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Anaplastic Large Cell Lymphoma (ALCL): Emerging Beliefs and Consenting Patterns among Board Certified Plastic Surgeons
Kenneth L. Fan, MD, Megan A. Rudolph, MD, Troy Pittman, MD.
Georgetown University Hospital, Washington, DC, USA.

BACKGROUND: Reported incidence of ALCL have been highly variable, with the most recent literature tally at 173. Despite the incidence and poorly understood relationship, discourse regarding ALCL is increasing with heightened public awareness. Our study seeks to examine patterns in relation to ALCL and impact this has on the consenting process for breast surgery with implants. METHODS: A survey, was designed to correlate physician demographics and how their attitudes toward to ALCL, specifically during the patient education and consent process. The survey was sent electronically to board certified plastic surgery members. Chi-squared and logistic regression analysis was performed for significance. RESULTS: Anonymous responses were obtained from 943 surgeons(695 ASPS, 248 ISAPS). The majority of surgeons were in solo private practice(63.9%) for more than 20 years(58.6%). Internationally, 66.8% of surgeons used textured implants most commonly. In the United States 66% of surgeons used smooth implants most commonly. Internationally, 32.3% of surgeons counsel their patient on ALCL every time; 23.73% never counsel. In the United States, 22% of surgeons counsel their patients on ALCL; 23.33% never counsel. Most surgeons, international and in the United States, do not include risk of ALCL in the informed consent(37.5% vs 62.5%). Most surgeons are never mention ALCL in the preoperative consultation(64.9%). Most surgeons initially manage a late seroma(>1 year) with aspiration and ultrasound(45.1%). 28.6% of these surgeons aspirate late seroma but do not send off for cytologic analysis routinely. 10% of surgeons had 1-5 cases of ALCL in their practice, 20.8% have had colleagues who have had ALCL in their patients. There was no correlation between years and practice and if a surgeon includes risk of ALCL in consent or if a physician counsels their patient on ALCL in their initial visit(P>0.05). There is no correlation between years of practice and ability to answer patients questions(P>0.05). Interestingly, those with colleagues(P < 0.05, OR = 1.924) or personal experience(P < 0.05, OR = 2.163) with ALCL are two times more likely to include it in their consent. Furthermore, surgeons who use textured implants are two times more likely to discuss ALCL in the preoperative consultation(P < 0.05, OR = 1.712) but not more likely than the average surgeon to include discussion of ALCL in their consent(P > 0.05). CONCLUSIONS: Little difference in consenting patterns exists between American and International surgeons. Further, practice patterns and years in practice, did not influence whether or not a surgeon discusses or includes ALCL in the surgical consent. Those with personal or colleague experience with the disease are twice as likely to include ALCL in the consent. Furthermore, those who use textured implants are twice as likely to discuss ALCL in the preoperative consultation. Despite the initial management of late seroma, 28% of surgeons are not sending fluid from a late seroma(>1 year) for further cytological markers to identify ALCL, deviating from FDA guidelines. 10% of plastic surgeons have experienced 1-5 cases of ALCL.

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