TBD Meeting (5002-19)

Breast cancer patients with HER2-positive disease are more likely to be nonsurgical candidates for clinical trials after neoadjuvant systemic therapy if they have eradicated both invasive and ductal carcinoma in situ (DCIS) disease, according to research presented in a recent webcast from the annual meeting of the American Society of Breast Surgeons.

While there is a high rate of pathologic complete response (pCR) in HER2-postive breast cancer after neoadjuvant systemic therapy, it is difficult to determine which patients have achieved pCR because standard imaging generates a high rate of false negatives, noted Susie Sun, MD, from the University of Texas MD Anderson Cancer Center, Houston.

“Although radiological imaging such as mammograms, ultrasounds, and MRIs have been shown to be unreliable in identifying patients with pCR, we have previously determined that patients with clinically significant residual disease can be accurately identified using a combination of multimodality imaging and image-guided, vacuum-assisted biopsy to the tumor bed,” Dr. Sun said in her presentation.

In the Multicenter Trial for Eliminating Breast Cancer Surgery in Exceptional Responders With Neoadjuvant Systemic Therapy, Dr. Sun and colleagues enrolled 280 patients with T1-T2, N0-N1 HER2-positive breast cancer who had undergone HER2-targeted therapy, followed by surgical resection and axillary surgery. The researchers studied both the effects of neoadjuvant therapy patients with pCR and the clinicopathologic characteristics of residual disease to determine how patients with pCR differed from those with residual disease.

After neoadjuvant systemic therapy, 55.4% of pCR invasive cancer was eradicated in patients, 37.5% of both pCR invasive and DCIS cancer was eradicated in patients, and 17.9% of patients had eradication of only residual DCIS. Compared with patients where DCIS was not identified at initial biopsy, DCIS identification was associated with a higher likelihood of residual disease (69% vs. 57%; P = .04). The researchers found patients having hormone receptor–positive/HER2-positive disease was associated with a higher rate of predictive residual disease (26.6%), compared with patients who had hormone receptor–negative/HER2-positive disease (49.2%; odds ratio, 2.7; 95% confidence interval, P less than .0001).

“For the currently occurring trial, evaluating the safety of eliminating surgery for patients who are exceptional responders to neoadjuvant systemic therapy, eradication of both the invasive and DCIS components are necessary because DCIS may serve as a nidus for carcinoma in the future,” said Dr. Sun.

The researchers also studied the effectiveness of multimodality imaging on identifying pathologic response. The multimodality imaging consisted of a mammogram and ultrasound for all patients, and approximately 13% of patients had MRI in addition to mammogram and ultrasound. The multimodality imaging response after neoadjuvant systemic therapy had a sensitivity of 97.1% and a negative predictive value of 70.6% for detecting residual disease in the breast and lymph nodes.

“[O]ur study found that multimodality imaging was not reliable in assessing for pathologic response within the breast or lymph nodes,” said Dr. Sun. “Therefore, imaging alone cannot be used to select patients for no surgery. This requires patients who have image-guided percutaneous biopsy to safely select patients for inclusion and elimination of surgery trial.”

In a discussion session, Dr. Sun clarified the combination of multimodality imaging and image-guided percutaneous biopsy was used to select HER2-positive patients for a clinical trial, and is not standard of practice to determine pCR at the University of Texas MD Anderson Cancer Center.

Dr. Sun reported no relevant financial disclosures.

Breast cancer patients with HER2-positive disease are more likely to be nonsurgical candidates for clinical trials after neoadjuvant systemic therapy if they have eradicated both invasive and ductal carcinoma in situ (DCIS) disease, according to research presented in a recent webcast from the annual meeting of the American Society of Breast Surgeons.

While there is a high rate of pathologic complete response (pCR) in HER2-postive breast cancer after neoadjuvant systemic therapy, it is difficult to determine which patients have achieved pCR because standard imaging generates a high rate of false negatives, noted Susie Sun, MD, from the University of Texas MD Anderson Cancer Center, Houston.

“Although radiological imaging such as mammograms, ultrasounds, and MRIs have been shown to be unreliable in identifying patients with pCR, we have previously determined that patients with clinically significant residual disease can be accurately identified using a combination of multimodality imaging and image-guided, vacuum-assisted biopsy to the tumor bed,” Dr. Sun said in her presentation.

In the Multicenter Trial for Eliminating Breast Cancer Surgery in Exceptional Responders With Neoadjuvant Systemic Therapy, Dr. Sun and colleagues enrolled 280 patients with T1-T2, N0-N1 HER2-positive breast cancer who had undergone HER2-targeted therapy, followed by surgical resection and axillary surgery. The researchers studied both the effects of neoadjuvant therapy patients with pCR and the clinicopathologic characteristics of residual disease to determine how patients with pCR differed from those with residual disease.

After neoadjuvant systemic therapy, 55.4% of pCR invasive cancer was eradicated in patients, 37.5% of both pCR invasive and DCIS cancer was eradicated in patients, and 17.9% of patients had eradication of only residual DCIS. Compared with patients where DCIS was not identified at initial biopsy, DCIS identification was associated with a higher likelihood of residual disease (69% vs. 57%; P = .04). The researchers found patients having hormone receptor–positive/HER2-positive disease was associated with a higher rate of predictive residual disease (26.6%), compared with patients who had hormone receptor–negative/HER2-positive disease (49.2%; odds ratio, 2.7; 95% confidence interval, P less than .0001).

“For the currently occurring trial, evaluating the safety of eliminating surgery for patients who are exceptional responders to neoadjuvant systemic therapy, eradication of both the invasive and DCIS components are necessary because DCIS may serve as a nidus for carcinoma in the future,” said Dr. Sun.

The researchers also studied the effectiveness of multimodality imaging on identifying pathologic response. The multimodality imaging consisted of a mammogram and ultrasound for all patients, and approximately 13% of patients had MRI in addition to mammogram and ultrasound. The multimodality imaging response after neoadjuvant systemic therapy had a sensitivity of 97.1% and a negative predictive value of 70.6% for detecting residual disease in the breast and lymph nodes.

“[O]ur study found that multimodality imaging was not reliable in assessing for pathologic response within the breast or lymph nodes,” said Dr. Sun. “Therefore, imaging alone cannot be used to select patients for no surgery. This requires patients who have image-guided percutaneous biopsy to safely select patients for inclusion and elimination of surgery trial.”

In a discussion session, Dr. Sun clarified the combination of multimodality imaging and image-guided percutaneous biopsy was used to select HER2-positive patients for a clinical trial, and is not standard of practice to determine pCR at the University of Texas MD Anderson Cancer Center.

Dr. Sun reported no relevant financial disclosures.

Breast cancer patients with HER2-positive disease are more likely to be nonsurgical candidates for clinical trials after neoadjuvant systemic therapy if they have eradicated both invasive and ductal carcinoma in situ (DCIS) disease, according to research presented in a recent webcast from the annual meeting of the American Society of Breast Surgeons.

While there is a high rate of pathologic complete response (pCR) in HER2-postive breast cancer after neoadjuvant systemic therapy, it is difficult to determine which patients have achieved pCR because standard imaging generates a high rate of false negatives, noted Susie Sun, MD, from the University of Texas MD Anderson Cancer Center, Houston.

“Although radiological imaging such as mammograms, ultrasounds, and MRIs have been shown to be unreliable in identifying patients with pCR, we have previously determined that patients with clinically significant residual disease can be accurately identified using a combination of multimodality imaging and image-guided, vacuum-assisted biopsy to the tumor bed,” Dr. Sun said in her presentation.

In the Multicenter Trial for Eliminating Breast Cancer Surgery in Exceptional Responders With Neoadjuvant Systemic Therapy, Dr. Sun and colleagues enrolled 280 patients with T1-T2, N0-N1 HER2-positive breast cancer who had undergone HER2-targeted therapy, followed by surgical resection and axillary surgery. The researchers studied both the effects of neoadjuvant therapy patients with pCR and the clinicopathologic characteristics of residual disease to determine how patients with pCR differed from those with residual disease.

After neoadjuvant systemic therapy, 55.4% of pCR invasive cancer was eradicated in patients, 37.5% of both pCR invasive and DCIS cancer was eradicated in patients, and 17.9% of patients had eradication of only residual DCIS. Compared with patients where DCIS was not identified at initial biopsy, DCIS identification was associated with a higher likelihood of residual disease (69% vs. 57%; P = .04). The researchers found patients having hormone receptor–positive/HER2-positive disease was associated with a higher rate of predictive residual disease (26.6%), compared with patients who had hormone receptor–negative/HER2-positive disease (49.2%; odds ratio, 2.7; 95% confidence interval, P less than .0001).

“For the currently occurring trial, evaluating the safety of eliminating surgery for patients who are exceptional responders to neoadjuvant systemic therapy, eradication of both the invasive and DCIS components are necessary because DCIS may serve as a nidus for carcinoma in the future,” said Dr. Sun.

The researchers also studied the effectiveness of multimodality imaging on identifying pathologic response. The multimodality imaging consisted of a mammogram and ultrasound for all patients, and approximately 13% of patients had MRI in addition to mammogram and ultrasound. The multimodality imaging response after neoadjuvant systemic therapy had a sensitivity of 97.1% and a negative predictive value of 70.6% for detecting residual disease in the breast and lymph nodes.

“[O]ur study found that multimodality imaging was not reliable in assessing for pathologic response within the breast or lymph nodes,” said Dr. Sun. “Therefore, imaging alone cannot be used to select patients for no surgery. This requires patients who have image-guided percutaneous biopsy to safely select patients for inclusion and elimination of surgery trial.”

In a discussion session, Dr. Sun clarified the combination of multimodality imaging and image-guided percutaneous biopsy was used to select HER2-positive patients for a clinical trial, and is not standard of practice to determine pCR at the University of Texas MD Anderson Cancer Center.

Dr. Sun reported no relevant financial disclosures.

Bioimpedance spectroscopy may better identify lymphedema progression in women at risk for breast cancer–related lymphedema over the traditionally used method of monitoring arm circumference with a tape measure, according to results from an interim analysis of the PREVENT trial presented in a recent webcast from the annual meeting of the American Society of Breast Surgeons.

“Despite advances in breast-conserving surgery, improved radiation protocol, the advent of sentinel [node] biopsies and recent improvement in chemotherapy regimens, breast cancer–related lymphedema ... remains a major source of morbidity and concern in this patient population,” Sheila Ridner, PhD, RN, FAAN, professor of nursing at the Vanderbilt University School of Nursing in Nashville, Tenn., said in her presentation. “Because it is thought that early identification of swelling in the limbs coupled with a compression intervention may reduce the risk of patients developing full-blown clinical lymphedema, clinicians are proposing to use a prospective surveillance model to follow breast cancer survivors post surgery in order to assess limbs in a routine fashion and perhaps instigate preventative mechanisms early.”

The larger randomized controlled Prevention of Lymphedema Following Locoregional Treatment for Breast Cancer (PREVENT) trial enrolled 1,201 patients, and 200 patients overall have completed the full protocol. The researchers plan to follow patients for 3 years after surgery. In this interim analysis, Dr. Ridner and colleagues analyzed data from 508 patients at eight sites in the United States and four sites in Sydney who had stage I through stage III or ductal carcinoma in situ (DCIS) breast cancer and underwent mastectomy, taxane-based chemotherapy, or an axillary treatment such as axillary radiation, axillary lymph node dissection, or sentinel lymph nose biopsy with more than 6 nodes.

The patients were randomized to be measured using either traditional tape measurement or bioimpedance spectroscopy (BIS). Patients were moved to a prevention intervention if there was a change in baseline volume of 5% or greater but less than 10% in the tape measure group and change from baseline L-Dex measurement of 6.5 or greater in the BIS group, which consisted of wearing an arm compression sleeve and chest gauntlet for 12 hours a day over 4 weeks. After surgery, the patients were followed up at 3 months, 6 months, 12 months, 18 months, and 24 months, with optional follow-up visits at 15 months and 21 months. Progression to full lymphedema was defined as a 10% or greater change in pretreatment baseline measurements in the tape measure group.

Of the 508 patients analyzed, 10 patients had already progressed to full lymphedema, leaving 498 patients available for the interim analysis. There were 68 patients in the tape measure group (28.5%) and 41 patients in the BIS group (15.8%) who received the prevention intervention, and 10 patients in the tape measure group (14.7%) and 2 patients in the BIS group (4.9%) eventually progressed to full lymphedema. In the BIS group, there was a 10% absolute reduction and 67% relative reduction in lymphedema progression, compared with the tape measure group.

“We believe that the 10% absolute reduction is clinically significant for this patient population,” said Dr. Ridner. “We also believe that our interim results may support the concept of posttreatment surveillance using BIS for early detection of subclinical lymphedema coupled with early intervention as our preliminary data suggest this does have clinical advantages to the patient.”

The study was funded by ImpediMed. Dr. Ridner reports being the principal investigator for ImpediMed and Tactile Medical through work agreements contracted between the companies and her institution.

Bioimpedance spectroscopy may better identify lymphedema progression in women at risk for breast cancer–related lymphedema over the traditionally used method of monitoring arm circumference with a tape measure, according to results from an interim analysis of the PREVENT trial presented in a recent webcast from the annual meeting of the American Society of Breast Surgeons.

“Despite advances in breast-conserving surgery, improved radiation protocol, the advent of sentinel [node] biopsies and recent improvement in chemotherapy regimens, breast cancer–related lymphedema ... remains a major source of morbidity and concern in this patient population,” Sheila Ridner, PhD, RN, FAAN, professor of nursing at the Vanderbilt University School of Nursing in Nashville, Tenn., said in her presentation. “Because it is thought that early identification of swelling in the limbs coupled with a compression intervention may reduce the risk of patients developing full-blown clinical lymphedema, clinicians are proposing to use a prospective surveillance model to follow breast cancer survivors post surgery in order to assess limbs in a routine fashion and perhaps instigate preventative mechanisms early.”

The larger randomized controlled Prevention of Lymphedema Following Locoregional Treatment for Breast Cancer (PREVENT) trial enrolled 1,201 patients, and 200 patients overall have completed the full protocol. The researchers plan to follow patients for 3 years after surgery. In this interim analysis, Dr. Ridner and colleagues analyzed data from 508 patients at eight sites in the United States and four sites in Sydney who had stage I through stage III or ductal carcinoma in situ (DCIS) breast cancer and underwent mastectomy, taxane-based chemotherapy, or an axillary treatment such as axillary radiation, axillary lymph node dissection, or sentinel lymph nose biopsy with more than 6 nodes.

The patients were randomized to be measured using either traditional tape measurement or bioimpedance spectroscopy (BIS). Patients were moved to a prevention intervention if there was a change in baseline volume of 5% or greater but less than 10% in the tape measure group and change from baseline L-Dex measurement of 6.5 or greater in the BIS group, which consisted of wearing an arm compression sleeve and chest gauntlet for 12 hours a day over 4 weeks. After surgery, the patients were followed up at 3 months, 6 months, 12 months, 18 months, and 24 months, with optional follow-up visits at 15 months and 21 months. Progression to full lymphedema was defined as a 10% or greater change in pretreatment baseline measurements in the tape measure group.

Of the 508 patients analyzed, 10 patients had already progressed to full lymphedema, leaving 498 patients available for the interim analysis. There were 68 patients in the tape measure group (28.5%) and 41 patients in the BIS group (15.8%) who received the prevention intervention, and 10 patients in the tape measure group (14.7%) and 2 patients in the BIS group (4.9%) eventually progressed to full lymphedema. In the BIS group, there was a 10% absolute reduction and 67% relative reduction in lymphedema progression, compared with the tape measure group.

“We believe that the 10% absolute reduction is clinically significant for this patient population,” said Dr. Ridner. “We also believe that our interim results may support the concept of posttreatment surveillance using BIS for early detection of subclinical lymphedema coupled with early intervention as our preliminary data suggest this does have clinical advantages to the patient.”

The study was funded by ImpediMed. Dr. Ridner reports being the principal investigator for ImpediMed and Tactile Medical through work agreements contracted between the companies and her institution.

Bioimpedance spectroscopy may better identify lymphedema progression in women at risk for breast cancer–related lymphedema over the traditionally used method of monitoring arm circumference with a tape measure, according to results from an interim analysis of the PREVENT trial presented in a recent webcast from the annual meeting of the American Society of Breast Surgeons.

“Despite advances in breast-conserving surgery, improved radiation protocol, the advent of sentinel [node] biopsies and recent improvement in chemotherapy regimens, breast cancer–related lymphedema ... remains a major source of morbidity and concern in this patient population,” Sheila Ridner, PhD, RN, FAAN, professor of nursing at the Vanderbilt University School of Nursing in Nashville, Tenn., said in her presentation. “Because it is thought that early identification of swelling in the limbs coupled with a compression intervention may reduce the risk of patients developing full-blown clinical lymphedema, clinicians are proposing to use a prospective surveillance model to follow breast cancer survivors post surgery in order to assess limbs in a routine fashion and perhaps instigate preventative mechanisms early.”

The larger randomized controlled Prevention of Lymphedema Following Locoregional Treatment for Breast Cancer (PREVENT) trial enrolled 1,201 patients, and 200 patients overall have completed the full protocol. The researchers plan to follow patients for 3 years after surgery. In this interim analysis, Dr. Ridner and colleagues analyzed data from 508 patients at eight sites in the United States and four sites in Sydney who had stage I through stage III or ductal carcinoma in situ (DCIS) breast cancer and underwent mastectomy, taxane-based chemotherapy, or an axillary treatment such as axillary radiation, axillary lymph node dissection, or sentinel lymph nose biopsy with more than 6 nodes.

The patients were randomized to be measured using either traditional tape measurement or bioimpedance spectroscopy (BIS). Patients were moved to a prevention intervention if there was a change in baseline volume of 5% or greater but less than 10% in the tape measure group and change from baseline L-Dex measurement of 6.5 or greater in the BIS group, which consisted of wearing an arm compression sleeve and chest gauntlet for 12 hours a day over 4 weeks. After surgery, the patients were followed up at 3 months, 6 months, 12 months, 18 months, and 24 months, with optional follow-up visits at 15 months and 21 months. Progression to full lymphedema was defined as a 10% or greater change in pretreatment baseline measurements in the tape measure group.

Of the 508 patients analyzed, 10 patients had already progressed to full lymphedema, leaving 498 patients available for the interim analysis. There were 68 patients in the tape measure group (28.5%) and 41 patients in the BIS group (15.8%) who received the prevention intervention, and 10 patients in the tape measure group (14.7%) and 2 patients in the BIS group (4.9%) eventually progressed to full lymphedema. In the BIS group, there was a 10% absolute reduction and 67% relative reduction in lymphedema progression, compared with the tape measure group.

“We believe that the 10% absolute reduction is clinically significant for this patient population,” said Dr. Ridner. “We also believe that our interim results may support the concept of posttreatment surveillance using BIS for early detection of subclinical lymphedema coupled with early intervention as our preliminary data suggest this does have clinical advantages to the patient.”

The study was funded by ImpediMed. Dr. Ridner reports being the principal investigator for ImpediMed and Tactile Medical through work agreements contracted between the companies and her institution.

An opioid prescription management program implemented at the Cleveland Clinic has led to a reduction in the number of narcotics prescribed to patients after breast surgery, according to research presented in a recent webcast from the annual meeting of the American Society of Breast Surgeons.

sdominick/iStock/Getty Images

“The opioid epidemic has become a critical issue, and narcotic abuse has continued to rise,” Stephanie Valente, DO, FACS, from the Cleveland Clinic, said in her presentation. “Excess narcotic prescriptions may be contributing to this opioid epidemic,” and there are no current narcotic prescribing guidelines for patients after breast surgery, she said. In addition, studies have shown surgeons can overestimate the number of opioid pills a patient needs after surgery for pain control, and any excess pills are at risk of being stolen or inappropriately used, she added.

Dr. Valente and colleagues performed a baseline evaluation of narcotic pills prescribed by surgeons at the Cleveland Clinic for patients who have undergone excisional biopsy or lumpectomy, mastectomy, and mastectomy with reconstruction. They found the median number of narcotics prescribed were 15 pills for excisional biopsy or lumpectomy patients, 20 pills for mastectomy patients and 28 pills for mastectomy with reconstruction patients.

The researchers sought to lower those numbers, and created a departmental change in which they decreased the median number of pills prescribed at discharge from 15 pills to 10 pills for excisional biopsy or lumpectomy patients and from 28 pills to 25 pills for patients who undergo mastectomy with reconstruction. They then examined 100 consecutive patients after a 3-month implementation period to determine whether prescribing numbers had changed and found the surgeons adhered to the prescribing guidelines, which resulted in a statistically significant reduction in median opioid pills prescribed for excisional biopsy or lumpectomy (P less than .01) and mastectomy with reconstruction patients (P less than .01).

“After their departmental plan change, we observed that, as planned, a statistically significant decrease in prescribing practices amongst surgeons was able to be performed, showing that surgeons were able to adhere to these new prescribing practices,” said Dr. Valente.

When they examined the number of pills patients reported they used after surgery, they found excisional biopsy or lumpectomy patients took an average of 1 pill, mastectomy patients took an average of 3 pills, and mastectomy with reconstruction patients took an average of 18 pills. “These were all statistically much less than what was being prescribed even after our purposeful reduction,” said Dr. Valente.

In the study, 40% of patients who underwent breast surgery overall reported that they did not have any postoperative narcotic use at all, with the least narcotic use seen among patients who underwent excisional biopsy or lumpectomy.

“Further directions for opiate reduction can include evaluation of the impact of type and amount of local anesthetic given intraoperatively, and the amount of narcotics used postoperatively … to identify patient factors that contribute to the low narcotic usage postoperatively, and finally, to figure out how to maximize the benefit of adding a formal ERAS [enhanced recovery after surgery] protocol to further reduce patient needs for as many narcotic pills,” said Dr. Valente.

Dr. Valente had no disclosures.

An opioid prescription management program implemented at the Cleveland Clinic has led to a reduction in the number of narcotics prescribed to patients after breast surgery, according to research presented in a recent webcast from the annual meeting of the American Society of Breast Surgeons.

sdominick/iStock/Getty Images

“The opioid epidemic has become a critical issue, and narcotic abuse has continued to rise,” Stephanie Valente, DO, FACS, from the Cleveland Clinic, said in her presentation. “Excess narcotic prescriptions may be contributing to this opioid epidemic,” and there are no current narcotic prescribing guidelines for patients after breast surgery, she said. In addition, studies have shown surgeons can overestimate the number of opioid pills a patient needs after surgery for pain control, and any excess pills are at risk of being stolen or inappropriately used, she added.

Dr. Valente and colleagues performed a baseline evaluation of narcotic pills prescribed by surgeons at the Cleveland Clinic for patients who have undergone excisional biopsy or lumpectomy, mastectomy, and mastectomy with reconstruction. They found the median number of narcotics prescribed were 15 pills for excisional biopsy or lumpectomy patients, 20 pills for mastectomy patients and 28 pills for mastectomy with reconstruction patients.

The researchers sought to lower those numbers, and created a departmental change in which they decreased the median number of pills prescribed at discharge from 15 pills to 10 pills for excisional biopsy or lumpectomy patients and from 28 pills to 25 pills for patients who undergo mastectomy with reconstruction. They then examined 100 consecutive patients after a 3-month implementation period to determine whether prescribing numbers had changed and found the surgeons adhered to the prescribing guidelines, which resulted in a statistically significant reduction in median opioid pills prescribed for excisional biopsy or lumpectomy (P less than .01) and mastectomy with reconstruction patients (P less than .01).

“After their departmental plan change, we observed that, as planned, a statistically significant decrease in prescribing practices amongst surgeons was able to be performed, showing that surgeons were able to adhere to these new prescribing practices,” said Dr. Valente.

When they examined the number of pills patients reported they used after surgery, they found excisional biopsy or lumpectomy patients took an average of 1 pill, mastectomy patients took an average of 3 pills, and mastectomy with reconstruction patients took an average of 18 pills. “These were all statistically much less than what was being prescribed even after our purposeful reduction,” said Dr. Valente.

In the study, 40% of patients who underwent breast surgery overall reported that they did not have any postoperative narcotic use at all, with the least narcotic use seen among patients who underwent excisional biopsy or lumpectomy.

“Further directions for opiate reduction can include evaluation of the impact of type and amount of local anesthetic given intraoperatively, and the amount of narcotics used postoperatively … to identify patient factors that contribute to the low narcotic usage postoperatively, and finally, to figure out how to maximize the benefit of adding a formal ERAS [enhanced recovery after surgery] protocol to further reduce patient needs for as many narcotic pills,” said Dr. Valente.

Dr. Valente had no disclosures.

An opioid prescription management program implemented at the Cleveland Clinic has led to a reduction in the number of narcotics prescribed to patients after breast surgery, according to research presented in a recent webcast from the annual meeting of the American Society of Breast Surgeons.

sdominick/iStock/Getty Images

“The opioid epidemic has become a critical issue, and narcotic abuse has continued to rise,” Stephanie Valente, DO, FACS, from the Cleveland Clinic, said in her presentation. “Excess narcotic prescriptions may be contributing to this opioid epidemic,” and there are no current narcotic prescribing guidelines for patients after breast surgery, she said. In addition, studies have shown surgeons can overestimate the number of opioid pills a patient needs after surgery for pain control, and any excess pills are at risk of being stolen or inappropriately used, she added.

Dr. Valente and colleagues performed a baseline evaluation of narcotic pills prescribed by surgeons at the Cleveland Clinic for patients who have undergone excisional biopsy or lumpectomy, mastectomy, and mastectomy with reconstruction. They found the median number of narcotics prescribed were 15 pills for excisional biopsy or lumpectomy patients, 20 pills for mastectomy patients and 28 pills for mastectomy with reconstruction patients.

The researchers sought to lower those numbers, and created a departmental change in which they decreased the median number of pills prescribed at discharge from 15 pills to 10 pills for excisional biopsy or lumpectomy patients and from 28 pills to 25 pills for patients who undergo mastectomy with reconstruction. They then examined 100 consecutive patients after a 3-month implementation period to determine whether prescribing numbers had changed and found the surgeons adhered to the prescribing guidelines, which resulted in a statistically significant reduction in median opioid pills prescribed for excisional biopsy or lumpectomy (P less than .01) and mastectomy with reconstruction patients (P less than .01).

“After their departmental plan change, we observed that, as planned, a statistically significant decrease in prescribing practices amongst surgeons was able to be performed, showing that surgeons were able to adhere to these new prescribing practices,” said Dr. Valente.

When they examined the number of pills patients reported they used after surgery, they found excisional biopsy or lumpectomy patients took an average of 1 pill, mastectomy patients took an average of 3 pills, and mastectomy with reconstruction patients took an average of 18 pills. “These were all statistically much less than what was being prescribed even after our purposeful reduction,” said Dr. Valente.

In the study, 40% of patients who underwent breast surgery overall reported that they did not have any postoperative narcotic use at all, with the least narcotic use seen among patients who underwent excisional biopsy or lumpectomy.

“Further directions for opiate reduction can include evaluation of the impact of type and amount of local anesthetic given intraoperatively, and the amount of narcotics used postoperatively … to identify patient factors that contribute to the low narcotic usage postoperatively, and finally, to figure out how to maximize the benefit of adding a formal ERAS [enhanced recovery after surgery] protocol to further reduce patient needs for as many narcotic pills,” said Dr. Valente.

Dr. Valente had no disclosures.