JAMA: Nearly a quarter of all patients who underwent initial breast
conservation surgery (BCS) for breast cancer had a subsequent surgical
intervention, according to a report published online by JAMA Surgery.
Completely removing breast cancer is seen as the best way to reduce
recurrence and improve survival. A lack of consensus on an adequate
margin width has led to variable rates of reexcision and, as a result,
patients undergo repeat or additional surgeries, according to background
information provided in the study.
Lee G. Wilke, M.D., of the University of Wisconsin School of Medicine
and Public Health, Madison, and fellow co-authors looked at patient,
tumor and facility factors that influenced repeat surgery rates in U.S.
patients undergoing BCS from 2004 through 2010. The authors’ study
included 316,114 patients with diagnosed breast cancer (stage 0 to II)
who had initial BCS. Patients initially treated with chemotherapy to
shrink their tumors (neoadjuvantly treated) or those who were diagnosed
by excisional biopsy were excluded.
The study found 241,597 patients (76.4 percent) underwent a single
lumpectomy and 74,517 patients (23.6 percent) had at least one
additional operation. Of the patients who had an additional operation,
46,250 (62.1 percent) had a completion lumpectomy and 28,267 (37.9
percent) underwent mastectomy. The proportion of patients undergoing
repeat surgery decreased during the study period from 25.4 percent to
22.7 percent. Tumor size and histologic subtype were the two most
notable patient factors associated with repeat surgeries. Academic
research facilities had a 26 percent repeat surgery rate compared with a
22.4 percent rate at community facilities. Facilities in the Mountain
region of the U.S. were less likely to perform repeat surgery compared
with facilities in the Northeast (18.4% and 26.5% respectively).
“These findings can be used by surgeons to better inform patients
regarding repeat surgery rates and how patient or tumor characteristics
influence these rates. More important, these data can be used to further
support the vitally important adoption of guidelines regarding
reexcision after initial BCS. Standard definitions of adequate margins
as set forth in the consensus guidelines by the Society of Surgical
Oncology and the American Society for Radiation Oncology and the
indications for reexcision will decrease the wide variation in repeat
surgery rates and decrease costs and patient anxiety surrounding
tumor-positive margins,” the authors conclude.
(JAMA Surgery. Published online November 12, 2014. doi:10.1001/jamasurg.2014.926. Available pre-embargo to the media at http://media.jamanetwork.com.)
Editor’s Note: Please see the article for additional information,
including other authors, author contributions and affiliations,
financial disclosures, funding and support, etc.
Commentary: Breast Conservation Surgery, Definition of Adequate Margins
In a related commentary, Julie A. Margenthaler, M.D., Washington
University School of Medicine, St. Louis, and Aislinn Vaughan, M.D., of
the Sisters of St. Mary’s Breast Care, St. Charles, Mo., write: “The
Society of Surgical Oncology and the American Society for Radiation
Oncology developed a consensus statement, supported by systematic review
data, encouraging adoption of ‘no tumor on ink’ as the standard
definition of a negative margin for invasive stage I and II breast
cancer. It is time to put our biases aside. We have robust evidence that
additional operations for close, but negative, margins do not result in
better outcomes.”
“However, additional operations increase health care costs, misuse of
resources, patient anxiety and delay in adjuvant therapy. With more
than 200,000 new invasive breast cancers diagnosed each year, a
staggering number of women are undergoing procedures that are
unnecessary and simply wasteful. Our hope is that the Society of
Surgical Oncology and the American Society for Radiation Oncology
guidelines will be rapidly adopted by surgeons. Data from the study by
Wilke et al will provide an excellent historical reference for future
investigation of the success of this paradigm shift,” the authors
conclude.
(JAMA Surgery. Published online November 12, 2014. doi:10.1001/jamasurg.2014.950. Available pre-embargo to the media at http://media.jamanetwork.com.)
Editor’s Note:
Please see the article for additional information, including other
authors, author contributions and affiliations, financial disclosures,
funding and support, etc.