Not all breast markers are created equal ... Part 1 of the debate from this year's ASBrS Annual Meeting
When faced with a variety of alternative localization devices to sub-optimal guidewires, what makes one marker stand out above all others?
Is it the ease of locating it ahead of removal? Or the ability of the marker to reduce unnecessary surgical intervention? To some, it may be that a focus on clinical data to prove efficacy is top of the list, or simply the financial cost of setting up a seed program.
At this year’s ASBrS Annual Meeting in Las Vegas, these questions and more were posed to a panel composed of five of the world’s leading surgeons - Anne Peled, MD, Michael Alvarado, MD, Lucy De La Cruz, MD, Dr Stefan Paepke and Brigid Killelea, MD, FACS - in a debate hosted by ASBrS President-Elect, Susan Boolbol, MD.
Filmed in front of a packed room of attending delegates, here are just some of the highlights including why the stopped routinely using guidewires, how a decision was made on the best marker and the steps taken to make the adoption case to their hospital administrations:
First and foremost – why switch from wires?
It’s a question many physicians have had to toggle with when considering if now is the time to move away from this highly used traditional technique. So what is it specifically that is driving more and more hospitals to ditch the wire for good?
“The most compelling reason is for patients. We have all used wires for over 10, 20 years and there is an inconvenience, anxiety and discomfort for patients having to go through an extra procedure on the day of surgery”Brigid Killelea, MD FACS, Hartford HealthCare, Connecticut
Away from the patient perspective, the clear logistical benefits and ease of using wire-free localization were also a key consideration for many of the panel.
“I think there’s the ease of scheduling. And wires are tricky as well! Unlike my esteemed panelists, I have cut the wire with the Bovie. I have accidentally pulled the wire out, and had issues. With the Magseed, it doesn't happen” said Michael Alvarado, MD.
For Anne Peled, MD, a champion for oncoplastic surgery, a key advantage of moving to Magseed® has been that it's provided more options for reconstructive surgery:
“If you just look at the patient experience, it's better, but just also in terms of how we do our surgery. Now, I have this very targeted location. I know what I need to take out. I can find it quickly. I don't have to worry about a wire. I can design my pedicle, my hidden scar, whatever I want to do in that way.”
Which technologies have the panel trialled so far?
Having established a clear consensus that it is time to reduce guidewire usage, the next topic of discussion centered around how to select the most complete alternative from the other available technologies. For Dr Stefan Paepke, the decision was simple.
“I have the Sentimag system in OR that covers sentinel lymph node, and every procedure around seeds. To have a different one, only for breast tumor localization, out of my perspective, it makes no sense.”Dr Stefan Paepke, TUM, Munich
Other panelists had spent time at institutions where RFID and Radar technologies had been utilized, but held deep concerns over marker size and risks of deactivation and migration.
“If they [Radar devices] deactivate, then you're like, "Okay, a needle in a haystack, where is this?” said Lucy De La Cruz, MD. “I was terrified that it would get hit by the Bovie while dissecting and I would be stuck with this implantable device that needs to be removed.”
Speaking of a similar experience with RFID, Dr Killelea recounted: “I unfortunately, had some episodes where it would squirt out and it made me very anxious because if you lose the seed or the target, Game's almost over. It’s not a pretty conversation with the patient”
Making the hospital business case for a seed program
You’ve made the decision to move away from wires and selected your localization device, in agreement with your OR team. Now comes the complex part – making the business case for implementing the new technology to hospital administration.
Where is the starting point for selling it to those in charge of the purse strings?
“It's about showing this is going to be cost efficient for the institution, like decreasing OR time. If I don't lose a clip, I'm not spending 25 minutes looking for a clip.
The other thing is a 7:30am start. Not having the patient going to radiology and coming back and waiting. That's a big deal. Those are things that the institutions look at” explained Dr De La Cruz.
“I started with hospital administration and I think every hospital is always looking for ways to reduce costs. I would say that our rep was really helpful and in terms of the customer support and the availability, I had an excellent experience with Endomag” said Dr Killelea.
That brought an end to the first part of the discussion, having ticked off the key considerations for getting started with a new wire-free technology and acknowledged some of the issues encountered with deactivation and migration of alternative non-magnetic seeds.
In the next part of this on-demand symposium we'll take a look at seed suitability for axillary placement, the benefits of being able to use a lymphatic tracer with the same platform as your seed, and what the very near future of breast localization could look like.