Thesis (M. D.)--University of Hong Kong, 2008. / Includes bibliographical references (leaves 126-145) Also available in print.

published_or_final_version / Medicine / Master / Doctor of Medicine

OBJECTIVE: Breast cancer represents a significant risk in women's health, affecting many women worldwide. Current treatment options in the U.S involve a multidisciplinary approach, most often beginning with surgery to remove cancerous tissue. Evaluation of margins for cancer on excised tissue is an important part of surgery, an important predictor of survival. As a result, there has been a great deal of research interest in intraoperative margin assessment, with a focus on fast and accurate results. Micro-computed Tomography (micro-CT) has emerged as a promising avenue to this end. We hypothesize that micro-CT scans will show a statistically significant difference in radiodensity between cancerous and non-cancerous tissue at intraoperative scan times. METHODS: 15 breast lumpectomy specimens were collected from patients undergoing surgery at Massachusetts General Hospital (MGH). Lumpectomies were scanned with a Nikon XTH225 Micro-CT scanner. Corresponding histology slides were scanned with a whole slide scanner, and matched with micro-CT scans. Representative areas of cancerous and non-cancerous tissues were segmented from micro-CT scans, and their respective radiodensity differences were tested for statistical significance. RESULTS: 9 of 15 lumpectomy cases were successfully matched with histology sections. Of the 9 cases matched, 8 showed a statistically significant difference in mean radiodensity. CONCLUSION: Due to potential confounds in the study, the results are difficult to deem conclusive. However, micro-CT remains a promising tool in margin assessment, and could be fit for clinical use with further study.

This study explores the relationship between race and surgical treatment and radiation therapy use for localized breast cancer patients in the state of Florida in 2001. The study will be useful in raising awareness of the relationship between Black race and appropriate breast cancer treatment within the Florida Cancer Data System. The Healthy People 2010 initiatives call to eliminate racial disparities and the high placement of breast cancer on the national research agenda make this study timely and insightful for health policymakers, clinicians and other health researchers. Also, the study evaluates the effect of other health system and patient related factors such as insurance provider and rural versus urban residence, to the appropriate use of cancer therapy in order to present an up-to-date and accurate picture of the quality of breast cancer care for women in the state of Florida. The study used multivariate logistic regression modeling and chi-square distribution to compare models in order to disentangle the effects of age, rural residence, marital status and primary health insurance provider from race and to determine how these factors influenced breast conserving surgery versus mastectomy use. Further, the second research question exclusively focused on the population that received breast conserving surgery in order to examine the impact of race and the other covariates as explanatory measures of appropriate receipt of radiation therapy. The first hypothesis found that there was no statistically significant difference between Black and White women in terms of receipt of breast conserving surgery for treatment of localized breast cancer. The second hypothesis, which focused on appropriate receipt of radiation therapy following breast conserving surgery, found that there was a statistically significant interaction between Black race and Medicaid as primary health insurance provider. The study concludes by examining possible areas of improvement in data collection in the State of Florida. Also, the study contains recommendations as to previously unexplored facets of breast cancer research and breast cancer health policy that could be beneficial in the reduction of health and healthcare disparities in other geographic areas and in other diseases.

Bakgrund: Bröstcancer är den främsta cancerformen hos kvinnor världen över. Kirurgi är den viktigaste behandlingen vid bröstcancer och innebär att antingen delar av bröstet eller hela bröstet avlägsnas. Till följd av kirurgin kan kvinnorna antingen välja att rekonstruera sitt bröst eller använda en protes. Många kvinnor beskriver en förändrad kroppsuppfattning efter bröstoperationerna. Syfte: Syftet med studien var att belysa kvinnors upplevelser av sin kroppsuppfattning och dess inverkan på vardagen efter bröstoperation till följd av bröstcancer. Metod: Tolv kvalitativa artiklar valdes ut, sammanställdes och analyserades enligt kvalitativ innehållsanalys. Sökningen av artiklarna genomfördes i CINAHL, PubMed och PsycINFO. Även manuell sökning genomfördes. Resultat: Att genomgå lumpektomi eller mastektomi visade sig ha en inverkan på kvinnornas identitet och feminitet. Det resulterade också i en upplevelse av asymmetri. Kvinnorna hade svårigheter att bemöta operationsområdet och sörjde sina tidigare kroppar. De copingstrategier som kvinnorna använde sig av för att hantera kroppsuppfattningen var anpassning av klädval, protesanvändning eller bröstrekonstruktion. Kroppsuppfattningen som kvinnorna erhöll efter operationen inverkade på deras sexualitet. Deras partner och andra sociala faktorer inverkade också på den kroppsuppfattning kvinnorna erhöll efter bröstoperationerna. Konklusion: Resultatet visar på att upplevelsen av kroppsuppfattningen efter bröstoperation är komplex. Det är därför viktigt att sjuksköterskan har ett personcentrerat förhållningssätt i bemötandet av den bröstopererade kvinnan. / Background: Breast cancer is the leading cancer among women worldwide. Surgery is the main treatment for breast cancer and leads to that part of the breast or the whole breast being removed. Following the surgery women can choose either to reconstruct their breast or use prosthesis. Many women describe an altered body image after the breast surgeries. Aim: The aim with the study was to illustrate women’s experience of their body image and its impact on everyday life after breast surgery due to breast cancer. Method: Twelve qualitative articles were included and were compiled and analyzed with qualitative content analysis. The article search was performed in CINAHL, PubMed and PsycINFO. Articles were also searched manually. Results: To undergo lumpectomy or mastectomy was found to have an impact on the identity and the femininity. It also resulted in an experience of asymmetry. The women had difficulties to face the surgical site and mourned their former bodies. The coping strategies that the women used to deal with their body image were to adapt their clothing choices, use prosthesis or undergo breast reconstruction. The body image the women received after the surgery had an impact on the women’s sexuality. Their partners and other social factors influenced the body image that the women received after the breast surgeries. Conclusion: The results show that the perception of body image after breast surgery is complex. That is why it is important that the nurse have an person-centered approach in the treatment of the breast operated woman.

Breast cancer is the leading cause of death in women ages 35-54. A research consensus has been published stating that breast conserving therapy or surgery (BCT/BeS) and mastectomy treatments for T1 breast cancers yield comparable recurrence and survival rates. Standards of medical practice for various diseases and conditions are known, but very little if any, information or research exists on individual hospital medical practice. This study focused on the grassroots level of health care by investigating local treatment protocols, patient/physician beliefs and actual treatments chosen concerning early diagnosis of breast cancer. / Ed. D.

<p>One of the challenges facing clinical practice today is intra-operative margin detection in breast conserving surgeries (BCS) or lumpectomy procedures. When a surgeon removes a breast tumor from a patient during a BCS procedure, the surgically excised tissue specimen is examined to see whether it contains a margin of healthy tissue around the tumor. A healthy margin of tissue around the tumor would indicate that the tumor in its entirety has been removed. On the other hand, if cancerous tissue is at the surface of the specimen, that would indicate that the tumor may have been transected during the procedure, leaving some residual cancerous tissue inside the patient. The most effective intra-operative real-time margin detection techniques currently used in clinical practice are frozen section analysis (FSA) and touch-prep cytology. These methods have been shown to possess inconsistent accuracy, which result in 20% to 30% of BCS patients being called back for a repeat BCS procedure to remove the residual tumor tissue. In addition these techniques have been shown to be time-consuming--requiring the operating room team to have to wait at least 20 minutes for the results. Therefore, there is a need for accurate and faster technology for intra-operative margin detection. </p><p>In this dissertation, we describe an x-ray coherent scatter imaging technique for intra-operative margin detection with greater accuracy and speed than currently available techniques. The method is based on cross-sectional imaging of the differential coherent scatter cross section in the sample. We first develop and validate a Monte Carlo simulation of coherent scattering. Then we use that simulation to design and test coherent scatter computed tomography (CSCT) and coded aperture coherent scatter spectral imaging (CACSSI) for cancerous voxel detection and for intra-operative margin detection using (virtual) clinical trials. Finally, we experimentally implement a CACSSI system and determine its accuracy in cancer detection using tissue histology. </p><p>We find that CSCT and CACSSI are able to accurately detect cancerous voxels inside of breast tissue specimens and accurately perform intra-operative margin detection. Specifically, for the task of individual cancerous voxel detection, we show that CSCT and CACSSI have AUC values of 0.97 and 0.94, respectively. Whereas for the task of intra-operative margin detection, the results of our virtual clinical trials show that CSCT and CACSSI have AUC values of 0.975 and 0.741, respectively. The gap in spatial resolution between CSCT and CACSSI affects the results of intra-operative margin detection much more than it does the task of individual cancerous voxel detection. Finally, we also show that CSCT would require on the order of 30 minutes to create a 3D image of a breast cancer specimen, whereas CACSSI would require on the order of 3 minutes. </p><p>These results of this work show that coherent scatter imaging has the potential to provide more accurate intra-operative margin detection than currently used clinical techniques. In addition, the speed (and therefore low scan duration: 3 min) of CACSSI, along with its ability to automatically classify cancerous tissue for margin detection means that coherent scatter imaging would be much more cost-effective than the clinical techniques that require up to 20 minutes and a trained pathologist. With the cancerous voxel detection accuracy of a 0.94 AUC and scan time of on the order of 3 minutes demonstrated for coherent scatter imaging in this work, coherent scatter imaging has the potential to reduce healthcare costs for BCS procedures and rates of repeat BCS surgeries. The accuracy for CACSSI can be considerably improved to match CSCT accuracy by improving its spatial resolution through a number of techniques: incorporating into the CACSSI reconstruction algorithm the ability to differentiate noise from high frequency signal so that we can image with higher frequency coded aperture masks; implementing a 2D coded aperture mask with a 2D detector; or acquiring additional angles of projection data.</p> / Dissertation