Resurgery Common for Breast Conservation Patients

Almost a quarter of US women undergoing breast conserving surgery have repeat procedures

medwireNews: Research published in JAMA Surgery highlights concerns over the high rate of repeat surgery for women who choose breast conserving surgery (BCS) and identifies factors predicting these procedures.

Overall, 23.6% of the 316,114 patients registered in the National Cancer Data Base who underwent BCS for stage 0 to II breast cancer between 2004 and 2010 required at least one further operation, report Lee Wilke, from University of Wisconsin in Madison, USA, and co-authors.

Of the women who underwent repeat surgery, 62.1% had completion lumpectomy and 37.9% mastectomy.

Multivariate analysis revealed that the likelihood of repeat surgery was significantly and inversely related to increasing age, while Black and Asian patients were more likely to have repeat procedures than White patients.

Relative to patients with ductal carcinoma in situ (DCIS), those with invasive ductal carcinoma or other subtypes were significantly less likely to have repeat procedures, while women with invasive lobular carcinoma or mixed subtypes were more likely.

Repeat procedures were also significantly linked to node-positive disease and tumours that were larger than 2 cm, above grade 1 or Oestrogen receptor-negative.

Finally, the likelihood of a repeat procedure was significantly predicted by the hospital location and its annual volume of breast cancer cases. Academic or research facilities and hospitals with a comprehensive community cancer program were more likely to recommend repeat procedures than those without.

“At the root of the variability in repeat surgery rates for BCS is the lack of standardization of an acceptable margin width”, explain the authors, noting that there was only a slight reduction in resurgery rates over the study period.

However, the team hopes the wide variation in repeat surgery will narrow following a consensus statement by the Society of Surgical Oncology and the American Society for Radiation Oncology. This sets out an adequate negative margin as “no ink on tumor” for stage I and II invasive breast cancer and a 2 mm margin for DCIS.

Julie Margenthaler, from Washington University in St Louis, Missouri, USA, and Aislinn Vaughan, from Sisters of St Mary’s Breast Care in St Charles, Missouri, observe in an accompanying comment that many of the patients who underwent repeat surgery had margins that were likely “negative at ink”.

“We have robust evidence that additional operations for close, but negative, margins do not result in better outcomes”, they write.

“However, additional operations increase health care costs, misuse of resources, patient anxiety, and delay in adjuvant therapy.”

The commentators therefore conclude: “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.”

References

Wilke L, Czechura T, Wang C, et al. Repeat surgery after breast conservation for the treatment of stage 0 to II breast carcinoma. A report from the National Cancer Data Base, 2004–2010. JAMA Surg; 12 November 2014 doi:10.1001/jamasurg.2014.926

Margenthaler J, Vaughan A. Breast conservation surgery and the definition of adequate margins. More is not better... It’s just more. JAMA Surg; 12 November 2014 doi:10.1001/jamasurg.2014.950.

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