ABS Educational Bursary: Learning how to set up a survivorship programme in Boston

I would like to thank the ABS for awarding  me the Educational Bursary. This  was initially granted in 2019-2020, alas COVID-19 happened and travel ground  to a halt. I was fortunate that Dr DuPree, whom I had previously planned to see, had  been invited to run a pre-ASBrS course  entitled “How to set up a survivorship program that fulfills NAPBC standards and  how to utilize integrative oncology in breast  cancer care.” I had met Dr DuPree in 2015 and experienced first-hand her unique  approach to patient centric care and  survivorship. I wanted to learn more about  how I could help shape survivorship in my breast unit and beyond. 

After arriving safely in Boston, I joined  Dr Beth DuPree, Dr William Scarlett  (Plastic surgeon and survivorship course  co-director) and Dr Jill Dietz (Past President, ASBrS) for a morning stroll. We headed for the Public Garden & Boston Common – a sight to behold with the 
trees bursting with blossom. I spent a few hours walking some of the ‘Freedom Trail’, an iconic red brick trail connecting 16 nationally significant historic sites within the Centre of Boston – I’m afraid 
the Brits don’t come off too well and one had to be careful to avoid any 
mention of tea! In the evening, I was invited to join Dr DuPree & Dr Scarlett, at a talk they were giving regarding nipple sparing mastectomy. I was interested by the description of primary 
buttonhole mastopexy & nipple sparing mastectomy (1-2) and about the advances being made in nerve grafting to preserve nipple and breast sensation. (3)

The next day was the Survivorship course. In the USA, the National Accreditation Program for Breast Centers (NAPBC) helps to deliver high-quality care for breast disease by setting standards and providing 
quality measures. NAPBC publishes a report called ‘Optimal Resources for Breast Care’ and section 5.15 is dedicated to ‘Survivorship’. They specifically state ‘Survivorship and surveillance begin at the point of diagnosis.’ The challenge to the audience was what were they doing to address survivorship issues in their practice? For example: Nutritional programs; Smoking cessation programs; 
Exercise programs; Support groups; Mental health; Social & Financial 
counselors; Lymphoedema programs. 

Survivorship topics were addressed that were often missed or skirted over during my surgical training. These included: exercise oncology; psychological aspects of cancer diagnosis; caring for the care 
giver; Integrative oncology in breast cancer; lymphodema; sexual health after breast cancer; ‘food as medicine’. 

I was particularly impacted by the exercise oncology session (re-iterated in a session during the main ASBrS conference). We 
all know exercise is good, although often hard to commit to. However, I hadn’t realised the growing evidence not only suggesting that exercise can reduce the chance of getting breast cancer, but also having meaningful impact for those with breast cancer. Randomised control trials have been dramatically increasing in the field of ‘exercise oncology’. The WISER survivor trial has demonstrated the combined effect of exercise and weight loss interventions on inflammation in 
breast cancer. (4) A recent study describes an association of physical activity with risk of mortality among breast cancer survivors. (5) This is translating through to recommendations, with the ‘Exercise is Medicine’ programme from the American College of Sports Medicine. An exercise prescription for breast cancer survivors is: 150-300min/week – moderate intensity activity. 2x weekly resistance exercise. New NAPBC standards ask centers to document policies for exercise recommendations. It isn’t just the USA, the Clinical Oncology Society of Australia (COSA) have also released a position statement on exercise in cancer care.

Next was the main conference, with my highlight being ‘The great debates’: Should Lymph Nodes be Clipped at time of biopsy? For - Michael Alvarado, Against - Monica Morrow. The debate distilled down 
to: Plenty of studies demonstrate clipped node is not the SLNB after NACT – thus high false negative rate (10%+) when using SLNB alone, whereas axillary PCR is often high, local recurrence is rare and good 
outcomes are obtained with SLNB with dual mapping and attempts to obtain >3 SLNBs. There is no evidence that clipping (and TAD) improves axillary recurrence or survival, though given the low axillary 
recurrence rate and high PCR rates, existing studies may be underpowered to demonstrate this. I (and most of the audience) sided with Dr Alvarado.

Overall, I had a highly enjoyable trip, expanding my knowledge and making new friends and acquaintances. It was lovely to travel again after the COVID enforced pause and I was reminded how much we 
have in common across our international communities. There are so many chances to collaborate, learn, and make lifelong connections. Often in the NHS it feels like we are limited in what we can focus on and afford. I was shown many great examples of survivorship programmes in action, and I hope these spread ‘over the pond’ and 
become embraced here in the UK.

References:

1. Salibian AH, Harness JK, Mowlds DS. Primary Buttonhole Mastopexy and Nipple-Sparing Mastectomy: A Preliminary Report. Ann Plast Surg. 2016 Oct;77(4):388-95
2. Oven SD, Scarlett WL. Reconstruction of Large Ptotic Breasts After Nipple-Sparing Mastectomy: A Modified Buttonhole Technique. Ann Plast Surg. 2020 Sep;85(3):233-236
3. Peled AW, Peled ZM. Nerve Preservation and Allografting for Sensory Innervation Following Immediate Implant Breast Reconstruction. Plast Reconstr Surg Glob Open. 2019 Jul 24;7(7):e2332
4. Sturgeon KM, Brown JC, Sears DD, Sarwer DB, Schmitz KH. WISER Survivor Trial: Combined Effect of Exercise and Weight Loss Interventions on Inflammation in Breast Cancer Survivors. Med Sci Sports Exerc. 2023 Feb 1;55(2):209-215
5. Chen LH, Irwin MR, Olmstead R, Haque R. Association of Physical Activity With Risk of Mortality Among Breast Cancer Survivors. JAMA Netw Open. 2022 Nov 1;5(11):e2242660

Edward St John
Portsmouth Hospitals University