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The Cochrane Database of Systematic... Apr 2017Decision aids are interventions that support patients by making their decisions explicit, providing information about options and associated benefits/harms, and helping... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Decision aids are interventions that support patients by making their decisions explicit, providing information about options and associated benefits/harms, and helping clarify congruence between decisions and personal values.
OBJECTIVES
To assess the effects of decision aids in people facing treatment or screening decisions.
SEARCH METHODS
Updated search (2012 to April 2015) in CENTRAL; MEDLINE; Embase; PsycINFO; and grey literature; includes CINAHL to September 2008.
SELECTION CRITERIA
We included published randomized controlled trials comparing decision aids to usual care and/or alternative interventions. For this update, we excluded studies comparing detailed versus simple decision aids.
DATA COLLECTION AND ANALYSIS
Two reviewers independently screened citations for inclusion, extracted data, and assessed risk of bias. Primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were attributes related to the choice made and the decision-making process.Secondary outcomes were behavioural, health, and health system effects.We pooled results using mean differences (MDs) and risk ratios (RRs), applying a random-effects model. We conducted a subgroup analysis of studies that used the patient decision aid to prepare for the consultation and of those that used it in the consultation. We used GRADE to assess the strength of the evidence.
MAIN RESULTS
We included 105 studies involving 31,043 participants. This update added 18 studies and removed 28 previously included studies comparing detailed versus simple decision aids. During the 'Risk of bias' assessment, we rated two items (selective reporting and blinding of participants/personnel) as mostly unclear due to inadequate reporting. Twelve of 105 studies were at high risk of bias.With regard to the attributes of the choice made, decision aids increased participants' knowledge (MD 13.27/100; 95% confidence interval (CI) 11.32 to 15.23; 52 studies; N = 13,316; high-quality evidence), accuracy of risk perceptions (RR 2.10; 95% CI 1.66 to 2.66; 17 studies; N = 5096; moderate-quality evidence), and congruency between informed values and care choices (RR 2.06; 95% CI 1.46 to 2.91; 10 studies; N = 4626; low-quality evidence) compared to usual care.Regarding attributes related to the decision-making process and compared to usual care, decision aids decreased decisional conflict related to feeling uninformed (MD -9.28/100; 95% CI -12.20 to -6.36; 27 studies; N = 5707; high-quality evidence), indecision about personal values (MD -8.81/100; 95% CI -11.99 to -5.63; 23 studies; N = 5068; high-quality evidence), and the proportion of people who were passive in decision making (RR 0.68; 95% CI 0.55 to 0.83; 16 studies; N = 3180; moderate-quality evidence).Decision aids reduced the proportion of undecided participants and appeared to have a positive effect on patient-clinician communication. Moreover, those exposed to a decision aid were either equally or more satisfied with their decision, the decision-making process, and/or the preparation for decision making compared to usual care.Decision aids also reduced the number of people choosing major elective invasive surgery in favour of more conservative options (RR 0.86; 95% CI 0.75 to 1.00; 18 studies; N = 3844), but this reduction reached statistical significance only after removing the study on prophylactic mastectomy for breast cancer gene carriers (RR 0.84; 95% CI 0.73 to 0.97; 17 studies; N = 3108). Compared to usual care, decision aids reduced the number of people choosing prostate-specific antigen screening (RR 0.88; 95% CI 0.80 to 0.98; 10 studies; N = 3996) and increased those choosing to start new medications for diabetes (RR 1.65; 95% CI 1.06 to 2.56; 4 studies; N = 447). For other testing and screening choices, mostly there were no differences between decision aids and usual care.The median effect of decision aids on length of consultation was 2.6 minutes longer (24 versus 21; 7.5% increase). The costs of the decision aid group were lower in two studies and similar to usual care in four studies. People receiving decision aids do not appear to differ from those receiving usual care in terms of anxiety, general health outcomes, and condition-specific health outcomes. Studies did not report adverse events associated with the use of decision aids.In subgroup analysis, we compared results for decision aids used in preparation for the consultation versus during the consultation, finding similar improvements in pooled analysis for knowledge and accurate risk perception. For other outcomes, we could not conduct formal subgroup analyses because there were too few studies in each subgroup.
AUTHORS' CONCLUSIONS
Compared to usual care across a wide variety of decision contexts, people exposed to decision aids feel more knowledgeable, better informed, and clearer about their values, and they probably have a more active role in decision making and more accurate risk perceptions. There is growing evidence that decision aids may improve values-congruent choices. There are no adverse effects on health outcomes or satisfaction. New for this updated is evidence indicating improved knowledge and accurate risk perceptions when decision aids are used either within or in preparation for the consultation. Further research is needed on the effects on adherence with the chosen option, cost-effectiveness, and use with lower literacy populations.
Topics: Communication; Conservative Treatment; Decision Support Techniques; Elective Surgical Procedures; Health Knowledge, Attitudes, Practice; Humans; Patient Education as Topic; Patient Participation; Physician-Patient Relations; Publication Bias; Randomized Controlled Trials as Topic
PubMed: 28402085
DOI: 10.1002/14651858.CD001431.pub5 -
The New England Journal of Medicine Aug 2002In women with breast cancer, the role of radical mastectomy, as compared with less extensive surgery, has been a matter of debate. We report 25-year findings of a... (Clinical Trial)
Clinical Trial Comparative Study Randomized Controlled Trial
BACKGROUND
In women with breast cancer, the role of radical mastectomy, as compared with less extensive surgery, has been a matter of debate. We report 25-year findings of a randomized trial initiated in 1971 to determine whether less extensive surgery with or without radiation therapy was as effective as the Halsted radical mastectomy.
METHODS
A total of 1079 women with clinically negative axillary nodes underwent radical mastectomy, total mastectomy without axillary dissection but with postoperative irradiation, or total mastectomy plus axillary dissection only if their nodes became positive. A total of 586 women with clinically positive axillary nodes either underwent radical mastectomy or underwent total mastectomy without axillary dissection but with postoperative irradiation. Kaplan-Meier and cumulative-incidence estimates of outcome were obtained.
RESULTS
No significant differences were observed among the three groups of women with negative nodes or between the two groups of women with positive nodes with respect to disease-free survival, relapse-free survival, distant-disease-free survival, or overall survival. Among women with negative nodes, the hazard ratio for death among those who were treated with total mastectomy and radiation as compared with those who underwent radical mastectomy was 1.08 (95 percent confidence interval, 0.91 to 1.28; P=0.38), and the hazard ratio for death among those who had total mastectomy without radiation as compared with those who underwent radical mastectomy was 1.03 (95 percent confidence interval, 0.87 to 1.23; P=0.72). Among women with positive nodes, the hazard ratio for death among those who underwent total mastectomy and radiation as compared with those who underwent radical mastectomy was 1.06 (95 percent confidence interval, 0.89 to 1.27; P=0.49).
CONCLUSIONS
The findings validate earlier results showing no advantage from radical mastectomy. Although differences of a few percentage points cannot be excluded, the findings fail to show a significant survival advantage from removing occult positive nodes at the time of initial surgery or from radiation therapy.
Topics: Breast Neoplasms; Combined Modality Therapy; Disease-Free Survival; Female; Follow-Up Studies; Humans; Incidence; Lymphatic Metastasis; Mastectomy, Radical; Mastectomy, Simple; Neoplasm Recurrence, Local; Randomized Controlled Trials as Topic; Survival Analysis
PubMed: 12192016
DOI: 10.1056/NEJMoa020128 -
Gland Surgery Jan 2021Breast sensation has recently become an integral aspect of the reconstructive goal after mastectomy and is an important consideration for many patients. Neurotization... (Review)
Review
Breast sensation has recently become an integral aspect of the reconstructive goal after mastectomy and is an important consideration for many patients. Neurotization techniques using primary coaptation, autograft, allograft, or nerve conduit have been used for autologous flaps, such as the deep inferior epigastric perforator (DIEP) flap. Outcomes have shown improved sensation and faster sensory recovery in the flap skin in immediate neurotized DIEP flap breast reconstructions compared to delayed reconstruction. Breast flap neurotization during reconstruction is a rapid and simple procedure with minimal morbidity. An improved understanding of breast anatomy and innovative modifications to breast reconstruction have made the restoration of breast sensation achievable, and promising results have been obtained with respect to sensory return and patient satisfaction.
PubMed: 33634007
DOI: 10.21037/gs.2020.03.22 -
Journal of Breast Cancer Feb 2021Surgical approaches in breast cancer have been changing to ensure both oncologic safety and cosmetic results. Although the concept of "oncoplastic breast surgery" has... (Review)
Review
Surgical approaches in breast cancer have been changing to ensure both oncologic safety and cosmetic results. Although the concept of "oncoplastic breast surgery" has been accepted for decades, breast and plastic surgeons have been striving to develop more advanced surgical skills that ensure non-inferior oncologic outcomes with better cosmetic outcomes. Endoscopic or robotic devices, which are currently available only for chest or abdominal surgeries, could be used for breast surgery to ensure better cosmetic outcomes. The authors refer to this surgical concept as "aesthetic scar-less breast surgery and reconstruction," a term that encompasses the consequential concepts rather than naming it with simple technical words such as endoscopy-assisted or robot-assisted surgery. The "scar-less" term simply means leaving less of a scar, and better results can be expected by designing incisions on invisible areas. Herein, we summarize our experiences with various techniques of "aesthetic scar-less" surgery and review the existing literature on this topic.
PubMed: 33634618
DOI: 10.4048/jbc.2021.24.e11 -
International Journal of Surgery... 2012To reconstruct a breast mound from cutaneous mastectomy flap tissue alone, obviating the need for additional flap or implant techniques.
OBJECTIVE
To reconstruct a breast mound from cutaneous mastectomy flap tissue alone, obviating the need for additional flap or implant techniques.
SUMMARY BACKGROUND DATA
With growing numbers of obese and elderly women facing breast cancer, options outside of simple mastectomy without reconstruction and formal breast reconstruction using complex autologous flap harvesting techniques or artificial implants need to be explored.
METHODS
Patients who declined traditional methods of breast reconstruction were offered standard skin sparing mastectomy with closure utilizing a standard Wise pattern. A completely autologous breast mound was created by preserving and de-epithelializing residual mastectomy flap tissue.
RESULTS
Over 24 months, 32 women (50 breasts) underwent mastectomy and closure using this technique. Seromas occurred in 1 of 50 operated breasts and cellulitis developed in 3 of 50 breasts. One of the two patients had active hidradenitis at the time of surgery which made expander placement a contraindication and post operative infection a high risk. There has been no incidence of locoregional breast cancer recurrence.
CONCLUSIONS
Some patients are poor candidates for traditional methods of breast reconstruction secondary to medical comorbidities, while others may decline for more personal reasons. For these patients, we describe an additional option. The procedure is performed in a single stage and does not necessitate closure by a reconstructive surgeon, although a team approach can improve aesthetic results. Disadvantages include limited applicability in patients with small, non-ptotic breasts. Deemed the "Goldilocks Mastectomy", it is neither amputation of the breast, nor is it full reconstruction. It is a third, middle option. This offers an aesthetic advantage for women over simple mastectomy without reconstruction and potentially decreases cost and number of procedures sometimes associated with formal reconstruction.
Topics: Adult; Aged; Aged, 80 and over; Breast; Breast Neoplasms; Female; Humans; Mammaplasty; Mastectomy; Middle Aged; Surgical Flaps
PubMed: 22892093
DOI: 10.1016/j.ijsu.2012.08.003 -
The Indian Journal of Surgery Apr 2015Ductal carcinoma in situ (DCIS) of the breast is a potentially invasive neoplasm. Risk factors include high estrogen states such as use of oral contraceptive (OC) pills,... (Review)
Review
Ductal carcinoma in situ (DCIS) of the breast is a potentially invasive neoplasm. Risk factors include high estrogen states such as use of oral contraceptive (OC) pills, nulliparity, advanced age at first birth, and also family history and genetic mutations. The incidence of this usually clinically silent condition has risen in the past few decades due to widespread screening and diagnostic mammography, with final diagnosis confirmed by biopsy. At present, treatment options include total or simple mastectomy or lumpectomy with radiation. Adjuvant therapy includes antiestrogens like tamoxifen and human epidermal growth factor receptor 2 (HER2) suppression therapy. With the latest advances in chemotherapy and better understanding on the pathogenesis of the lesion, it is anticipated that more effective modalities of treatment may soon be available.
PubMed: 26139969
DOI: 10.1007/s12262-013-0987-0 -
Wounds : a Compendium of Clinical... Jan 2018Everyone has experienced itch. It might simply be the nuisance of a mosquito bite or a transient itch on the scalp that is relieved by a simple scratch. For wounds such...
Everyone has experienced itch. It might simply be the nuisance of a mosquito bite or a transient itch on the scalp that is relieved by a simple scratch. For wounds such as venous ulcers, itch may be present but is usually mild. For some of the 40% of people with neuropathic itch or pain that can develop and persist following mastectomy, itch can be overwhelming, intractable, not widely appreciated by the medical community, and poorly responsive to current treatment regimens. Why are some wounds in some patients itchy whereas seemingly equivalent ones in the same or other patients not? Why is the sensation of itch present in the wound itself in some cases while in the surrounding skin in others? Why are burns so frequently associated with itch? How commonly do wounds itch? Detailed answers to these questions are lacking, but this area is beginning to be explored. Herein, the author provides an overview of the current understanding of the physiology of itch. An effort is made to place that understanding in the context of wounds, and therapeutic approaches that may be outside of the conventional toolkit are made based on this background.
Topics: Humans; Peripheral Nerves; Pruritus; Signal Transduction; Wound Healing; Wounds and Injuries
PubMed: 29406291
DOI: No ID Found -
Journal of Clinical and Diagnostic... Jan 2017Phyllodes Tumour (PT) of the breast is a relatively rare breast neoplasm (<1%) with diverse range of pathology and biological behaviour.
INTRODUCTION
Phyllodes Tumour (PT) of the breast is a relatively rare breast neoplasm (<1%) with diverse range of pathology and biological behaviour.
AIM
To describe the clinical course of PT and to define the role of Radiotherapy (RT) in PT of the breast.
MATERIALS AND METHODS
Retrospective analysis of hospital data of patients with PT presented from 2005 to 2014 was done. Descriptive statistics was used to analyze the results. Simple description of data was done in this study. Age and duration of symptoms were expressed in median and range. Percentages, tables and general discussions were used to understand the meaning of the data analyzed.
RESULTS
Out of the 98 patients, 92 were eligible for analysis. The median age of presentation was 43 years. A total of 64/92 patients were premenopausal. There was no side predilection for this tumour but 57/92 patients presented as an upper outer quadrant lump. Fifty percent of the patients presented as giant (10 cm) PT. The median duration of symptoms was 12 months (range: 1-168 months). A 60% of patients had Benign (B), 23% had Borderline (BL) and 17% had malignant (M) tumours. The surgical treatment for benign histology included Lumpectomy (L) for 15%, Wide Local Excision (WLE) for 48%, and Simple Mastectomy (SM) for 37%. All BL and M tumours were treated with WLE or SM. There was no recurrence in B and BL group when the margin was ≥1 cm. All non-metastatic M tumours received adjuvant RT irrespective of their margin status. Total 3/16 patients with M developed local recurrence. Total 6/16 M patients had distant metastases (lung or bone). Our median duration of follow up was 20 months (range: 1-120 months).
CONCLUSION
Surgical resection with adequate margins (>1 cm) gave excellent local control in B and BL tumours. For patients with BL PT, local radiotherapy is useful, if margins are close or positive even after the best surgical resection. There is a trend towards improved local control with adjuvant radiotherapy for malignant PT. Metastatic malignant PT has a poor outcome.
PubMed: 28274029
DOI: 10.7860/JCDR/2017/24591.9167