Publications

Scholarly Journals--Published

  • Friedman Garrett, Celestin Arthur, Lum Sharon, & Reeves Mark E. (2014). Giant Abdominal Mass: A Unique Form of Metastatic Malignant Phyllodes Tumor of the Breast. American Surgeon, 80(5), E144-E146. (05/2014)
  • Choi Audrey, Rodriguez Samuel, Surrusco Matthew, Lum Sharon, & Senthil Maheswari. (2014). The Impact of Extranodal Extension of Lymph Node Metastasis on Breast Cancer Outcomes. Ann Surg Oncol, 21, 12-12. (04/2014)
  • Bianchi Elisa, Pairawan Seyed, Rodriguez Samuel, & Lum Sharon. (2014). Current Guidelines and Past Patients: Missed Opportunities for BRCA Testing. Ann Surg Oncol, 21, 29-29. (04/2014)
  • Anderson Kendra, Pairawan Seyed, Cora Cherie, Kazanjian Karin, Bae Won, & Lum Sharon. (2014). Mammographic Breast Density and Call-Backs: Does Breast Density Legislation Affect Reporting?. Ann Surg Oncol, 21, 22-22. (04/2014)
  • Kim A, Scharf K, Senthil M, Solomon N, Garberoglio C, & Lum S S. (2014). The prevalence of overweight and obesity in a breast clinic population: consideration for weight loss as a therapeutic intervention. Surg Obes Relat Dis, 10(2), 348-53. BACKGROUND: Obesity is an important risk factor for breast cancer and weight loss may be associated with a decreased risk for breast cancer and its recurrence. We evaluated the prevalence of overweight, obesity, and obesity-related co-morbidities in a breast health clinic population to determine the potential need for weight loss intervention. METHODS: A retrospective review was conducted of sequential patients seen at a breast health clinic from July 1 to December 31, 2011. Body mass index (BMI), reason for visit (breast cancer diagnosis, high risk for breast cancer, or benign condition), and presence of obesity-related co-morbidities were recorded. RESULTS: The 302 patients who met inclusion criteria had a median age of 52 years (10-91) and median BMI of 26 kg/m(2) (15.4-56.5). Overall, 36.8% of patients had a BMI between 18.5-24.9 kg/m(2); 32.1%, 25-29.9 kg/m(2); 14.2%, 30-34.9 kg/m(2); 8.3%, 35-39.9 kg/m(2); and 4.3%, >/= 40 kg/m(2). Overweight or obesity (BMI >/= 25 kg/m(2)) occurred in 64.2% of breast cancer, 65.0% of high-risk, and 57.1% of benign patients (P value not significant). Criteria for bariatric surgery (BMI 35-39.9 kg/m(2) with >/= 1 obesity-related co-morbidity or BMI >/= 40 kg/m(2)) were met in 8.2% of breast cancer, 16.7% of high-risk, and 11.5% of benign patients (P value not significant). CONCLUSIONS: Regardless of diagnosis, a significant proportion of patients visiting the breast health clinic meet criteria for weight loss intervention, including bariatric surgery. Weight management represents an underutilized therapeutic modality that could potentially decrease the risk of breast cancer and its recurrence, and improve overall prognosis. (03/2014) (link)
  • Saunders A C, Ji L, Cupino A, Dyke C, Morgan J W, . . . Solomon N L. (2014). Credit where Credit is Due: Using Population-based Registries to Identify Treating Hospitals. Ann Surg Oncol, 21, S133-S133. (02/2014)
  • Choi Audrey H, Surrusco Matthew, Rodriguez Samuel, Bahjri Khaled, Solomon Naveen, . . . Senthil Maheswari. (2014). Extranodal Extension on Sentinel Lymph Node Dissection: Why Should We Treat It Differently?. American Surgeon, 80(10), 932-935. American College of Surgeons Oncology Group Z0011 concluded that axillary lymph node dissection (ALND) may be avoided in selected patients with breast cancer with limited axillary nodal metastasis on sentinel lymph node dissection (SLND). However, patients with extranodal extension (ENE) were excluded to the follow existing standard of care, which is completion ALND. The significance of ENE detected on SLND is not well defined. Our objective was to determine the impact of ENE found on SLND on nonsentinel lymph node (NSLN) metastasis, recurrence, and overall mortality. We evaluated patients with breast cancer treated at a tertiary cancer center from 2005 to 2012. SLND was performed in 655 patients. Of those, 478 of 655 (73.0%) patients had no SLN metastases, 124 of 655 (18.9%) had SLN metastases without ENE (SLN-ENE), and 53 of 655 (8.1%) had SLN metastases with ENE (SLN+ENE). Of patients undergoing ALND, NSLN metastasis was detected in 37 of 84 (44.0%) of patients in the SLN-ENE group and 26 of 45 (57.8%) patients in the SLN+ENE group (P = 0.14). On adjusted analyses, ENE was associated with increased disease recurrence (odds ratio [OR], 5.48; 95% confidence interval [CI], 1.23 to 24.48; P = 0.03) as well as increased overall mortality (OR, 8.16; 95% CI, 1.72 to 38.63; P = 0.01). In conclusion, ENE is associated with increased overall axillary nodal burden, disease recurrence, and overall mortality. [ABSTRACT FROM AUTHOR] Copyright of American Surgeon is the property of Southeastern Surgical Congress and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.) (2014) (link)
  • Wanis M L, Wong J A, Rodriguez S, Wong J M, Jabo B, . . . Senthil M. (2013). Rate of re-excision after breast-conserving surgery for invasive lobular carcinoma. Am Surg, 79(10), 1119-22. Invasive lobular carcinoma (ILC) accounts for approximately 5 to 20 per cent of all breast cancers and is often multicentric. Despite pre- and intraoperative assessments to achieve negative margins, ILC is reported to be associated with higher rates of positive margin. This cross-sectional study examined patients with breast cancer treated at our institution from 2000 to 2010. The objective was to investigate the rate of re-excision resulting from positive or close margin (1 mm or less) in patients who underwent breast-conserving surgery (BCS) for ILC compared with invasive ductal carcinoma (IDC) and ductal carcinoma in situ (DCIS). Of the 836 patients treated, 416 patients underwent BCS. The rate of re-excision after BCS for ILC was 35.1 versus 17.7 per cent for IDC and 20.0 per cent for DCIS (P = 0.04). Re-excisions were more often performed for positive margin in patients with ILC (11 of 37 [29.7%]) versus IDC (36 of 334 [10.8%]) and DCIS (five of 45 [11.1%];(P = 0.004). In this single-institution review, BCS for ILC had significantly higher rates of re-excision as a result of positive margins when compared with IDC and DCIS. Tumor size greater than 2 cm and lymph node involvement were identified as factors associated with positive surgical margin in ILC. The higher possibility of positive margins and the need for additional procedures should be discussed with patients undergoing BCS for ILC. (10/2013)
  • Wanis M L, Wong J A, Rodriguez S, Wong J M, Jabo B, . . . Senthil M. (2013). Rate of Re-excision after Breast-conserving Surgery for Invasive Lobular Carcinoma. American Surgeon, 79(10), 1119-1122. Invasive lobular carcinoma (ILC) accounts for approximately 5 to 20 per cent of all breast cancers and is often multicentric. Despite pre- and intraoperative assessments to achieve negative margins, ILC is reported to be associated with higher rates of positive margin. This cross-sectional study examined patients with breast cancer treated at our institution from 2000 to 2010. The objective was to investigate the rate of re-excision resulting from positive or close margin (1 mm or less) in patients who underwent breast-conserving surgery (BCS) for ILC compared with invasive ductal carcinoma (IDC) and ductal carcinoma in situ (DCIS). Of the 836 patients treated, 416 patients underwent BCS. The rate of re-excision after BCS for ILC was 35.1 versus 17.7 per cent for IDC and 20.0 per cent for DCIS (P = 0.04). Re-excisions were more often performed for positive margin in patients with ILC (11 of 37 [29.7%]) versus IDC (36 of 334 [10.8%]) and DCIS (five of 45 [11.1%];(P = 0.004). In this single-institution review, BCS for ILC had significantly higher rates of re-excision as a result of positive margins when compared with IDC and DCIS. Tumor size greater than 2 cm and lymph node involvement were identified as factors associated with positive surgical margin in ILC. The higher possibility of positive margins and the need for additional procedures should be discussed with patients undergoing BCS for ILC. (10/2013)
  • Chidester J R, Ray A O, Lum S S, & Miles D C. (2013). Revisiting the Free Nipple Graft: An Opportunity for Nipple Sparing Mastectomy in Women with Breast Ptosis. Ann Surg Oncol, 20(10), 3350-3350. Objective. Nipple areolar complex (NAC) sparing mastectomy improves the cosmetic outcome of patients with breast cancer. However, women with significant breast ptosis are not candidates for this technique due toexcessive skin flap length and ensuing risk of NAC ischemia.1-3 We report a novel technique using free nipple graft during skin sparing mastectomy for patients with significant ptosis while concurrently maintaining oncologic integrity. Design. Case series. Setting. Community and tertiary care hospital practices. Patients. Women with breast cancer desiring NAC preservation who are otherwise candidates for nipple sparing mastectomy, but with significant breast ptosis that precludes NAC viability. All women underwent immediate, autologous breast reconstruction. Interventions. Bilateral and unilateral free nipple grafts were harvested, placed on ice during skin sparing mastectomy and free flap reconstruction, grafted at the conclusion of the case and secured with a bolster. Outcome Measures. Full or partial NAC preservation, ischemia time, local wound complications at NAC grafting site, pathologic outcomes. Results. A total of three patients underwent free nipple grafting at the time of skin sparing mastectomy and free or pedicled flap for breast cancer between March and September 2012. Of five total nipple grafts, one had partial NAC loss but did not require operative debridement. Pathologic review of areolar tissue removed during intraoperative defatting of free nipple graft demonstrated residual duct epithelium. Conclusions. Women with significant breast ptosis that would preclude them from NAC sparing mastectomy can successfully preserve their NAC using a free nipple graft. Duct epithelium present in defatted tissue during preparation of the free nipple graft suggests that oncologic integrity can also be maintained. (10/2013) (link)
  • Olaya W, Wong J, Morgan J, Kazanjian K, & Lum S. (2013). When is a Lymph Node Dissection a Lymph Node Dissection? The Number of Lymph Nodes Resected in Sentinel and Axillary Lymph Node Dissections. Ann Surg Oncol, 20(2), 627-632. We sought to compare the number of lymph nodes (LN) resected in axillary lymph node dissections (ALND) and sentinel lymph node dissections (SLND), and to assess the validity of registry reporting for axillary staging in breast cancer. Women in the California Cancer Registry who underwent surgical axillary staging for T1/T2, M0 breast cancer between 2004 and 2008 were evaluated. The number of LN resected in patients reported as having SLND+ALND and ALND were assessed for compliance with 6 and 10 LN threshold definitions for ALND. The proportion of patients with a parts per thousand currency sign3 LN removed was assessed for patients receiving SLND only. Of 71,907 patients, 45.5 % had SLND, 24.0 %, SLND+ALND, and 30.5 %, ALND. The median number of LN resected with SLND cases was 2 (range 1-41); SLND+ALND, 9 (range 1-63); and ALND, 11 (range 1-81) (p < 0.0001). Of patients undergoing ALND, 56.7 % had a parts per thousand yen10 LN removed; 46.2 % of patients with SLND+ALND had a parts per thousand yen10 LN removed (p < 0.0001). Overall, 75.5 % of patients with ALND had a parts per thousand yen6 LN removed and 67.8 % of patients with SLND+ALND had a parts per thousand yen6 LN removed (p < 0.0001). Of those receiving only SLND, 83.4 % had a parts per thousand currency sign3 LN removed. A significant proportion of patients did not meet the minimum LN count thresholds for full ALND or had excess LN removed in a SLND. Further investigation is required to determine whether absolute LN number or reported operative procedure and implied surgical technique better defines axillary staging in a registry database. (02/2013) (link)
  • Mogannam A, Bianchi C, Chiriano J, Patel S, Teruya T H, Lum S S, & Abou-Zamzam A M. (2012). Effects of Prior Abdominal Surgery, Obesity, and Lumbar Spine Level on Anterior Retroperitoneal Exposure of the Lumbar Spine. Archives of Surgery, 147(12), 1130-1134. Objective: To evaluate the effects of prior abdominal surgery and obesity and the level of spine exposure on the technical aspects and complications of anterior retroperitoneal exposure of the lumbar spine (ARES). Design: Retrospective review of prospective database. Setting: Academic vascular surgery practice. Patients: Patients undergoing ARES from 2001 to 2011. Main Outcome Measures: Influence of prior abdominal surgery, obesity, and level of exposure on time to spine exposure and incidence of vascular and perioperative complications. Results: Four hundred seventy-six patients underwent ARES. Mean (SD) age was 47.7 (12.6) years; 46.6% had undergone prior abdominal surgery. Mean (SD) body mass index (BMI) was 28.3 (5.5); 61.6% of procedures included the L4-5 disk. Mean (SD) time to exposure was 70.0 (25.5) minutes. Vascular injury occurred in 23.3% (3.8% major). Perioperative complications occurred in 16.4% of cases. Prior abdominal surgery had no effect on time to exposure, vascular injury, and perioperative complications. A BMI of 30 or more had no effect on time to exposure compared with a lower BMI. A BMI of 30 or more led to higher rates of vascular injury (30.8% vs 19.7%; P=.007) and overall complications (21.4% vs 14.0%; P=.04). Exposures involving L4-5 led to increased time to exposure (77.0 vs 56.2minutes; P<.001) and higher rates of vascular injury (29.7% vs 13.1%; P<.001) but had no effect on overall complications compared with exposures for other levels. Conclusion: Prior abdominal surgery should not be considered a contraindication to ARES. Caution is warranted in obese patients and exposures involving L4-5. Arch Surg. 2012; 147(12): 1130-1134 (12/2012)
  • Lum S S. (2012). Preoperative breast magnetic resonance imaging: a solution looking for a problem: comment on "selective preoperative magnetic resonance imaging in women with breast cancer"a solution looking for a problem. Arch Surg, 147(9), 839-40. (09/2012) (link)
  • Lum S S. (2012). Preoperative Breast Magnetic Resonance Imaging: A Solution Looking for a Problem INVITED CRITIQUE. Archives of Surgery, 147(9), 839-840. (09/2012)
  • Lum S S. (2012). Preoperative Breast Magnetic Resonance Imaging: A Solution Looking for a Problem INVITED CRITIQUE. Archives of Surgery, 147(9), 839-840. (09/2012)
  • Morgan J W, Cho M M, Guenzi C D, Jackson C, Mathur A, . . . Lum S S. (2011). Predictors of Delayed-Stage Colorectal Cancer: Are We Neglecting Critical Demographic Information?. Annals of Epidemiology, 21(12), 914-921. PURPOSE: We sought to distinguish roles of demographic variables and bowel segments as predictors of delayed versus early stage colorectal cancer in California. METHODS: Demographic and anatomic variables for 66,806 colorectal cancers were extracted from the California Cancer Registry for 2004-2008 and analyzed using logistic regression as delayed versus early stage. RESULTS: Odds ratios (OR) for binary stage categories comparing age < 40 (OR = 2.58; 95% CI = 2.26-2.94), 40-49 (1.71; 95% = 1.60-1.83) and 75+ (1.05; 1.02-1.09) relative to 50-74 years were computed. Compared with non-Hispanic whites, ORs for stage categories were: 1.05; 0.99-1.13 (non-Hispanic blacks), 1.08; 1.02-1.13 (Hispanics), and 1.05; 1.00-1.10 (Asian/others). Females had higher odds of delayed diagnosis (1.09; 1.06-1.13) than males. Descending ORs were measured for successively lower to highest socioeconomic status (SES) quintiles (OR 4:5= 1.08; 1.03-1.14, OR 3:5 = 1.13; 1.08 1.19, OR 2:5 = 1.18; 1.12 - 1.24, and OR 1:5 = 1.21; 1.14-1.28). CONCLUSIONS: Younger and older than age 50-74; females; Hispanic ethnicity; bowel segment contrasts (right/left, proximal/distal, cecum plus appendix/distal), and lower SES were independent predictors of delayed diagnosis. Low SES was the most robust predictor of delayed diagnosis, independent of other covariates. Approximately 77% of delayed diagnoses were in non-Hispanic whites and Asian/others. These findings illustrate the value of a community SES index for targeting egalitarian colorectal cancer screening. Ann Epidemiol 2011;21:914-921. (C) 2011 Elsevier Inc. All rights reserved. (12/2011) (link)
  • Tran T, Miles D, Hill M, & Lum S S. (2011). The Impact of Radiation on Surgical Outcomes of Immediate Breast Reconstruction. American Surgeon, 77(10), 1349-1352. We sought to determine the differences in surgical outcomes associated with adjuvant radiation versus no radiation in patients undergoing concurrent breast oncologic and reconstructive operations. A retrospective review of patients who underwent combined oncologic and plastic surgeries for breast diseases from January 2005 to June 2010 was compared for demographic factors and outcomes by receipt of radiation therapy. During the study period, 175 patients were identified; 25.7 per cent received radiation therapy. Mean patient age was 51 years and median follow-up was 355 days. Overall, 80.2 per cent of patients underwent mastectomy; 19.8 per cent partial mastectomy; 42.1 per cent autologous tissue reconstruction; and 54.8 per cent implant-based reconstruction. There were no significant differences between radiated and nonradiated patients in rates of overall or oncoplastic-specific complications. Lymphedema was the only complication seen more frequently in the radiated arm (P = 0.03). In our series of carefully selected patients undergoing a variety of reconstructive techniques for repair of partial or total mastectomy defects, radiation was not associated with worse outcomes in patients undergoing immediate breast reconstruction. With careful collaboration among plastic surgeons, breast surgeons, and radiation oncologists, patients requiring breast surgery may safely be considered for reconstruction of partial or total mastectomy defects when adjuvant radiation is required. (10/2011)
  • Aragon R, Morgan J, Wong J H, & Lum S. (2011). Potential Impact of USPSTF Recommendations on Early Diagnosis of Breast Cancer. Annals of Surgical Oncology, 18(11), 3137-3142. Objective. Current US Preventive Services Task Force (USPSTF) guidelines recommend against routine screening mammography in women aged 40-49 years. However, diagnosis of early-stage breast cancer relies on mammographic screening for detection. We hypothesized that screening at younger age may be important for detecting earlier and more treatable cancers for women in different demographic groups. Methods. All women with ductal carcinoma in situ (DCIS) or T1N0 breast cancer between 2004 and 2008 in the California Cancer Registry were evaluated. Patients were divided into: (1) women aged 40-49 years, who would be excluded from USPSTF recommendations for screening, and (2) women aged 50-74 years, who are recommended for screening. Patients in the two age groups were compared by race/ethnicity, socioeconomic status (SES), and hormone receptor (HR), human epidermal growth factor receptor 2 (HER-2), and triple-negative (TN) status. Results. Of 46,691 patients identified, 22.6% were aged 40-49 years, and 77.4% were aged 50-74 years. Younger women with DCIS had statistically higher odds of being HR positive and having higher SES, and Hispanic and Asian/Pacific Islander (PI) race/ethnicity, while younger women diagnosed with T1N0 breast cancer had higher odds of being HR positive, HER-2 positive, and triple negative and of having higher SES and non-white race/ethnicity. Conclusions. Young Hispanic, Asian/PI, and non-Hispanic (NH) Black women in California have greater odds of being diagnosed with early breast cancer than their older counterparts. Excluding 40-49-year-old women from screening could impact early diagnosis of HR-positive, HER-2-positive, and TN tumors. Implementation of USPSTF recommendations could disproportionately impact non-white women and potentially lead to more advanced presentation at diagnosis. (10/2011) (link)
  • Tran T, Miles D, Hill M, & Lum S S. (2011). The impact of radiation on surgical outcomes of immediate breast reconstruction. Am Surg, 77(10), 1349-52. We sought to determine the differences in surgical outcomes associated with adjuvant radiation versus no radiation in patients undergoing concurrent breast oncologic and reconstructive operations. A retrospective review of patients who underwent combined oncologic and plastic surgeries for breast diseases from January 2005 to June 2010 was compared for demographic factors and outcomes by receipt of radiation therapy. During the study period, 175 patients were identified; 25.7 per cent received radiation therapy. Mean patient age was 51 years and median follow-up was 355 days. Overall, 80.2 per cent of patients underwent mastectomy; 19.8 per cent partial mastectomy; 42.1 per cent autologous tissue reconstruction; and 54.8 per cent implant-based reconstruction. There were no significant differences between radiated and nonradiated patients in rates of overall or oncoplastic-specific complications. Lymphedema was the only complication seen more frequently in the radiated arm (P = 0.03). In our series of carefully selected patients undergoing a variety of reconstructive techniques for repair of partial or total mastectomy defects, radiation was not associated with worse outcomes in patients undergoing immediate breast reconstruction. With careful collaboration among plastic surgeons, breast surgeons, and radiation oncologists, patients requiring breast surgery may safely be considered for reconstruction of partial or total mastectomy defects when adjuvant radiation is required. (10/2011) (link)
  • Olaya W, Morgan J W, & Lum S S. (2011). Unnecessary Axillary Surgery for Patients With Node-Negative Breast Cancer Undergoing Total Mastectomy. Archives of Surgery, 146(9), 1029-1033. Objective: To identify factors associated with the use of axillary lymph node dissection (ALND) as the initial axillary staging in node-negative breast cancer patients undergoing total mastectomy. Design: California Cancer Registry study. Setting: Academic research. Patients: Women treated with total mastectomy for Tis, T1, or T2 node-negative breast carcinoma treated between January 1, 2004, and December 31, 2008. Main Outcome Measures: Proportions of patients who underwent ALND without prior sentinel lymph node dissection were compared by demographic characteristics. Results: Of 18 238 women treated with total mastectomy for Tis, T1, or T2 node-negative breast carcinoma, 35.1% underwent initial axillary staging by ALND without prior sentinel lymph node dissection. On multivariable analyses, patients were significantly more likely to undergo ALND if they had T2 disease or were 65 years or older, were hormone receptor negative, of Hispanic or Asian/Pacific Islander race/ethnicity, of lower socioeconomic quintile, operated on during earlier years of the study period, and not treated by a hospital cancer program approved by the American College of Surgeons. Conclusions: More than one-third of patients in California who underwent total mastectomy for treatment of early-stage node-negative breast carcinoma received ALND without prior sentinel lymph node dissection; furthermore, certain subsets of patients have higher odds of undergoing ALND alone. To avoid the unnecessary morbidity of ALND in early-stage breast carcinoma, further research is required to elucidate how tumor, patient, and system factors can be modified to improve delivery of optimal breast cancer care. (09/2011)
  • Lum S S. (2011). Sentinel Lymph Node Nomograms Predicting the Future. Archives of Surgery, 146(9), 1040-1040. (09/2011)
  • Wong J H, Lum S S, & Morgan J W. (2011). Lymph Node Counts as an Indicator of Quality at the Hospital Level in Colorectal Surgery. Journal of the American College of Surgeons, 213(2), 226-230. BACKGROUND: Substantial evidence suggests that the number of lymph nodes examined in colorectal cancer (CRC) is a powerful predictor of outcomes. However, the lymph node count as a benchmark of quality in CRC is controversial. We sought to examine the impact of lymph node counts on disease-specific survival (DSS) of CRC patients at the hospital level. STUDY DESIGN: This study used data obtained between 1994 and 2003 from Region 5 of the California Cancer Registry. Hospitals in Region 5 of the California Cancer Registry were stratified according to the median number of nodes examined and grouped according to the median number of nodes examined, <7, 7 to 9, and >= 10. These hospital groups were then evaluated for the frequency of meeting the 12-node threshold, frequency of positive lymph nodes, and DSS at the hospital level. RESULTS: Median number of nodes examined in group A was 4 (mean 5.6, SD 5.9), in group B was 8 (mean 9.7, SD 8.5), and in group C was 10 (mean 11.3, SD 9.2). In group A, 13.7%, in group B 32.8%, and in group C, 42.8% met the 12-node threshold. The frequency of N1 and N2 disease for group A was 20.7% and 9.1%, 19.7% and 11.1% for group B, and 20.1% and 11.3% for group C (p = 0.12). Five-year DSS was 72.7% for group A, 73.7% for group B, and 76.7% for group C (p = 0.002). DSS survival of N0 patients for group A was 78.6%, 81.5% for group B, and 85.1% for group C (p < 0.0001). There was no statistically significant difference in DSS for N1 (p = 0.18) or N2 (p = 0.90) between the 3 groups. CONCLUSIONS: Lymph node counts can have value as a benchmark of surgical/pathologic quality in node-negative CRC. These results question the value of lymph node counts as a benchmark of surgical/pathologic quality for node-positive CRC. (J Am Coll Surg 2011;213:226-230. (C) 2011 by the American College of Surgeons) (08/2011) (link)
  • Kuo I, Wong J H, Roy-Chowdhury S, Lum S S, Morgan J W, & Kazanjian K. (2010). The Use of Pelvic Radiation in Stage II Rectal Cancer: A Population-Based Analysis. American Surgeon, 76(10), 1092-1095. National Institutes of Health (NIH) guidelines recommend the use of pelvic radiation in T3N0 rectal cancer. We sought to determine the rate of compliance with NIH radiation guidelines for patients with T3N0 rectal cancer. We performed a retrospective cohort study of T3N0 rectal cancer diagnosed between January 1, 1994, and December 31, 2003, in Region 5 of the California Cancer Registry (R5 CCR). Three hundred twenty-nine patients with T3N0 rectal cancer were identified. The mean age of the study population was 68 years (range, 28 to 93 years). Only 54.1 per cent of patients with T3N0 cancer received pelvic radiation. There was no difference in gender (P = 0.13) or the number of nodes examined (P = 0.19) between patients who had treatment with pelvic radiation and those who did not. However, patients receiving radiation were significantly younger (mean 64 years with radiation therapy [XRT] vs 72 years without XRT, P < 0.001) and significantly more likely to be treated with systemic chemotherapy (75% with XRT vs 8.6% without XRT, P < 0.001). Significant numbers of patients with T3N0 rectal cancer are not receiving pelvic radiation in R5 CRR. NIH guidelines are not being translated into clinical practice. The reasons for this warrant continued investigation. (10/2010)
  • Wright G P, Wong J H, Morgan J W, Roy-Chowdhury S, Kazanjian K, & Lum S S. (2010). Time from Diagnosis to Surgical Treatment of Breast Cancer: Factors Influencing Delays in Initiating Treatment. American Surgeon, 76(10), 1119-1122. No clear guidelines exist defining the appropriate time frame from diagnosis to definitive surgical treatment of breast cancer. Studies have suggested that treatment delays greater than 90 days may be associated with stage migration. We sought to evaluate demographic factors that influence 30-day and 90-day benchmarks for time from diagnosis to definitive surgical treatment of breast cancer. Between 2004 and 2007, 19,896 women with stage I to III invasive breast cancer were treated with primary surgical therapy and did not receive preoperative systemic therapy in the California Cancer Registry. Overall, 75.7 per cent of patients were treated within 30 days of diagnosis, and 95.5 per cent of patients were treated within 90 days of diagnosis. Multivariate analyses revealed that treatment delays were associated with smaller tumor size, use of total mastectomy, lower socioeconomic status, and Hispanic and nonHispanic black race/ethnicity. Furthermore, disparities in those that did not meet 30-day benchmark timeframes were exaggerated with 90-day treatment delays. These benchmarks can be used to measure disparities in health care delivery. (10/2010)
  • Roos M, Wong J H, Roy-Chowdhury S, Lum S S, Morgan J W, & Kazanjian K. (2010). The Impact of Multidisciplinary Therapy in Node-Positive Rectal Cancer. American Surgeon, 76(10), 1163-1166. Multidisciplinary therapy (MDT) of node-positive rectal cancer is considered optimal. We performed a retrospective cohort study of node positive rectal cancer patients diagnosed between January 1, 1994 and December 31, 2003 in Region 5 of the California Cancer Registry to determine the impact of MDT on disease specific survival (DSS). During the study period, 398 patients with stage III rectal cancer were identified. Only 251 patients (63.1%) received radiation (XRT). Patients receiving XRT had significantly improved survival when compared with those who did not (5 year DSS 55% with XRT vs 36% without XRT, median follow-up 43 months, P < 0.001). There was no statistically significant difference in T stage (P = 0.41), the number of N1 patients (P = 0.45), or the number of positive nodes harvested (mean 11.5 w/o XRT vs 12.8 w/XRT, P = 0.37) between patients receiving XRT and those who did not. Patients receiving XRT were far more likely to receive systemic chemotherapy (83% vs 27%, P < 0.0001). Multidisciplinary therapy of node-positive rectal cancer is associated with improved DSS. However, substantial numbers of node positive rectal cancer patients are not receiving MDT. Greater efforts are needed to implement consistent multidisciplinary algorithms into rectal cancer management. (10/2010)
  • Olaya W, Wong J, Morgan J W, Truong C, Roy-Chowdhury S, Kazanjian K, & Lum S. (2010). Factors Associated with Variance in Compliance with a Sentinel Lymph Node Dissection Quality Measure in Early-Stage Breast Cancer. Annals of Surgical Oncology, 17, S297-S302. Background. Guidelines recommend sentinel lymph node dissection (SLND) for patients with clinical stage I/IIA/IIB breast cancer; however, a significant fraction of patients do not undergo this procedure. We sought to identify factors associated with noncompliance with the SLND benchmark in early-stage breast cancer. Materials and Methods. All patients with an initial diagnosis of Stage I/IIA/IIB invasive breast carcinoma who were treated between 2004 and 2007 with records in the California Cancer Registry were evaluated. Odds ratios evaluating receipt of SLND were compared for sex, age, stage, socioeconomic status (SES), race/ethnicity, surgery type, year of diagnosis, and hospital cancer program approval from the American College of Surgery (ACOS). Results. Of 55,207 patients identified, 66% underwent SLND. On multivariable analyses, patients were significantly less likely to undergo SLND if they were >65 years of age, stage IIA or IIB, of lower socioeconomic status, of nonwhite race/ethnicity, treated with total mastectomy, treated during 2004-2005, or at a non-ACOS approved institution. Conclusions. SLND use in California has increased over time; however, only two-thirds of eligible patients undergo this recommended procedure. Using SLND as a quality measure demonstrates significant disparities that have implications not only for patient and provider education, but also for health care policy and reform. (10/2010) (link)
  • Roos M, Wong J H, Roy-Chowdhury S, Lum S S, Morgan J W, & Kazanjian A K. (2010). The impact of multidisciplinary therapy in node-positive rectal cancer. Am Surg, 76(10), 1163-6. Multidisciplinary therapy (MDT) of node-positive rectal cancer is considered optimal. We performed a retrospective cohort study of node positive rectal cancer patients diagnosed between January 1, 1994 and December 31, 2003 in Region 5 of the California Cancer Registry to determine the impact of MDT on disease specific survival (DSS). During the study period, 398 patients with stage III rectal cancer were identified. Only 251 patients (63.1%) received radiation (XRT). Patients receiving XRT had significantly improved survival when compared with those who did not (5 year DSS 55% with XRT vs. 36% without XRT, median follow-up 43 months, P < 0.001). There was no statistically significant difference in Tstage (P = 0.41), the number of N1 patients (P = 0.45), or the number of positive nodes harvested (mean 11.5 w/o XRT vs. 12.8 w/XRT, P = 0.37) between patients receiving XRT and those who did not. Patients receiving XRT were far more likely to receive systemic chemotherapy (83% vs. 27%, P < 0.0001). Multidisciplinary therapy of node-positive rectal cancer is associated with improved DSS. However, substantial numbers of node positive rectal cancer patients are not receiving MDT. Greater efforts are needed to implement consistent multidisciplinary algorithms into rectal cancer management. (10/2010) (link)
  • Ng M, Roy-Chowdhury S, Lum S S, Morgan J W, & Wong J H. (2009). The Impact of the Ratio of Positive to Total Lymph Nodes Examined and Outcome in Colorectal Cancer. American Surgeon, 75(10), 873-876. We sought to examine the significance of the number of nodes examined in node-positive colorectal cancer. Between January 1, 1994, and December 31, 2003, 7192 patients with colorectal cancer underwent potentially curative resection in Region 5 of the California Cancer Registry. Of these patients, 2636 patients were node-positive: 65.1 per cent were N1 and 34.9 per cent were N2. The median follow up was 39.5 months. The mean number of nodes examined was 10.4 (range, 189) for NO, 11.0 (range, 1-72) for N1, and 14.6 (range, 4-79) for N2 (P < 0.0001). N1 and N2 patients were stratified according to the percentage of positive nodes into quintiles (0.19 or less, 0.20 to 0.39, 0.40 to 0.59, 0.60 to 0.79, and 0.80 to 1.0). In both N1 and N2 disease, a lower percentage of lymph nodes involved with metastatic disease was associated with improved survival (P < 0.0001). The increasing ratio of positive to total nodes was the result of a decrease in the total number of nodes examined in N1 disease and a steeper decline in total nodes examined in relation to the increase in the number of positive nodes in N2 disease. The ratio of positive to total nodes has prognostic significance in node-positive colorectal cancer. (10/2009)
  • Tan J T, Bagnell M, Morgan J W, Wong J H, Roy-Chowdhury S, & Lum S S. (2009). The identification and treatment of isolated tumor cells reflect disparities in the delivery of breast cancer care. American Journal of Surgery, 198(4), 508-510. BACKGROUND: Disparities in the quality of health care delivered among different socioeconomic strata (SES), race/ethnic groups, and health care systems are well documented; however, relevant quality measures in breast cancer have been debated. The identification of isolated tumor cells (ITCs) in axillary lymph nodes of patients with breast cancer requires diagnosis of early stage disease, appropriate implementation of sentinel lymph node (SLN) dissection, and pathologic analysis of the SLN with serial sectioning and immunohistochemical staining. We hypothesized that ITCs could be interpreted as a quality indicator and sought to determine factors that are associated with the identification and treatment of ITCs. METHODS: We performed a retrospective cohort review of women with N0(i+) breast cancer diagnosed between 2004 and 2006 in the California Cancer Registry. The proportions of patients in SES quintiles (1 = lowest, 5 = highest), race/ethnicity groups, and hospital surgical volume tertiles (low, 1-241 cases/y; medium, 242-491 cases/y; high, 492 cases/y) were compared for use of SLN dissection, identification of ITCs, and treatment of ITCs with additional axillary surgery or chemotherapy. RESULTS: SLN dissections were performed less frequently in women of lower SES, of nonwhite race/ethnicity, and in hospitals with lower surgical volumes (P <0001). A total of 369 patients had ITCs (.6%). With increasing SES, the proportion of patients with ITCs increased: 7.1% of patients with ITCs were from SES 1; 15.7% were from SES 2; 20.3% were from SES 3; 23.9% were from SES 4; and 33.1% were from SES 5. A total of 69.4% of patients with ITCs were non-Hispanic white, 12.8% were Asian, 11.9% were Hispanic, and 5.2% were non-Hispanic black. A total of 46.9% of ITCs were identified in high-volume hospitals, although high-volume hospitals represented only one third of all surgical cases. There were no differences in the use of additional axillary surgery among different groups with ITCs, but chemotherapy was given more frequently to Hispanic women (P = .002) and those in higher-volume hospitals (P = .01). CONCLUSIONS: Although the identification and chemotherapy treatment of ITCs vary among SES categories, race/ethnic groups, and hospitals, the infrequent occurrence of ITCs precludes its use as a valid quality indicator. Because significant disparities exist in the use of SLN dissection, further research will be required to validate the use of SLN dissection as a quality measure. (C) 2009 Elsevier Inc. All rights reserved. (10/2009) (link)
  • Olaya W, Wong J H, Morgan J W, Roy-Chowdhury S, & Lum S S. (2009). Disparities in the Surgical Management of Women with Stage I Breast Cancer. American Surgeon, 75(10), 869-872. We sought to evaluate factors influencing the choice of surgery for women with early-stage breast cancer. Between 1996 and 2005, 47,837 women who were diagnosed with Stage I breast cancer underwent partial (PM) or total mastectomy (TM) in the California Cancer Registry. A total of 72.8 per cent of women underwent PM. Those treated in the most recent 5-year period were more likely to undergo PM than in the prior 5 years (76.5 vs 69.5%, P < 0.0001). PM rates increased with increasing socioeconomic status (SES): 65.1 per cent of patients in the lowest SES quintile underwent PM versus 77.2 per cent in the highest SES quintile (P < 0.0001). Forty- to 64-year-old women were more likely to receive PM compared with their older and younger counterparts (74.5 vs 71.2 and 67.0%, respectively; P < 0.0001). Asian/Pacific Islander women were least likely to undergo PM (64.0%), whereas non-Hispanic black women were most likely to undergo PM (75.0%) (P < 0.0001). On multivariate analysis, these demographic factors remained independent predictors of surgical treatment. PM rates have increased over time; however, significant differences in surgical management exist among women of different race/ethnic groups, ages, and SES. Further research is required to elucidate modifiable factors that impact the choice of surgery for women with early-stage breast cancer. (10/2009)
  • Olaya W, Esquivel P, Wong J H, Morgan J W, Freeberg A, Roy-Chowdhury S, & Lum S S. (2009). Disparities in BRCA testing: when insurance coverage is not a barrier. American Journal of Surgery, 198(4), 562-565. BACKGROUND: Strategies to reduce the risk of developing breast and ovarian cancer in carriers of deleterious BRCA 1 and 2 mutations are readily available. However, many people who are at high risk of having these genetic mutations are reluctant to obtain the test. We sought to identify factors associated with choice of testing. METHODS: We performed a retrospective cohort review of high-fisk patients referred to a multidisciplinary breast health center for BRCA testing between January 2001 and March 2008. Demographic variables were compared by using logistic regression between those who completed genetic testing and those who did not. RESULTS: A total of 213 patients were referred for BRCA testing. The mean age was 49.2 years (range, 16-84 y). Five patients were male. The majority of individuals (63.4%) were white, 15% were Hispanic, 6.6% were black, and 4.7% were Asian. Insurance coverage for testing was available in 91.1% of patients, of whom 49.2% had private insurance, 26.7% had managed care insurance, and 24.1% had government-sponsored insurance. A total of 111 patients (52.1%) underwent testing. On multivariate analysis, patients were significantly more likely to complete testing if they had a personal history of breast cancer (73.0% of tested patients) (P = .005) and had at least some college education (61.3%) (P = .03). There were no statistically significant differences in tested versus untested groups by age, race, language, family history, parity, marital status, religion, socioeconomic status, or insurance status. Of patients whose insurance plans offered coverage for genetic testing, 51.4% underwent testing and 48.6% did not (P = not significant [NS]). Of those who had no insurance coverage for testing, 41.2% underwent testing and 58.9% did not (P = NS). CONCLUSIONS: Our data show that half of those patients at risk for carrying a BRCA mutation do not undergo testing. Insurance coverage for genetic testing does not influence the decision to test. Developing counseling instruments that explain the benefits of testing to unaffected high-fisk individuals or targeted to those with a high school level education may be a strategy to improve testing rates. (C) 2009 Elsevier Inc. All rights reserved. (10/2009) (link)

Abstract

  • Olaya W, Wong J, Morgan J, Kazanjian K, & Lum S. (2012). When Is a Lymph Node Dissection a Lymph Node Dissection? The Number of Lymph Nodes Resected in Sentinel and Axillary Lymph Node Dissections. Annals of Surgical Oncology, 19, 5-6. (05/2012)
  • Friedman G, Celestin A, Lum S, & Reeves M. (2012). Giant Abdominal Mass: A Unique Presentation of Metastatic Malignant Phyllodes Tumor of the Breast. Annals of Surgical Oncology, 19, 50-50. (05/2012)
  • Aragon R, Morgan J, Wong J, & Lum S. (2011). The Potential Impact of USPSTF Recommendations on the Early Diagnosis of Breast Cancer. Annals of Surgical Oncology, 18, S154-S154. (04/2011)
  • Tran T, Miles D, Hill M, & Lum S. (2011). Complications of Immediate Breast Reconstruction Do Not Cause Treatment Delays. Annals of Surgical Oncology, 18, S183-S183. (04/2011)
  • Olaya W, Wong J, Morgan J, Roy-Chowdhury S, Kazanjian K, & Lum S. (2010). Disparities in the Use of Sentinel Lymph Node Dissection in Early-Stage Breast Cancer. Annals of Surgical Oncology, 17(2), S155-S155. (04/2010)
  • Olaya W, Wong J, Morgan J, Roy-Chowdhury S, Kazanjian K, & Lum S. (2010). Disparities in the Use of Sentinel Lymph Node Dissection in Early-Stage Breast Cancer. Annals of Surgical Oncology, 17(2), S155-S155. (04/2010)
  • Truong C, Kempton S, Lum S, Morgan J W, Wong J H, & Roy-Chowdhury S. (2009). The impact of young age on outcome in colon cancer. Journal of Clinical Oncology, 27(15), . (05/2009)