52 minute read
Black Women and Breast Cancer
Black Women and Breast Cancer: Experts Discuss Shortcomings in Care
By CHRISTINA FRANGOU
Black women have more aggressive breast cancer at a young age than other women, and they’re more likely to die at a young age from these cancers. But they don’t have the same opportunities for screening, genetic testing, treatment and clinical trial participation, experts in oncology reported during a panel session at the 2021 Clinical Congress of the American College of Surgeons.
The speakers called on all health care providers involved in women’s cancer to improve care for Black women and their families.
“African American women are being deprived of maximum utilization of technologies [that can improve breast cancer outcomes],” said Lisa Newman, MD, MPH, the director of the breast program for the Weill Cornell Medicine/NewYork-Presbyterian Hospital Network, in New York City, during a press briefing at the Clinical Congress.
“That’s on us—this is the responsibility of oncology providers,” she said.
Risk Assessment at Age 30
Black women face barriers at every stage of breast cancer diagnosis and treatment, and the effects ripple through their families and communities, panelists said.
Debra Monticciolo, MD, a past president of the American College of Radiology and the section chief of breast imaging at Baylor Scott & White Medical Center – Temple, in Texas, said all Black women should undergo a risk assessment for breast cancer by 30 years of age. If the assessment suggests they’re at high risk for cancer, they should undergo supplemental screening, she said.
“Waiting until 45 or 50 is not good for any woman, but it’s a disaster for women of color and especially for Black women,” Dr. Monticciolo said.
Black women are at higher risk for aggressive cancers at younger ages, research shows. A study from Dr. Monticciolo and her colleagues found that nonHispanic Black women have a 45% higher risk for invasive cancers before age 50 than non-Hispanic white women (Cancer 2021;127[3]:4384-4392). Asian American/Pacific Islander, Native American and Hispanic women also have higher rates of early invasive cancers than white women, the study showed.
Minority women are 127% more likely to die from breast cancer before they are 50 years old compared with white women, according to the study.
Another study showed that Black women have a nearly threefold increased risk for triple-negative breast cancer (Cancer Med 2021;10[18]:6456-6467).
As a result of the growing evidence, the American College of Radiology and Society of Breast Imaging have updated their breast cancer screening recommendations to highlight the heightened risk for Black women and other women of color (J Am Coll Radiol 2021;18[9]:1280-1288).
The organizations want annual mammography screening beginning at 40 years of age for all women, but noted that delayed screening will disproportionately harm women of color.
Black Women Rarely Referred for Genetic Testing
geneticist and the Ingram Professor of Cancer Research at Vanderbilt-Ingram Cancer Center, in Nashville, Tenn.
Only 36% of Black women underwent BRCA testing compared with 69% of white women in a populationbased sample of women in Florida diagnosed with invasive breast cancer at 50 years of age or younger, in a study by Dr. Pal and her colleagues (Cancer 2017;123[13]:2497-2505).
Health care providers often fail to suggest genetic testing to Black women, who were 16 times less likely to receive a referral for genetic testing, the analysis showed. This gap was consistent for women treated across the state, regardless of the size and location of the clinic, according to the study.
“There is something systemic going on here where these women are not being told or referred for genetic testing,” Dr. Pal said.
If genetic testing confirms that a Black woman has a BRCA mutation, she’s also less likely to receive care that will reduce her cancer risk. Black women with a BRCA mutation were less likely to undergo risk-reducing salpingo-oophorectomy compared with Hispanic and non-Hispanic white women after controlling for clinical and demographic variables, the study showed.
Dr. Pal said the consequences of low genetic testing rates extend beyond the immediate patient. Women’s families will not know about their risk.
In addition, a lack of genetic information from Black communities affects the quality of risk assessment tools used to guide patient care, Dr. Pal said. Black, Asian and South Asian women are underrepresented in genome-wide association studies, which find associations between genetic variations and particular diseases, and they are used for polygenic risk scores that estimate a person’s risk for cancer.
“If we don’t have data on Black women, these risk prediction models do not work well in these women,” Dr. Pal said.
Underrepresented in Phase 3 Trials
Black women are disproportionately left out of research that guides cancer treatment decisions, said Oluwadamilola Fayanju, MD, MPHS, the chief of breast surgery and surgical director of Rena Rowan Breast Center, in Philadelphia.
Black and Hispanic patients are 20% to 50% less likely to participate in clinical trials, she said. But the situation is more complicated than simple underrepresentation, she added. Black and Latinx individuals tend to be overrepresented in phase 1 trials, which have the highest risk but lowest likelihood of personal benefit for participants. Conversely, they are underrepresented on the other end of the clinical trial continuum, the phase 3 trials with the greatest likelihood of personal benefit.
As a result, Black women are being treated with therapies and strategies that have rarely been tested on them, even for cancers that are disproportionately more common in women of color, such as triple-negative breast cancer, Dr. Fayanju said.
“We are in danger of potentially not treating breast cancer in those who have some of the most aggressive forms of disease, but also endangering our ability to better understand these diseases and better treat them across all kinds of people,” she said.
If more women of color were involved in breast cancer trials, researchers and clinicians would better understand the pathophysiology of the disease, she said.
She pointed out that multiple complex factors contribute to under-participation in trials. For instance, high-income Black patients were 50% less likely to participate in trials than low-income Black patients, she said.
She urged researchers to employ multipronged strategies to improve trial participation. Surgeons and researchers who are involved in clinical trials must proactively reach out to diverse populations, she said.
“The truth of the matter is many people who are involved in clinical investigation have never thought about disparities in research other than simply reporting racial and ethnic differences,” she said.
She said the Henrietta Lacks Enhancing Cancer Research Act, which was signed into law on Jan. 5, 2021, may improve representation in trials. The legislation requires the federal government to conduct a review of government-funded cancer research trials, including participation by underrepresented populations and the barriers to participation.
—Oluwadamilola Fayanju, MD, MPHS
Professional Organizations and Insurance Companies Have Role
Several panelists said they hope the American Medical Association will take a lead position in raising awareness about the heightened risk and poor outcomes among Black women with breast cancer.
Anita T. Johnson, MD, the chief of surgery and director of breast oncology at Cancer Treatment Centers of America, in Atlanta, said insurance companies need to cover screening, testing, counseling and care related to breast cancer risk for Black women.
She said these changes will improve cancer outcomes across the population.
“Once we fix this issue for Black women, we fix it for all women,” she said. “We fix the late-stage disease presentations, the incidence of triple-negative breast cancer as well as the lack of screening for genetic mutations in people of color.” ■
Safe Opioid Prescribing for Post-op Pain
continued from page 1
University of New Mexico Health Sciences Center, in Albuquerque.
Opioids are prescribed in 80% of surgical procedures, Dr. Fahy said. Approximately 6% of opioid-naive patients are prescribed opioids after minor procedures, and will continue using them three to six months later. Of long-term opioid users, 27% received their original prescription after surgery and have a substantially increased risk for opioid dependence and use disorder.
Surgeons should use different opioid prescribing strategies related to patient characteristics, said Melissa Red Hoffman, MD, ND, FACS, an acute care surgeon at Mission Hospital and an inpatient hospice physician at the John C. Keever Solace Center, both in Asheville, N.C. Care providers should be mindful about opioid prescribing in patients who are naive to treatment and undergoing uncomplicated elective operations, she said.
“The risk of transitioning from short- to long-term use begins to increase after the fifth day of exposure,” Dr. Hoffman said. “Patients who receive a five-day supply of opioids have a 7% chance of continued opioid use at one year.”
Preoperative management for these patients should include setting expectations about postoperative pain; discussing usual opioid consumption; and providing instructions on use of nonopioid pain medication and safe opioid use and disposal, she said. Perioperative care can incorporate acetaminophen (1 g preoperatively), infiltration of port sites with lidocaine, 30 mg of IV ketorolac given at the end of the procedure, and just telling post-acute care nurses to give opioids sparingly.
At discharge, Dr. Hoffman said, set expectations regarding postoperative pain and ensure patients have options to contact the team with questions. Instruct patients to take acetaminophen and ibuprofen on a scheduled basis for at least 72 hours. If prescribing opioids, use recommendations established by the Michigan OPEN (Opioid Prescribing Engagement Network). Patients should take opioids only for breakthrough pain during the first 24 to 48 hours after surgery.
For patients on long-term opioid therapy, verify the home opioid dose using your state’s prescription drug monitoring program (PDMP), Dr. Hoffman said. It is appropriate to continue established opioid medications throughout the hospital stay. However, that dose likely will not be enough to control any additional acute surgical pain. Multimodal analgesia should be used. If a patient cannot tolerate oral medications, consider converting to IV dosing of the home opioid or its equivalent.
At discharge, if opioids are needed for acute pain, inquire whether the patient has a pain contract, she advised. If so, contact the patient’s pain physician to discuss the need for additional opioids. For patients taking more than 50 morphine milligram equivalents (MMEs) per day, consider coprescribing naloxone.
When using the PDMP database, Dr. Hoffman said, it is important to know if patients are receiving either methadone or buprenorphine from an opioid treatment program; that prescription likely will not show up in the database. In addition, consider prescribing or coprescribing naloxone for patients who have an opioid use disorder, those who take more than 50 MMEs per day, and those who take an opioid and a benzodiazepine concomitantly.
The Surgeon Orients in the OR for More Accurate Margin Analysis
MarginMarker™
Sterile six-color ink kit; the surgeon applies ink to designate each margin for pathology.
S
CorrectClips™
Sterile radiographic clips; the surgeon applies clips to orient specimen on the image. L
I
Request a Sample | VectorSurgical.com | +1 (262) 798-7970
Pain management for patients with opioid use disorder who are on medication-assisted treatment (MAT) has its own considerations, Dr. Hoffman said. There are four main misconceptions regarding the treatment of acute pain in patients on MAT: • The maintenance dose of methadone and buprenorphine will provide adequate analgesia for acute pain. Actually, patients are likely to require higher doses of opioids. • Providing opioids to these patients will result in relapse. In fact, stopping
MAT and not adequately treating
acute pain is more likely to result in relapse than treating acute pain with additional opioids. • Buprenorphine causes respiratory depression and therefore needs to be stopped before starting an opioid for acute pain. In fact, stopping buprenorphine will cause patients to have a significant opioid debt that will necessitate even higher doses of opioids. • Patients with opioid use disorder who endorse pain are showing drug-seeking behaviors. In truth, patients with known opioid use disorder may have developed opioid tolerance, as well as opioid-induced hyperalgesia.
For patients on methadone, verify the maintenance dose with the opioid treatment program, Dr. Hoffman said. Methadone should be continued throughout hospitalization. Remember that the maintenance dose, even if it’s high, will not be enough to provide relief of acute pain. Use multimodal analgesia, and because of the alpha-elimination of methadone that is associated with analgesia, consider splitting the maintenance dose into twice-daily dosing to assist with pain control.
For patients who cannot take drugs by mouth, conversion to IV dosing should be done with the help of the pharmacy or a palliative care provider, she said. If the regular dose of methadone is interrupted for five or more days, reintroduction should only be done by a knowledgeable provider. Consider peripheral and regional anesthesia as well as opioids. Note that methadone will lengthen the QTc interval, so try to avoid other QTcprolonging drugs.
At discharge, contact the opioid treatment program and inform them of the patient’s discharge plan, including the timing of the last dose of methadone, and whether any other opioids have been prescribed, Dr. Hoffman said.
For patients on buprenorphine, verify the dose from the PDMP or opioid treatment program. During the perioperative period, continue buprenorphine and use multimodal analgesia, she said. The buprenorphine dose will not provide acute pain relief. Again, because of the alpha-elimination of the drug, splitting the dose into twice-daily dosing can assist with pain control. Consider opioids like fentanyl or hydromorphone, which will be more effective given buprenorphine’s mechanism of action.
At discharge, Dr. Hoffman said, contact the opioid treatment program or provider and inform them of the patient’s discharge plan, including whether the person is being discharged with any additional opioids. Ensure patients have a prescription for or a supply of buprenorphine at home. ■
Superior
Medial
Lateral
Inferior
The Global Standard
Fewer, More Accurate Re-excisions - ,
Military Surgery: Saving Life, Limb and Livelihood
continued from page 1
stairwell that descended into a nearby canal. A civilian from the U.S. State Department tumbled in after him. Together, they wrapped a tourniquet around the colonel’s upper thigh.
Minutes later, an army medic and battalion commander found them. They scooped Col. Walrath into a litter and carried him to a vehicle that raced to the nearest forward surgical team (FST), located about a mile away at a small camp at Forward Operating Base Wright.
He remembers physicians hovering over him with questions, needles and lights.
That was his last memory for several days.
Now retired, Mr. Walrath put the rest of his story together using medical reports, photos and his colleagues’ memories.
This fall at the 2021 annual meeting of SAGES, Mr. Walrath described the remarkable series of events that saved his life and leg, and allowed him to serve another nine years in the armed services, eventually returning to Afghanistan.
As part of an FST, surgeons work in a tent with very limited supplies. These forward operating bases are often described as similar to the television show ”MASH” But that characterization overplays their size, manpower and resources. Forward surgical teams are mobile; they may have to change their location and set up somewhere else within a few hours. As a result, they can’t carry much equipment and supplies, said Robert Lim, MD, the vice chair of education in the Department of Surgery, University of Oklahoma School of Medicine at Tulsa. Dr. Lim worked as a military surgeon for 23 years before retiring in the summer of 2019.
An FST’s interaction with a severely injured patient is usually just long enough to stabilize a patient for transport to a larger facility, Dr. Lim said. It’s a quick, highstakes interaction with a patient and leaves a surgeon with little information about a patient’s outcome— which “can be frustrating and depressing because you’d like to know if you did well,” he noted.
At FOB Wright, a surgical team stabilized the bleeding in Mr. Walrath’s leg and loaded him onto a Medivac helicopter headed for Bagram Air Base, then the largest U.S. military base in Afghanistan. In a photo taken mid-flight, Mr. Walrath holds up seven fingers to illustrate his level of pain to the flight medic. Immediately after the picture was taken, the flight medic, Staff Sgt. Troy Halfhill, recognized that his patient was in trouble—his blood pressure was dropping dangerously as bleeding from his leg worsened and the patient would not survive the 60-minute flight to Bagram. Sgt. Halfhill called on the pilot to make an emergency landing at the nearest surgical team at FOB Fenty, in Jalalabad.
Dr. Lim and William (BJ) Rice, MD, were working that day at FOB Fenty. Dr. Rice, now the medical director of bariatrics at Presbyterian Rust Medical Center in Rio Rancho, N.M., remembers the call about an incoming patient with severe injuries.
When the helicopter landed, Dr. Rice saw a patient who “was obviously bleeding to death.” Dr. Rice, who was the primary surgeon that day, and his team took him “straight into our little operating room,” where they resuscitated the colonel and prepped him for surgery.
In these places, surgeons must think about resource management differently than in the United States, especially the blood supply, Dr. Lim said. Blood supply is sometimes the deciding factor in how surgeons make the decision between amputation or limb salvage. “You can’t do anything that would take up too much time and too much blood,” he said. “Part of my thinking is ‘Can we save him? If yes, then can we save the leg?’”
But there was a good supply of blood that day. The surgeons first stopped the bleeding and shunted the patient’s distal popliteal artery. When bleeding continued, they performed a distal embolectomy and shunted the distal tibioperoneal trunk. Dr. Rice said the team spent several hours in the operating room working to resuscitate the patient, stop the bleeding and shunt the vessels to restore blood flow to the leg in order to stabilize their patient for the flight to Bagram Air Base.
Once Mr. Walrath arrived at Bagram, vascular surgeon Michael Hogan, MD, now in private practice in Mobile, Ala., carried out a nine-hour surgery to cut a vein out of the officer’s right thigh and graft it onto his left calf to restore blood flow, according to Mr. Walrath.
Dr. Hogan, then in his second deployment to Afghanistan, doesn’t recall the case. At the time, Bagram was non-stop with injuries like Mr. Walrath’s. It was hard to keep track of the many patients coming in from bases throughout Afghanistan with major lower-limb trauma.
“The likelihood of a limb salvage, even at that time, was very low,” Dr. Hogan said. “The idea was if there’s tissue there that we think we can salvage, you try to revascularize it, optimize the condition as best you can, debride as much grossly infected material as you can and leave some of the marginal stuff behind in hopes that the appearance would improve once you’ve reperfused the area.”
Months later, when a vascular surgeon in the United States checked the integrity of the graft, Mr. Walrath said the surgeon was “utterly amazed when I told him that the graft had been performed in a combat hospital in the middle of Afghanistan.”
Mr. Walrath was still intubated when he was evacuated to Landstuhl Regional Medical Center, in Germany. There, he was extubated and flown to the United States, arriving four days after the blast. By then, he had undergone six procedures at four military bases over four days in two countries.
Mr. Walrath spent three months recovering at Walter Reed Hospital, in Bethesda, Md. He had an additional 24 operations, mostly fasciotomies and wound washouts to remove infected flesh, he said.
Two months after the ambush, doctors told him that the infection had finally cleared and his leg would not have to be amputated. However, he lost all nerve and muscle function below his left knee.
That injury—a high-energy, lower-extremity trauma—is common among service members deployed to Afghanistan and Iraq. Approximately 15,000 cases of extremity injury were associated with these conflicts, with close to 1,600 amputations as a result.
In 2012, at the time of his injury, the published literature on amputation versus limb salvage among service members was unclear. The following January, a retrospective study of 324 service members deployed to Afghanistan and Iraq who sustained a lower-limb injury showed amputation was associated with better functional outcomes than limb salvage (J Bone Joint Surg Am
Clockwise from top left: Col. Daniel Walrath holds up seven fingers to indicate his pain level after sustaining an IED injury in Afghanistan. Minutes later, the flight medic directs the pilots to make an emergency landing at a nearby forward surgical team site. In July 2013, almost one year after his injury, Col. Walrath relinquished command of his brigade by carrying out a traditional inspection of troops. In January 2021, he deadlifts 340 pounds as part of the Army’s new Combat Fitness Test.
—Daniel Walrath, retired Major General
2013;95[2]:138-145).
However. staff at military hospitals had already begun to adopt new methods to help injured service members avoid amputation.
In 2009, prosthetist Ryan Blanck at the Center for the Intrepid at Brooke Army Medical Center, in San Antonio, had designed a new orthotic device to help limb salvage patients. The Intrepid Dynamic Exoskeletal Orthosis, or IDEO, is a customized, carbon fiber device that runs along the bottom of the foot and up the back of a person’s calf. It operates almost like a spring— transferring energy forward as a person steps down. In this way, the IDEO can help limb salvage patients return to activities like running and high levels of physical activity.
At the time of Mr. Walrath’s injury, major military centers had initiated formal rehabilitation programs for limb salvage patients, combining lengthy rehab with the IDEO. The program helped some injured service members return to duty and reintegrate into active lifestyles.
In 2013, Mr. Walrath received an IDEO device and started on an intensive rehabilitation program. At first, he learned to take a few steps, then walked, and eventually relearned to run and even jump. He dedicated himself to strength training, studying with experts and amateurs through videos on YouTube.
He called his rehabilitation “lifesaving,” saying it allowed him to continue military service, the only work he’d known since he was 17 years old.
In July 2013, almost one year after his injury, he relinquished command of his brigade by carrying out a traditional inspection of troops—walking approximately a quarter-mile in front of his brigade before passing leadership to a new commander.
“This final inspection of my brigade was, for me, my testament that the two attackers who blew themselves up 320 days prior had done so in vain,” Mr. Walrath told the SAGES audience.
He was promoted to brigadier general in 2015 and major general in 2018.
He completed the army’s full fitness test in 2016 and 2021 as part of his service, including a two-mile run accomplished in 19 minutes and 23 seconds.
“I was not interested in being a senior leader in the army who could not meet the baseline physical standards that every other soldier had to meet,” he said.
Mr. Walrath was deployed to Jordan in 2015-2016 and Afghanistan in 2018-2019, before retiring from service in 2021.
In his second deployment to Afghanistan, he returned to FOB Fenty and met with the surgical team working there at the time. He brought with him his medical records from his emergency surgery at the base. By chance, Dr. Lim’s colleague, surgeon Maj. Julia Greene, MD, was working at the base and she recognized her colleague’s name on the operative note.
She helped connect Dr. Lim and Mr. Walrath by phone.
Until then, Dr. Lim knew that Mr. Walrath had survived the flight to Germany, but that was all. “I thought he would live but that he would require an amputation,” Dr. Lim said. “I doubted he would be able to stay on active duty, let alone be as functionally independent.”
In speaking to SAGES, Mr. Walrath said he wanted surgeons to know their actions across operating suites in Afghanistan, Germany and the United States saved his life and allowed him to continue his career.
“What you do as medical professionals is a true calling. It matters to the lives of your patients and their families, more than you know,” he said. “I can only imagine how difficult it is to rarely see and understand the long-term impacts of your work beyond the operating room.”
For Dr. Rice, who was seated in the audience during the talk, Mr. Walrath’s story came as a surprise. Early on, Dr. Rice tried to follow up on his former patient— he’d heard that the injured man had arrived in the United States but suffered ongoing infections. Somewhere along the line, however, he’d heard that Mr. Walrath needed his leg amputated.
“I was so happy,” said Dr. Rice, after learning about his patient’s outcome, “because that’s why we do what we do. You know what I mean? It was like snatching a victory from the jaws of defeat—that kind of thing.”
Dr. Lim said Mr. Walrath’s story illustrates the unique skill set of military surgeons. “Very few surgeons outside of the military are expected to do emergent, lifesaving procedures with low resources in a tent and operate on very technically challenging laparoscopic procedures a few months later,” he said. “It made me pretty proud of what the military can provide to soldiers and servicemen as well as the general public.”
SAGES started a military committee in 2009, to provide surgical combat education and advanced laparoscopic education for its military members. Since then, the organization hosts an annual military symposium to highlight research and military-unique skill acquisition that is free for active-duty surgeons. ■
Mesh Removal: How Much Does Surgical Approach Matter?
continued from page 1
initial mesh placement. Mesh that was placed anteriorly in an open fashion was removed via the open technique, and preperitoneal mesh was removed either laparoscopically or robotically.
Patients were evaluated two weeks after removal, and long-term followup occurred at a mean of 2.5 years. The patients in the three cohorts were well balanced in terms of comorbidities and indications for mesh removal, which included foreign-body sensation, meshoma, reaction, neuralgia and infection.
The operative time was longest with the robotic approach (226 minutes), followed by open (181 minutes) and laparoscopic procedures (169 minutes). There was a significantly different rate of intraoperative injury and major vascular injury among the three approaches, with the laparoscopic group having the highest rate of injury (Table). The mean blood loss was 77 mL in open, 96 mL in laparoscopic and 52 mL in robotic procedures with significant variance. There was no difference in postoperative complications among approaches. There was no difference in pain scores between groups at two-week and long-term follow-up with a mean of 2.5 years. There was a significant improvement in pain scores in all patients after mesh removal. There was no difference in pain score improvement among the approaches.
The authors concluded that all mesh removal approaches were effective in treating chronic postoperative inguinal pain after inguinal hernia repair. The three groups were equally effective in treating postoperative chronic inguinal pain, yielding durable improvement. There was significant variance among the groups with regard to operative time, rate of injury and blood loss, with post hoc analysis suggesting that a robotic approach may confer some advantage, Dr. Huynh said. However, these observed differences were small.
“Based on [what the authors say], open repair is always going to be the procedure of choice for meshes that were placed anteriorly. In these cases, open removal was as good as robotic,” said Kamal Itani, MD, the chief of surgery at VA Boston
Table. Operative Complications
Open Laparoscopic Robotic P Value
Intraoperative injury 4 (10%) 8 (39%) 8 (16%) 0.044
Minor vascular (inferior epigastric, gonadal) 4 (10%) 4 (17%) 7 (14%) NS
Major vascular (external iliac) 0 (0%) 3 (13%) 1 (2%) 0.019
Nerve 0 1 (4.3%) 0 NS Health Care System, a professor of surgery at Boston University and a faculty member at Harvard Medical School, who was not involved with the study. “It then becomes a comparison between the laparoscopic and robotic approach for posteriorly placed meshes. Although the surgery was longer with the robot, there were less complications with the robotic approach compared to laparoscopic. The numbers are too small, and possible confounders too many to reach solid conclusions. However, [this study] could be hypothesis-generating for a larger prospective multicenter study looking at laparoscopic versus robotic explantation of meshes in patients that had posteriorly placed mesh.”
Dr. Huynh noted that mesh removal is safe and effective for treating chronic postoperative inguinal pain in the right patients, regardless of the approach taken. “Due to the reoperative setting and distorted anatomy, these cases should be approached judiciously by surgeons who are practiced in it,” Dr. Huynh said. “Based on our group’s own experience and trends in this data set, we prefer a robotic approach when appropriate. However, we continue to regularly employ the open and laparoscopic techniques when necessary.” ■
A Surgical Society’s Push to Increase Diversity, Equity and Inclusion
By KATE O’ROURKE
In the past year, the Central Surgical Association has focused on diversity, equity and inclusion. Some of these efforts were discussed at the 2021 joint annual meeting of the CSA and Midwest Surgical Association.
In the summer of 2020, the CSA established its Diversity, Equity and Inclusion (DEI) Task Force. According to L. Michael Brunt, MD, the 2020-2021 president of the CSA and Pruett Professor of Surgery and section chief of Minimally Invasive Surgery, Washington University School of Medicine in St. Louis, task force L. Michael Brunt, MD members took on this initiative with incredible enthusiasm and energy. Since then, the task force has been turned into a 15-member committee.
“We have done several proactive things when it comes to DEI,” Dr. Brunt said. “We appointed the most diverse group of committee chairs and committee members in the history of the Central Surgical Association for the coming year. The DEI Task Force will become a full-fledged committee in the coming year. We have decided to support a scholarship for a junior faculty member from an underrepresented minority to attend our annual meeting. And we have added a statement to our pathway to leadership that diversity in all its forms will be considered.”
For a regional surgical society, said Dr. Brunt, diversity doesn’t only mean race, gender or sexual orientation; it also means geographic diversity and includes surgical specialty diversity. “We don’t want to have everybody in leadership be overly concentrated in certain specialties either,” Dr. Brunt said.
Dr. Brunt said diverse representation at the periodic council meetings is now a priority. The DEI efforts are prominently announced on the CSA website.
“The bottom line is we have made a conscious move to become intentional about DEI issues, and I think the end result will be that the organization will be more robust and broadly inclusive, which will be better for patient care and surgical education,” Dr. Brunt said. He said the CSA is exploring partnerships with other societies to leverage collective strengths to advocate for social justice, reduce health care disparities and counter racism in the United States.
As part of the DEI push, the CSA held its first special panel session on DEI issues and disparities in surgery at the joint annual meeting. The panel was co-chaired by Anthony Stallion, MD, of Beaumont Children’s Hospital in Royal Oak, Mich., and Leena Khaitan, MD, MPH, of University Hospitals in Cleveland.
Unconscious Bias: Defining the Issue
Panelist Callisia Clarke, MD, an assistant professor and a surgical oncologist, Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, in Milwaukee, discussed diversity, equity and inclusion in surgical societies with a focus on unconscious bias. She said the impact of unconscious bias in academic surgical societies manifests in a few different ways.
“We know there are fewer women in leadership and that women surgeons have lower pay for equal work. We know that there is poorer retention in our field for women. There is low recruitment and low retention of underrepresented minorities in surgery and medicine in general. This is pervasive in private practice and academia,” Dr. Clarke said. “We know that even though there is very good representation of Asian Americans in the field of surgery that they are underrepresented in leadership. There is very little acknowledgment of LGBTQ issues in academic surgery, and it’s almost never talked about, and so has not been appropriately studied. You can’t really define the impact of the problem if we truly don’t even know what that is.”
Dr. Clarke said all of these factors lead to poor work satisfaction, poor attendance at meetings, poor involvement in organizations and ultimately health disparities.
Dr. Clarke said several steps can help move organizations in the right direction. First, organizations should take their pulse and learn where they stand on DEI. Second, they should make their intentions regarding DEI known. “I strongly encourage organizations to go back and look at their mission and incorporate DEI into part of their mission, so it is part of the structure, the backbone of the organization, and it’s not a separate or time-related event,” Dr. Clarke said. Third, organizations should implement effective programs for DEI using data to guide them, and they should have both short- and long-term goals.
“DEI work is not a fad. It takes time, effort and money to make a difference,” Dr. Clarke said.
—Callisia Clarke, MD
Panelist Steven Stain, MD, the chair of the Department of Surgery at Lahey Hospital and Medical Center in Burlington, Mass., discussed using sponsors and allies to advance DEI initiatives. He said he has been an ally for the Society of Asian Academic Surgeons and advanced their role with the American College of Surgeons by helping them achieve a governor position with the ACS. Dr. Stain was spurred to help the Society of Asian Academic Surgeons after helping the Society of Black Academic Surgeons achieve an ACS governorship.
Dr. Stain is one of several authors of a manuscript that offers a review of best practices to improve both the recruitment and retention of underrepresented minorities in training programs and beyond (J Surg Educ 2021;78[4]:1058-1065). According to Dr. Stain, diversifying the medical workforce is critical to reducing health care disparity and improving patient outcomes.
Steven Stain, MD
The University of Michigan Initiatives
Panelist Justin B. Dimick, MD, MPH, the Frederick A. Coller Distinguished Professor of Surgery and the chair of the Department of Surgery at the University of Michigan, in Ann Arbor, discussed work to improve the diversity and culture of equity and inclusion at the university. He said initiatives include working to improve the process by which surgeons are recruited, especially working to ensure a diverse applicant pool, objective questions and implicit bias training; improving the work environment so that all can succeed; and making sure everyone has equal access to mentorship, sponsorship and leadership development opportunities. Launch teams are offered to help all new surgical faculty gain access to mentorship and sponsorship and boost teams to help those in mid-career.
Two-year outcomes of these initiatives, said Dr. Dimick, show that the University of Michigan’s Department of Surgery increased the diversity of new faculty hires. A large group of staff, faculty and residents comprise a “culture crew” that is responsible for improving workplace culture and environment.
The University of Michigan also created a cultural complications curriculum to help create a forum to discuss and share perspectives around cultural issues (culturalcomplications.com). Designed to be presented during the standard hospital morbidity and mortality conferences, the curriculum covers 12 core themes in DEI. Each data-driven module introduces the audience to key terminology, provides scientific evidence for the concept and offers sample cases to spur discussion. “There are more than 130 institutions that are implementing this curriculum as part of a collaborative program across the country,” Dr. Dimick said.
Another initiative undertaken at the university was to change the walls. Like most walls, they contained almost exclusively white male portraits. “Our wall space has been redesigned and now represents the diversity of our faculty, staff and trainees,” Dr. Dimick said. “Walls do talk, and we want them to say to everyone, ‘You belong here and you can excel here.’”
During the question-and-answer session of the DEI special panel, numerous attendees applauded the DEI efforts. ■
—Justin B. Dimick, MD
Fluorescence Guided Surgery (FGS) is a medical imaging technique that uses fluorescent dye to identify anatomic structures during surgical procedures. Over the past decade, the benefits of incorporating FGS in surgical practice has resulted in rapid adoption by many leading surgeons and their institutions. The exponential growth in the field of FGS is demonstrated by the number of peer reviewed published articles, which has grown from under 50 in 1995, to over 5,000 being published in 2020.
Despite many advances in preoperative medical imaging such as CT and MRI scans, surgeons still almost exclusively operate under white (visible) light during their procedures and must rely on their ability to see and feel target tissues. With the increasing use of laparoscopic surgeries, this ability to ‘feel’ target tissues is taken away. FGS essentially gives the surgeon the ability to ‘see’ in a different wavelength of light that would otherwise be invisible. By combining this visual ability with the special dyes that glow in those wavelengths, surgeons can much more precisely target or avoid certain organs or tissues. In addition, the near-infrared light used in FGS can more easily penetrate human tissues, allowing surgeons to see ‘through’ layers of tissue and organs. As well as allowing a surgeon to see what otherwise would be invisible, FGS has the added advantage of being a real-time imaging process. Whereas traditional imaging like X-Rays, CT Scans, and MRI scans can provide excellent images, they are all limited to providing static images.
Fluorescence-guided surgery today is used in multiple surgical situations - perfusion assessment, sentinel lymph node (SLN) mapping, identification of solid tumors, and anatomical imaging during surgery. Importantly, FGS can be used seamlessly during the procedure without interrupting the surgeon’s workflow. Currently, ICG is one of the most frequently employed fluorophore used for FGS. ICG was first produced in 1955 by the Kodak Research Laboratories, and in 1959 it was approved by the U.S. Food and Drug Administration (FDA). Intraoperative fluorescence imaging offers the benefits of high contrast and sensitivity, low cost, absence of ionizing radiation, ease of use, safety, and high specificity.
Studies undertaken over the past decade support the overwhelming evidence on the benefits of FGS including the reduction in percentage of procedures with major complications, reduction in the rate of anastomotic leaks, significant reduction in conversion to open procedures as well as improvement in hospital profit margins and referrals.
The International Society of Fluorescence Guided Surgery (ISFGS) is a non-profit organization created for the global advancement of FGS through clinical practice, education, and the promotion of basic and clinical research. Membership in the ISFGS is essential for those who wish to be involved in FGS, to stay current with up-to-date scientific data as well as surgical techniques and thinking that will improve the practice of surgery.
For more information on ISFGS visit www.isfgs.org.
Surgeons Propose New Risk Model for 30-Day Mortality After Major Liver Resection
By MARCUS A. BANKS
Acluster of eight factors appears to help surgeons predict which patients scheduled for major liver resection are most likely to die within 30 days of the procedure.
The risk model, presented at the 2021 virtual Digestive Disease Week, found that patients who receive preoperative steroids, have an albumin–bilirubin score of 2 or more, experience weight loss greater than 10%, are male and at least 65 years of age are much more likely than other patients to die within 30 days of a trisegmentectomy or right hepatectomy (poster Sa671). Although multiple models exist to assess the risk for mortality soon after major liver resection, comprehensive preoperative models including clinical and laboratory values are scarce. The model presented at DDW aims to close this gap.
“Almost all of this information would be in a patient’s medical record after their very first visit,” said Andreas Karachristos, MD, a professor of surgery at the University of South Florida, in Tampa, and the senior author of the study. “We encourage surgeons to consider these various factors as they consult with patients on treatment plans.”
To build their model, Dr. Karachristos and colleagues queried the records of 4,469 major hepatectomies in the American College of Surgeons National Surgical Quality Improvement Program database. These surgeries occurred from 2014 to 2016; the researchers excluded any surgery without a complete preoperative record.
Approximately half of the procedures were in men (51.6%). Eight factors were associated with increased risk for death within 30 days after surgery: albumin–bilirubin grade of 2 or more, a history of congestive heart failure, being male, being 65 years of age or older, low patient functional status, diabetes mellitus, hypertension requiring treatment, and preoperative use of steroids. The researchers weighted all factors equally to make the model as easy to use in daily clinical practice without requiring clinicians to use statistical software to weigh the effects of the different components.
A patient with one of these risk factors appeared to be more likely to die within 30 days of surgery than someone with none of them (odds ratio [OR], 1.71), although the confidence interval crossed 0; thus, one risk factor alone may not matter, the researchers reported.
The risk for death rose with two risk factors (OR, 5.09; 95% CI, 1.53-16.91), and death was much more likely for anyone with three or more risk factors (OR, 12.46; 95% CI, 3.93-39.61; P<0.001). Of 119 total recorded deaths, 107 were linked to two or more risk factors.
“Risk scores like this can be incredibly helpful in terms of setting expectations for patients and families and helping improve our shared decision making,” said Katherine T. Morris, MD, a surgical oncologist and the vice chair of Academic and Research Advancement at the University of Oklahoma College of Medicine, in Oklahoma City.
Dr. Morris noted that eyeball assessments or even formal assessments of patient frailty can sometimes be misleading. Someone who seems likely to struggle following a major liver resection does well, while someone who expected to have no issues fares poorly. For this reason, more objective criteria for risk assessment would be useful.
Dr. Morris added that risk models rarely weight every criterion equally, and that the risk score as presented at DDW did not incorporate indication for resection, such as primary or secondary tumor. Such information would likely affect 30-day mortality as well, she said. ■
For complex hernia repair Forcomplexherniarepair For complex hernia repair
INDICATIONS INDICATIONS
STRATTICE™ Reconstructive Tissue Matrix (RTM), STRATTICE™ RTM Perforated, STRATTICE™ RTM Extra Thick, and STRATTICE™ RTM STRATTICE™ Reconstructive Tissue Matrix (RTM), STRATTICE™ RTM Perforated, STRATTICE™ RTM Extra Thick, and STRATTICE™ RTM Laparoscopic are intended for use as soft tissue patches to reinforce soft tissue where weakness exists and for the surgical repair of damaged or Laparoscopic are intended for use as soft tissue patches to reinforce soft tissue where weakness exists and for the surgical repair of damaged or ruptured soft tissue membranes. Indications for use of these products include the repair of hernias and/or body wall defects which require the ruptured soft tissue membranes. Indications for use of these products include the repair of hernias and/or body wall defects which require the use of reinforcing or bridging material to obtain the desired surgical outcome. STRATTICE™ RTM Laparoscopic is indicated for such uses in open use of reinforcing or bridging material to obtain the desired surgical outcome. STRATTICE™ RTM Laparoscopic is indicated for such uses in open or laparoscopic procedures. These products are supplied sterile and are intended for single patient one-time use only.or laparoscopic procedures. These products are supplied sterile and are intended for single patient one-time use only.
IMPORTANT SAFETY INFORMATION IMPORTANT SAFETY INFORMATION CONTRAINDICATIONS CONTRAINDICATIONS
These products should not be used in patients with a known sensitivity to porcine material and/or Polysorbate 20.These products should not be used in patients with a known sensitivity to porcine material and/or Polysorbate 20.
WARNINGS WARNINGS
Do not resterilize. Discard all open and unused portions of these devices. Do not resterilize. Discard all open and unused portions of these devices. Do not use Do not use if the package is opened or damaged. Do not use if seal is if the package is opened or damaged. Do not use if seal is broken or compromised. After use, handle and dispose of all unused product and packaging in accordance with accepted medical practice and broken or compromised. After use, handle and dispose of all unused product and packaging in accordance with accepted medical practice and applicable local, state, and federal laws and regulations. applicable local, state, and federal laws and regulations. Do not reuse once the surgical mesh has been removed from the packaging and/or is in contact with a patient. This increases risk of patient-to-Do not reuse once the surgical mesh has been removed from the packaging and/or is in contact with a patient. This increases risk of patient-topatient contamination and subsequent infection. patient contamination and subsequent infection. For STRATTICE™ RTM Extra Thick, For STRATTICE™ RTM Extra Thick, do not use if the temperature monitoring device does not display “OK.”do not use if the temperature monitoring device does not display “OK.”
PRECAUTIONS PRECAUTIONS
Discard these products if mishandling has caused possible damage or contamination, or the products are past their expiration date. Ensure Discard these products if mishandling has caused possible damage or contamination, or the products are past their expiration date. Ensure these products are placed in a sterile basin and covered with ro these products are placed in a sterile basin and covered with room temperature sterile saline or room temperature sterile lactaom temperature sterile saline or room temperature sterile lactated Ringer’s ted Ringer’s solution for a minimum of 2 minutes prior to implantation in the body. Place these products in maximum possible contact with healthy, solution for a minimum of 2 minutes prior to implantation in the body. Place these products in maximum possible contact with healthy, well-vascularized tissue to promote cell ingrowth and tissue remodeling. These products should be hydrated and moist when the package is well-vascularized tissue to promote cell ingrowth and tissue remodeling. These products should be hydrated and moist when the package is opened. If the surgical mesh is dry, do not use. opened. If the surgical mesh is dry, do not use.
Effect of Pot Smoking on Major Surgical Outcomes Insignificant
By MICHAEL VLESSIDES
As more North Americans are partaking of legal cannabis, exposure to the substance does not seem to affect major surgical outcomes, according to the results of a large cohort study.
Canadian researchers have concluded that routine cannabis use does not affect a composite outcome of respiratory/cardiac arrest, ICU admission, stroke, myocardial infarction and mortality during hospital stays.
“Cannabis contains cannabinoids, which can interact with neurotransmitters, thereby creating potential drug interactions in the perioperative period,” said Betty Huiyu Zhang, MD, a resident at the University of Ottawa, in Ontario. “Preclinical studies indicate the potential for such cardiovascular complications as arrhythmias and blood pressure changes.
“Smoking cannabis can also cause airway hypersensitivity, and smaller retrospective studies have suggested that cannabis may be associated with increased propofol requirements for induction and sedation,” Dr. Zhang added.
Other research has found a potential link between cannabis use and perioperative analgesic difficulties, and mixed results with respect to postoperative pain control.
Therefore, Dr. Zhang and her colleagues evaluated the effect of routine cannabis use on perioperative outcomes in a large patient cohort. The researchers captured data from 1,818 surgical patients presenting to the institution between January 2018 and March 2019. Cannabis users were identified by selfdisclosure at their preoperative visit.
Multiple logistic regression with propensity score matching was used to adjust for a number of potentially confounding baseline variables, including age, sex, body mass index, smoking status, other recreational drug use, surgical setting (inpatient vs. ambulatory), type of surgery and type of anesthesia.WITH WITH THE
STRATTICE STRATTICE™ RTM is designed to be positively recognized, RTM is designed to be positively recognized, allowing for allowing for regeneration regeneration and a repair that holds. 1,2,*and a repair that holds.
*Correlation of these results, based on animal studies, to results in humans has not been established. *Correlation of these results, based on animal studies, to results in humans has not been established.
In a recent retrospective evaluation of biologic meshes, including STRATTICE In a recent retrospective evaluation of biologic meshes, including STRATTICE™ , , 91.7% OF PATIENTS WERE RECURRENCE-FREE AT OF PATIENTS WERE RECURRENCE-FREE AT 7 YEARS POST-OP3,†POST-OP3,†
†Includes porcine and bovine acellular dermal matrices (ADMs) (n = 157). Bridged repair and human ADM were excluded from the study group.Includes porcine and bovine acellular dermal matrices (ADMs) (n = 157). Bridged repair and human ADM were excluded from the study group.
For more information, contact your Allergan Aesthetics For more information, contact your Allergan Aesthetics representative or visit hcp.StratticeTissueMatrix.com representative or visit hcp.StratticeTissueMatrix.com
PRECAUTIONS (continued) PRECAUTIONS (continued)
Certain considerations should be used when performing surgical procedures using a surgical mesh product. Consider the risk/benefit balance of Certain considerations should be used when performing surgical procedures using a surgical mesh product. Consider the risk/benefit balance of use in patients with significant co-morbidities; including but not limited to, obesity, smoking, diabetes, immunosuppression, malnourishment, use in patients with significant co-morbidities; including but not limited to, obesity, smoking, diabetes, immunosuppression, malnourishment, poor tissue oxygenation (such as COPD), and pre- or post-operative radiation. poor tissue oxygenation (such as COPD), and pre- or post-operative radiation. Bioburden-reducing techniques should be utilized in significantly contaminated or infected cases to minimize contamination levels at the Bioburden-reducing techniques should be utilized in significantly contaminated or infected cases to minimize contamination levels at the surgical site, including, but not limited to, appropriate drainage, debridement, negative pressure therapy, and/or antimicrobial therapy prior and surgical site, including, but not limited to, appropriate drainage, debridement, negative pressure therapy, and/or antimicrobial therapy prior and in addition to implantation of the surgical mesh. In large abdominal wall defect cases where midline fascial closure cannot be obtained, with in addition to implantation of the surgical mesh. In large abdominal wall defect cases where midline fascial closure cannot be obtained, with or without separation of components techniques, utilization of the surgical mesh in a bridged fashion is associated with a higher risk of hernia or without separation of components techniques, utilization of the surgical mesh in a bridged fashion is associated with a higher risk of hernia recurrence than when used to reinforce fascial closure.recurrence than when used to reinforce fascial closure. For STRATTICE™ RTM Perforated, if a tissue punch-out piece is visible, remove using aseptic technique before implantation.For STRATTICE™ RTM Perforated, if a tissue punch-out piece is visible, remove using aseptic technique before implantation. For STRATTICE™ RTM Laparoscopic, refrain from using excessive force if inserting the mesh through the trocar. For STRATTICE™ RTM Laparoscopic, refrain from using excessive force if inserting the mesh through the trocar. STRATTICE STRATTICE™ RTM, STRATTICE™ RTM, STRATTICE™ RTM Perforated, STRATTICE™ RTM Perforated, STRATTICE™ ™ RTM Extra Thick, and STRATTICE RTM Extra Thick, and STRATTICE™ ™ RTM Laparoscopic are available by RTM Laparoscopic are available by
prescription only. prescription only.
For more information, please see the Instructions for Use (IFU) for all STRATTICEFor more information, please see the Instructions for Use (IFU) for all STRATTICE™ RTM ™ RTM
products available at www.allergan.com/StratticeIFU or call 1.800.678.1605.products available at www.allergan.com/StratticeIFU or call 1.800.678.1605. To report an adverse reaction, please call Allergan at 1.800.367.5737.To report an adverse reaction, please call Allergan at 1.800.367.5737. For more information, please call Allergan Customer Service at 1.800.367.5737, For more information, please call Allergan Customer Service at 1.800.367.5737, or visit hcp.StratticeTissueMatrix.com.or visit hcp.StratticeTissueMatrix.com.
References: 1. Connor J, McQuillan D, Sandor M, et al. Retention of structural and biochemical integrity in a biological mesh supports References: 1. Connor J, McQuillan D, Sandor M, et al. Retention of structural and biochemical integrity in a biological mesh supports tissue remodeling in a primate abdominal wall model. Regen Med. 2009;4(2):185-195. 2. Sun WQ, Xu H, Sandor M, Lombardi J. tissue remodeling in a primate abdominal wall model. Regen Med. 2009;4(2):185-195. 2. Sun WQ, Xu H, Sandor M, Lombardi J. Process-induced extracellular matrix alterations affect the mechanisms of soft tissue repair and integration. J Tissue Eng. Process-induced extracellular matrix alterations affect the mechanisms of soft tissue repair and integration. J Tissue Eng. 2013;4:2041731413505305. doi: 10.1177/2041731413505305. 3. Garvey PB, Giordano SA, Baumann DP, Liu J, Butler CE. 2013;4:2041731413505305. doi: 10.1177/2041731413505305. 3. Garvey PB, Giordano SA, Baumann DP, Liu J, Butler CE. Long-term outcomes after abdominal wall reconstruction with acellular dermal matrix. J Am Coll Surg. 2017;224(3):341-350. Long-term outcomes after abdominal wall reconstruction with acellular dermal matrix. J Am Coll Surg. 2017;224(3):341-350.
No Difference Across Several End Points
In a presentation during the 2021 Annual Regional Anesthesiology and Acute Pain Medicine Meeting of the American Society of Regional Anesthesia and Pain Medicine (abstract 1875), Dr. Zhang noted that 606 patients preoperatively reported cannabis use, while the remaining 1,212 served as controls. The total prevalence of reported cannabis use was 4% (606/15,048).
For the propensity score–matched analyses, there was a final cohort of 524 cannabis users with complete information and 1,152 controls. No difference was found between groups with respect to the study’s primary end point: Seven cannabis users (1.2%) experienced the composite outcome of respiratory/cardiac arrest, ICU admission, stroke, myocardial infarction or mortality during their hospital stay, compared with 11 controls (0.9%), yielding an odds ratio of 1.06 (95% CI, 0.23-3.98).
Although cannabis users experienced a greater incidence of arrhythmias than controls (2.7% vs. 1.6%; P=0.15), along with a decreased incidence of postoperative nausea and vomiting requiring treatment (9.6% vs. 12.6%; P=0.08), these differences were not statistically significant. The incidence of severe pain during recovery was also comparable between groups, affecting 30.9% of cannabis users and 33.5% of their counterparts who did not use cannabis (P=0.31).
Cannabis Use Hard to Pinpoint
“More rigorous study should be designed to examine these outcomes,” Dr. Zhang said. As the researchers discussed, the study represents the largest single-center effort examining regular cannabis use in average doses. Nevertheless, the analysis was not without its shortcomings,
