breast Neoplasms↗
Current management of carcinoma of the breast.
OBJECTIVE: An in-depth retrospective review of the multidisciplinary approach to the management of carcinoma of the breast was done. The author reviewed previous trials and treatment from the past to the present. The indications and contraindications of surgical procedures, radiation therapy, systemic chemotherapy, and hormonal therapy are discussed. SUMMARY BACKGROUND DATA: Carcinoma of the breast is one of the most common malignancies treated by the practicing general or oncologic surgeon. The disease is best treated using a multidisciplinary approach, combining the efforts of surgery, radiation therapy, and systemic treatments. Understanding the indications and contraindications for each of these modalities will provide the practicing surgeon the most up-to-date algorithms for the management of his/her patient. CONCLUSIONS: The author provides a comprehensive analysis of the multidisciplinary approach to the management of carcinoma of the breast. It emphasizes the results of previous trials and discusses future controversies and areas for study.
Breast Neoplasms↗