New Study Reports Improved Patient Outcomes for Breast Cancer Patients

  • Author: Health Informer
  • Filed under: Health News
  • Date: Feb 19,2009

A new clinical study published this month in The Breast Journal (Vol. 15, No. 1) reports that high-quality patient outcomes for breast-conserving surgery can be achieved in the community hospital setting. This is one of the few and the most recent studies of its kind and is particularly relevant given that nearly two-thirds of all breast cancer patients in the United States are treated at community centers.

The study tracked 185 cases from 1997-2003 at Henry Mayo Newhall Memorial Hospital, located in the Southern California suburb of Valencia. The patients underwent a lumpectomy typically with a 5mm margin, as opposed to the 1-2mm margin performed in surgeries at most institutions. The study includes five-year follow-up data that shows a local recurrence rate of 2 percent as compared to the national norm of 4-9 percent.

“This study basically suggests a resetting of the bar on how to do lumpectomies and what patients can expect if it is done this way,” said Henry Mayo’s Breast Center Medical Director Gregory Senofsky, M.D. “Our findings are hard to ignore.”

According to Barbara Florentine, M.D., medical director of the department of pathology at Henry Mayo and lead author of the study, the first objective of the study was to evaluate the factors known to influence outcomes. “These include tumor and patient characteristics, completeness of local surgical tumor excision, and adjuvant radiation therapy and/or chemotherapy/hormonal treatment,” she says. “The second objective was to evaluate the percentage of cases in which the initial breast-conserving surgery did not achieve adequate surgical oncological results (5mm margins) and the number and type of subsequent surgeries that were required to achieve this goal.”

Of the 185 cases tracked in this study, 87 percent had successful breast-conserving surgery. A single surgery was deemed sufficient to achieve the desired outcome in 54 percent of the cases while 46 percent required additional surgeries because of the 5mm requirement. Survival rates for patients undergoing this treatment at Henry Mayo compared favorably with data presented by the National Council Database reporting on outcomes at teaching/research hospitals. Disease free survival for early stage cancer was 91 percent at five years.

The flap-advancement reconstruction surgery performed by Dr. Senofsky requires a team that includes a specially trained surgeon and radiologist plus the presence of a pathologist in the operating room to provide real-time information. “The procedure requires extra work and extra training in how radiologists insert the wires and how surgeons approach their craft relative to performing larger targeted lumpectomies with excellent cosmetic results, but it is what patients should come to expect based on our study,” he said.

“It is difficult to successfully obtain adequate excision of the cancer while still maintaining a beautiful breast with no distortions–and that’s very important to a woman,” stated Dr. Florentine. “Dr. Senofsky is able to achieve both through the use of oncoplastic techniques.”

While Henry Mayo has no comprehensive breast center building, the hospital does provide equivalent services thanks to a well-integrated medical campus and a multi-modality breast team that meets regularly to discuss care plans tailored to the uniqueness of each patient, including age, health status, risk factors, and the patient’s own desires and needs. The hospital owns and operates the pathology, breast imaging, and inpatient and outpatient surgical operating suites while on-campus radiation, medical oncology and breast surgery services are provided by independent physician groups.

The study was conducted by a nine-person investigative team, six of whom are affiliated with Henry Mayo. Leading the study were Drs. Senofsky and Barbara Florentine. In addition to his role at Henry Mayo, Dr. Senofsky is a clinical faculty member at UCLA’s surgical oncology department and the author of The Patient’s Guide to Outstanding Breast Cancer Care. Dr. Florentine is medical director of the department of pathology and is affiliated with the department of pathology at the Keck School of Medicine at the University of Southern California. Additional Henry Mayo participants include physicians John Barstis, M.D.; Alexander Black, M.D.; and Robert Zimmerman, M.D., along with Brian Cooper, tumor registrar officer.

Source: Henry Mayo Newhall Memorial Hospital


A University of Ottawa Heart Institute (UOHI) research team has unlocked the mechanism that turns on a weight-loss gene in muscle. A new UOHI study shows that the mechanism – a DNA sequence variant identified as rs2419621 – increases the activity levels of ACSL5, among the first genes associated with weight loss, and enables rapid weight loss in people who are dieting.

Heart Institute scientists working with The Ottawa Hospital Weight Management Clinic had previously identified the ACSL5 gene, which influences how quickly overweight people lose weight in response to diet. Unlocking the mechanism to activate this gene represents a major step forward in developing new treatments for chronic illnesses such as cardiovascular diseases and diabetes, which are increased as a consequence of obesity. Diet and exercise are both important in weight loss. But individual response to diet and exercise vary dramatically – something that has long perplexed medical professionals.

“Weight loss, especially among people who are dieting, is affected by several factors and we’ve long suspected that personal genetic makeup is a real influence. We are learning that genes which make you fat are not the same as the genes that help you lose weight. And now we can put our finger on just how the weight-loss gene is activated,” said Alexandre Stewart, PhD, principal investigator of the Ruddy Canadian Cardiovascular Genetics Research Centre, UOHI.

The UOHI research is expected to lead to the development of therapies to fuel ACLS5 activity in people. Further, medical professionals will be able to identify people who won’t respond to diet and target drug treatment to help them lose weight more quickly.

Details of the latest UOHI discovery were published online in the Journal of the Federation of American Societies for Experimental Biology (http://www.fasebj.org/cgi/content/abstract/fj.08-120998v) The research was undertaken by molecular biologists at UOHI’s Ruddy Canadian Cardiovascular Genetics Centre, led by Alexandre Stewart, PhD, and Frederique Tesson, PhD.

UOHI scientists found that the people who carry the ACSL5 DNA variant are able to lose weight faster when following a low calorie diet than those who do not. About 33% Caucasians carry this genetic variant, as do 50% of Blacks, and 29% of Orientals.

Obesity and weight-related illness have been the focus of major scientific projects at UOHI and is part of a global drive to fight obesity. One UOHI research team led by Dr. Ruth McPherson has been investigating the genetics behind obesity – considered a serious risk factor for coronary artery disease. They are searching for patterns among obese people to help explain why one obese person suffers from heart disease or diabetes when an equally heavy person does not.

“We know that controlling obesity is hugely important in managing serious chronic disease such as heart disease and diabetes. But clearly we also know the problem is much more complex than just teaching people how to eat better and get more exercise. We need to understand the genetics and biology of obesity in order to individualize treatment,” said Dr. McPherson, Director of the Lipid Clinic, UOHI.

Source: Ottawa Heart Institute, University of Ottawa


The twins were conjoined from the breast bone to the groin

A multidisciplinary team of surgeons, pediatricians and nurses at Children’s Hospital of Pittsburgh of UPMC has successfully separated conjoined twins during a 24-hour procedure.

The 2-year-old twin girls — Dagian and Danielle Lee, of Cleveland — were separated during a procedure that began at 6:30 a.m. Saturday, Dec. 13, 2008, and ended 24 hours later. The girls currently are recovering well at Children’s Hospital.

The team that separated Dagian and Danielle was led by Joseph E. Losee, MD, FACS, FAAP, chief of the Division of Pediatric Plastic Surgery at Children’s Hospital. He orchestrated more than 50 physicians and nurses who were either involved with the Lees’ preoperative care or in the surgery itself. The surgical team consisted of specialists from Pediatric Anesthesiology, General and Thoracic Surgery, Orthopaedics, Plastic Surgery and Urology. Specialists from Cardiology, Critical Care Medicine, Nursing, the Paul C. Gaffney Diagnostic Referral Service and Pulmonology have also been involved in the twins’ pre- and post-operative care.

The girls were conjoined from the breast bone to the groin. Among the many challenges facing the team was the fact that the twins shared a colon and had livers that were connected. They also shared a third leg.

“This complex separation was the culmination of 18 months of preparation and planning. The surgery itself went extremely well and we’re very optimistic that Dagian and Danielle will continue their strong recovery,” Dr. Losee said. “It’s important to emphasize how remarkable it was to have more than 50 people working together in such a smooth and orchestrated fashion to ensure the best possible outcome for these two beautiful little girls. They still face future risks and surgeries, but we look forward to watching them live long, happy lives.”

The twins spent the majority of their first two years of life as patients at Children’s Hospital, undergoing more than 10 procedures during the 18-month period of preparation. The procedures included the placement of tissue expanders, which were used to stretch the skin to allow for reconstruction following the separation. They likely will require further reconstructive procedures in the future, according to Dr. Losee.

“It was such a difficult decision to make, and I knew the separation involved a very complicated surgery. I was scared, but I wanted the girls to be separated so they could give them the best life possible. When I met the team at Children’s Hospital in Pittsburgh, I knew this is where we should come even though it is so far from my family and friends in Cleveland,” said the girls’ mother, Catherine Nickson. “The entire team has been amazing, and I can’t thank them enough for all they’ve done for my girls.”

Dagian and Danielle were ischiopagus twins, meaning they were joined at the pelvis and shared a colon. Conjoined twins are rare and occur in about one in every 100,000 births.

The team leaders from the various specialties involved in their separation are:

Timothy Kane, MD, FACS, FAAP — Division of Pediatric General and Thoracic Surgery

Francis Schneck, MD — Division of Pediatric Urology
Stephen Mendelson, MD — Division of Orthopaedic Surgery
Franklyn Cladis, MD — Division of Pediatric Anesthesiology
Sheila Willis, RN — Perioperative Nursing

Megan Natali, PA-C — Physician assistant in the Division of Pediatric Plastic Surgery

Patricia Dubin, MD — Division of Pulmonary Medicine, Allergy and Immunology

For more information about Dr. Losee or the team, please visit www.chp.edu.


Association’s Mission: Lifeline initiative to use survey data to make improvements

Preliminary results of one of the nation’s largest national surveys of Emergency Medical Services (EMS) systems indicate the need for improvements in the way heart attack, specifically ST-elevation myocardial infarction (STEMI), is managed.

STEMI is the most serious and deadly type of heart attack, characterized by a complete blockage of a coronary artery. It requires rapid response and treatment to reopen the artery and restore blood flow to the heart muscle. The preferred treatment is primary percutaneous coronary intervention (PCI), which involves mechanically opening the artery using a small balloon to clear the blockage followed by the insertion of a stent, a type of scaffolding used to prop open the artery.

The American Heart Association conducted the survey as part of its Mission: Lifeline initiative to improve the response and treatment of STEMI patients and ultimately all heart attack patients. The association gave the survey October – December 2008 to more than 5,400 EMS system or agency directors and asked questions about staffing, funding, training, and existing processes for handling patients who have experienced a STEMI.

The most significant findings:

  • Only half of EMS systems have 12-lead electrocardiograms (ECGs), used to detect STEMI, on 75 percent or more of their vehicles.
  • Of EMS systems with 12-lead ECGs: Most lacked a standard method for EMS to communicate the 12-Lead ECG results to the hospital. Currently, paramedics use one or more of the following methods:

- verbally reporting the ECG algorithm (an automatic, software-generated analysis of the ECG reading),
- verbally reporting their own interpretation of the ECG reading, or
- using an advanced technology like Blue Tooth or mobile phone to transmit the ECG algorithm or reading.

  • EMS field personnel remotely activate hospital catheterization (“cath”) labs only 40 percent of the time. (Cath labs perform procedures like angioplasty and stenting). This can significantly delay evaluation and treatment.
  • Destination protocols are only used a third of the time to enable EMS to take STEMI patients directly to a hospital capable of providing angioplasty/stenting 24 hours a day, seven days a week. Instead,  any EMS departments take patients to the closest hospital, which can cause significant delays to appropriate care.
  • Only about 20 percent of hospitals are able to perform procedures like angioplasty and stenting for STEMI patients 24 hours a day, seven days a week.

“We were encouraged that more EMS systems than anticipated had vehicles equipped with 12 lead ECGs, devices that diagnose STEMI and other heart attacks,” said Robert E. O’Connor, M.D., chair of the American Heart Association’s Mission: Lifeline Emergency Cardiovascular Care task force. “However, we found the need for better systems to allow EMS to transmit data from ECGs and activate the cath lab on the way to the hospital and for policies allowing them to take patients to the facility able to provide appropriate care, whether it’s the closest facility or not.”

According to the American College of Cardiology/American Heart Association guidelines, primary PCI, typically balloon angioplasty with stenting, is the preferred treatment over clot busting drugs if it can be achieved within 90 minutes. EMS is a critical part of the system of care to decrease time to treatment for STEMI patients.

In coming months, the association’s staff will receive survey data for their state or region and share it with coalitions composed of EMS and hospital personnel, physicians and nurses and health policy makers. The coalitions will use the information to create appropriate plans to improve the care of STEMI patients.

“EMS systems are the point of entry for all heart attack patients and are extremely important to reducing delays to STEMI care,” said Alice K. Jacobs, M.D., former president of the American Heart Association and chair of the Mission: Lifeline advisory working group. “Our survey provides the American Heart Association and its coalition partners a great snapshot of their local EMS and where we need to make progress. It confirms the need for better coordination between EMS, emergency departments and hospitals in order to do what’s best for the patient.”

Other findings include:

  • More paramedics should receive training on interpreting 12 lead ECGs.
  • Funding is needed for additional 12 lead ECG devices and training.
  • Information sharing between EMS and hospitals is poor, so it’s difficult to track the quality of care a patient receives as they move from EMS to hospital-based care. Confidentiality requirements are hindering the process.

The need for Mission: Lifeline

Each year, about 400,000 people in the U.S. have a type of heart attack known as STEMI, in which blood flow is completely blocked to a portion of the heart. Unless the blockage is eliminated quickly, the patient’s health and life are at serious risk. The American Heart Association recommends that STEMI patients receive PCI procedures like angioplasty to restore blood flow to the heart muscle within 90 minutes. The association created Mission: Lifeline to close the gaps that separate STEMI patients from timely access to appropriate treatment.

For more information about Mission: Lifeline, visit www.americanheart.org/missionlifeline.


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