UK Interdisciplinary Breast Cancer Symposium



N1Clinical Research –Available to all women diagnosed with Breast Cancer?Zoe V HiltonUniversity Hospital of Llandough, Cardiff, United KingdomThe Strategic plan for Health and Care Research Wales 2015-2020 aims to increase the number of patients recruited to portfolio studies by 10% and the number of commercially sponsored studies by 5%. As a result more patients will have access to new innovative treatments and potentially more frequent check-ups and medical monitoAim/Purpose: By increasing collaboration across South Wales, more patients with breast cancer can have access to clinical studies. This project intends to promote The Breast Centre as research active therefore attracting investment from pharmaceutical, biotechnology and industry.Method: Recent Collaboration with Velindre Cancer Centre and Public Health Wales has enabled research to become available to a whole new cohort of patients. The Research Team Lead now chairs the Breast MDT meeting ensuring clinical research remains central to care planning and the forefront of clinical decision making.Results/Outcome: As a result, 100% of patients in the Breast MDT are screened for eligibility into clinical trials. In 2018-19 recruitment exceeded our target, with a total of 6251 patients in Cardiff and Vale UHB enrolled in research beating the target of 5636.?Conclusion: Cardiff patients have reported a ‘sense of security’ when recruited to trials along with the sense of satisfaction that they have ‘given something back’. By working with other health care settings and overcoming historical difficulties of collaboration, a larger number of patients with breast cancer can access life changing clinical research. This in turn, will increase the capacity for inclusion whist developing a robust, productive network for future projects and recruitment.?N2Implementing new NICE approvals for CDK4/6 inhibitors: Resource implications and potential solutionsJoni R Howells, Julie Douglas, Badrriyya Mohamedali, Caroline D Archer, Chris CoyleQueen Alexandra hospital, Portsmouth, United KingdomAims/objectives: CDK4/6 inhibitors are a major step-forward in the management of hormone receptor positive HER2 negative locally advanced or metastatic breast cancer. In December 2017 NICE approved the use of ribociclib or palbociclib in combination with an aromatase inhibitor in the first-line setting. Patients are seen in clinic bi-weekly for the first six weeks, then monthly. We aim to investigate the demand on physician clinic time and explore potential solutions.?Methods: We reviewed the number of patients on first-line CDK4/6-inhibitors between January 2018 and September 2019 in Portsmouth Hospitals NHS Trust. Patients were excluded if they were taking CDK4/6-inhibitors in a clinical trial or compassionate use programme. We recorded the number of related clinic appointments, health professional seen, and the associated overall clinic costs for patients receiving CDK4/6-inhibitors and compared projected estimates if the same patients had received standard endocrine therapy alone, and cost estimates for alternative approaches including telephone clinics and non-physician prescribers.?Results: Since January 2018, 58 patients received either ribociclib or palbocilib in combination with an aromatase inhibitor in the first-line setting, and required 618 clinic appointments with a consultant oncologist or registrar. Estimates for standard endocrine therapy alone during the same time frame was 208 clinic appointments. Projected costs for clinic appointments for standard endocrine therapy alone is ?19,950 compared to ?50,700 for patients on CDK4/6-inhibitors. Cost estimates will be presented on alternative approaches.?Conclusion: Our results show a significant increase in the demands on physician clinic time (three-fold rise) compared to standard endocrine therapy alone (acknowledging a minority may have received chemotherapy first-line or had resource savings by delaying subsequent therapies). Our data supports the need for more non-physician prescribers, telephone/telemedicine follow-up and community support programmes, particularly in light of more recent NICE approvals for CDK4/6-inhibitor abemaciclib in the first-line setting and ribociclib with fulvestrant in the second-line setting.PC1Epirubicin chemotherapy in women with breast cancer: alternating arms for intravenous administration to reduce chemical phlebitisRosie Roberts1, Annabel Borley1, Louise Hanna1, Gina Dolan2, Mark Williams21Velindre Cancer Centre, Cardiff, United Kingdom. 2University of South Wales, Cardiff, United KingdomIntroduction:?Anthracycline chemotherapy including epirubicin is a key component of breast cancer chemotherapy regimens and is known to have the potential to cause phlebitis and venous sclerosis when administered via a peripheral cannula. It has been widely accepted practice following breast surgery to avoid using the ipsilateral arm for intravenous treatments. Following a review of the evidence a decision was made at Velindre Cancer Centre to recommend using alternate arms for chemotherapy administration in patients who had not undergone an axillary node clearance. It was anticipated that this would reduce the incidence of anthracycline -induced chemical phlebitis.?Aims: To establish whether using alternating arms for peripheral intravenous epirubicin administration affects the severity or duration of epirubicin-induced phlebitis.?Methods; A prospective observational study of females with breast cancer (n= 237) in a single Cancer Centre. After 3 treatment cycles data were analysed according to the arm used for epirubicin administration: same, alternating, or mixed arm (2 consecutive cycles in one arm, one in the alternate arm). Phlebitis severity was graded by staff after each treatment, participants also self-reported symptoms during treatment and for up to 6 months after.?Results: The alternating arms group experienced significantly less severe symptoms than the other arm use groups, 6% (4 of 64) compared to 34% (p <0.001, odds ratio: 0.13 (95% CI: 0.043- 0.38) alternating arm compared to same arm group). The alternating arm group reported less pain (p=0.013), lower overall impact (p= 0.009) lower effect on function (p= 0.032) and shorter duration of symptoms (p=0.001) than the other arm use groups.?Conclusion: Using alternating arms for peripheral administration of epirubicin significantly reduces the severity and duration of chemical phlebitis, is recommended to improve patient experience and to enable prudent use of resources by reducing the need for central venous access devices.?PC2What treatment do patients want? Informing shared decision making in treatment of metastatic breast cancerAlistair Bullen1, Holly Ennis1, Lauren Murdoch1, Ewan Gray1, Emily Ross1, Olga Oikonomidou1,2, Morag McIntyre2, Nicolas Krucien3, Mandy Ryan3, Peter Hall1,21University of Edinburgh, Edinburgh, United Kingdom. 2NHS Lothian, Edinburgh, United Kingdom. 3University of Aberdeen, Aberdeen, United KingdomIntroduction:?Shared decision making requires patients with metastatic breast cancer and their care teams to make complicated choices between diverse and unfamiliar treatments. Patient input is vital to ensure productive discussion, but it is required at a time when the patient is emotionally vulnerable. Qualitative research provides the understanding of patient preferences which can help care-teams guide patients through difficult decisions. Aim: To use a range of qualitative sources to identify the most relevant goals of treatment and relative importance of outcomes for metastatic breast cancer patients. Methods:? Three study designs were employed in parallel work packages (WP): ?(1) a systematic review of the qualitative literature in the area of metastatic cancer, (2) a thematic analyses of 9 metastatic breast cancer patient interviews and, (3) secondary data from the Scottish Medicines Consortium. Results:?We found strong evidence across all WPs that extending overall survival was a dominant goal of treatment. This preference only diminishes in special cases where there are either exceptional levels of pain, debilitating symptoms and side effects, or the condition is putting the patient and their family under severe financial strain. Secondly, specific symptoms and side effects, such as nausea, fatigue and diarrhoea, became concerning for patients when they began to interfere with the patient’s daily living, for example when they limited the patient’s ability to leave the house or complete basic tasks. Finally, the patient’s concept of making the most of their final days did not involve grand new experiences but rather to continue living their life as they had before their incurable diagnosis. Conclusion: A broad portfolio of qualitative evidence can provide diverse perspectives and tell us why a treatment outcome such as overall survival is important, but quantitative evidence is required to understand relative importance to other treatment outcomes such as specific toxicities.PC3Evaluating Effectiveness of a Breast Cancer Survivorship Program: Quality Improvement Pilot StudyRachel Rolph1, Lyn Phippen1, Abi Bowden2, Dibendu Betal11Western Sussex Breast Care Centre, Worthing Hospital, Western Sussex Hospitals NHS Foundation Trust, Worthing, United Kingdom. 2Breast Cancer Care, London, United KingdomBackground: Breast Cancer Care is the only UK-Wide charity providing specialist information and support for people affected by breast cancer supporting them in their day-to-day life management and emotional upheaval of breast cancer and healthcare professionals who care for them. Moving Forward Course helps people to adjust to life after hospital-based treatment. It is provided in partnership with NHS trusts and health boards across the UK. Information and support encouraging self-management of ongoing physical and emotional issues is provided in four sessions over four weeks sharing their experiences with peers in a safe and caring environment.?Methods: All women who attended the Breast Cancer Care's Moving Forward Course at a District General Hospital between 2015-2018 were contacted by telephone with regards to evaluating the effectiveness of the impact of the course. Face-validated questionnaires were to those wishing to take part that focused on four aspects of cancer survivorship – physical, social, psychological and spiritual well-being. Quantitative data was analysed using a 5-point Likert Scale and qualitative data through free text at the end of the questionnaire.?Results: Thirty-seven questionnaires were returned for analysis. Physical Well-being – the majority of women have kept physically active (95%), returned back to full activity (79%) and following a balance diet (86%). Most women are not in pain (67%), able to sleep (56%) but report fatigue (70%). Social Well-being – The majority of women were confident in their appearance (67%), have a good support network (86%), able to speak to friends and family (81%), do not feel isolated (67%) and have confidence in their intimate relationship (51%). Psychological Well-being - Most patients had a good understanding of the side effects of treatment (86%), confident keeping breast aware (86%), aware of the signs and symptoms of recurrence (54%). Most are worried about cancer recurrence (97%), anxious of the future (65%). There was good knowledge of available support (94%) and felt support was readily accessible (89%). Spiritual Well-being – the respondents did not feel more religious/spiritual (43%). Most understood the meaning of their diagnosis (75%) but felt uncertainty (57%). Some had gained inner strength (51%), and most were hopeful of the future (73%) and their perspective of life had changed (75%). The main themes highlighted from the qualitative data was the establishment of an important support network course with fellow attendees. Some felt the course would have been useful when they were first diagnosed, others felt it would have been too much information at the time of diagnosis. Some felt the course could be adapted to account age differences, those that were working and have a program for partners. Others felt it would be useful to have a rolling program they could access as required.?Conclusion: This pilot study has shown that a breast cancer survivorship program is effective for physical, social, psychological and spiritual well-being even months after the course. This forms the foundations for a larger focus group study to help implement and continually improve a program that breast cancer survivors feel is effective and will be long-lasting.PC4Independent Cancer Patients' Voice, continuing to speak clearly and be heardAdrienne Morgan, Julie Croft, Helen Edwards, Pat Fairbrother, Chris Finch, Jacqui Gath, Margaret Grayson, Sue Henry, Debbie Keatley, Mairead MacKenzie, Sam McDonnell, Carolyn Morris, Liz O’Riordan, Esme Radin, Jan Rose, Lesley Stephen, Hilary Stobart, Lesley Turner, Maggie WilcoxIndependent Cancer Patients' Voice, London, United KingdomIndependent Cancer Patients' Voice (ICPV) was set up by patients on the Breast CSG in 2007 because more patients were needed for the workload. ICPV has held study days in Leeds, Velindre, Barts' & The London, the House of Lords, Universities of Birmingham, Sussex, Glasgow, Warwick and Stirling, CRUK, and a Radiotherapy Day in London. The training was formalised into the VOICE (Vision On Information, Confidence & Engagement) Science Course for patient advocates which has been run since 2013 jointly by the Barts’ Cancer Institute and ICPV. ? ?So far, the course has trained 56 graduates. ICPV believes that "Clinical research is improved by patients being partners with clinicians and healthcare professionals, rather than passive recipients of healthcare"ICPV was initially almost entirely breast cancer patients, but now has 67 members across most tumour groups, although breast still predominate. ?ICPV members are now involved in over 95 cancer related National, European and International Committees; the Breast CSG and all Subgroups; have been to NCRI conferences and San Antonio; are on over 100 Trial Management and Steering Groups; have been co-applicants on at least 30 trials; and have also been involved in the initial design of trials. Good examples are treatment reduction trials (PERSEPHONE, PRIMETIME, LORIS & OPTIMA), MENOS4 (Nurse delivered CBT for Hot Flushes) and the SWEET programme (Adherence to endocrine therapy) which are unmet needs highlighted by ICPV members. Other trials include: Add Aspirin, AsCaP, AZURE, POETIC, MAMMO-50, MENOS4, NEPTUNE, PALLET, PEACE, FASTForward, SMALL, ROSCO, IMPORT HIGH & LOW, PRECISION (CRUK Grand Challenge), MyPeBS (Horizon 2020).ICPV is an established partner in cancer research in the UK, has received affirmation from cancer researchers, works with Cancer52, AllTrials, use MY data, BCN, BCN tissue bank, WCRF, the MHRA, HTA, CCB and is a stakeholder with the APPGC, APPGBC, and ABPI.?PC5An evaluation of patient reported outcomes following oncoplastic breast conserving surgery with an arc modification of the chest wall perforated flap utilizing Breast QAmtul R Carmichael1,2, Amit Goyal3, Kefah Mokbel41UHDB, Burton, United Kingdom. 2University of Aston, Birmingham, United Kingdom. 3UHDB, Derby, United Kingdom. 4London Breast Institute, London, United KingdomIntroduction:?An increasing acceptance of chest wall perforator flaps has provided additional options for enhancing the cosmetic appearance of the conserved breast after breast cancer surgery.?Traditional lateral?intercostal anterior perforator (LICAP) flap involves a lateral chest wall scar. To enhance the cosmetic results of LICAP flap, we propose?arc modification of LICAP?flap to conceal the scar in the inframammary crease.Aim:?The aim of our study was to investigate patient satisfaction and cosmetic outcome by using the BREAST-Q after undergoing?arc-LICAP?flap partial breast reconstruction.?Methods: All eighteen consecutive patients with who underwent?arc-LICAP?flap reconstruction for partial breast reconstruction after wide local excision of breast cancer between June 2017 and July 2019?were invited to complete the BREAST-Q questionnaire. All patients were prospectively evaluated and their demographic, clinical and pathological details were recorded on a database.Results:?The median psychological, physical and sexual well-being scores were 93 (IQR 63-100), 82 (IQR 69-95) and 70 (IQR 46-96) respectively. The median satisfaction score with breast was 88 (IQR 66-100)??Conclusions: In a carefully selected group of women with breast cancer, our study demonstrates that the arc-LICAP flap for partial breast reconstruction provides a safe and effective technique with preservation of satisfaction with breast, physical, psychological and sexual well-being.PC6Outcomes after the Breast Care MDT: concordance between MDT outcomes and patient careEuan Strachan, Virginia Caddick, Mark Burnett, Prakash SinhaPrincess Royal University Hospital, London, United KingdomIntroduction: The Multidisciplinary Team (MDT) forms the Gold Standard structure for formalising the decision-making process within the Breast Cancer pathway. It is important that the outcomes are actioned and the plan adhered to in order to provide best care for our patients. Doing so enables a cohesive approach, robust medico-legal framework and fosters an environment of learning and patient-centred care. On occasion, however, patients will receive alternative management to that agreed at the prior MDT meeting. Rajan et al., categorised such instances as ‘justifiable’ (e.g. patient autonomy or receipt of new clinical information) or ‘unjustifiable’. In addition, it is crucial that the outcomes are clearly documented for medico-legal purposes and, crucially, the rationale for any deviation from an MDT outcome must be recorded and re-discussed at a subsequent MDT meeting if appropriate.Aims:?To review concordance between the Breast Care MDT outcome and patient care received over an initial 2-month period at Princess Royal University Hospital.?To further delineate those cases in which the care our patient has received deviates from the previously agreed MDT outcome in order to establish areas for service improvement and learning.??To re-audit concordance between MDT outcomes and patient care following a period of feedback and implementation.Guidelines:?NICE?(2009) Early and locally advanced breast cancer: Diagnosis and?treatment?NHSBSP?(2005) Quality assurance guidelines for breast cancer screening radiology. NHS Cancer Screening?Programmes.?Association of Breast Surgery at BASO (2009): Surgical guidelines for the management of breast cancerMethod: An initial retrospective review of all Breast MDT outcomes for April 2019 was carried out. Data was retrieved from our Electronic Patient Records (EPR) system, specifically analysing uploaded MDT outcomes for content. Data was stratified according to referral type, e.g., new biopsy, post-operative histology, imaging, etc. Reasons for any discordance between MDT outcome and care actually received was recorded and categorised as ‘justified’ or ‘unjustified’ in accordance with the recommendations of Rajan et al. These initial findings were presented to the Breast Care MDT in order to increase awareness prior to a re-audit, which was conducted during August 2019. Re-audit took place following the implementation of the new electronic MDT Outcomes proforma and the findings are presented here.?Results: In the initial retrospective study, 140 MDT cases were reviewed, of which 125 had MDT documentation available for inclusion. 20 of these (14.3%) were found to be discordant. Of these, 16 (80%) were justifiable. Reasons included: patient preference, onward specialist referral and the need for down-staging of tumour. Therefore, 4 cases (20%) were deemed 'unjustifiable'. The majority of these were due to inaccurate or poor documentation, whilst one patient was inappropriately counselled for the wrong treatment, which was later corrected.?The re-audit period identified 162 cases following implementation of the new electronic outcomes proforma and presentation of our initial findings. Concordant outcomes improved to 87%. Of the 13% non-concordant outcomes, 92% were justifiable for reasons of patient preference, new information becoming available or disease recurrence. Unjustifiable outcomes were again attributed to administrative and documentation errors. 61.5% of non-concordant plans were re-discussed with the MDT, which improved from 20% in the initial audit period.Conclusions: Inevitably, there are instances in which the care a patient receives will deviate from the agreed MDT plan. In cases where this is appropriate, it is imperative to clearly document the rationale for change and to inform the MDT by re-presenting the case. This acts to ensure the most appropriate care is delivered to our patients through an evidence-based and consensus-driven process. The greatest improvement we achieved with the process of feedback and standardisation was in this aspect of re-discussion, leading to greater transparency in the direction of patient care. ??'Unjustifiable' reasons for contradicting the MDT plan must be avoided where at all possible. When occurring, they must be documented and reflected upon as a learning opportunity for all involved. Standardised electronic recording of the MDT outcomes with clear reasoning has seen an appreciable improvement in our practice, both increasing concordance with the MDT outcome and reducing 'unjustifiable deviations' in practice.PC7Post-operative exercise guidance app (BAPSApp Wales) for breast cancer patients empowers patients and reduces problems with positioning at radiotherapy planningDonna M Egbeare1, Kate Baker2, Karen Bonham3, Glenn Hapgood41Cardiff and Vale University Health Board, Cardiff, United Kingdom. 2Velindre Cancer Centre, Cardiff, United Kingdom. 3Nil, Cardiff, United Kingdom. 4Orchard Media, Cardiff, United KingdomIntroduction: Surgery for breast cancer is performed in different health boards in South East Wales that refer patients for radiotherapy and oncological treatment at Velindre Cancer Centre. ?There was disparity in information given to patients about post-operative exercise, who gave the information, at what point from diagnosis to surgery any information was given and the demonstration of the position for radiotherapy that was required throughout the region. The commonest information given to patients was verbal advice, followed by the giving of information in written form, either health board information (often photocopied) or a leaflet provided by Breast Cancer Care.Aim: Following feedback from patients, a multi-disciplinary team was put together to address the disparity in information and to encourage patients to regain control over this aspect of their care following breast cancer surgery. Our aim was to standardise information given to patients, their relatives and friends in a way that the user felt motivated to achieve goals and would understand why they were being asked to do specific exercises. ?This would hopefully reduce the need for intensive physiotherapy for those patients not able to achieve position for radiotherapy and reduce the numbers of patients who fail radiotherapy planning - ultimately saving money for the health service and preventing psychological distress for patients suffering a delay in adjuvant therapy.Methods: Our team entered the Bevan Commission 2018 Welsh Health Hack. ?We presented our problem and proposed developing an app to help reduce variation in information, encourage patients to exercise and identify those patients having difficulties with post-operative exercise to get into position for radiotherapy earlier so that physiotherapy could be offered to help prevent delays in adjuvant treatment. ?We discussed that bits of paper are not practical, difficult to understand correct techniques for exercises as only in two dimensions and often photocopied poorly. A mobile app would mean a patient could take the app with them, it would remind them to do the exercises and family and friends could interact and do exercises together. ?As our aim would be to roll out across Wales eventually we also wanted the app to be bilingual so Welsh language speakers would not be disadvantaged. We were one of the successful teams at the Hack and worked with Orchard Media and were given funding to develop the project. The BAPSApp (Breast Axilla Postoperative Surgery App) Wales launched in at the end of January 2019 after filming, text editing, translation and voice overs. ?We covered four guided sessions and each session was followed by a functional assessment. We also developed a section for relaxation and deep inspirational breath hold. ?All sessions were accompanied by explanations and links to relevant guidance.Results: In the first six months of the BAPSApp Wales launch we had good uptake of use of the App. There was good engagement of healthcare staff and a patient questionnaire is currently being answered for one month at the Cancer Centre to gain anonymous feedback. App analytics of the first 100 days show that most users are in the UK, but there are worldwide users. This may be because of social media advertising. ?Over 80% UK users are from direct download/QR code referrals. The most popular pages are the breath hold page, session 1, session 2, FAQs then session 3. ?There were less viewers of session 4, but until the App has been running for a longer period of time and patient feedback is complete it is difficult to see if this is because patients don't complete all sessions or if they are repeating earlier sessions. Less patients have been referred for urgent physiotherapy input because they couldn't get into position for radiotherapy; data continues to be collected.Conclusions: We are confident that this initiative has saved money and most importantly enabled patients to feel in control of this aspect of their care and reduce distress caused by delayed adjuvant treatment. It has reduced disparity in information. The roll out of the BAPSApp across Wales will commence Autumn 2019 and data continues to be collected.PC8Presentation of breast cancer in women under 40 years: pain is not a symptomYvette Jaffe1, Juan McDonnell2, Fawzia Imtiaz-Crosbie2, Victor Jaffe21Imperial College Medical School, London, United Kingdom. 2Royal Free NHS Foundation Trust, London, United KingdomIntroduction: There is huge pressure on breast units to see ‘target’ suspected cancer patients within the two-week referral process. ?Increasing numbers of young women are referred as ‘targets’ when their only symptom is breast pain. We decided to audit the presenting symptoms of women under 40 years who were subsequently diagnosed with breast cancer.Methods: We reviewed the presenting features of all breast cancer patients under 40 in a single breast unit between 2007 and 2017.??We estimated the number of under-40s seen in the one-stop clinic during this period and what percentage had pain as their only presenting symptom.Results: We identified 114 patients under 40 diagnosed with breast cancer. 102 presented with a breast lump (89.5%), 4 with discharge (3.5%), 3 with nipple change (2.6%) and 2 an axillary lump (1.8%). 2 others came through the family history clinic (asymptomatically). One patient (0.9%) presented exclusively with pain but her cancer was in the contralateral breast. We estimated a total of 13,520 women under 40 were seen in the one-stop clinic (2007-2017). 60% had pain as their only presenting symptom (total 8,112).Conclusion: Although 8,112 women under 40 were seen in the target clinic with pain as their sole presentation, only one was eventually diagnosed with breast cancer (and that was by serendipity).We suggest there is little indication to refer these young women through the two-week wait process. Huge pressure would be taken off clinics and allow young women to be seen in more relaxed and suitable setting.PC9Is Duel Technique for sentinel node biopsy in patients with breast cancer superior to single modality technique using Radioactive Tc99 only?Amtul Shafee Sami, Jibril Jibril, Anzors Gvaramadze, Dinesh ThekkinkattilLincoln County Hospital, Lincoln, United KingdomIntroduction: Sentinel Node Biopsy is a standard technique to detect axillary metastasis in patients with Lymph Node Negative Breast cancer. The current practice of using duel technique with radioactive Tc99 and Blue dye has a low but recognised risk of serious allergic reaction. Injection of blue dye can lead to non-fatal but serious cardiac morbidity. At Lincoln Hospital, two Breast Cancer patients developed life threatening anaphylactic reaction after injection of blue dye. Their cancer surgery had to be cancelled and they were admitted in intensive Care Unit. Since then United Lincolnshire Hospitals NHS Trust Breast Surgical team decided to use single modality technique, using radioactive Tc99 alone for SLNB. In patients with failed mapping with Tc99, it was agreed to do perform four node axillary sampling.?Aim: The aim of our study was to investigate the outcome of SLNB using Tc99 only in patient with breast cancer and to compare results with duel technique.?Method: In this prospective study, we assessed the outcome of SLNB using single modality technique using Tc99 in 114 consecutive patients with breast cancer. All patients pre-operative clinical and radiological assessment of axilla and were proven to have no suspicious axillary lymph nodes. All patients who had breast conserving surgery for invasive cancer were included. Patients with DCIS or invasive cancer who underwent mastectomy were also included in this study.?Results: We found that the detection rate of SLNB with single modality technique using radioactive Tc99 alone was 97% and false negative rate is 2%. Our results are comparable with SLNB using duel technique.Conclusion: We conclude that in experienced hands, Single modality technique using radioisotope Tc99 for SLNB is a safe and reliable technique. Our results show that the axillary lymph node pickup rate is comparable with duel technique. The false negative rate is low and similar to duel technique. Hence using single modality can save patients unnecessary risk of severe complications.? ? ??PC10Biopsy of solid breast lesions in the women under 35s – Is it safe?SAU LEE CHANG, Sophia SakellariouNHS Greater Glasgow & Clyde, Glasgow, United KingdomIntroduction: Current best practice is to biopsy breast lumps in women above 25 years old. In view of low incidence rate of breast carcinoma among young population, biopsy risks and psychological impact of benign breast biopsy, many studies had suggested to extend the biopsy age threshold to above 35 years old if the Starvos criteria of benignity are satisfied. ?Aims/Objectives: We aim to study if this is a safe practice to avoid biopsy women <35 years old in our local population.Method: Retrospective study on breast biopsy in women aged <41 years old who attended symptomatic clinics between 1/6/2016 and 31/7/2018. Patients with U4/U5, M4/M5 lesions, family history or previous breast carcinoma, known phyllodes tumour were excluded from study.Results: 485 biopsies were eligible for the study (mean age 31.3 years old). Majority of breast lumps were graded U3. 421 solid breast lesions were sonographically thought to be fibroadenoma. 331/421 (79%) ultrasound judgements were pathologically proven accurate.? 98% were B1-B3 masses.? 10 were B5 lesions and 5 cancer patients aged <35 years old. 3/5 lesions demonstrated suspicious features on ultrasound which warranted biopsy. One lesion in a 25 year-old women measured 3 cm also merited biopsy. The only cancer patient aged <35 years old with benign appearance was the only potential true miss (0.2%), if new practice was implemented.? Of note, 2 out of 10 cancer patients were pregnant or breastfeeding at diagnosis. Overall negative predictive value of Starvos benign ultrasound features in the study was reasonably high (70%-97 %%).Conclusion: The risk of missing cancer diagnosis in our population is extremely low (0.2%). It is safe to avoid breast biopsy in women <35 years old, with the exception to pregnant/breastfeeding ladies. Young women could otherwise be reassured without biopsy if Starvos criteria are satisfied.PC11Pattern of disease relapse and treatment outcomes of triple negative breast cancer: Experience from a cancer referral centre in NigeriaMubashir Adekunle Ibrahim1,2, Rasaaq Adisa Oyesegun1, Ridwan Oladotun Ahmed1,2, Nandul Nimark Maurice1, Sururat Opeyemi Ibrahim31National Hospital, Abuja, Nigeria. 2African Cancer Institute, Stellenbosch University, Cape Town, South Africa. 3Federal Medical Centre, Katsina, NigeriaIntroduction: Among different factors that are responsible for the higher burden of breast cancer in sub – Saharan African countries, higher prevalence of a biologically aggressive type of breast cancer known as Triple Negative Breast Cancer (TNBC) - which lacks expression for oestrogen and progesterone receptors as well as human epidermal growth factor receptor - tends to be a major factor among African women. Unfortunately, limited data exist on the pattern of care and treatment outcome of this disease subtype in native African women.?Aims / Objectives: The aim of this study was to characterize pattern of recurrence and clinical outcome among patient cohorts of TNBC. ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ?Methods: We conducted retrospective study on consecutive cases of histologically diagnosed triple negative breast cancer that were managed at the Radiotherapy and Oncology Department of National Hospital Abuja, Nigeria from 2012 to 2016. Out of 166 cases of TNBC, 145 met the study’s eligibility criteria and were analysed using statistical package for social sciences (SPSS) Version 20. Patients were followed up for a median duration of 18 months. ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? Results: Approximately 80% of the study population had definitive surgery and a third of this figure had their surgery after undergoing neoadjuvant chemotherapy with mostly Anthracycline –based cytotoxic and/or Taxanes. At around 80%, adjuvant chemotherapy regimen was predominantly with Platinum/Taxane combination or Anthracycline-based either as 1st or 2nd line regimen. Bevacizumab was the only targeted therapy used for just one patient as a 3rd line regimen. Nearly two-third of the cases received adjuvant radiotherapy and about one-third eventually had radiotherapy as a palliative care. ?The median duration of disease relapse/or metastasis was 7 months. Majority of the relapses occurred in the 1st and 2nd year of follow up and waned thereafter. Two-third of all disease relapses (62 out of 96) occurred as distant recurrence and lung was the leading metastatic site (34.4%) followed by brain (14.6%). As at last follow up, 45.5% of the cases maintained disease remission but almost half of the cases (48.3%) had experienced either loco-regional relapse and/or distant metastasis. A significant association was observed between time of surgery and clinical outcome with primary surgery (without prior neoadjuvant chemotherapy) being strongly associated with disease remission (P = .001).?Conclusion: Despite the aggressiveness of TNBC, surgical intervention at an early stage may be a crucial factor to favourable outcome in this highly lethal subtype of breast cancer. Excellent follow up care especially in the 1st three years after treatment could lead to prompt identification of early relapse cases which may be amenable to further care and possibly improve patients’ overall quality of life.PC12Compliance with Chemotherapy administration safety guidelines: Consensus for standardizing practice in three Kenyan hospitalsDavid Echesa Odada1, Roselyn Okumu Erick2, Stacy Hallonda3, Margaret Barton Burke4, Victoria Harmer51Aga Khan University Hospital, Nairobi, Kenya. 2Kenyatta National Hospital, Nairobi, Kenya. 3Machakos County Level Five Hospital, Machakos, Kenya. 4Memorial Sloan Kettering Cancer Center, New York, USA. 5Imperial College Healthcare NHS Trust, London, United KingdomIntroduction: The burden of cancer in Kenya is increasing, now ranked as third leading cause of mortality after infectious and cardiovascular diseases. Kenya’s healthcare system is struggling with a shortage of specialized staff to manage this burden along with the increasing demand of setting up Cancer treatment facilities. With limitation in expertise, the focus in care points to compromised practice outcomes in cancer management. Chemotherapy administration is one of the important aspects of practice that is directly related to treatment outcomes.?Objectives: This study examines the current chemotherapy administration practice in three hospitals in Kenya in relation to the (American society of clinical oncology and oncology nursing society) chemotherapy safety guidelines.?Methods: A descriptive study where data were collected from panel interview session during an international breast symposium held in 2019, Nairobi, Kenya. The panel brought together practice experts in oncology nursing from a private tertiary hospital, a public tertiary hospital and a county level five hospital. The focus was on the level of compliance and practicability of full compliance of six chemotherapy administration standards from the ASCO/ONS chemotherapy safety guidelines.?Results: The private hospital fully applied four of the standards to practice. There was a consensus that three standards were practical for compliance by all the hospitals and the idea that practice could be standardized. Pre-typed chemotherapy prescriptions, staff qualifications and dose calculation verifications of chemotherapy were either not met or partially met in all the hospitals.Conclusion: These results highlight the importance of formulating and implementing a national guideline for chemotherapy administration safety guideline. The Kenyan National cancer institute also has the task of providing a training program that will serve as a minimum training requirement for nurses taking care of cancer patients. At the hospital level, leadership should develop chemotherapy administration policies and guidelines which should be updated and shared.PC13Process evaluation of the Bridging the Age Gap in Breast Cancer decision support intervention cluster randomised trialMaria Burton1, Kate J Lifford2, Lynda Wyld3, Fiona Armitage3, Karen Collins1, Malcolm Reed4, Kate Brain2, Adrian Edwards2, On behalf of *51Sheffield Hallam University, Sheffield, United Kingdom. 2Cardiff University, Cardiff, United Kingdom. 3University of Sheffield, Sheffield, United Kingdom. 4Brighton and Sussex Medical School, Brighton, United Kingdom. 5Age Gap Trial Team, Sheffield, United KingdomIntroduction: The Age Gap cluster randomised trial sought to test “complex” decision-support interventions (DESIs) which included an online decision tool, a brief decision aid (BDA) and a booklet for patients facing a treatment choice of either:1. ? ? ? surgery + endocrine therapy (ET) versus primary endocrine therapy (PET), for frail older women; or,2. ? ? ? adjuvant chemotherapy or no chemotherapy for women having had surgery for high recurrence risk breast cancer.?A process evaluation (PE) was undertaken to identify how the interventions worked and aid interpretation of the trial results.?Aim?of the PE were to understand how the DESIs were implemented, the barriers and facilitators, and how acceptable and useful they were to staff and patients.Methods: Multiple methods of data collection were used: questionnaires, interviews, case report forms (CRFs) and audio-recording of consultations. Of 46 trial recruiting sites, 16 were PE sites. ?Interviews were analysed using a Framework approach. Numeric data were analysed using SPSS.Results: The trial included 1321 participants, 176 from PE sites were invited to participate; 77 patients provided data for the PE. Ten healthcare professionals (HCPs) took part in a telephone interview and seven in audio-recorded consultations. The online tool was used by surgeons in ways personalised to the patient and their own practice and, provided structure to guide treatment options. The booklets were introduced predominantly by nursing staff, with the BDA used as a summary sheet rather than to stimulate discussion as intended. The information provided encouraged more active involvement in decision making. Barriers to implementation were seeing the DESIs as time consuming as well as logistical problems e.g. access to computers.Conclusion: Patient and HCPs feedback on the tools was positive but utilisation was variable both between centres and clinicians. Adoption was hindered by other information materials commonly provided to patients, time and IT constraints.??PC14PREDICT: the potential pitfalls of visualisations of riskGabriel L Recchia1, Anne Marthe V D Bles2, Alexandra L J Freeman11University of Cambridge, Cambridge, United Kingdom. 2University of Groningen, Groningen, NetherlandsIntroduction:?PREDICT is a tool that presents the potential benefits of different treatment options for individuals, personalized to their characteristics. There are versions for prostate and breast cancer. Originally designed for use by clinicians, it has now been developed so that its outputs can be shared with patients, using 5 different visualisations.Aims/Objectives: We set out to evaluate the effects of different visualisations on comprehension and decision-making in a hypothetical clinical scenario.Methods: 789 men and 790 women were asked to imagine themselves recently diagnosed with prostate or breast cancer, respectively, and were shown modified versions of PREDICT demonstrating 10-year survival rates of 77% with no treatment that increased by 7% to 84% with “cancer therapy.” Each participant saw results in only one format: bar chart or table. Participants answered questions concerning comprehension and treatment decision among others.Results: 21% of participants who viewed the stacked bar chart incorrectly concluded that monitoring only led to better survival (vs. 4% who viewed the table). This was also reflected in hypothetical treatment decisions, with 43% of those viewing the chart opting for “monitoring only” (vs. 31% who viewed the table).Conclusions: Participants appeared to confuse the additional benefit of cancer therapy (7%) with the probability of survival (84%) when looking at the chart, but not the table. Visualisations affect comprehension and can influence decision-making. As a result of this, we are carrying out further studies testing forms of the bar chart with a lower risk of misinterpretation, as well as evaluations of other visualisations used in Predict. We will be carrying out further such evaluations in light of proposed additions to Predict, such as showing increased non-cancer mortality as a result of treatment which may result in ‘negative benefits’ for some patients: a challenge to visualise in the current formats.PC15Cancer, Fertility and Me: a NEW fertility preservation patient decision aid to support YOUNG women with breast cancerGeorgina Jones1, Frances Darby1, Rachael Moss1, Kathy Vogt1, Jonathan Skull2, Galina Velikova3, Diana Greenfield4, Hilary Bekker3, Neda Mahmoodi1, John Snowden4, Daniel Yeomanson5, Jacqui Gath6, Bob Phillips7, Sheila Lane8, Richard Anderson91Leeds Beckett University, Leeds, United Kingdom. 2Jessop Fertility, Sheffield, United Kingdom. 3University of Leeds, Leeds, United Kingdom. 4Sheffield Teaching Hospitals, Sheffield, United Kingdom. 5Sheffield Children's Hospital, Sheffield, United Kingdom. 6Blue Yonder, Leeds, United Kingdom. 7University of York, York, United Kingdom. 8University of Oxford, Oxford, United Kingdom. 9University of Edinburgh, Edinburgh, United KingdomIntroduction:?Women with cancer of child-bearing age often need to make time-sensitive fertility preservation decisions whilst simultaneously planning and starting cancer treatment.?Aims/Objectives:?To report our experiences of developing and evaluating the first fertility preservation patient decision aid (PtDA) suitable for women with breast cancer aged 16 years and older and living in the UK.?Methods: In a?prospective mixed-method, three stage study, the PtDA was: 1) developed following the IPDAS criteria, involving a large steering group, 2) user (alpha) tested to gather feedback on its content and format from patients (n=12), cancer and fertility healthcare professionals (HCPs) (n=10) and other key stakeholders (n = 5), and finally, 3) field (beta) tested to evaluate its acceptability when integrated into routine cancer care pathways at diagnosis. Forty-one women (of which 27 had breast cancer) were given the resource and completed questionnaires to measure decision-making and quality of life. Thirty women took part in an in-depth interview. Further interviews (n=3) and a focus group with other HCPs were also undertaken.Results: Patients who received the PtDA, described a positive impact on their ability to make fertility preservation decisions and support them at a stressful time. However, many women (>200) were not given the PtDA within breast cancer services and there were contrasting views between patients and their clinical teams regarding the content in the resource, who should receive it, and at what stage in the cancer pathway. Lack of clarity amongst the oncology team about whose role it is to have a FP discussion also hindered its use.Conclusion: Our PtDA has the potential to address an unmet need for breast cancer patients and their clinicians. However, further work is needed to ensure the successful adoption and integration of fertility preservation PtDAs within a breast cancer clinical setting.?S1A retrospective case series assessing the efficacy and tolerability of Romiplostim for the treatment of chemotherapy induced thrombocytopenia (CIT) in cancer patients – The UK ExperienceRamin Ajami, Natasha Antoinette Quyn, Angela Graham Douglas, Alison Jones, Robert MarcusLeaders in Oncology Care-LOC, London, United KingdomIntroduction: Although the thrombopoietin receptor was discovered in 1991 and thrombopoietin (TPO) was purified in 1994, the development of a clinically useful TPO was hampered by the appearance of neutralizing antibodies to some forms of recombinant TPO. However, in 2008 two new drugs that mimic the effect of TPO became available to treat thrombocytopenia.? Romiplostim - a TPO peptide mimetic given by subcutaneous injection. Eltrombopag - ?a TPO non-peptide mimetic administered. Both increase the platelet count in healthy humans as well as in >80% of patients with immune thrombocytopenic purpura (ITP). Although initially restricted to the second-line treatment of ITP, both agents could help treat many thrombocytopenic disorders such as Chemotherapy Induced Thrombocytopenia (CIT). There are a few case reports as well as a retrospective case series showing successful treatment with Romiplostim for CIT.1 Current guidance at The Leaders in Oncology Care on the use of Romiplostim includes recommendations on a starting dose of 1 microgram/kg/week and adequate platelet counts to be achieved within a 4 week period of therapy.2?AIMS: Assess the response to Romiplostim in the treatment of Chemotherapy Induced Thrombocytopenia (CIT). Determine the safety of Romiplostim in the treatment of CITResponse assessment:A response to Romiplostim was evaluated as the following:Maintenance of SACT schedule and SACT dose at initiation of Romiplostim and at each Romiplostim dose escalation.Maintenance of platelet count at a level of ≥100 x 109/L over a 4 week consecutive period.Safety assessment:Hypersensitivity reactions to RomiplostimDevelopment of thrombosis?METHODOLOGY: Retrospective data collection from our breast cancer patient cohort over a 3 year period (Jan 2015 – Dec 2018).??This was obtained from electronic patient records.?RESULTS: Data collected and analysed on 35 breast cancer patients.? Treatment intent was disease control for 33 patients (94%) and 17 patients (49%) were on ≥4th line of therapy. 18/35 (51%) patients had bone metastases of which 5 patients had established BM infiltration on imaging.? Romiplostim initiation dose (1 mcg/kg/wk): 6/35 patients?(17%) maintained platelet counts at ≥100 x 109/L over a 4 week consecutive period. All 6 patients received SACT at the next scheduled interval and maintained SACT dose.1st Dose escalation (@ 2mcg/kg/wk): 13/29 (45%) received SACT at the next scheduled interval. Of the 13 patients that received SACT 12 (41%) maintained the SACT dose.2nd dose escalation (@ 3mcg/kg/wk): 13/21 (62%) received SACT at the next scheduled interval. Of the 13 patients that received SACT 11(52%) maintained the SACT dose.3rd dose escalation (@4mcg/kg/wk): 3/9 (33%) received SACT at the next scheduled interval. All 3 patients maintained SACT dose.?All the patients with bone metastases including BM infiltration were noted to respond well to Romiplostim and maintained SACT. The average maximum Romiplostim dose received was 6mcg/kg/wk.The average time to Platelet recovery was 2-4 weeks.There were no reported hypersensitivity reactions or thrombosis with Romiplostim.?LIMITATIONS: Not all patients received consecutive weekly dose of Romiplostim as per the LOC clinical guidelines. Therefore the average time to platelet recovery was difficult to measure accurately.?Complete/ accurate data regarding Romiplostim dose administration was unable to be obtained for patients who received their doses in a community setting (e.g. via Healthcare at Home).?CONCLUSION: Romiplostim was effective in the treatment of Chemotherapy induced Thrombocytopenia in our cohort of breast cancer patient and allowed for SACT scheduling and SACT dose to be maintained during treatment with no associated toxicities.? Further data collection and analyses from more Tumour group cohorts is warranted in order to establish the optimum dosing schedule for Romiplostim in the treatment of CIT.REFERENCES:R. Parameswaran, M. Lunning, S. Mantha, S. Devlin, A. Hamilton, G. Schwartz, G. Soff. (2014). Romiplostim for management of chemotherapy-induced thrombocytopenia [Abstract]. Support care cancer [online]LOC Guideline - Guidelines on the use of Romiplostim in chemotherapy induced thrombocytopenia ( v 1.0)S2Patient and Clinician Engagement statements as a tool to explore patient preferences for metastatic breast cancer treatments in ScotlandAlistair Bullen1, Holly Ennis1, Lauren Murdoch1, Ewan Gray1, Emily Ross1, Olga Oikonomidou1,2, Morag McIntyre2, Nicolas Krucien3, Mandy Ryan3, Peter Hall1,21University of Edinburgh, Edinburgh, United Kingdom. 2NHS Lothian, Edinburgh, United Kingdom. 3University of Aberdeen, Aberdeen, United KingdomIntroduction:?Effective?patient centred care requires sufficient understanding of patient preferences. Qualitative research has been key to developing our understanding in this area and is particularly useful in the area of metastatic breast cancer, where an incurable diagnosis and high uncertainty leads to complicated and emotionally charged reasoning. In 2014, Scotland’s advisory body for medicines, the Scottish Medicines Consortium (SMC), introduced the Patient and Clinician Engagement (PACE) process, giving voice to the clinician and patient perspectives on new medicines. PACE statements are useful?for the area of patient preference because, a) they provide patient and clinical perspectives for societal decisions rather than the individually personal and highly emotional context of a consultation, b) secondary data forgoes the need for potentially lengthy and costly data collection, c) they provide qualitative data from an independent source. Methods:?Between Oct 2014 and Oct 2018, eight PACE meetings had been convened for medicines seeking reimbursement for the treatment of metastatic breast cancer. In this study, we conducted a formal thematic analysis using the PACE statements from those meetings in order to systematically identify the dominant issues that patients consider important regarding new medicines. NVIVO software was used to facilitate analysis conducted by consensus of two researchers. Results:?We identified six core themes: symptoms and side effects, survival, psychological effects, ability to live a normal life, effect on family and close ones, and effect on daily routine. Conclusions:?PACE statements are a useful secondary data resource. The results of our analysis offer a summary of the issues that are considered important by patients and clinicians. In particular, they highlight how the goals of treatment for metastatic breast cancer extend beyond simply prolonging life. Our analysis of PACE statements has highlighted the lived experience of the patient and also the effects of their family and carers.S3Cadaver courses for oncoplastic breast training; where are the bodies coming from?Amtul R Carmichael1,2, Ian M Lahart3, Neil Ashwood11University Hospital of Derby and Burton, Burton, United Kingdom. 2University of Aston, Birmingham, United Kingdom. 3University of Wolverhampton, Wolverhampton, United KingdomIntroduction: ?There has been an increase in the number of training courses using cadavers for the oncoplastic and reconstructive breast procedures. As yet there is no published evidence evaluating the usefulness of these courses. While it is perfectly acceptable to dissect human bodies for deeper technical learning and professional training, the ethics of sourcing bodies to meet this increasing demand need to be understood.Aim/Objective: ?We wished to explore the ethics of using human cadavers and body parts for medical teaching, especially those sourced commercially, in terms of processes of procuring cadavers, informed consent and any safeguards to protect vulnerable. ?.Methods: For this narrative review, we searched Pubmed, Google scholar and Research gate under the terms of ethics, cadaver and teaching for literature published in English language.Results: The literature suggests that there has been an increase in the availability of willed bodies. Mostly, individuals may donate their bodies for free or in exchange for covering the cost of cremation and funeral, but some cadavers are obtained by questionable sources such as a compulsory donation. There is no transparent system to ensure that cadavers are sourced after a valid informed consent. There are no internationally agreed safeguards to protect the vulnerable, unclaimed and those at risk of coercion against exploitation. ?Most body donation organisations do not openly provide comprehensive and transparent information about processes by which they provide cadavers to those organising teaching courses. There are no internationally agreed ethical principles governing the proper and legal handling of willed bodies.Conclusions: There is a need for ethically justifiable mechanisms in the use of cadavers for surgical teaching. Breast surgeon’s community can lead the way by defining the moral and ethical principles for using cadavers for surgical teaching and only using ethically sourced bodies from non-profit making, non-commercial organisations.?S4An evaluation of American College of Surgeons Risk Score as a predictor of surgical site infection for breast surgeryAmtul R Carmichael1,2, Manas Dube3, Shahd Noor1, Amtul Shafee Sami41UHDB, Burton, United Kingdom. 2University of Aston, Birmingham, United Kingdom. 3George Elliot Hospital, Nuneaton, United Kingdom. 4Univesity Hospital Lincoln, Lincoln, United KingdomAbstractBackground: Infection rates for surgical treatment of breast cancer are documented at between 3% and 15%, higher than average for a clean surgical procedure. SSI after breast surgery can lead to increased length stay, lower quality of life, lower satisfaction with the surgical outcome and increased costs. Therefore, it is important to identify the modifiable risk factors associated for SSI after breast surgery. ?Aims/Objective:? ? ? ? ?1. To identify women at an increased risk of SSI using a risk score of American College of Surgeons for the National Surgical Quality Improvement Program2. ?To facilitate the process of an informed consent for surgeryMethods: An SSI risk calculation using Surgical risk calculator of American College of Surgeons National Surgical Quality Improvement Program was completed for 178 women at the time of consent and pre-op clinic appointments prospectively. The data regarding SSI over the 30 days was prospectively recorded.Results:? An overall risk of infection was 4% (8 patients). A risk score of less than 3 has a 3% SSI rate. Of 9 women (5%) in the SSI score group of more than 3, 33% developed SSI.?ACS risk score for SSITotal PatientsPatients who developed an infectionMore than 393 (33%)3 or less1695 (3%)?Conclusion: An SSI risk calculation using Surgical risk calculator of American College of Surgeons has the potential to identify women at an increased risk of SSI after breast surgery. These findings need to be confirmed in a larger study.? ................
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